care plan (cp) team meeting notes (as updated during meeting)

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

2011-04-05With 3 new pages (4, 5, 6) provided by Stephen: processes, structure, principles.These will be discussed on April 6th or 13th as time permits

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

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

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

Care Plan – Process-based Structure


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

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


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 perspectiveo Peter and co-chair of IHE AUo 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

Participants- Meetg of 2011-03-23 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

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 Yes

Margaret Dittloff [email protected] US Yes

Audrey Dickerson [email protected] US

Ian McNicoll [email protected] UK Yes

Danny Probst [email protected] US

Kevin Coonan [email protected] US

mailto:[email protected]

Participants- Meetg of 2011-03-23 p2Name 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 LM&A Consulting Ltd.

Serafina Versaggi [email protected] US

Sasha Bojicic [email protected] CALead 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] CAPharmacist. Clinical Leader, Canada Health Infoway

Gordon Raup [email protected] USWas CEO, CareFacts Information Systems, Inc.

Notes on new wiki page

• Add team members that are regulars. Include profile notes.

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 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

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

datao Would it contain care plan? Not settled where it sits

Patient instructions is a prospective view and patient facing

• 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

conditiono 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

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• 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

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,

Action Items as of 2011-03-23

No. Action Items By Whom For When Status

1. Clarify procedure and obtain rights for André/Laura to update CP wiki André Completed. New wiki page created

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

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

APPENDIX

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

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!

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

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

care plan (cp) team meeting notes (as updated during meeting)

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