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Preface Care Provision Domain

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Patient Care

Patient Care Normative Ballot Content

i Notes to Readers

On Sept, 2010 the Patient Care Working Group voted to use the evaluation report of four years of use of Care Provisioin materials as the baseline for upgrading the ballot materials. This upgrade is required since the 4 year DSTU period has expired in 2011. The evaluation report is available at the patient care website at HL7.org. Beside the evaluation of its use, the Care Provision materials had to change according to changes in the RIM, updates of data types and other. Finally, the PCWG also made the decision to remove the Care Statement and use the full Clinical Statement R-MIM instead. That will ease the harmonisation with other Working Groups, in particular structured documents, and facilitate re-use of our smart R-MIMs such as for Care Plan, Concern Tracker and Assessment Scales in other Domains, Messages, Services and CDA's.

For those browsing the Care Provision Domain work for the first time please note it is arranged into building blocks. The domain description discusses the overall scope of the domain with a few supporting domain storyboards. The detail found in the description of the domain information model emphasizes the focal class of the domain, the Care Provision Act. The remaining documentation on the other classes in the domain is found in separate Topics, where much of the detailed clinical information is represented.

Both the Care Provision Domain and the Clinical Statement Topic provide a good amount of theory and guidance to the reader. As well there are two Reference documents Explanation and Guidance Topic and the Requirements Analysis Artifacts Topic. Although both are beginning to mature with respect to the date of creation, they still form the fundaments for this domain. In addition two publications: "Electronic patient records: domain message information model perinatology" http://www.ncbi.nlm.nih.gov/pubmed/12909178, describing the origin of the current core parts, and "Model once, use multiple times", http://www.ncbi.nlm.nih.gov/pubmed/15360836, describing how different components can be used and reused again in different domains, offer good background materials for this domain. The Explanation and Guidance Topic provides background to engineers writing implementation guides to ensure good clinical functionality in the document, message, and service specifications created from the models.

ii Acknowledgements

The Patient Care technical Committee would like to recognize the contributions of the following authors / editors, developers and organizations without whom this document could not have been produced:

Dan Russler Daniel Russler, MD, XXXXXXXXXX, USA who is a primary author and editor in the following Care Provision Domain parts: the Domain Model (REPC_DO000000UV), Care Record, Care Record Query, Care Transfer, and Care Structures Topics. Note, the Care Structures will be separated into different Topics to achieve easy access.

Heath Frankel, BSc, Frankel Informatics, Australia, who is a primary author and modeling facilitator in the following Care Provision Domain parts: the Domain Model (REPC_DO000000UV), Care Record, Care Record Query, Care Transfer, and Care Structures Topics.

Isobel Frean RN, MSc, XXXX. who provided the major contribution of storyboard content. This was part of her doctoral work at the Health Informatics Research Centre University of Wollongong Australia.

Charlie Bishop, i-Soft Health who is the primary author for the NHS Clinical Statement Structure (COCS_DM000000UV) and the care statement structure ( REPC_RM000100UV), both which informed the Domain Model (REPC_DO000000UV) and subsequent changes from the Care Statement into Clinical Statement.

Davera Gabriel RN, Terminology Manager, CIS Knowledge Management University of California, Davis Health System, for her publishing support.

Mary Ann Juurlink, Lead, e-Health Standards, Ministry of Health and Long-Term Care, Ontario Health, Canada for her publishing support of all the core DSTU materials.

Lloyd McKenzie, LM&A Consulting, HL7 Canada

Nictiz, the Netherlands, for providing the time of experts and the Care Provision materials for inclusion in this ballot.

Special thanks to all those who take the time to review the ballots and submit comments.

iii Changes from Previous Release

The DSTU process in 2007 involved Patient Care reviewing that all HL7 standard processes were adhered to e.g. all the ballot comments addressed, negatives reconciled, posted dispositions within the supporting content deadline and notices sent to the voters. Similarly, this is done with the evaluation report, for which each comment is carefully analyzed and decisions are made about what to do with it. Finally, of course for the Normative ballot(s) the current HL7 ballot procedures are respected.

iv Known Issues & Planned Changes

Ongoing work in Care Provision can be seen on the HL7 wiki site. The url is: http://wiki.hl7.org/index.php?title=Patient_Care_WG#Project_Information

In addition to the increasing detail and maturity of existing material, considerable additions will be made to this domain in future releases. Each area that requires attention will be handled as a separate Topic. As such the Assessment Scale Topic has been moved up from the Care Structures Topic to be a separate Topic. This in particular to facilitate ease of finding and use and reuse.

v Message Design Element Navigation

Table to be created and included