Download Care Plan - HL7 Wiki

2011-04-05
With 3 new pages (4, 5, 6) provided by Stephen: processes, structure, principles.
These will be discussed on April 6th or 13th as time permits
Care Plan (CP) Team Meeting Notes
(As updated during meeting)
André Boudreau ([email protected])
Laura Heermann Langford ([email protected])
2011-03-23 (No. 7)
HL7 Patient Care Work Group
Agenda for March 23rd, 2011
• Update on new wiki page for Care Plan initiative
• Review IHE approach to care coordination and planning,
including the nursing perspective; assess reusability for our CP
work
 Peter and co-chair of IHE AU
 Laura Heermann Langford, co-chair of PCCC
• Update from Danny on use cases
• Update on work with ONC team on transitions of care for the
US and could report on that
• Start defining the in-scope and out-of-scope contents and
aspects of care plan
• Then, decide on the deliverables and how we will produce the
DAM
Page 2
Agenda for March 30th
• Feedback on IHE PCC documents: quick overview
and what is relevant to our CP (Stephen, peter, jay,
ian)
• Review of our deliverables (André)
• Updates on deliverables
• Updated status on the wiki and uploaded documents
• Start surfacing the agenda for WGM in Orlando
 Check with William and Stephen (André)
 Who will be there?
 How much time do we want and to do what? 1 to 1,5 days?
• Tentative goal: ballot DAM in September, so need
schedule
Page 3
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
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
Set outcome target date
Develop Plan of Care
Determine/plan appropriate interventions
Determine/assign resources
 healthcare providers
 other resources
Care Plan Implementation
Implement interventions
Care Plan
Evaluation
Evaluate patient outcome
Review interventions
Follow-up Actions
Document outcomes
Revise/modify interventions
OR
Stephen Chu
5 April 2011
Close problem/issues/reason/care plan
Page 4
Care Plan – Process-based Structure
Initial Assessment
Identify problems/issues/reasons
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
Assess impact/severity:
 referral
 order tests
Diagnosis/problem/issue
- primary
- secondary …
Determine Problems & Outcomes
Problem/issue/risk/reason
Confirm/finalize problem/issue/reason list
Desired goal/outcome
Outcome target date
Determine goals/intended outcomes
Set outcome target date
Develop Plan of Care
Determine/plan appropriate interventions
Determine/assign resources
 healthcare providers
 other resources
Care Plan Implementation
Implement interventions
Planned intervention/care service
Planned intervention datetime/time interval
(including referrals)
links to other care plan as service plan
Responsible healthcare & other provider(s)
Intervention review datetime
Responsible review party/parties
Care Plan
Evaluation
Evaluate patient outcome
Review interventions
Follow-up Actions
Review outcome
Document outcomes
Revise/modify interventions
Review recommendation/decision
OR
Stephen Chu
5 April 2011
Close problem/issues/reason/care plan
Page 5
Care Plan Development - Principles
• High level processes can be used to guide
storyboards, use cases and care plan structure
development
• 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
• Care plan should be goal/outcome oriented
• 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
Stephen Chu
5 April 2011
Page 6
Done on March 16th
• Presentation by Canada (Ron Parker and Sasha
Bojicic) on the COPD use case they developed:
 Done, see separate PP deck with discussion notes. See also
the COPD use case document
• Next meeting (March 23rd):
 Review IHE approach to care coordination and planning,
including the nursing perspective
o Peter and co-chair of IHE AU
o Laura Heermann Langford, co-chair of PCCC
 Start defining the in-scope and out-of-scope contents and
aspects of care plan
 Update from Danny
• Then, decide on the deliverables and how we will
produce the DAM
Page 7
Participants- Meetg of 2011-03-23 p1
Name
email
Country
Yes
André Boudreau
[email protected]
CA
Yes
Laura Heermann Langford
[email protected]
US
Yes
Stephen Chu
[email protected]
AU
Yes
Peter MacIsaac
[email protected]
AU
Adel Ghlamallah
[email protected]
CA
William Goossen
[email protected]
NL
Anneke Goossen
[email protected]
NL
Ian Townsend
[email protected]
UK
Rosemary Kennedy
[email protected]
US
Jay Lyle
[email protected]
US
Yes
Margaret Dittloff
[email protected]
US
Yes
Audrey Dickerson
[email protected]
US
Ian McNicoll
[email protected]
UK
Danny Probst
[email protected]
US
Kevin Coonan
[email protected]
US
No
Notes
Yes
Yes
Page 8
Participants- Meetg of 2011-03-23 p2
Name
email
Country
Yes
No
Notes
David Rowed
[email protected]
AU
Charlie Bishop
[email protected]
UK
Walter Suarez
[email protected]
US
Peter Hendler
[email protected]
US
Ray Simkus
[email protected]
CA
Elayne Ayres
[email protected]
US
Lloyd Mackenzie
[email protected]
CA
Serafina Versaggi
[email protected]
US
Sasha Bojicic
[email protected]
CA
Lead architect, Blueprint
2015, Canada Health Infoway
LM&A Consulting Ltd.
Agnes Wong
[email protected]
CA
RN, BScN, MN, CHE.
Clinical Adoption - Director,
Professional Practice & Clinical
Informatics, Canada Health
Infoway
Cindy Hollister
[email protected]
CA
RN, BHSc(N), Clinical
Adoption -Clinical Leader,
Canada Health Infoway
Valerie Leung
[email protected]
CA
Pharmacist. Clinical Leader,
Canada Health Infoway
Gordon Raup
[email protected]
US
Was CEO, CareFacts
Information Systems, Inc.
Page 9
Notes on new wiki page
• Add team members that are regulars. Include
profile notes.
Page 10
IHE PCCP IHE
• Peter and Laura connected and reviewed what IHE did
 Included AU work done
• Key documents: need to extract business requirements and
principles
 PCCP Patient Centered Coordination Plan (Ian- compare to Swedish)
o Scoped back for the USA
o Full version
 Patient Plan of Care: for nursing (Jay)
 eNursing summary (Peter and Stephen)
•
•
•
•
Volume 1 and 2: IHE specific constructs: may not be useful
Get ok from IHE that we can post on wiki: pdf versions?
Some harmonization would be required
May need to consider 2 architectures: one central dynamic CP,
and a series of CP interconnected
Page 11
S&I Framework in the USA
• 3 topics:
• Transfer of care: 3 sub-groups
 Discharge summary
 Care plan
 Laura presented on what we are doing with CP.
o 3 calls with them since
 Identifying data elements and instructions
 Discharge summary is a retrospective view of transition
data
o Would it contain care plan? Not settled where it sits
 Patient instructions is a prospective view and patient facing
Page 12
• Stephen
 [17:29:19] Stephen Chu: discharge summary is a
retrospective (after the fact) but may contain care plan
 [17:30:24] Stephen Chu: allergy - is retrospective, it is a
condition
o Important to be on prospective
 [17:30:54] Stephen Chu: adverse reaction is also
retrospective, but assessment of future adverse reaction
risk is prospective
• Stephen
 With the multiple care plan scenario that Laura mentioned there will be a master care plan and subcare plans from
collaborative care providers linked to the master care plan
Page 13
Danny’s work on story boards
• 4 areas of hi priorities




Perinatalogy
Chronic illness
Home health
Acute
• Trying to make them similar
• Allergies and intolerance: is this relevant to us?
 Add a complicated scenario: primary care treatment plus a referral (Ian)
 Stephen: [17:50:18] Stephen Chu: allergy and intolerance can produce a
care plan of its own, e.g. coeliac disease, but I agree that we can embed it
in all other care plans
• It would be useful to have a long term use case: see COPD
• We need to separate the clinical contents from the infrastructure that
manages the care activities
• Not sure that we would want to build a composite use case but we
should be able to abstract principles and requirements common to all
• [17:54:53] Stephen Chu: the content details will vary, but the
structure should remain constant
Page 14
• we need to differentiate the concepts - contents vs structure
• Need to understand contents enough to decide what
is a must
• Stephen
 content - is the detail data collected as per patient
management according to care plan
 structure - defines what a care plan will look like
 create, modify, update, transfer care plan , etc are dynamic
behaviours
Page 15
DRAFT- Scope of 2011 Care Plan Initiative
• In scope
• Range of situations: curative,
emergency, rehabilitation, mental
health, social care, preventative,
stay healthy, etc.
• Business /clinical needs around
care planning: dynamics of
creating, updating and
communication care plans;
functional perspective; dynamics;
data exchange
• Out of scope
• Patient information
complementary to the care plan:
demographics, diagnostic,
allergies and AR,
Page 16
Action Items as of 2011-03-23
No.
Action Items
By Whom
For
When
Status
André
Completed. New wiki page
created
Laura
(Danny)
Active: Underway
Ask William for an update (add in a diff colour to the appropriate pages)
André
Outstanding - Request
made
4
Prepare summary of the steps from HDF to produce the DAM
André
Done. See Appendix 1 in
first decks
5
Obtain and share the published version of the CEN Continuity of care P1 and P2;
obtain ok from ISO
Audrey/Laura
Outstanding
6
Provide copy of the DAM presentation in Sydney and the name of a free mind
mapping tool
Stephen
Done. Sent to list.
7
Update new wiki page with previous meeting material. Adjust structure of wiki.
André
8
Draft list of deliverables for this phase
André
9
Draft a new PSS and review with project group
André
1.
Clarify procedure and obtain rights for André/Laura to update CP wiki
2.
Do an inventory of use cases and storyboard on hand
3.
Page 17
APPENDIX
Page 18
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
Page 19
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!
Page 20
CARE PLAN AND HEALTH CONCERN
Health Concern
Records what Happens
fCare Plan: set of ongoing and future actions
GOAL
• 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)
Page 21
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
Page 22