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Care Plan Topic project

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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
Other interested parties IMIA-NI and IHE
Publishing facilitator Jean Duteau
Vocabulary facilitator Susan Matney
Modeling facilitator Jean Duteau
Domain expert representative 1 Rosemary Kennedy
Domain expert representative 2 Anneke Goossen
Data Analyst facilitator Gay Gianone
Business requirement analyst Rosemary Kennedy
Requirements process facilitator
Business requirement analyst
Requirements process facilitator Frank Oemig
Implementor Ewout Kramer

Action items

Action Description Timeline Status
Analyse and model Glasgow Coma Scale for DSTU An DCM for the Glascow Coma Scale is in enterprise archtect available for ballot.Also available is an export document so clinicians can give comment on the clinical content. Informative ballot september 2010 In progress.
Revise Barthel index in PC DSTU and ISO 13606-3 An DCM for the Barthel index is in enterprise architect available for ballot. Also available is an export document so clinicians can give comment on the clinical content. Informative ballot september 2010 In progress
Translate Dutch example scales into English Examples are available. Different scales with different modeling issues should be choosen for balloting. the different examples must be modeled in EA. An export document must be made and available. Informative ballot september 2010 To be discussed during the HL7 WGM in Rio de Janeiro
Identify use cases for larger scales and make new R-MIM for nested scales based on PC DSTU and Oemig’s set of scores and model and Coonans clinical examples Last revisions underway before filing DSTU status. Informative ballot september 2010 Status to be discussed in HL7 WGM in May 2010.
Proof of concept with Top 10 of items Together with CIC (clinical), Terminfo (apply Snomed CT and or LOINC), Templates (authorization and registry) for 10 items (now 9).Simultaneous work. Send out the material now and ask for review feedback. Informative ballot september 2010 In Progress. Material is available on the HL7 wiki. General feedback has been given. Yes must go on.
Specification how to link to the work in clinical groups To be specified in the ballot. Before that a discussion in the clinical groups May 2010 In Progress
Analyse the feedback on the actions above Feedback given on the content of the DCM. Feedback given on the methodology of DCM. After the ballot of september 2010 Waiting.
Outline a methodology for making DCM, checking for vocabulary requirements, template requirements Based on the analysis of the feedback. Informative ballot January 2011 Waiting.
Transform DCM to R-MIM, archetypes and EHR profiles See DAM vs DCM vs SAEAF Informative ballot 2011 Some progress made.
Develop a guideline for creating a DCM Simultaneous work with work for the ISO standard and NIctiz. Include quality criteria for DCM. Informative ballot september 2010 In progress
Publishing DCM in the HL7 repository Contribution to the work done by Jane Curry, Mark Shafarman and Keith Boone To be determined Waiting.
Publishing the top 10 of DCM on the wiki HL7 Patient Care Includes the Glasgow Coma Scale and the Barthel index. Open for feedback Is published already In Progress.
Publishing the examples DCM of some scales on the wiki HL7 Patient Care May 2010 Waiting.
Publishing the guideline for creation of a DCM on the wiki HL7 Patient Care May 2010 Waiting.
Develop and use metrics for quality criteria This will be based on the work of Sunju Ahn from South Korea.This is put into ISO work as soon as this is allowed due to PhD obligations After May 2010 Waiting.
Make a summary of different existing models, approaches and their implementation
Identify where work is done and future work should be done, in relationship with ISO and JIC
Do comparison of DCM work as in first motion This is a follow up on the Cologne DCM meeting where some work started from
Create tooling to do DCM and exchange with other tools A tool has been created in Enterprise Architect. This is ungoing work. Exchange with other tools is work to be done Before 2011 In Progress
Identify a method for inclusion of DCM into the larger SAEAF picture of HL7 methodology This included how to engage clinicians in particular in the HL7 space, and methods for how to go from DCM to HL7 templates and message artefacts. It will include also the position of DCM in the overall picture which is about decoupling semantics from constraining and from implementing. It should account why this reduces complexity in HL7 as a whole in keeping the clinical data element expression and use consistent. Patient care will accept the request to become an ARB SAEAF alpha project In Progress
Set up joint meeting with ARB and MnN and publishing This to ascertain that DCM fits in the overall SAEAF approach as part of methodology in HL7 and can be published for balloting May 2010 In Progress
Identify dependencies for success and how these can be met In particular to identify dependencies such as on a templates registry and specification, tooling, publishing and linkage to SAEAF May 2010 In Progress
Submitting DCM to JIC A particular approach was agreed roughly a year ago with the JIC chair. That is in particular to bring it to JIC once it is established as a project in both HL7 (May 2008) and ISO (July 2009). The plan has always been to bring the JWG requested projects to JIC As soon as possible by William In Progress

Remark: The actions came from the project scope statement, but must be reviewd by William Goossen as a co-chair of Patient Care.

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

Project Objectives and Deliverables

Project Dependencies

Project Timeline

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


DCM Users

DCM Annonators

DCM Liasons

DCM Developer

DCM Contributors

Collaborating with Agreement status Comments
CEN Existing
ISO Existing
OpenEHR Unknown Informal agreement on this work

Sub Projects