Preface Care Provision Domain

Patient Care

Patient Care Normative Ballot Content

i Notes to Readers

On Sept, 2010 the Patient Care Working Group voted to use the evaluation report of four years of use of Care Provisioin materials as the baseline for upgrading the ballot materials. This upgrade is required since the 4 year DSTU period has expired in 2011. The evaluation report is available at the patient care website at HL7.org. Beside the evaluation of its use, the Care Provision materials had to change according to changes in the RIM, updates of data types and other. Finally, the PCWG also made the decision to remove the Care Statement and use the full Clinical Statement R-MIM instead. That will ease the harmonisation with other Working Groups, in particular structured documents, and facilitate re-use of our smart R-MIMs such as for Care Plan, Concern Tracker and Assessment Scales in other Domains, Messages, Services and CDA's.

For those browsing the Care Provision Domain work for the first time please note it is arranged into building blocks. The domain description discusses the overall scope of the domain with a few supporting domain storyboards. The detail found in the description of the domain information model emphasizes the focal class of the domain, the Care Provision Act. The remaining documentation on the other classes in the domain is found in separate Topics, where much of the detailed clinical information is represented.

Both the Care Provision Domain and the Clinical Statement Topic provide a good amount of theory and guidance to the reader. As well there are two Reference documents Explanation and Guidance Topic and the Requirements Analysis Artifacts Topic. Although both are beginning to mature with respect to the date of creation, they still form the fundaments for this domain. In addition the publications Electronic patient records: domain message information model perinatology http://www.ncbi.nlm.nih.gov/pubmed/12909178 describing the origin of the current core parts and Model once, use multiple times http://www.ncbi.nlm.nih.gov/pubmed/15360836 describing how the different components can be used and reused again in different domains, offer good further reading materials. offer good background materials for this domain. The Explanation and Guidance Topic provides background to engineers writing implementation guides to ensure good clinical functionality in the document, message, and service specifications created from the models.

ii Acknowledgements

The Patient Care technical Committee would like to recognize the contributions of the following authors / editors, developers and organizations without whom this document could not have been produced:

Dan Russler Daniel Russler, MD, XXXXXXXXXX, USA who is a primary author and editor in the following Care Provision Domain parts: the Domain Model (REPC_DO000000UV), Care Record, Care Record Query, Care Transfer, and Care Structures Topics. Note, the Care Structures will be separated into different Topics to achieve easy access.

Heath Frankel, BSc, XXXXX, Australia who is a primary author and modeling facilitator in the following Care Provision Domain parts: the Domain Model (REPC_DO000000UV), Care Record, Care Record Query, Care Transfer, and Care Structures Topics.

Isobel Frean RN, MSc, XXXX. who provided the major contribution of storyboard content. This was part of her doctoral work at the Health Informatics Research Centre University of Wollongong Australia.

Charlie Bishop, i-Soft Health who is the primary author for the NHS Clinical Statement Structure (COCS_DM000000UV) and the care statement structure ( REPC_RM000100UV), both which informed the Domain Model (REPC_DO000000UV) and subsequent changes from the Care Statement into Clinical Statement.

Davera Gabriel RN, Terminology Manager, CIS Knowledge Management University of California, Davis Health System, for her publishing support.

XX Ontario Health, Canada for her publishing support of all the core DSTU materials.

Lloyd McKenzie, LM&A Consulting, HL7 Canada

Nictiz, the Netherlands, for providing the time of experts and the Care Provision materials for inclusion in this ballot.

Special thanks to all those who take the time to review the ballots and submit comments.

iii Changes from Previous Release

The DSTU process involved Patient Care reviewing that all HL7 standard processes were adhered to e.g. all the ballot comments addressed, negatives reconciled, posted dispositions within the supporting content deadline and notices sent to the voters.

iv Known Issues & Planned Changes

Ongoing work in Care Provision can be seen on the HL7 wiki site. The url is: http://www.hl7.org/v3ballot/html/domains/uvpc/uvpc.htm.

In addition to the increasing detail and maturity of existing material, considerable additions will be made to this domain in future releases:

  1. Goal Management
  2. List Management
  3. Assessment Scales whitepaper in progress
  4. Additional Direct Care Topics as identified by EHR TC
  5. Additional Clinical Topics as identified by Clinical SIG's

v Message Design Element Navigation

Table to be created and included