care plan (cp) team meeting notes (as updated during meeting)
DESCRIPTION
Note 1: see April 13 th preliminary agenda on slide 5. Note 2: see notes received by email on page 12 and new Appendix 1 on Health Concern (by Kevin). Care Plan (CP) Team Meeting Notes (As updated during meeting). André Boudreau ([email protected]) - PowerPoint PPT PresentationTRANSCRIPT
Care Plan (CP) Team Meeting Notes(As updated during meeting)
André Boudreau ([email protected])
Laura Heermann Langford ([email protected])
2011-04-06 (No. 8)
HL7 Patient Care Work Group
Note 1: see April 13th preliminary agenda on slide 5.Note 2: see notes received by email on page 12 and new Appendix 1 on Health Concern (by Kevin)
Page 2
Participants- Meetg of 2011-04-06 p1Name email Country Yes No Notes
André Boudreau [email protected] CA Yes
Laura Heermann Langford [email protected] US Yes
Stephen Chu [email protected] AU Yes
Peter MacIsaac [email protected] AU Yes
Adel Ghlamallah [email protected] CA Yes
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
Margaret Dittloff [email protected] US Yes
Audrey Dickerson [email protected] US
Ian McNicoll [email protected] UK
Danny Probst [email protected] US YesKevin Coonan [email protected] US YesGordon Raup [email protected] US Yes .
Page 3
Participants- Meetg of 2011-04-06 p2Name email Country Yes No Notes
David Rowed [email protected] AUCharlie Bishop [email protected] UKWalter Suarez [email protected] USPeter Hendler [email protected] USRay Simkus [email protected] CAElayne Ayres [email protected] USLloyd Mackenzie [email protected] CA LM&A Consulting Ltd.Serafina Versaggi [email protected] US
Sasha Bojicic [email protected] CA Lead architect, Blueprint 2015, Canada Health Infoway
Agnes Wong [email protected] CA
RN, BScN, MN, CHE. Clinical Adoption - Director, Professional Practice & Clinical Informatics, Canada Health Infoway
Cindy Hollister [email protected] CARN, BHSc(N), Clinical Adoption -Clinical Leader, Canada Health Infoway
Valerie Leung [email protected] CA Pharmacist. Clinical Leader, Canada Health Infoway
Page 4
Agenda for April 6th
• Review of Stephen’s slides on processes, structure and principles
• Review of Care Plans comparison provided by Ian• Review of IHE Patient Plan of Care by Jay• Review of draft list/description of deliverables
(André)• Identify agenda items for WGM in Orlando
Who will be there? We seem to have 1.5 hour
• Updated status on the wiki and uploaded documents• Update from Danny on use cases• Agenda for next meeting
Page 5
Agenda for April 13th
• Storyboard criteria (Laura, Stephen, Danny)• Care Plan elements from KP, Intermountain, etc. (Laura)• Business requirements: summary of key aspects since
February (André) This will become eventually our first formal deliverable: tentative structure:
o Business and clinical context, overall needo Definition of the topic (theme)o Stakeholders and needso Overall description of processes: contents dynamic, interchange: integrate Laura’s and Stephen’s modelso Interrelationships with other processes (context diagram)o Scope (in and out)o Business objectives and outcomeso Vision Statement
• Introduction to Eclipse Workbench (Kevin): download and quick start
• Updated high level processes (Stephen)• IHE Patient Plan of Care (PPOC)? (
Page 6
Care Plan – High Level Processes
Stephen Chu5 April 2011
Identify problems/issues/reasons
Assess impact/severity: referral order tests
Initial Assessment
Confirm/finalize problem/issue/reason list
Determine goals/intended outcomes
Determine Problems & Outcomes
Set outcome target date
Determine/plan appropriate interventions
Determine/assign resources healthcare providers other resources
Develop Plan of Care
Implement interventions
Care Plan Implementation
Evaluate patient outcome
Review interventions
Evaluation
Document outcomes
Revise/modify interventions
OR
Close problem/issues/reason/care plan
Follow-up Actions
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 Plan
This is based on a broad review.All converge.
May need to revise goals and outcomes during the process ofcare.
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 beactive participants.This diagram is about process, notInteractions and actors
Add care coordination activitiesin these activities
Need a concept of a master care planwith all the concerns and problems
Page 7
Care Plan – Process-based Structure
Stephen Chu5 April 2011
Identify problems/issues/reasons
Assess impact/severity: referral order tests
Initial Assessment
Confirm/finalize problem/issue/reason list
Determine goals/intended outcomes
Determine Problems & Outcomes
Set outcome target date
Determine/plan appropriate interventions
Determine/assign resources healthcare providers other resources
Develop Plan of Care
Implement interventions
Care Plan Implementation
Evaluate patient outcome
Review interventions
Evaluation
Document outcomes
Revise/modify interventions
OR
Close problem/issues/reason/care plan
Follow-up Actions
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 Plan
Diagnosis/problem/issue - primary - secondary …
Problem/issue/risk/reason Desired goal/outcome Outcome target date
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 datetimeResponsible review party/parties
Review outcome
Review recommendation/decision
Need a master plan with linkages to sub-plansSame as the problem list
2 levels: global that everyone Can see: what by whom. Then a detail
Need to decide what tool to use for the next version
Page 8
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 Chu5 April 2011
Page 9
Comparison of Care Plan Elements (Ian)
• See Xmind map: HL7 Care Plan- Models comparison- Sweden IHE NEHTA.xmind
• Sweden, IHE PCCP, NEHTA, IHE Nursing and aligned model
• Excellent work and tool• Add a few more: find examples that are used a lot
KP? VA? Intermountain? Mayo?
• Laura has direct contacts Danny and Laura to add to the analysis
Page 10
IHE PCCP IHE (from March 23rd)
• 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 USAo 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
IHE Nursing plan of care
• Not adequate• Incomplete
• See Jay’s deck
• IHE focus is on the exchange of documents, mainly HL7 CDA
Page 12
Notes sent by email- April 6th
• Kevin Coonan (1) The medication list is defined by the care plan. It is part of the therapy for a given
problem. (2) The "problem list" is largely covered as well by the care plan. If you are getting a
specific therapy or plan for something, it is a problem (health concern!). (3) We really need to determine which file formats are allowed. There are a lot of
tools, many of which overlap in what software can use it, so we should be able to settle on some parsimonious set (mind map, outline, text files, information models, UML, etc.).
• Lloyd McKenzie: Usually "Medication List" refers to what meds a patient is on, not what the care plan
intends them to be on. The lists are often quite different. You may or may not have a care plan for a given problem. But a patient's current problem list would be of interest for all care plans.
Page 13
Review of draft list/description of deliverables• See wiki: HL7_PCWG_CarePlanDeliverables-Draft-20110405a.doc• Business Requirements, Scope and Vision• Standards context• Storyboards and Use Cases• Process Flow• Domain Glossary• Information Model• Business triggers and Rules• Harmonization (should be in parallel to produce the above to
minimize rework)• Interaction diagram• 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
Page 14
Tools that we will use
• Word• Excel• Power Point • HL7 Eclipse (Open source), very powerful and MDA
Who will guide us: Kevin• Select tool that XML open source• No: Enterprise Architect (for all models)
• ? Xmind (for brainstorm?) Can export to FreeMind
• Are there standard templates somewhere for Word, Excel?• Or do we create our own?
Page 15
Agenda for Orlando WGMs
• Time available for care plan: Thursday, Q1 May have a bit more time (allergy Q) Add Q5 on one or more days
• Who is attending? André, Laura, Kevin, Margaret, Stephen?, William Unlikely: Peter, Adel
• Our focus? TBD
Page 16
Notes on restructured wiki page
• Add team members that are regulars. Include profile notes.
Page 17
Danny’s work on story boards (from March 23rd)• 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• we need to differentiate the concepts - contents vs structure• Lots of variety on different documents• Have a matrix of what exists?• Need an agreed way of producing storyboard: what are we trying to get out of it (Stephen
and Laura)
Page 18
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 19
Action Items as of 2011-04-06
No. Action Items By Whom For When Status
2. Do an inventory of use cases and storyboard on hand Laura (Danny) Active: Underway
3. Ask William for an update (add in a diff colour to the appropriate pages) André Outstanding - Request made
5 Obtain and share the published version of the CEN Continuity of care P1 and P2; obtain ok from ISO
Audrey/Laura Outstanding
7 Update new wiki page with previous meeting material. Adjust structure of wiki. André Wiki restructured
8 Draft list of deliverables for this phase André Draft prepared
9 Draft a new PSS and review with project group André
10
11
12
13
14
NB: Completed action items have been removed.
Page 20
APPENDIX 1- HEALTH CONCERN AND CARE PLANS
Page 21
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
From Kevin
Page 22
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!
From Kevin
Page 23
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)
fCare Plan: set of ongoing and future actions GOAL
Health ConcernRecords what Happens
From Kevin
Page 24
APPENDIX 2
Page 25
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