Care Plan (CP) Orlando WGM Meeting (With meeting notes)

1. V4- With discussion notes verified and augmented as of 2011-06-10. Includes post WGM meeting comments by Jay Lyle on Dynamic Federated Plan of Care Model. Includes new slides for Danish model, ISO CONTSYS project, EHR-S FM R1.1 extracts for Care Plans. Slide 36 should be filled to ensure that we don’t miss reusable material and do not reinvent contents. Care Plan (CP) Orlando WGM Meeting(With meeting notes) André Boudreau (a.boudreau@boroan.ca) Stephen Chu (mailto:stephen.chu@nehta.gov.au) Laura Heermann Langford (Laura.Heermann@imail.org) 2011-05-19, Q1, 9h00 to 10h30 Care Plan wiki:http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 HL7 Patient Care Work Group

2. Agenda - May 19th – Q1- 9h00 to 10h30 • Attendance and agenda check – Stephen/Laura (5) • Background: history, need for a Care Plan DAM -André (5) • Approach followed /deliverables – André (10) • Status of Care Plan DAM project - André (5) • Storyboard review: chronic care, home care - Laura (15) • Sample of discussions: models, structures - Laura (15) • Identifying key resources for the Care Plan DAM project – All participants (15) • Material and people from other Patient Care work (Pressure Ulcer, DCM) and other WG (Emergency Care, Care Provision, Care Statement, Structured Document, CDA consolidation, etc.) • Suggestions and concerns of participants - Laura (15) • Close -Laura (5)

3. Participants- WGM Meetg of 2011-05-19 p1* *: includes on site and teleconference participants

4. Participants- WGM Meetg of 2011-05-19 p2* *: includes on site and teleconference participants

5. Background

6. History and Need for CP DAM • Care Plan has been balloted some years ago as DSTU. However, it was felt at that time that more work needed to be done in defining care plan, the components of the care plan, identifying use cases and use. • Items about Care Planning to be discussed towards a future round of DSTU include: • Existing RMIM: does it cover all kinds of care plans and pathways. • Definition of care plan • The overall structure that has been agreed: Care Plan -> Order set -> Clinical Statement. Discussion about this hierarchy is done in PC, O&O and CDS WG. Source: HL7 Patient Care WG Wiki

7. Project Scope (2010) – to Be Updated • 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, Generally a care plan greatly aids the team (responsible parties – it could be the patient caregiver/family) in understanding and coordinating the actions that need to be performed for the person. • The Care Plan structure is used to define the management action plans for the various conditions identified for the target of care. • It is the structure in which the care planning for all individual professions or for groups of professionals can be organized, planned and checked for completion. • Communicating explicitly documented and planned actions and goals greatly aids the team in understanding and coordinating the actions that need to be performed for the person. • Care plans also permit the monitoring and flagging of unperformed activities and unmet goals for later follow up. Source: HL7 Patient Care WG Wiki - Care Plan Topicproject (Archived)

8. Discussion Notes (Background) • Focus on requirements • Do not worry about RMIM for 2 years • Issue • Contents are derivation from RIM components, F class • Should not find anything that is not covered in the RIM • D-MIM is top • Informed by use cases • CP DAM is key to validate our DMIM • Care Provision DMIM is key • Clinical Statement will be used in the future: to be proven • Copy what is useful from past work • Plan Walkthrough of DSTU and other existing material at a future meeting by William (André/Laura to schedule) • Patient Care WG has 18 projects

9. Approach and Deliverables

10. Approach • The plan for 2011 is to first develop a Domain Analysis Model (DAM) for the Care Plan, and then decide on follow on activities. • The HDF 1.5 (HL7 development framework) approach will be followed. • HL7 PC will work together with various groups including HL7 Work Groups (e.g. EHR, Structured documents), IHE, NEHTA, Canada Health Infoway, and others.

11. Last updated: 2011-02-09 HDF- Domain Analysis Overview Source: HDF_1.5.doc, page 37

12. Requirements Document- Structure • Business and clinical context, overall need • Definition of the topic (theme) • Stakeholders and needs • Overall description of processes: contents dynamic, interchange • Interrelationships with other processes • Scope (in and out) • Business objectives and outcomes • Vision Statement

13. Discussion Notes (Approach and Deliverables) • Care Plan can be dynamic and also have static moments • Important to be pragmatic to achieve results in reasonable time • Coordination of care is the key • Keep things simple otherwise we will be caught in a lot of complexity • Understand context and stakeholders needs • We will not focus on the process of developing care plan • There are 100’s of ways of developing CPs • But the interoperable info has to accommodate all this • We are modeling only the info, not the process

14. Progress and Status of CP DAM Project

15. Regular Participants at Weekly Meetings • André Boudreau, Co-Lead • Laura Heermann Langford, Co-Lead • Stephen Chu, Patient Care WG Co-Chair • Susan Campbell • Kevin Coonan • Margaret Dittloff • Adel Ghlamallah • Rosemary Kennedy • Jay Lyle • Ian McNicoll • Danny Probst • Luigi Sison, modeller

16. Progress Achieved • We clarified the process we would follow to conduct the Care Plan Domain Analysis • We identified the storyboards required to cover the range of situations to be covered in the DAM • We developed / refined 2 storyboards • Chronic care • Home Care • We discussed and modeled the dynamics of care plans • We looked at and compared the contents of some care plans: Sweden, IHE, NEHTA, Nursing • We started drafting requirements

17. Storyboard Review • Chronic Care • Home Care

18. List of Required Care Plan Storyboards • Chronic Care • Acute Care • Home Care • Perinatology • Pediatric and Allergy/Intolerance • Stay healthy/ health promotion • Sources: IHE, CHI, HL7, etc. • This is the starter set. Is it sufficient?

19. Guiding Principles for Storyboards • Describe a specific healthcare business problem (or processes) that require(s) the exchange of data/information • By clinicians • Need to ensure • Readability • Clinical accuracy, validity • Coverage (focus on the 80%, not the exceptions) • Refined as we progress in the DAM process • Remember: storyboards get improved over time, as the project advances

20. Sample of Discussions Regarding Care Plan DAM

21. Dynamic Federated Plan of Care Model provided by Laura

22. Dynamic Federated Plan of Care Model provided by Laura- Discussion • This model illustrates a collaborative care model where the care plan is dynamically updated and maintained by multiple organizations and providers • Referral is connected to the plan • The pink line shows the flow when there is no federated care plan • What is to be transmitted? The whole contents? Or the latest and most relevant data for the target organization/provider? • We need to look at a typical chronic disease case where multiple organizations are involved without a federated care plan and no common system • Sweden is moving to a patient centric model with a central dynamic care plan with greater fluidity of information among providers

23. Discussion Notes (Dynamic Plan of Care) • ONC Transition of Care initiative • Care Plan topic: exchange of information and knowledge • Very time driven • HIN- • 3 use cases: • 2 approved: simple discharge, simple referral from primary care to specialist, • Out for public comment: Discharged from hospital to nursing home/skilled nursing

24. Questions by Jay Lyle- Post WGM-20110525 • Terminology • I appreciate the distinction between the 'dynamic' and 'static' care plans, but I wonder if they might be better named as a “care plan application” and “care plan interoperability specification.” I think the HL7 spec will describe static documents or messages (interoperability specifications); I don't think it will provide functional requirements for applications. • 20110608: these are different concepts, so no renaming • “Federated” plan • Is this intended to represent a government-mandated central care plan repository or application that other EHRs can use? In the US, that probably won't fly. • 20110608: this is country/organization specific. It is conceptual model, agnostic to implementation • System boundaries • If System A and System B are applications, then there is only one interaction: communicate care plan (from A to B, or vice versa). If System A contains several applications (outpatient, inpatient, home, etc.), then there are many more interactions shown--each of which may have one or more use cases. In a SOA environment, those distinctions begin to blur, but we need to determine what processes (and constituent interactions, and, implicitly, system boundaries) the model should support. • 20110608: noted.

25. Candidate simplified context diagram, Submitted by Jay Lyle, post-WGM, 20110525 Communications System Functional Care Plan System B 2. Exchange Plan 5. Alert Functional Care Plan System A 2a. Synchronize Plan User Interface 4. Get Observation 1. View Plan 3. Place Order Care Plan Query / View System Ancillary System (outpatient, inpatient, home, ED, etc.) View may support different sorts of queries, possibly for different sorts of clients (pink boxes in slide 19). Exchange may support different levels of detail, or possibly a focus area Should ‘plans’ place orders? Should they use existing HL7 order specifications? 20110608: NO Ditto #3 for observations System may alert provider based on plan, rule, and date or incoming observation.

26. Created: 2011-03-09 Types of care plans (provided by Stephen) • Dynamic care plans • Care plans that are developed, shared, actioned and revise realtime by participating care providers via a collaborative (likely to be web-based) care plan management environment supported by complex workflow management engine. • dynamic and organic • coordinated by care coordinator (e.g. GP) • shared realtime • updated/managed realtime by all care provider • can contain other care plans • dynamic links to relevant patient information (where appropriate and feasible, i.e. privacy and security permit) and evidence-based resources • Interchanged care plans • Care plans that are shared (preferrably via electronic exchanges) and actioned by participating care providers • lack support of a realtime collaborative care plan management environment • master care plan managed and updated/maintained mainly by a care coordinator (e.g. GP) with contributions from participating care providers • interchanged care plan is essentially a snap shot of the master care plan at a point in time • communicated often together with referral/request for services to target care providers • can contain other care plans as attachments

27. Discussion Notes (Dynamic/Interchanged Care Plans) • Charlie Bishop (2011-06-10) • My notes and recall of the discussion are around the need for us to concentrate our efforts in the area that HL7 focuses on – i.e. the information and information structures related to Care Plans rather than the operational processes involved with the generation and use of Care Plans. It was this that brought the two Care Plan ‘definitions’ into the discussion: • Dynamic Care Plans – updated and grow as patient care progresses and are updated and accessible to all carers linked to the patient at any point in time • Interchanged Care Plan – static and communicated for continuity of care purposes • It is the second of these that is of primary concern to our work in developing a small set of generic HL7 v3 information models that can be used to facilitate the many specialist care plan communication scenarios that are required in a multi-disciplinary care environment. HL7 v3 also has a ‘Dynamic’ component but this is not really concerned with how and why information is made available and persisted but how and why it is communicated/interchanged. • There are clearly aspects of Dynamic Care Plans that are relevant to our understanding of the Interchanged Care Plans but this is primarily the information that is used rather than the processes that generate, access and use the information in a care setting.

28. Notes by Sam missing Discussion Notes (Dynamic/Interchanged Care Plans) • Sam: he will send notes • Susan: how is the information exchanged: real time? • VS CDA nested information • On a selective basis

29. 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 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

30. Care Plan – High Level Processes 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 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 Stephen Chu 12 April 2011

31. Discussion Notes (High Level Processes) • Versioning must be allowed • Proposed and accepted Care Plans may be different • Required approval by care giver, patient • Implicit approval? Or explicit • Key with static CPs • Ensure that the patient is central to the process • Vs provider centric • Both approaches should be allowed? • Patient control? Preferences? • Financial responsibility implied? • NL mental health: central CP to individual CP • Institution resources vs patient needs • Each country has their process • Patient care DMIM: can be author of CP

32. 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. Stephen Chu 5 April 2011

33. Sample of Structure and Contents (xmind models) Ian McNicoll 2011-04-06

34. Sample of Structure and Contents (xmind models) Ian McNicoll 2011-04-06

35. key resources for the Care Plan DAM project

36. To be filled Material and People

37. Discussion Notes- Key Resources for the Care Plan DAM Project - 1 • DAM for devices • DAM CIC CV (cardio-vascular) • ISO CONSYS work: see brief descriptive summary on next slide • ISO 13940 Health Informatics: System of concepts to support continuity of care • aka ISO_TC215_N821_NWIP_13940_ContSys

38. What is ISO 13940 Health Informatics: System of concepts to support continuity of care? • This ISO/TC215 Health informatics New Work Item Proposal (NWIP) N821 is intended to merge the previous work items 13940-1 System of concepts to support continuity of care Part 1 Basic concepts and Part 2 Healthcare process and workflow. • This International Standard seeks to identify and define those processes which relate to co-operation between all parties involved in health care provided to human beings (to the exclusion of other living subjects). • Given the definition of health as agreed by the World Health Organization (WHO), this International Standard will include those aspects of health care that rely on the acts of other actors than simply health care professionals. • This International Standard specifically addresses aspects of sharing information related to a subject of care that is needed in the process of health care. • This International multi-part standard addresses topics including: • health care actors and other parties; • organisational principles of health care, including co-operation between actors; • health issues, health conditions and their management; • time-related concepts like contacts, encounters, episodes of care and periods of care; • concepts related to process, workflow and activities; • concepts related to decision support, use of clinical knowledge and quality; • concepts related to responsibility and information flows within the clinical process, like health mandates and their notification; • concepts related to health data management. • Whenever continuity of health care delivery implies social care activities as part of, or in support to, the process towards health recovery, these are to be mentioned wherever relevant in the process and workflow. • In order to establish a common conceptual framework for continuity of care across national, cultural and professional barriers, all of these concepts are defined in this document, and their inter-relationships identified. Note: this was prepared by Canada Health Infoway at ballot time.

39. Discussion Notes- Key Resources for the Care Plan DAM Project - 2 • Danish washing machine project • http://www.openecg.net/WS1_slides/S3_3_kvrneland/S3_arne.pdf • See next 2 slides

40. Extracts: National IT-strategy in the Danish Health Care System, Arne Kverneland, MD, National Board of Health • Link various patient contacts around one episode of care

41. Extracts: National IT-strategy in the Danish Health Care System, Arne Kverneland, MD, National Board of Health • Where care plans fit

42. Discussion Notes- Key Resources for the Care Plan DAM Project - 3 • In the EHR-S FM and the PHR-S FM there are functionalities about the care plan. Maybe its helpful to have a look at it, because it says something about the behavior of the system • See summary model prepared by Anneke, next 3 slides • This is based on R1.1 version • We need to look at the draft R2 material (see HL7 EHR WG)

43. HL7/ISO EHR-S FM R1.1 Care Plan Elements: Direct Care 1.6, Care Plans, Treatment Plans, Guidelines, and Protocols • Statement and Description of 2 functions Provided by Anneke Goossen

44. HL7/ISO EHR-S FM R1.1 Care Plan Elements: Direct Care 1.6, Care Plans, Treatment Plans, Guidelines, and Protocols • Conformance Criteria for DC 1.6.1- Present Guidelines and Protocols for Planning Care Provided by Anneke Goossen

45. HL7/ISO EHR-S FM R1.1 Care Plan Elements: Direct Care 1.6, Care Plans, Treatment Plans, Guidelines, and Protocols • Conformance Criteria for DC 1.6.2- Manage Patient Specific Care and Treatment Plans Provided by Anneke Goossen

46. Discussion Notes- Key Resources for the Care Plan DAM Project - 4 • ISO standard for the Care Plan: definition, see Care Plan- option 3 on the wiki PC Glossary • http://wiki.hl7.org/index.php?title=Patient_Care_Glossary • This definition may be updated by the current CONTSYS work underway

47. Suggestions and concerns

48. Suggestions and Concerns • Australia project • Uses DSTU material • Some issues: what are they? Specific functions and attributes • DAM work is good • Need clarification of static vs dynamic

49. Conclusion

50. Concluding Notes • Reminder: Care Plan DAM weekly meetings • Wednesday, 17h00 EDT, 1.5 to 2 hours • = 11h00 PM in NL • All are welcome • See wiki below for phone number and webex. • HL7 Wiki: Patient Care WG/ Care Plan Initiative 2011 • http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011