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<br>
 
<br>
* Go to Care Plan project archived wiki pages:
 
: - [[Care Plan Project 2012]]
 
: - [[Care Plan Initiative project 2011]]
 
: - [[Care Plan Topic project]] (Project contents prior to 2011)
 
 
<BR>
 
 
 
=Introduction=
 
=Introduction=
 
+
Care Plan and related standards are evolving over time. <br>
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 evolutionary changes are result of changes in clinical knowledge, clinical care models, clinical practices and workflow, funding models, and the rapidly changing technology landscape. <br>
 
+
The Patient Care Workgroup is committed to evolve and improve the Care Plan and related standards, keeping in pace in the changing healthcare and technology landscapes. <br>
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.
 
 
 
The Care Plan DAM project concluded in 2014 after complete resolution of informative ballot 2 comments.
 
 
 
 
 
Post Care Plan DAM publication: the PCWG care plan project moves into the following areas of activities:
 
 
 
: (1) Harmonization of the Care Plan model with FHIR care plan model
 
 
 
: (2) Harmonization of the Care Plan model with C-CDA R2 care plan templates
 
 
<br>
 
<br>
 
+
This PCWG Care Plan wiki page is the landing page for all Care Plan and related standards work commenced by the Care Plan Team since 2000.
==Project Co-Leaders==
 
:''' Laura Heermann Langford '''
 
:: Intermountain Healthcare, USA
 
:: Phone: 801.290.6888
 
:: Email: Laura.Heermann@imail.org
 
:''' Stephen Chu, MD '''
 
:: Australia
 
:: Phone: +61.416.960.333
 
:: Email: chuscmi88@gmail.com
 
  
 
<br>
 
<br>
  
==Meeting Information==
+
=Conference call details and Minutes=
 
 
'''Meeting Schedule''': Fortnightly Wednesday at:
 
 
 
{| class="wikitable sortable" border="1" cellpadding="5" cellspacing="0"
 
 
 
|- style="background:#2f4f4f; color:white"
 
|width="200pt"|Call Time
 
|width="200pt"|Region
 
|width="200pt"|Call Time
 
|width="200pt"|Region
 
 
 
|-
 
|17h00||NA / US Eastern ||23h00||UK
 
|-
 
|16h00||NA / US Central ||22h00||Europe Central
 
|-
 
|15h00||NA / US Midwest || ||
 
|-
 
|14h00||NA / US Pacific ||07h00||Australia Eastern Standard
 
|-
 
 
 
|}
 
 
 
 
<br>
 
<br>
'''Call Logistics''':
+
===Frequency===
 
 
{| class="wikitable sortable" border="1" cellpadding="5" cellspacing="0"
 
 
 
|- style="background:#2f4f4f; color:white"
 
|width="200pt"|Call number
 
|width="200pt"|Audio PIN
 
|width="200pt"|Web conference
 
 
 
|-
 
|770-657-9270||943377#||See HL7 conference call notice emails
 
|-
 
 
 
|}
 
 
 
 
<br>
 
<br>
 
+
* Fortnightly between Workgroup Face-to-Face meetings
'''Meeting Agendas and Minutes'''
 
 
<br>
 
<br>
:[[carePlan:Agendas and Minutes|Agendas and Minutes]]
+
* Post January 2018 Workgroup meeting Conference Call schedule:
 +
: - To be announced
 
<br>
 
<br>
 
+
===Audio===
=Care Plan Domain Analysis Model (DAM) Documents=
+
: - Phone Number: +1 563-999-2090
 
+
:: - Participant Passcode: 792564
 
 
==Current Care Plan DAM==
 
 
 
* November 2015 - Pre-publication Draft Care Plan DAM specification
 
: ~ The pre-publication draft of Care Plan DAM specification is intended to be a "preview" of what the contents of the specification are likely to be
 
: ~ A number review and revision changes are anticipated to be applied to the document before it is released for final publication as HL7 Informative document:
 
:: - Storyboard 8: how care plans are used and exchanged within the case management/disease management perspectives
 
:: - Restructuring of the contents: it is planned that all storyboards (which are contextual and supportive in nature) will be moved into the appendix section and not being placed in the main body of the document
 
 
 
: - Note - due to the (2MB) file size limitation of the HL7 wiki, the draft document has been split into two parts. Consequently, the section and line numbers be disrupted
 
 
 
 
 
: - [[Media: PCWG Care Plan DAM Specification - Part 1 - Draft 2015-11-04.pdf | Care Plan DAM Spec - Pre-Publication Draft - 2015-11-04 Part 1 (pdf)]]
 
: - [[Media: PCWG Care Plan DAM Specification - Part 2 - Draft 2015-11-04.zip | Care Plan DAM Spec - Pre-Publication Draft - 2015-11-04 Part 2 (zip)]]
 
 
 
 
<br>
 
<br>
 +
===Web Meeting Information===
 +
: - https://intermountainmeetings.webex.com/intermountainmeetings/e.php?MTID=m594f41bbd5a8ae7d4ee3578870920237
  
=Care Plan Models and Related Projects=
 
 
<br>
 
<br>
  
==Care Team Definition Project==
+
=PCWG Care Plan and related Standards Project resources=
<br>
 
===Introduction===
 
<br>
 
The US ONC (Office of National Coordination for Health IT) is supporting an initiative to review the FHIR Care Team resource and to define what constitutes a care team, the types of care team, and code values required for supporting the implementation of the CareTeam resource in various care settings.
 
 
<br>
 
<br>
This initiative has attracted the participation and contributions from domain experts and industry stakeholders. The group meets weekly via conference calls on Friday at 4:00pm US Eastern.
+
==Current Care Plan Project: Care Plan DAM 2.0==
 
<br>
 
<br>
As of Friday 3 March 2017, the ONC Care Team definition project has been consolidated into the HL7 Learning Health Systems (LHS) Care Team Domain Analysis Project (see link to the LHS project in the subsection below)
+
In 2008, the PCWG Care Plan Project Team initiated the Care Plan Domain Analysis Model 2.0 (CP DAM 2.0) project. <br>
  
===Reference/Resource Documents===
+
Project details are available on this wiki page:
A number of artefacts/documents have been produced as the analysis and discussions progress over time. These documents are uploaded to the ONC CareTeam Definition Confluence page. Interested parties outside this group may not be able to access these documents.
+
* [[Care Plan Domain Analysis Model 2.0]]
 
 
At a PCWG conference call, it was discussed and agreed that it is highly useful for these documents to be made available to the HL7 PCWG members.  Members from the PCWG who contribute to the ONC CareTeam definition initiative agrees to make the documents they created also available on the PCWG Care Plan wiki.
 
 
<br>
 
<br>
 
+
==Care Plan and related standard project history==
* [[Media: HL7_Care-Team-Types-v009_2017-01-09.pptx | Care team types and Care team member types analysis_2017-01-09 (powerpoint slide deck)]]
 
 
 
* [[Media: Care Plan-Care Team - UseCases-WalkThro 20170225.xlsx | Care team Use Cases Walkthrough (spreadsheet)]]
 
 
 
===Learning Health Systems Project===
 
 
 
* [[Patient-Centered Care Team Domain Analysis Model]]
 
 
 
 
 
<br>
 
 
 
==Children with Special Needs Plan Project==
 
 
<br>
 
<br>
* http://wiki.hl7.org/index.php?title=Essential_Information_for_Children_with_Special_Healthcare_Needs
+
Prior to 2018, the PCWG Care Plan Project has completed a number of analysis and standards development work on the Care Plan topic. <br>
 
+
Project details are capture and available at the following wiki pages:
 
<br>
 
<br>
 +
* [[Care Plan - 2015 to 2017 Contents]]
 +
* [[Care Plan Project 2012]]
 +
* [[Care Plan Initiative project 2011]]
 +
* [[Care Plan Topic project]] (Project contents prior to 2011)
  
==Care Plan Models Harmonization==
 
 
<br>
 
===Care Plan Mode - FHIR Harmonization===
 
 
* Contents to go into here
 
<br>
 
 
===Care Plan Model - C-CDA Care Plan Template harmonization===
 
<br>
 
 
* Placeholder for C-CDA care plan templates harmonization work
 
 
<br>
 
* PCWG Care Plan Model and C-CDA R2.x Care Plan templates Collaborative
 
<br>
 
: ~ PCWG and Structured Document Workgroup have collaborated closely to harmonize the PCWG care plan models and the C-CDA R2.x care plan templates. The collaboration activities are continuing.
 
 
<br>
 
: ~ C-CDA R2.x includes a set of sections and entry templates to support care plan exchanges.
 
 
:: - These templates were developed in parallel to the Care Plan DAM informative ballot 1 contents.
 
 
:: - Also in scope for exploration/discussion is the terminology/code sets required to support Care Plan implementations
 
 
<br>
 
* [[Care Plan - C-CDA Templates Implementation]]
 
<br>
 
 
: ~ The Care Plan DAM has since gone through the second cycle of informative ballot, which results in further changes to the original DAM design.
 
 
: ~ It is anticipated that there may be differences between the care plan model as published in the DAM informative ballot 2 document and the C-CDA R2 care plan templates.
 
 
: ~ The harmonization activities are intended to address these differences such that the two sets of artefacts are as closely aligned as possible
 
 
<br>
 
* Place holder for Care Plan Model - C-CDA R2.x harmonization contents
 
 
<br>
 
'''C-CDA R2.x Case Management/Disease Management Care Plan Implementation''':
 
<br>
 
: - The need to use Care Plan in chronic conditions case management/disease management was raised as ballot comments in response to the first informative Care Plan DAM ballot in 2013.
 
: - The PCWG Care Plan team received storyboard contributions on case management/disease management which was balloted and finalised through ballot comments reconciliation processes. This storyboard is scheduled for publication in the final Care Plan DAM specification before October 2015 WGM
 
: - A project has been initiated to implement case management/disease management care plan as C-CDA R2.x compliant documents
 
:: Project documents are available via the following wiki link:
 
 
:: * [[Case Management/Disease Management C-CDA R2.x Project Documents]]
 
 
<br>
 
 
=Important Discussion Topics=
 
<br>
 
During the development of the Care Plan models and related work, a number of topics continue to attract numerous inputs and debates.
 
 
They include:
 
 
* '''Types of Plan''': The concepts "Care Plan", "Plan of Care" and "Treatment/management Plan" attracted extensive debates over a long period of time. Summary of the discussions and final resolution/decision is available on this wiki page:
 
:: [[Types of Plan - Differentiation and Definitions]] (This topic replaces previous topic: Care Plan Definition)
 
 
<br>
 
 
* '''Health Concern''': The Health Concern is one of the important components/concept in care plan
 
: This topic has been extensively debated on a number of HL7 Workgroup mailing lists.
 
: PCWG has a Health Concern project with the objectives of clearing defining this topic and related concepts, and how these concepts are used in patient care. Information on the Health Concern project can be access through this wiki:
 
:: [[Health Concern]]
 
 
:: How the Health Concern and Concern Tracking topics are related to the "Health Concern", "Health Goal", "Care Activity", etc concepts identified in the Care Plan Domain Analysis Model will also be addressed by the Health Concern project
 
 
<br>
 
 
* '''Care Team''': The composition of Care Team has also be discussed quite extensively and evolves over time. It is anticipated that this will continue to attract discussions and will continue to evolve.
 
: Currently, the following is a list of roles/professional roles that is considered as care team members:
 
:: - Medical Practitioners (including all specialties and sub-specialties)
 
:: - Nurses
 
:: - Allied Health Practitioners (including Physiotherapist, Occupational Therapist, Speech Therapist, Psychologist, Pharmacist, etc)
 
:: - Social workers
 
:: - Care Managers, Disease Managers, Care Coordinators
 
:: - Patient
 
:: - Nominated patient family members
 
:: - Care givers/carers
 
 
<br>
 
 
=Care Plan DAM Project Resource Documents=
 
 
==Project Scope Statement==
 
<br>
 
* Care Plan Clinical Model - draft project scope statement:
 
 
: - [[Media: HL7 Project Scope Statement_PCWG-CarePlan-ClinicalModel_2015_v03.doc | Care Plan clinical model draft PSS - updated: 2014-12-19]]
 
 
 
==Care Plan DAM Previous Drafts==
 
* '''April 2015 Version'''
 
: - Please note the following:
 
:: - Due to file size limitation imposed by HL7 wiki, the complete Care Plan DAM draft specification has been split into 3 parts
 
:: - As the result of the split, the numbering sequence of Sections and Subsections in Part 2 and Part 3 are out of syn with the complete document
 
:: - The documents are working drafts. Editing of the full document is still in progress. Hence the contents should not be taken as final
 
: - [[Media: PCWG Care Plan DAM Specification Final edits 2015-04-06_Part-1.docx | Care Plan DAM Spec - 2015-04-06 edits - Part 1]]
 
: - [[Media: PCWG Care Plan DAM Specification Final edits 2015-04-06_Part-2.docx | Care Plan DAM Spec - 2015-04-06 edits - Part 2]]
 
: - [[Media: PCWG Care Plan DAM Specification Final edits 2015-04-06_Part-3.docx | Care Plan DAM Spec - 2015-04-06 edits - Part 3]]
 
<br>
 
 
==Care Plan DAM Informative Ballot 1 Document==
 
* [[Media: PCWG Care Plan DAM Specification 20130721-Draft.doc | Care Plan DAM 2013 September ballot - Draft]]
 
 
<br>
 
 
==Other Useful Resources==
 
 
* [[Care Plan Concept Overview]] wiki page
 
 
*[[Requirements Definition Documents]]
 
 
*[[Storyboard Documents]]
 
 
*[[Activity Diagrams and Business Process Models]]
 
 
*[[Care Plan Models]]
 
 
*[[Glossary of Terms]]
 
 
*[[Presentations on Care Plan Projects - from project team and others]]
 
 
<br>
 
 
==Comparison of International Care Plan Structure as at 2011:==
 
 
*[[Media: CarePlanStructure_compare_Australia_Sweden_IHE_NHS_20110406.jpg | Care Plan Structure Comparison]]
 
 
* Coordinated Care Services Specification:
 
 
: http://wiki.hl7.org/index.php?title=Coordinated_Care_Services_Specification
 
  
 
<BR>
 
<BR>
  
==Older documents==
+
=Leadership=
 
 
*[[ Description of deliverables]]
 
 
 
*[[ Working Documents-CP]]
 
 
 
*[[ Reference Material-CP]]
 
 
 
*[[ Care Plan | Care Plan Model]]
 
 
 
  
 +
===Project Co-Leads===
 
<br>
 
<br>
 +
* Laura Heermann Langford, RN, PHD (Project co-lead)
 +
* Stephen Chu, PhD (Project co-lead)
 +
* Emma Jones, RN (Project co-lead)
  
=Related and Relevant Activities/Projects=
 
 
<br>
 
<br>
 
+
===Contributors===
===2016 List of Care Plan Topics===
 
 
 
{| class="wikitable sortable" border="1" cellpadding="5" cellspacing="0"
 
 
 
|- style="background:#2f4f4f; color:white"
 
|width="200pt"|Topic
 
|width="200pt"|Source/Owner
 
|width="200pt"|Comments
 
 
 
|-
 
|HL7 Care Plan Domain Analysis Model||PCWG||(generic care plan standards)
 
|-
 
|HL7 C-CDA 2.1 Care Plan Document Template ||SDWG||(generic care plan [C-CDA templates] standards)
 
|-
 
|HL7 FHIR Care Plan Resource ||PCWG||(generic care plan standards)
 
|-
 
|CCDA on FHIR Care Plan||SDWG||(generic care plan standards)
 
|-
 
|IHE PCC Dynamic Care Planning Profile ||IHE - PCC||(generic care planning standards)
 
|-
 
|HL7 Care Coordination Services (CCS) functional model; OMG CCS Technical Specification||PCWG, SOA||(generic care planning and coordination standards)
 
|-
 
|IHE QRPH Early Hearing Detection and Intervention (EHDI) Plan of Care||IHE - QRPH||(use case specific care plan standards)
 
|-
 
|HL7 Clinical Oncology Treatment Plan and Summary||SDWG||(use case specific care plan standards)
 
|-
 
|Survival-ship plan||SDWG||hl7.org - master grid - family = CDA
 
|-
 
|NCPDP/HL7 Pharmacist Care Plan||NCPDP, HL7 Pharm||(use case specific care plan standards)
 
|-
 
|HL7 CDA R2 Personal Advanced Care Plan Document||SDWG||(use case specific care plan standards)
 
|-
 
|Payers unstructured care plan||HL7 Payers||(use case specific care plan standards)
 
|-
 
|Care team DAM project||Learning Health Systems WG||(model the relationship between care team members and the patient and between other members of the team)
 
|-
 
|Care team members definition update project||ONC||(define care team types, roles and members)
 
|-
 
|x---x||x---x||
 
|-
 
|DAF (Data Access Framework): minimum mandatory requirements for recording, searching for, and fetching patient information||ONC||(includes ONC 2015 Certification Criteria for the Common Clinical Data Set (CCDS) for  Assessment and Plan of Treatment, e.g. Condition, Care Team, Goal ... http://hl7.org/fhir/us/daf/2016Sep/daf-core-careplan.html)
 
|-
 
|xx||xx||
 
|-
 
 
 
|}
 
<br>
 
 
 
 
 
'''Care Coordination'''
 
 
 
* The '''IHE Patient Care Coordination''' Technical Committee has published an IHE Technical Framework supplement:
 
: - [[Media: IHE_PCC_Suppl_RECON_Rev2.0_PC_2014-06-06.pdf | IHE - Reconciliation of Clinical Content and Care Providers profile]]
 
: - This document is open for public comment in the period from June 6 through July 5, 2014
 
: - More details about comments submission can be obtained from this IHE link:
 
:: o http://ihe.net/Public_Comment/#pcc
 
: - IHE comment spreadsheet:
 
:: o [[Media: RECON -PCC_Technical_Framework_Supplement_Public_Comment_Form.xlsx | IHE - Reconciliation profile comment spreadsheet]]
 
:: o Comments can be emailed to: pcccomments@googlegroups.com
 
 
 
 
<br>
 
<br>
  
'''Care Coordination Services Project details:'''
+
* Russ Leftwich, MD
 +
* Michael Padula, MD
  
* http://wiki.hl7.org/index.php?title=Care_Coordination_Capabilities
+
* Lisa Nelson
  
 
<br>
 
<br>
 
+
===Modelling Facilitator===
'''ONC/LCC Project website:'''
 
 
 
* http://wiki.siframework.org/LCC+Longitudinal+Care+Plan+%28LCP%29+SWG
 
 
 
 
<br>
 
<br>
 +
* Jay Lyle, PhD
  
===Other related parties of the Care Plan Topic===
 
 
To be updated.
 
 
{| class="wikitable sortable" border="1" cellpadding="5" cellspacing="0"
 
 
|- style="background:#2f4f4f; color:white"
 
|width="200pt"|Collaborating with
 
|width="200pt"|Agreement status
 
|width="200pt"|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
 
 
See also the reference material wiki page (link above)
 
  
 
<br>
 
<br>

Latest revision as of 07:19, 26 November 2018


Return to: Patient Care


Introduction

Care Plan and related standards are evolving over time.
The evolutionary changes are result of changes in clinical knowledge, clinical care models, clinical practices and workflow, funding models, and the rapidly changing technology landscape.
The Patient Care Workgroup is committed to evolve and improve the Care Plan and related standards, keeping in pace in the changing healthcare and technology landscapes.

This PCWG Care Plan wiki page is the landing page for all Care Plan and related standards work commenced by the Care Plan Team since 2000.


Conference call details and Minutes


Frequency


  • Fortnightly between Workgroup Face-to-Face meetings


  • Post January 2018 Workgroup meeting Conference Call schedule:
- To be announced


Audio

- Phone Number: +1 563-999-2090
- Participant Passcode: 792564


Web Meeting Information

- https://intermountainmeetings.webex.com/intermountainmeetings/e.php?MTID=m594f41bbd5a8ae7d4ee3578870920237


PCWG Care Plan and related Standards Project resources


Current Care Plan Project: Care Plan DAM 2.0


In 2008, the PCWG Care Plan Project Team initiated the Care Plan Domain Analysis Model 2.0 (CP DAM 2.0) project.

Project details are available on this wiki page:


Care Plan and related standard project history


Prior to 2018, the PCWG Care Plan Project has completed a number of analysis and standards development work on the Care Plan topic.
Project details are capture and available at the following wiki pages:



Leadership

Project Co-Leads


  • Laura Heermann Langford, RN, PHD (Project co-lead)
  • Stephen Chu, PhD (Project co-lead)
  • Emma Jones, RN (Project co-lead)


Contributors


  • Russ Leftwich, MD
  • Michael Padula, MD
  • Lisa Nelson


Modelling Facilitator


  • Jay Lyle, PhD