1. Care Plan (CP) Meeting - Minutes October 17, 2012 1700-1830 EDT Laura Heermann Langford (Laura.Heermann@imail.org) Stephen Chu (stephen.chu@nehta.gov.au) *C are Plan wiki: http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 HL7 Patient Care Work Group To join the meeting: Phone Number: +1 770-657-9270 Participant Passcode: 943377# With meeting discussion notes

2. Page 2 Participants- Nameemail Country YesNotes Laura Heermann Langford Laura.Heermann@imail.org US Co-Lead- Care Plan initiative/HL7 Patient Care WG. Intermountain Healthcare. RN PhD,: Nursing Informatics; Emergency Informatics Association, American Medical Informatics Association; IHE Stephen Chu stephen.chu@nehta.gov.au AU Y NEHTA-National eHealth Transition Authority. RN, MD, Clinical Informatics; Clinical lead and Lead Clinical Information Architecture; co-chair HL7 Patient care WG; vice-chair HL7 NZ Carolyn Silzle Carolyn.silzle@choa.org US American Dietetic Association Susan Campbell bostoncampbell@mindspring.com USY PhD microbiologist. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer; registered nurse specialist Kevin Coonan Kevin.coonan@gmail.com US MD. Emergency medicine. HL7 Emergency care WG. Nancy Wilson RomanUS Enrique Meneses enrique@careflow.com US Y Serafina Versaggi serafina.versaggi@gmail.com USClinical Systems Consultant Jon Farmer Jon.farmer@thrasis.com USY Chris White Chris.white@thrasis.com US Luigi Sison lsison@yahoo.com US Information Architect at LOINC and at HL7. Enterprise Data Architect at VA. Developing standard for Detailed Clinical Models (DCM), information models for Electronic Health Record (EHR) Diabetes Project, etc. Brett Esler brett.esler@oridashi.com.au AUY Russ LeftwichUSY

3. Page 3 Tentative: October 17, 2012 (subject to change)  Revamped Care Plan wiki o http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012 http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012 o Contributions to story boards that include care services coordination scenarios http://wiki.hl7.org/index.php?title=Care_Plan_Storyboards_with_care_coordination_services _scenarios http://wiki.hl7.org/index.php?title=Care_Plan_Storyboards_with_care_coordination_services _scenarios  Compare/contrast Case Manager and PCP Perspective – Jon Farmer  Modeling –Enrique o To review work in progress through wiki conversation o Discuss and work out any “kinks” in the working process using the wiki for discussion/updates etc. o Continue with a synchronous working session on the model with Enrique facilitating

4. Page 4 MODELING Enrique Meneses

5. Page 5 Discussion Notes  Jon: CMSA “barrier” discussion  Need - some real-world examples of barriers that case managers routinely encounter in acute, EMS, or chronic settings Notes from last meeting  Review of Luigi’s model and decided need to more analysis concentrating on scope and the boundaries in addition to the project scope discussion.  Next Steps o Document additional use cases as discussed earlier o Break Luigi’s model down for more discussion. Enrique will put it on the wiki page to facilitate more off line conversation. Enrique will send out email notice when ready for review.

6. Page 6 Discussion Notes  Jon: CMSA “barrier” discussion  Need - some real-world examples of barriers that case managers routinely encounter in acute, EMS, or chronic settings  Draft document from Jon on modeling barriers  Patient has medical/physiological problems or concerns  Socio-economical and or psychological issues/problems may present barriers for attainment of goals set and interventions planned to resolve the medical/physiological problems  Examples: absence of social support network; or lack of transport means  Question: how should these barriers be modeled o In paper care plans: These barriers are represented as problems or concerns independently o In electronic care plans They need to be represented/modelled as co-dependencies between the barriers and medical/physiological problems  Action item: o Jon Farmer to produce draft of 2-3 use cases and circulate to Laura, Stephen, Russ, Kevin, etc for further inputs o Use cases to be discussed at next meeting (31 october)

7. Page 7 Discussion Notes  Enrique presented a spreadsheet that contains breakdown of storyboard sentences into “subject-verb-object” predicates  Spreadsheet contents form the basis for modelling work  Screen shot of spreadsheet – see next slide  Action item: o Enrique to continue work on decomposition and population of spreadsheet o Draft model to be circulated prior to next conference call o Continue discussion at next conference call

8. Page 8 Care Plan storyboard decomposition

9. Page 9 Care Plan Discussions  Similar and related concepts causing confusion: o Care Plan o Plan of Care o Master care plan o Clinical pathway o Critical pathway  Links included in Baltimore WGM meeting slide deck by Susan Campbell provide useful information on some of these concepts  These links are in the next few slides extracted from the Susan Campbell slide deck

10. Page 10 From Susan Campbell slide deck (Baltimore WGM September 2012) 1.LCC Use Case. Outlines three scenarios for health information exchanges between: 1) an acute care hospital and home health agency (HHA); 2) a skilled nursing facility (SNF) and the Emergency Department (ED); and 3) a Physician and a HHALCC Use Case  Two of the scenarios center on the Home Health Plan of Care (HH-POC), based off CMS 485 form. The HH-POC supports the HHA in providing patient service via MD orders. The HHA and physician exchange information on patient’s evolving condition and needs, and the services the HHA will perform. 2.LCC Whitepaper. Meaningful Use Requirements For: Transitions of Care & Care Plans For Medically Complex and/or Functionally Impaired Persons. Includes a robust discussion of needs and issues regarding interoperable care plan collaboration and exchange.LCC Whitepaper.  A summary is also available here.here 3.Preliminary Stage 3 MU Recommendations. Provided for July 16, 2012 meeting of Health IT Policy Committee Meaningful Use Subworkgroup #3 (includes comments on proposed Meaningful Use Stage 2 requirements related to care plans)Preliminary Stage 3 MU Recommendations

11. Page 11 From Susan Campbell slide deck (Baltimore WGM September 2012) An animated Powerpoint presentation of this LCC vision of longitudinal care planning is available on the wiki here.here Definition, content, sections, and standards of a collaborative care plan that can support care planning for a variety of patient types over time – interoperably.

12. Page 12 From Susan Campbell slide deck (Baltimore WGM September 2012) Long Term and Post-Acute Care (LTPAC) Transitions of Care SWG: Priority Transitions. Examined transitions to/from eleven providersPriority Transitions IMPACT Project Data Elements List. Updated and merged LCC Use Case 1.0 Data ElementsIMPACT Project Data Elements List  Five transitions of care data sets, all subsets of the LCC Use Case Data Elements. The permanent transfer of care contains the entire set of data elements. Patient Assessment Summary (PAS) SWG: Balloted Functional Status, Cognitive Status, & Pressure Ulcer templates for Consolidated CDA (May 2012) Balloted Patient Questionnaire Assessment Summary Implementation Guide for CDA Release 2 (September 2012) Mapped the MDS, OASIS, CARE Tool, Massachusetts Universal Transfer Form (IMPACT Dataset #5 with 328 data elements), and C83 data elements (prioritized by Beacon Community Affinity Group). (link)link

13. Page 13 FUTURE MEETINGS Conference calls between now and January 2013 – see wiki 90 min., Wednesday 5-6:30pm US Eastern, fortnightly (every 2 weeks) Starting September 19 Next Agenda Meeting adjourned at 6:35pm US Eastern Next meeting: Wednesday 31 October 2012 at 5:00pm US Eastern

14. Page 14 Next meeting Agenda- October 31 (Lead: tentative: Laura) Meeting Agenda  To be announced Future topic

15. Page 15 APPENDIX