Care Plan Topic project

return to: Patient Care

further to: Care Plan Topic & Ordersets

further to: Care Plan Glossary

further to: Care Plan Storyboards

further to: Care Plan Use cases

Introduction

Care Plan has been balloted some years ago as DSTU. However, it was felt at that time that more work needed to be done in defining care plan, the components of the care plan, identifying use cases and use. The plan for 2010 is to complete the contents of Care Plan.

HL7 PC will work together with: HL7 Structured Documents WG IMIA-NI IHE For the content of this DSTU material.

Project Need

Items about Care Planning to be discussed towards a future round of DSTU include:

• Existing RMIM: does it cover all kinds of care plans and pathways.
• Definition of care plan
• The overall structure that has been agreed: Care Plan -> Order set -> Clinical Statement. Discussion about this hierarchy is done in PC, O&O and CDS WG.

Project Scope

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, Generally a care plan greatly aids the team (responsible parties – it could be the patient caregiver/family) in understanding and coordinating the actions that need to be performed for the person. The Care Plan structure is used to define the management action plans for the various conditions identified for the target of care. It is the structure in which the care planning for all individual professions or for groups of professionals can be organized, planned and checked for completion. Communicating explicitly documented and planned actions and goals greatly aids the team in understanding and coordinating the actions that need to be performed for the person. Care plans also permit the monitoring and flagging of unperformed activities and unmet goals for later follow up.

Project Team

Primary Sponsor/Work Group is Patient Care WG

Co-sponsor Work Group(s) is Structured Documents WG

Role	Name	Email	Notes
Project facilitator	Rosemary Kennedy	rkennedy@qualityforum.org
Other interested parties	IMIA-NI and IHE
Publishing facilitator	??
Vocabulary facilitator	Susan Matney	susan.matney@utah.edu
Modeling facilitator	??
Domain expert representative 1	Rosemary Kennedy	rkennedy@qualityforum.org
Domain expert representative 2	Anneke Goossen	agoossen@results4care.nl
Data Analyst facilitator	Gay Gianone	gay@alschulerassociates.com
Business requirement analyst	Rosemary Kennedy	rkennedy@qualityforum.org
Requirements process facilitator
Business requirement analyst
Requirements process facilitator	Frank Oemig	hl7@oemig.de
Implementor	Ewout Kramer	e.kramer@furore.com

Action items

Action	Description	Timeline	Status
Conceptuel, contextual and structural definitions of Care Plan	new text	Informative ballot 2011	In progress.
Definitions for each part of the care plan	The parts must be consistent with the structural definition of care plan	Informative ballot 2011	In progress.
Work on Storyboards	Multiple: for example for Emergency, Clinical hospital (discharge), Nursing home, chronic disease, primary care. Mono- and Multidisciplinary	Informative ballot 2011	In progress.
Work on Use cases	Example use cases can be: chronic condition, obstetric case with transfer	Informative ballot 2011	In progress.
Development of a Dynamic model for the Care Plan Topic		Informative ballot 2011	Waiting.
Development of a Structural model	DAM (HDF within HL7)	Informative ballot 2011	Waiting.
R-MIM update, meeting all care plan and pathway requirements	This is work for PC WG only	2011	Waiting.
CDA for discharge of a nursing care plan	Joint PC, SD and IHE), including a robust set of examples	2011	Waiting.
Work on relationship of care plan with ordering, verifying and reporting of orders			Waiting.

Remark: The actions came from the project scope statement.

Project Process

• Teleconferences on Wednesday at 4 pm Eastern time.

• Using Tooling's telecon. Will be announced via the Patient Care mailing list.

• Standing Agenda Items
  • Review of project plan and action items
  • Opportunity to ask questions and answers

Please also refer to IHE PPC page 7 in attached linked document. http://www.ihe.net/Technical_Framework/upload/IHE_PCC_Patient_Plan_Of_Care_PPOC_TI_-2009-08-10.pdf

IHE approves to reuse the existing storyboard / use case / swim lane diagrams for HL7 PC use cases.

Also Australia agreed to the Patient Care WG the use cases they developed in the Care Plan project in Australia.

These can be found at http://ihe-australia.wikispaces.com/Care+Coordination+and+eReferra along with some background.

Project Objectives and Deliverables

1. Domain Analysis Model with the following deliverables (together with SD WG):

• • Definitions of Care Plan and others.
  • Work on storyboards and use cases (multiple). Emergency, Clinical hospital (discharge), Nursing home, chronic disease, primary care. Multidisciplinary. Example use cases can be: 1 chronic condition, obstetric case with transfer. After that CDA can use the work that is be done. CDS is an addition to the messages which already exist. They must be updated.
  • Dynamic model for the Care Plan Topic
  • Structural model. -> DAM (HDF within HL7)

2. R-MIM update, meeting all care plan and pathway requirements (PC WG only)

3. CDA for discharge of a nursing care plan (joint PC, SD and IHE), including a robust set of examples.

4. Work on relationship of care plan with ordering, verifying and reporting of orders

Success Criteria

Clear definitions of Care Plan and components, harmonized with CEN Contsys standard, the risk management standards, IHE profiling and IMIA NI project work. Use cases and storyboards updated Proper description how the care plan and pathways can be mapped to the Care Plan R-MIM Update of the R-MIM, if necessary to accommodate the use cases

Project Timeline

Work will be done during 2010 en 2011. Accepted as DSTU end of 2011

Project Resources

Most will be done in normal committee work time, and online via meetings, where all contributors have their normal responsibilities to develop DCM for their day job / clients / projects.

Project Budget

There will be a budget necessary for the HL7 repository

=Ballot strategy - general||

Revision of existing DSTU materials, inclusion of new scales into ballot and ongoing maintenance and new materials. Future normative will probably only possible if HL7 at large has established a repository of templates / R-MIMs.

Links to relevant documents

Templates Registry Pilot

Participants

Contributors of the Care Plan Topic

Collaborating with	Agreement status	Comments
IMIA-NI	Existing
IHE	Existing
CEN	Existing	Swedish Care Plan project

Download CEN materials from Sweden here: http://www.hl7.org/Special/committees/patientcare/docs.cfm