Health Concern

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Health Concern DAM Questions

Model artifacts

This is a new Health Concern Project initiated October 2013.
This wiki page contains latest contents for the Health Concern Project post September 2013 WGM at Cambridge.

Introduction

Care Plan has been balloted in 2007 as DSTU. However, a number of ballot issues were not resolved satisfactorily and consequently the balloted contents did not reach DSTU status.

The project plan initiated in 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.

Project Co-Leaders

Michael Tan

Organisation: Nictiz

Phone: +31-70-3173450

Email: tan@nictiz.nl

Jay Lyle

Organisation

Phone:

Email:

Publishing Faciliator

David Pyke

Organisation: Ready Computing

Phone:

Email: david.pyke@readycomputing.com

Domain Experts

Larry McKnight

Lisa Nelson

Stephen Chu

Meeting Information

Weekly call on Tuesday's 1 p.m. Eastern Time

Insert conference call details here

• Call Logistics- voice
  • Phone Number: 770-657-9270
  • Participant Passcode: 943377#

• Call Logistics- screen sharing/
  • Web conferencing URL:

https://meetings.webex.com/collabs/#/meetings/joinbynumber

The meeting number is 238 558 505
No password is required.

Meeting Agendas and Minutes

Health Concern Meetings/Conference Calls Agenda and Minutes

Working Documents and Project Deliverables

Note: the following list of documents/deliverables will change as the project progresses.

Working documents are found here

• Storyboard/Use Case Documents:

* http://wiki.hl7.org/index.php?title=File:Health_concern_use_cases.docx

* Health Concern Observation and Tracking Storyboard 2013-11-20

• Health Concern Project Ballot Materials:

* Health Concern Meetings/Conference Ballot material

Open (and closed) questions about the domain

Health Concern and Related Concepts: Definitions and Discussions

Concern

Definition:

A concern is a matter of interest, importance or worry to someone

Health Concern

Definition:

A Health Concern is a health related matter that is of interest, importance or worry to someone, who may be the patient, patient's family or patient's health care provider

(approved, PCWG San Antonio WGM, Monday 20 January 2014 Q3)

The "Health Concern" concept is often used interchangeably with "Condition" or "Issue"

• The health related matter is of sufficient interest/importance that someone in the health care environment (patient, family, provider) has identified to be requiring some attention and perhaps tracking

• A health concern may be identified from different perspectives:

- Patient

- Family member/carer

- Providers (physician, surgeon, physical therapist, respiratory therapist, nutritionist, health educator, social worker, etc)

• From information management or engineering perspective, "health concern" can been considered to encompass two subconcepts:

- Health Concern Tracker/Tracking

- Health Concern Observation

Health Concern Event

Definition

A health Concern event can be defined as an activity that may bring about or detect change in health status of a person

(Note - this definition is adapted from

CDC: http://www.cdc.gov/osels/scientific_edu/ss1978/lesson1/Section1.html

definition of "health related state or event"; and

http://www.cs.columbia.edu/digigov/LEXING/CDCEPI/gloss.html

Columbia University Glossary of Epidemiology

In the context of Health Concern topic, a health concern event is a health care related activity

Examples of Health Concern Event include:

- identification and monitoring of health condition (including risks, problems, diagnosis, barriers that may become risks/problems, etc)

- continuous observation and evaluation of identified health condition

- identification and continuous monitoring of health goals and their milestones

- interventions/care activities

- evaluation of intervention outcomes) that may bring about or detect changes (e.g. deterioration, improvement or resolution of issues/problems) in patient's health status

Health Concern Observation

• Health concern observations are observations and evaluations (meta-observations) of matters related to a patient's health that are of interest or important to someone
• The observations and evaluations can be from the perspective of the patient, the patient's family, the carer, or any health care providers involved in the care of the patient
• The scope of observations and evaluations cover health issues, conditions, problems, diagnosis
• Related health concern observations are linked and tracked by the Health Concern Tracker

Health Concern Thread

Tracking:

• A patient's health condition (expressed as one of more complaints, issues, findings, risks, problems, diagnoses, risks, barriers, etc) and its course are identified and monitored by healthcare provider(s) and/or the patient and patient family
• Goals and their milestones for resolving the health condition are identified, negotiated, agreed upon and progress monitored
• Intervention(s) to realize the health goals, milestones are identified, negotiated, agreed upon, implemented and monitored
• Any preference(s) and barrier(s) are also identified, considered in goals, milestones setting and intervention design

• As a patient's condition evolve through its course, the condition is assessed, monitored, interventions implemented, outcomes of interventions evaluated against the agreed milestones and goals, the goals and milestones are modified along with the interventions.
• The assessments, implementations, outcome evaluations, goals and intervention modifications comprise a set of inter-related health events

• In the context of Health Concern topic, the construct Health Concern Thread is used as mechanism for tracking relevant health concern(s) and related health concern events

• A Health Concern Thread may contain no semantics beyond that need for tracking, excepting the link between related Conditions (as identified through ObservationEvent or ObservationRisk assessments conveying Event, Clinical Finding, Disorder assertions, etc).

The relationships between health concern, its related/supporting information and health concern tracking is depicted in the following diagram (as discussed at 2014-03-20 conference call)"

• [NOTE - the following diagram are approved as per discussions at 2014-04-17 conference call]

Health Concern Topic:

Health Concern Topic:

• NOTE:

These conceptual diagrams were approved at the 2014-04-17 Conference call.

They will form the basis for continuous analysis and use case/storyboard development

They are likely to be refined based on the the analysis and storyboard development outcomes

Logical model(s) will be developed which will form part of the DAM package artefacts

A simple patient journey storyboard on Health Concern Observations and Health Concern Tracker/Tracking

- A patient presented to his Primary Care Physician (PCP) with chief complaints of cough and slight shortness of breath. There was no wheezing on examination
- A week later, he returned to see his PCP with presenting symptoms of cough, shortness of breath and fever
- Three days later, he presented himself at the Emergency Department of local hospital with cough, severe shortness of breath, wheezing and fever
- He was diagnosed with asthma and bronchopneumonia
- he was admitted, treated in the hospital and discharged back to the care of his PCP a week later

Each of the above events was recorded in the PCP electronic medical record as individual Health Concern observations

As the patient is now diagnosed with asthma, the PCP considers it important to track these inter-related conditions to help better monitoring and management of the patient's condition
The Health Concern tracker function of the EMR is activated which links all the related health concern observations under a principal Health Concern observation - Asthma

An analogy:
The health concern tracker and health concern observations relationship can be akin to the health concern tracker as the connecting vines of a bunch of grapes
The entry point is the principal health concern observation: e.g. asthma in the simple patient journey storyboard
Each health concern observation (e.g. chief complaints on first encounter, presenting problems at local hospital emergency department, etc) can be considered as a grape
From the entry point, navigation can be made along the branches of the vine to individual grape

Health Concern Tracking high level examples:

• Tracking Allergies/Intolerance as Health Concern:

• Tracking Back Pain as a Health Concern:

Health Concern and C-CDA

C-CDA includes a number of Section- and Entry- level templates. A number of these templates are relevant to the PCWG "Health Concern" topic:

• Health Concern Act
• Allergy Concern Act
• Problem Concern Act

Health Concern and Problem Concern Act in C-CDA

Health Concern in C-CDA
C-CDA contains a Health Concern section and a Health Concern Act

• Health Concern Section:

This section contains data describing an interest or worry about a health state or process that could possibly require attention, intervention, or management

• Health Concern Act:

It is a wrapper for health concerns derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.).

A Health Concern Act can represent a health concern that a patient currently has. Health concerns require intervention(s) to increase the likelihood of achieving the goals of care for the patient.

A Health Concern Act can also represent a health concern that is a risk. A risk is a clinical or socioeconomic condition that the patient does not currently have, but the probability of developing that condition rises to the level of concern such that an intervention and/or monitoring is needed.

Health Concerns can be identified/expressed from both the provider or patient (and family) perspectives

Health concerns identify matters of interest/worry from health perspective

Problem Concern Act in C-CDA

The Problem Concernt Act reflects an ongoing concern on behalf of the provider that placed the concern on a patient’s problem list.

So long as the underlying condition is of concern to the provider (i.e. so long as the condition, whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is “active”. Only when the underlying condition is no longer of concern is the statusCode set to “completed”.

The effectiveTime reflects the time that the underlying condition was felt to be a concern – it may or may not correspond to the effectiveTime of the condition (e.g. even five years later, the clinician may remain concerned about a prior heart attack)

Problem concerns are identified/expressed from provider perspective

Problem concerns may be further organised through Health Concern Tracker

Problem concerns identify matters of interest/worry from clinical perspectives (e.g. including medical, nursing, allied health)

Example:

- A patient may have multiple instances/episodes of chest infections. Each is identified by the patient's PCP as Problem Concern

- This same patient may also have multiple instances/episodes of asthmatic attacks, some of them are triggered by chest infection episodes. Each is also identified by the patient's PCP as another type of Problem Concern

- All chest infection problem concerns that triggers asthma and all other asthmatic attack problem concerns may be linked by a Asthma Health Concern Tracker

C-CDA xml Examples and Guidelines

Questions are often raised regarding how certain demographic and clinical data should be represented using C-CDA templates.

Questions are raised on the Structured Document and FHIR listserv on:

why "Health Concern", "Allergy Concern" and "Problem Concern" Acts are required (mandatory vs optional) in C-CDA?

what are they used for?

are they included to satisfy some clinician fantasy?

The extensive email exchanges highlight that there are serious disagreements on whether they are required, whether approaches to data representations and the use of these templates are desirable, correct or constitute best practices.

PCWG is keen to collaborate with experts from Structured Document WG and other interested parties to:

• Disambiguate what health concerns are, how they differ from condition, how they relate to condition
• Develope guidelines on how best to represent various concern data using C-CDA templates
• xml examples representing a variety of use cases

Link to C-CDA Example Task Force wiki page

The C-CDA Example Task Force is working on producing a number of xml examples to provide guidance on how different C-CDA templates can/should be used to exchange demographic and clinical data.

• http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force

Links to Other Related and Relevant Projects/Resources

C-CDA

See Health Concern and Problem Concern Act in C-CDA above for more details

Other Related Projects/Resources

This is a link to the 2009 PCWG materials on "Concern Tracking":

• http://www.hl7.org/v3ballotarchive_temp_3C384E4F-1C23-BA17-0C8DEBCD5487C1C7/v3ballot2009sep/html/domains/uvpc/uvpc_CareStructures.htm#REPC_RM000300UV01-rmi

Presentations/Slide Decks on "Concern and Concern Tracking":

• Slide deck from Dr Larry McKnight on Concern and Tracking (2006)

Project Scope

Definition

A Health Concern is any health related issue which is identified by a user of an EHRS as needing tracking. The concept of a Health Concern is agnostic to the specific content or who identified the need to track it. It is principally concerned with the tracking and maintenance of the expressed content. In all cases there will need to be an Observation (a Condition) which names the Health Concern. Condition can be diagnosis, signs, symptoms, risks (of some future undesirable state), risk factors, abnormal diagnostic study, barrier to care, propensity to adverse reaction (aka "allergy"), or patient preference. This is based on a long-standing convention, and has been broadened to accompany the range of Health Concerns. Additional types of Health Concerns are quite possible, if they differ substantially from some existing type.

Additional criteria based on the specific Condition which names the Health Concern

Previous discussion has indicated that a Health Concern requires some sort of action on the part of the care team (which potentially includes the subject and/or record target), based on the specifics of the Condition which names the Health Concern. Thus, there is a Condition specific requirement to be the reason for some action, even if that action is to simply observe. A Condition also implies one or more (prioritized) Goals, i.e. an assertion of what should happen or the desired outcome.

Project Objectives and Outcomes

As per Health Concern Project Scope Statement.

Project Work Plan and Timeline

As per Health Concern Project Scope Statement.