Care Plan (CP) Team Meeting Notes (As updated during meeting)

1. Care Plan (CP) Team Meeting Notes(As updated during meeting) André Boudreau (a.boudreau@boroan.ca) Laura Heermann Langford (Laura.Heermann@imail.org) 2011-04-20 (No. 10) HL7 Patient Care Work Group

2. Agenda for April 20 • Preparation for WGM in Orlando • Care Plan elements from KP, Intermountain, etc. (Laura) • Feedback on models prepared by Stephen (Laura and Susan) • Updated doc on storyboards (Danny) • IHE Patient Plan of Care (PCCP) (Ian M.): deferred • Modeling tool to use (Eclipse or EA) (André) • Overarching term to use (Ian M.) deferred • Business requirements: summary of key aspects since February (André) deferred • This will become eventually our first formal deliverable • Next meeting agenda

3. Agenda for April 27 • Summary of care plan situations (Susan) • Feedback and discussion on first storyboard: Chronic Care (Danny to circulate in advance) • Highlights from IHE Patient Centered Coordination Plan (PCCP) (Ian M.) • Coaching on Eclipse: what to install for our needs, quick start (Kevin)

4. Participants- Meetg of 2011-04-20 p1

5. Participants- Meetg of 2011-04-20 p2

6. Preparation for WGM in Orlando in May • Try to have conf call facility during our Care Plan session to allow participation of those who will not be on site • Lillian Bigham, director of meetings is responsible for logistics • Stephen will contact her with that • Scheduled for Thursday Q1: 9-11h30 (time in AU will be 23h00 to 00h30) • Try swapping with another period? • NO. Stephen to double check.

7. Care Plan Elements from KP, VA, Intermountain, Mayo, etc. • Request was sent out by Laura • Some initial feedback, better to wait next week • Working with these organizations. Still in process. • What are they using today in terms of contents • Try collecting policies and rules especially on the interchange of clinical info related to care plans • Different models are used for different contexts: simple coordination to catastrophic intervention (whole range of levels from non licensed person to catastrophic case with multi dimensional coverage) • Susan could prepare matrix or summary • Will enrich our statement of requirements

8. Care Plan – High Level Processes

9. Process Models • Models are generating a lot of discussions in the US. Not discussed at this level in the past. • Linking of components is not clear, how to connect detailed plans to the master? • Patient may/should (?) be the coordinator with exceptions • Make the patient owner of the CP • We are not there yet, but it is a trend • Patient has the last say in many actions (comply or not comply) • PHR are rudimentary yet, no standards to interoperate • PHR does not equal care coordination • We need to assume a coordinator, whomever he/she is • Most countries have not had that concept in place, formally • Dynamism: a key concept because things happen and move • Transition on care (S&I): handoff required, need to prevent void of care • CP are complex. Aim at better outcomes from our care • Multi level dynamic care planning requires tool that may not exist • See: www.healthycircles.com www.patientsknowbest.com

10. Process Models cont’d • We need to scope out what kind of care plan we want to deal with • What are the priority cases? • Take complex cases that are very costly • Look at whole series of processes: prep, coordinate, update, assess, close • Understanding the whole process to ensure that we capture the correct data in the interchange • There is a ramp up before the transition of care to ensure patient safety: patient preparation, search for availability of resources for the patient care needs, awareness and readiness of receiving of organization • High volume cases: simple model • Simple or complex cases have the same contents • Detailed clinical contents will vary • Wrapper of care plan communication • Stephen will look at the range of situations that Susan will document • We will need to restrict ourselves to the Care Plan: structure and contents in the information exchange

11. Care Plan – High Level Processes IHE has more loose connections. Here assumes workflow engine that connects tightly problem, goal, task. Need distinct process to manage/communicate/update/track/close the Care Plan. See IHE. Make more explicit here. High Level Shared Plan Initial Assessment Problem/concern/reason 1..* Target goals/outcomes Planned intervention Assessed outcome Identify problems/issues/reasons Assess impact/severity:  referral  order tests Confirm/finalize problem/concern/reason list Determine goals/intended outcomes Develop Plan of Care Detailed Care Plan Determine/plan appropriate interventions Refer to other provider (s) Set outcome target date Determine/assign resources  healthcare providers  other resources Care Plan Implementation Implement interventions Follow-up Actions Evaluate patient outcome Evaluation Document outcomes Review interventions Revise/modify interventions OR Close problem/issues/reason/care plan April 13 This is illustrative Goals/Outcomes: - Optimize function - prevent/treat symptoms - improve functional capability - improve quality of life - Prevent deterioration - prevent exacerbation; and/or - prevent complications - Manage acute exacerbations - Support self management/care Care orchestration Determine Problems & Outcomes Care orchestration Care Plan Need to study this more: Laura and Susan to work on it Stephen Chu 12 April 2011

12. Care Plan – Process-based Structure Will need to add explanations and maybe some different scenarios High Level Shared Plan Initial Assessment Problem/concern/reason 1..* Target goals/outcomes Planned intervention Assessed outcome Identify problems/issues/reasons Assess impact/severity:  referral  order tests Determine Problems & Outcomes Problem/issue/risk/reason Desired goal/outcome Outcome target date Confirm/finalize problem/concern/reason list Determine goals/intended outcomes Develop Plan of Care Planned intervention/care service Planned intervention datetime/time interval (including referrals) links to other care plan as service plan Responsible healthcare & other provider(s) Determine/plan appropriate interventions Refer to other provider (s) Set outcome target date Determine/assign resources  healthcare providers  other resources Intervention review datetime Responsible review party/parties Care Plan Implementation Implement interventions Follow-up Actions Evaluate patient outcome Evaluation Review outcome Document outcomes Review interventions Review recommendation/decision Revise/modify interventions OR Close problem/issues/reason/care plan Care orchestration Goals/Outcomes: - Optimize function - prevent/treat symptoms - improve functional capability - improve quality of life - Prevent deterioration - prevent exacerbation and/or - prevent complications - Manage acute exacerbations - Support self management/care Care orchestration Care Plan Stephen Chu 12 April 2011

13. Storyboards

14. Storyboard: what is it? Narrative of business (clinical; administrative) processes on domain/area of interest Non technical (conceptual in nature) Describes: Activities, interactions, workflows Participants High level data contents feeding into or resulting from processes Provides inputs for: Activity diagrams Interaction diagrams State transition diagrams High level class diagrams Stephen Chu 12 April 2011

15. Storyboards • 5 to 10 max • See list on wiki • Identify actors and understand their roles • Understanding the care planning processes will help understand the needs for info exchange • E.g. query for resource availability vs the care plan needs for patient X • 3 types of requirements • Functions to be carried out, workflow, processes • Static semantics: info model, glossary, vocabulary • Functions to be carried out by the system: EHR FM, PHR FM, etc • Interactions between systems: interoperability • Include meaningful use items that are universal in perspective

16. IHE Patient Plan of Care (PPOC) • Deferred

17. Includes post-meeting notes Modeling Tool to Use • Responses from Lloyd Mackenzie and Jean Duteau • Both use Enterprise Architect (EA) • Response from Andy Stechishin, HL7 Tooling and V3 Publishing co-chair • First, there is an active Tooling project (called MAX) to export information from EA using MIF, the HL7 official interchange format. • Second, at the WGM in Sydney, Sparx gave each attendee a license for EA. • Third, during my tenure as a co-chair of Publishing, most DAMs that have been submitted for ballot have been developed (or at least published) using EA. • It seems to me that a convergence is occurring and EA seems to at least be the tool of choice for many. • Eclipse is a platform for doing many different things using specific plug-ins • Recommended by HL7 • Open Source but not as intuitive as Enterprise Architect (which costs some 100$ for a desktop version) • However, choosing which tool and plug-in (for UML) to install is difficult for non technical folks (vs the easy-to-use EA) • We would need some coaching to allow a quick start • Adel agreed to help us there • André will find a resource • The tool will be used to do: • Use cases • Activity and workflow diagrams • Interaction diagrams • Class models

18. Issue: What overarching term to use? • Condition • Health concern and care Plans

19. Issues • What overarching term to use? • Condition: favoured by Care Provision: more neutral than ‘concern’ • Concern: allows for broader set of contexts for care planning, including health maintenance activities • Problem: focus on ‘wrong’ things; not well applicable to pregnancy: NO • Health status: ‘current’ is not a term used • Health issue: many people use it. Europe uses it (e.g. Sweden) • See terms proposed (Susan) • Synonyms: issue, concern • We need to choose, define it and map it to existing terms • Wait for our storyboards and map the correct word to each • Build on existing term work done by reliable sources: HL7 Care Provision, ISO/CEN concepts (Continuity of Care) • Existing glossaries: HL7, CCMC (case management assoc), NLM • Retain meaning of natural language where possible • Use reliable sources • Ian: he has done a term analysis • Note: None of these terms are in the HL7 Core Glossary. See • http://www.hl7.org/v3ballot/html/welcome/environment/index.html

20. ‘Condition’ vs ‘Problem’: From Care Provision (Jan 2011) • …the term “Condition” is used generally in HL7 because it is less negative than “problem,” i.e. management of normal pregnancy or wellness is not considered management of a “problem.” In addition, assessing and optimizing the condition of a patient is considered central to effective healthcare by clinicians. Much of the following is shared by the generalized discussions under Condition List and Condition Tracking. Additional guidance on the use of the Condition List and Condition Tracking structures in the specific use cases of allergy and intolerance is given following the general discussions below. Source: ExplanationandGuidance.pdf document in the Care provision package v3_careprovision_2011JAN.zip

21. From Kevin Health concern and care plan: new paradigm to define the EHRS • Historically, the EHR was similar to the GHR (Guttenberg Health Record) that was systematically adhered to as it had since Sir. William Osler told us how to treat patients. Often it is even pre-Guttenberg technology dependant (hand written). • This paradigm was implemented in EHRS: PMH, CC, Social Hx, HPI, etc. etc. • This paradigm was somewhat impacted in the 1960’s by crazy Dr. Larry Weed • Every 50 years we need to re-think how we think of patients. • We use information and generate information and actions. • Information used is typically current problems/medications, HPI, and ROS/PE. • Actions are surgery, medical therapy, psychotherapy • We translate what we know into what we do. This defines us and our profession. • So lets formalize it in a model which is optimized to support this

22. From Kevin What We Know (information) and what we do (actions) • A Health Concern can be linked to any relevant data: labs, encounters, medications, care plan • A Health Concern POV looks like a long hall way, with doors to rooms with all kinds of crap in them. You can, if you read the door name (aka Observaiton.code) query for all of the relevant data (and graph it is numeric, etc.). • At any given instant, what we know is effectively what is in the health concern, and the H&P/initial nursing assessment. • At a given point we have enough information to take action. This action is captured in the Care Plan. Diagnosis or identified problems/concerns then get updated. • For every plan of care there better be some health concern!

23. From Kevin Health Concern Records what Happens fCare Plan: set of ongoing and future actions GOAL Care Plan and health concern • Care plans need goals, i.e. tries to cause some ObservationEvent to match it. • Care plan has intimate relationship with HealthConcern—is is the reason for the care plan • Can view things via the HealthConcern POV, CarePlan POV, the individual encounter POV, and Health Summary (extraction/view)

24. Requirements

25. Conclusion

26. Action Items as of 2011-04-20 NB: Completed action items have been removed.

27. Appendix

28. Review of draft list/description of deliverables 2011-04-06 • See wiki: HL7_PCWG_CarePlanDeliverables-Draft-20110405a.doc • Business Requirements, Scope and Vision • Standards context • Storyboards and Use Cases • Interaction diagram • Process Flow • Domain Glossary • Information Model • Business triggers and Rules • Diagram of health concerns/problems and care plan on a timeline? • State machine diagram applied to concerns?? Lifecycle? Status of acts, referrals • Continuity of care timeline • Harmonization (should be in parallel to produce the above to minimize rework)

29. Care Plan Development - Principles High level processes can be used to guide storyboards, use cases and care plan structure development and activity diagram and interaction diagram Care plan should preferably be problem/issue oriented, although may need to be reason-based where problem/issue not applicable, e.g. health promotion or health maintenance as reason. Use ‘health concern’ as encompassing term? (see Care Provision, 2006-7) Care plan should be goal/outcome oriented- to allow measurement Interventions are goal/outcome oriented External care plan(s) can be linked to specific intervention/care services Goal/outcome criteria are essentially for assessment of adequacy/effectiveness of planned intervention or service Reason for care plan is for guiding care and for communication among care participants. Need to support exchange of information. 2011-04-06 Stephen Chu 5 April 2011

30. Definition of Care Plan on Wiki • The Care Plan Topic is one of the roll outs of the Care Provision Domain Message Information Model (D-MIM). The Care Plan is a specification of the Care Statement with a focus on defined Acts in a guideline, and their transformation towards an individualized plan of care in which the selected Acts are added. • The purpose of the care plan as defined upon acceptance of the DSTU materials in 2007 is: • To define the management action plans for the various conditions (for example problems, diagnosis, health concerns)identified for the target of care • To organize a plan for care and check for completion by all individual professions and/or (responsible parties (including the patient, caregiver or family) for decision making, communication, and continuity and coordination) • To communicate explicitly by documenting and planning actions and goals • To permit the monitoring, and flagging, evaluating and feedback of the status of goals, actions, and outcomes such as completed, or unperformed activities and unmet goals and/or unmet outcomes for later follow up • Managing the risk related to effectuating the care plan, • Source: http://wiki.hl7.org/index.php?title=Care_Plan_Topic_project

31. Care Plan – High Level Processes Initial Assessment Identify problems/issues/reasons Assess impact/severity:  referral  order tests Determine Problems & Outcomes Confirm/finalize problem/issue/reason list Determine goals/intended outcomes Determine/plan appropriate interventions Develop Plan of Care Set outcome target date Determine/assign resources  healthcare providers  other resources Care Plan Implementation Implement interventions Follow-up Actions Evaluate patient outcome Evaluation Document outcomes Review interventions Revise/modify interventions OR Close problem/issues/reason/care plan From April 6th Goals/Outcomes: - Optimize function - prevent/treat symptoms - improve functional capability - improve quality of life - Prevent deterioration - prevent exacerbation; and/or - prevent complications - Manage acute exacerbations - Support self management/care This is based on a broad review. All converge. Need a concept of a master care plan with all the concerns and problems May need to revise goals and outcomes during the process of care. Nutrition has similar model. Also use standardized language Hierarchy or interconnected plans can apply. Every prof group has specific ways to deliver care. Here we focus on the overall coordination of care. Is there always a care coordinator? Patients could be the coordinator of their own care. They should be active participants. This diagram is about process, not Interactions and actors Add care coordination activities in these activities Care Plan Stephen Chu 5 April 2011

32. Care Plan – Process-based Structure Initial Assessment Diagnosis/problem/issue - primary - secondary … Identify problems/issues/reasons Assess impact/severity:  referral  order tests Problem/issue/risk/reason Desired goal/outcome Outcome target date Determine Problems & Outcomes Confirm/finalize problem/issue/reason list Determine goals/intended outcomes Planned intervention/care service Planned intervention datetime/time interval (including referrals) links to other care plan as service plan Responsible healthcare & other provider(s) Determine/plan appropriate interventions Develop Plan of Care Set outcome target date Determine/assign resources  healthcare providers  other resources Intervention review datetime Responsible review party/parties Care Plan Implementation Implement interventions Follow-up Actions Evaluate patient outcome Evaluation Review outcome Document outcomes Review interventions Review recommendation/decision Revise/modify interventions OR Close problem/issues/reason/care plan Need to decide what tool to use for the next version From April 6th Goals/Outcomes: - Optimize function - prevent/treat symptoms - improve functional capability - improve quality of life - Prevent deterioration - prevent exacerbation and/or - prevent complications - Manage acute exacerbations - Support self management/care Need a master plan with linkages to sub-plans Same as the problem list 2 levels: global that everyone Can see: what by whom. Then a detail Care Plan Stephen Chu 5 April 2011