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return to: [[Patient Care]]   
+
Return to: [[Patient Care]]   
  
'''Current Activity:''' Finish the ballot resolutions for Health Concern
+
Goto [[Health Concern: Archive]]
Health Concern is in Ballot reconciliation phase, about half has been tackled in Atlanta Sept 2009
 
  
== Project Summary ==
+
[[Health Concern DAM Questions]]
Concern Tracking and Care statements provide a framework for tracking and managing health concerns, however there are many undefined relationships and representations that remain to be defined.  Issues identified include.
 
* Standard representation of how observations should be characterized (eg diagnosis vs problem)
 
* Standard representation of distinction and linkage between provider roles in problem lists (eg nursing problems vs physician problems).
 
* Standard representation of common attributes about a problem (eg clinical status, problem severity, etc)
 
* Methods for adding diagnosis specific attributes (eg Cancer Stage, CHF Class,...)
 
* Correct representation of problem modifiers and negation.  (eg rule out MI, or history of MI vs AMI)
 
* List maintenance issues in messaging. (eg send full list including history, send full list, but no history, only send updates for a concern)
 
* Correct relationships terms for episode links and sub-concerns.
 
** Multiple Related Episodes
 
*** Repeated Acute problems (eg, 2 bouts of community acquired pneumonia)
 
*** For exacerbations and remissions (eg, chronic asthma with multiple acute exacerbations )
 
** Different levels of Granularity (eg, internist calls "CAD s/p CABG", cardiologist calls "2 vessel disease with LIMA to mid LAD, SVG to RCA")
 
** Causality
 
*** Assumed in Term (eg Gestational Diabetes <- Pregnancy  )
 
*** Manually Asserted (eg Diabetes & ESRD)
 
*** Therapy related (GI bleed while on Coumadin for Afib)
 
** Others??
 
  
== Artifacts and related modeling ==
+
[[ Health Concern Cases and Scenarios | Model artifacts]]
*[http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=33309 ISO 18104]
 
*[http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=41141 ISO 22789]
 
*ISO 13940
 
*[http://informatics.mayo.edu/wiki/index.php/Continuity_of_Care_Document_%28CCD%29 CCD]
 
*[http://www.hitsp.org/ConstructSet_Details.aspx?&PrefixAlpha=4&PrefixNumeric=32 HITSP IS C32]
 
*[http://www.hl7.org/v3ballot/html/infrastructure/terminfo/terminfo.htm The TermInfo Ballot Draft]
 
  
todo:
+
[[Category:Patient_Care]][[Category:Health Concern]]
* add related articles
 
* links/pointers to info from campbell, chute, elkin, va, terminfo
 
  
== Use Cases ==
 
  
== Implementors ==
+
<br>
Canada Infoway
+
This is a new Health Concern Project initiated October 2013.
 +
<br> This wiki page contains latest contents for the Health Concern Project post September 2013 WGM at Cambridge.
  
== Participants ==
 
*Larry McKnight
 
*John Kufuor-Boakye
 
*Jim Campbell
 
*Tom Oniki
 
*Bob Dolin
 
*Kevin Coonan
 
*William Goossen
 
  
== Meetings/T-Conn's ==
+
<br>
  
The discussion from the list is deferred to this spot.
+
=Introduction=
  
== Discussion Area from the Patient Care list on Diagnosis label ==
+
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.
  
Larry McKnight asked to make a summary, this is not the summary but William's start to make one.  
+
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.
  
May I suggest that all of you look back at your initial mails and include the questions, the answers and the discussions in this?
+
<BR>
  
 +
==Project Co-Leaders==
 +
:''' Michael Tan '''
 +
:: Organisation: Nictiz
 +
:: Phone: +31-70-3173450
 +
:: Email: tan@nictiz.nl
 +
:''' Jay Lyle'''
 +
:: Organisation
 +
:: Phone:
 +
:: Email:
  
John stated the following:
+
==Publishing Faciliator==
 +
:''' David Pyke'''
 +
:: Organisation: Ready Computing
 +
:: Phone:
 +
:: Email: david.pyke@readycomputing.com
  
"Since I started the thread, I like to recap (more than summarize) the various options and suggestions that have been put forward. First, I like to re-state the use-case that triggered a search for this label/name. It was to come up with a unifying concept for diagnoses, symptoms, and any other recordable finding that can be referenced by a healthcare provider (doctors, pharmacists, dentists, nurses, etc) as a reason for performing (indication) or not performing (contraindication) care provision activity on/for a patient.
+
<BR>
  
+
==Domain Experts==
 +
:'''Larry McKnight'''
 +
:'''Lisa Nelson'''
 +
:'''Stephen Chu'''
  
Here is a list of names/labels that have been suggested for the concept:
+
<BR>
  
-          Problem
+
==Meeting Information==
-          CareIndication
 
-          CareActivityIndication
 
-          CareActivityReason
 
-          CareProvisionReason
 
-          ClinicalFinding
 
-          ClinicalAssertion
 
-          Condition
 
-          ClinicalCondition
 
-          HealthIssue
 
-          HealthState
 
  
So far, there hasn’t been a consensus on the list as to which of the suggested name/label best describes the perceived concept domain. Personally, I tend to lean towards ‘CareProvisionReason’ (though the observation may be referenced as the reason for provisioning or not provisioning care) as an all-encompassing label for such a concept, but then, this is in the purview of the clinical domain experts.
+
Weekly call on Tuesday's 1 p.m. Eastern Time
  
Regards,
+
Insert conference call details here
  
John Kufuor-Boakye"
+
<br>
 +
* Call Logistics- voice
 +
** Phone Number: 770-657-9270   
 +
** Participant Passcode: 943377#
  
Hi John,
+
<br>
 +
* Call Logistics- screen sharing/
 +
** Web conferencing URL:
 +
:: https://meetings.webex.com/collabs/#/meetings/joinbynumber
 +
<br>
 +
The meeting number is 238 558 505
 +
<br>
 +
No password is required.
 +
<br>
  
I'm not thrilled with anything that has the word Reason or Indication in
+
==Meeting Agendas and Minutes==
the name. Reason/Indication is the name of the relationship between the
+
<br>
observation and the intended action. It's not a name for the observation
 
itself. The observation is simply a statement of "The patient has X".
 
  
 +
: [[Health Concern Meetings/Conference Calls Agenda and Minutes]]
  
Lloyd
+
<br>
  
This is one discussion brought to our attention nov 3 08 by prof. Pieter de Vries Robbe from Nijmegen, NL:
+
=Working Documents and Project Deliverables=
  
Since the introduction of the problem oriented medical record by Weed in 1968 there are discussions about the term 'problem'. In our view the term is used by Weed for non medical 'diagnosis', for 'intermediate' diagnosis and for aspects of worry. For the intermediate diagnosis one can think of the evolving idea about the underlying problem. The worry things are just a list of things you want to pay attention to. For one doctor this can be another list than for another doctor. The underlying problem is patient specific and is of interest for one or more doctors.
+
''Note: the following list of documents/deliverables will change as the project progresses.''
  
The evolving idea of the underlying problem is modeled in HL7 by the ELNK. This evolving idea is not between different worries! Therefore we used the ELNK between different Conditions. About a condition or about a labtest result or about a procedure one can have a Concern. These concerns are doctor specific.
 
Furthermore one can have an assertion about an underlying problem. This assertion is an idea on a specific moment. In that sense it is like a test result. Therefor we use Observation to represent assertions about Conditions.
 
So in our view we need Observations, Conditions and Concerns with heir specified relationships. End quote:
 
  
Then Tom de Jong answered:
+
Working documents are found here
I agree about the ingredients (conditions, observations, concerns), but  with some comments:
 
 
* I would like a better definition of what a condition is and how it  relates to the other concepts. It is the most ambiguous term of the  three, which leads to recurring discussions.
 
 
* I would like a split between two broad branches of observations:  tests versus assertions. I agree that an assertion is an observation,  but so is a condition (in the current RIM). Yet, I do feel they are
 
semantically distinct enough to warrant a separate class code.
 
 
* I disagree with your statement that a Concern is doctor-specific. In  the way Concern is used in the current Patient Care materials, it is  specifically overarching, linking the observations (and other acts)
 
from different doctors to a common underlying problem.
 
 
So it seems we disagree about the hierarchy between Condition and  Concern... I think if we would ask 10 Patient Care gurus, they would  give 5 different definitions of both, and they wouldn't agree on the  hierarchy either. That is exactly where we need consensus...fast.
 
  
End Tom's quote.
+
* Storyboard/Use Case Documents:
  
Comment by William:
+
:: * http://wiki.hl7.org/index.php?title=File:Health_concern_use_cases.docx
  
We have agreed already that a Concern is not an observation. And we have agreed that a Concern is not professional specific.
+
:: * [[Media: HealthConcern-Obs-and-Tracking-Storyboard_2013-11-20.docx| Health Concern Observation and Tracking Storyboard 2013-11-20]]
However, one question would then be: how does a concern start? Well that is the perspective of one clinician starting the thread because she/he worries.
 
  
In the DSTU it is now an R-MIM A_ConcernTracking(REPC_RM000300UV01)for which Concern is defined as:
+
<br>
"....Concern Class as result of harmonization work: An interest or focus of attention that tends to persist over time and has as a subject a state or process. The subject of the interest or focus of attention has the potential to require intervention or management."
+
* Health Concern Project Ballot Materials:
  
This implies not only Pieter's 'worrying', but also the imperative for the health professional to 'do something about it'.
+
:: * [[Health Concern Meetings/Conference Ballot material]]
 
  
"
+
<br>
  
== Project Committee Overlaps and Dependency ==
+
[[Health Concern Questions | Open (and closed) questions about the domain]]
* Orders and Observations
+
 
* Structured Doc
+
=Health Concern and Related Concepts: Definitions and Discussions=
* Term Info
+
 
* M&M
+
===Concern===
 +
 
 +
'''Definition:'''
 +
: A concern is a matter of interest, importance or worry to someone
 +
 
 +
<BR>
 +
 
 +
===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"
 +
 
 +
 
 +
<BR>
 +
 
 +
* 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
 +
<BR>
 +
 
 +
 
 +
===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
 +
 
 +
<br>
 +
: 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
 +
 
 +
 
 +
<br>
 +
 
 +
'''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===
 +
 
 +
<BR>
 +
'''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
 +
 
 +
<br>
 +
* 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). 
 +
 
 +
<br>
 +
'''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]
 +
 
 +
<br>
 +
'''Health Concern Topic''':
 +
 
 +
<br>
 +
[[Image:HealthConcern_2014-05-06.jpg]]
 +
 
 +
<br>
 +
'''Health Concern Topic''':
 +
 
 +
<br>
 +
[[Image:HealthConcernTracking_2014-04-17.jpg]]
 +
 
 +
<BR>
 +
* '''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
 +
 
 +
<BR>
 +
 
 +
'''A simple patient journey storyboard on Health Concern Observations and Health Concern Tracker/Tracking'''
 +
 
 +
<br> - 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
 +
<br> - A week later, he returned to see his PCP with presenting symptoms of cough, shortness of breath and fever
 +
<br> - Three days later, he presented himself at the Emergency Department of local hospital with cough, severe shortness of breath, wheezing and fever
 +
<br> - He was diagnosed with asthma and bronchopneumonia
 +
<br> - he was admitted, treated in the hospital and discharged back to the care of his PCP a week later
 +
 
 +
<BR> Each of the above events was recorded in the PCP electronic medical record as individual Health Concern observations
 +
 
 +
<BR> 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
 +
<br> 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
 +
 
 +
<br> An analogy:
 +
<br> 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
 +
<br> The entry point is the principal health concern observation: e.g. asthma in the simple patient journey storyboard
 +
<br> 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
 +
<br> From the entry point, navigation can be made along the branches of the vine to individual grape
 +
 
 +
<BR>
 +
'''Health Concern Tracking high level examples''':
 +
 
 +
<br>
 +
* Tracking Allergies/Intolerance as Health Concern:
 +
<br>
 +
 
 +
[[Image:AllergyConcernTracking-02.jpg]]
 +
 
 +
<br>
 +
* Tracking Back Pain as a Health Concern:
 +
<br>
 +
 
 +
[[Image:BackPain-ConcernTracking.jpg]]
 +
 
 +
<br>
 +
 
 +
=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
 +
 
 +
<br>
 +
 
 +
== Health Concern and Problem Concern Act in C-CDA==
 +
 
 +
<BR>
 +
'''Health Concern''' in C-CDA
 +
<br> 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.
 +
<br>
 +
: 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
 +
 
 +
<br>
 +
'''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)
 +
<br>
 +
: 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
 +
 
 +
<BR>
 +
 
 +
==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
 +
 
 +
<br>
 +
 
 +
===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
 +
 
 +
 
 +
<br>
 +
 
 +
 
 +
=Links to Other Related and Relevant Projects/Resources=
 +
 
 +
<br>
 +
 
 +
==C-CDA==
 +
 
 +
<br>
 +
See '''Health Concern and Problem Concern Act in C-CDA''' above for more details
 +
 
 +
 
 +
==Other Related Projects/Resources==
 +
<br>
 +
 
 +
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
 +
 
 +
<br>
 +
 
 +
Presentations/Slide Decks on "Concern and Concern Tracking":
 +
 
 +
* [[Media: ConditionTracking-slideDeck_2006.pdf| Slide deck from Dr Larry McKnight on Concern and Tracking (2006)]]
 +
 
 +
<br>
 +
<br>
 +
 
 +
=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) [[Goal]]s, i.e. an assertion of what ''should'' happen or the desired outcome.
 +
 
 +
 
 +
 
 +
<br/>
 +
 
 +
=Project Objectives and Outcomes=
 +
 
 +
'''As per Health Concern Project Scope Statement.'''
 +
 
 +
<BR>
 +
 
 +
== Project Work Plan and Timeline ==
 +
 
 +
'''As per Health Concern Project Scope Statement.'''
 +
 
 +
<BR>
 +
 
 +
 
 +
<BR>

Latest revision as of 07:20, 26 November 2018

Return to: Patient Care

Goto Health Concern: Archive

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:


HealthConcern 2014-05-06.jpg


Health Concern Topic:


HealthConcernTracking 2014-04-17.jpg


  • 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:


AllergyConcernTracking-02.jpg


  • Tracking Back Pain as a Health Concern:


BackPain-ConcernTracking.jpg


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.




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":


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



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.