care plan (cp) meeting - minutes october 17, 2012 1700-1830 edt laura heermann langford...
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Care Plan (CP) Meeting - Minutes October 17, 20121700-1830 EDT
Laura Heermann Langford ([email protected])
Stephen Chu ([email protected])
*Care Plan wiki: http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011
HL7 Patient Care Work Group
To join the meeting:
Phone Number: +1 770-657-9270Participant Passcode: 943377#
With meeting discussion notes
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Participants-
Name email Country Yes Notes
Laura Heermann Langford
[email protected] US Co-Lead- Care Plan initiative/HL7 Patient Care WG. Intermountain Healthcare. RN PhD,: Nursing Informatics; Emergency Informatics Association, American Medical Informatics Association; IHE
Stephen Chu [email protected] AU Y NEHTA-National eHealth Transition Authority . RN, MD, Clinical Informatics; Clinical lead and Lead Clinical Information Architecture; co-chair HL7 Patient care WG; vice-chair HL7 NZ
Carolyn Silzle [email protected] US American Dietetic Association
Susan Campbell [email protected] US Y PhD microbiologist. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer; registered nurse specialist
Kevin Coonan [email protected] US MD. Emergency medicine. HL7 Emergency care WG.
Nancy Wilson Roman US
Enrique Meneses [email protected] US Y
Serafina Versaggi [email protected] US Clinical Systems Consultant
Jon Farmer [email protected] US Y
Chris White [email protected] US
Luigi Sison [email protected] USInformation Architect at LOINC and at HL7. Enterprise Data Architect at VA. Developing standard for Detailed Clinical Models (DCM), information models for Electronic Health Record (EHR) Diabetes Project, etc.
Brett Esler [email protected] AU Y
Russ Leftwich US Y
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Tentative: October 17, 2012 (subject to change)
Revamped Care Plan wiki
o http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012
o Contributions to story boards that include care services coordination scenarios
http://wiki.hl7.org/index.php?title=Care_Plan_Storyboards_with_care_coordination_services_scenarios
Compare/contrast Case Manager and PCP Perspective – Jon Farmer
Modeling –Enrique
o To review work in progress through wiki conversation
o Discuss and work out any “kinks” in the working process using the wiki for discussion/updates etc.
o Continue with a synchronous working session on the model with Enrique
facilitating
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MODELING• Enrique Meneses
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Discussion Notes
Jon: CMSA “barrier” discussion Need - some real-world examples of barriers that case managers routinely
encounter in acute, EMS, or chronic settings
• Notes from last meeting Review of Luigi’s model and decided need to more analysis concentrating on scope and the boundaries in addition
to the project scope discussion.
Next Stepso Document additional use cases as discussed earliero Break Luigi’s model down for more discussion. Enrique will put it on the wiki page to facilitate more off line
conversation. Enrique will send out email notice when ready for review.
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Discussion Notes
Jon: CMSA “barrier” discussion Need - some real-world examples of barriers that case managers routinely
encounter in acute, EMS, or chronic settings Draft document from Jon on modeling barriers
Patient has medical/physiological problems or concerns Socio-economical and or psychological issues/problems may present
barriers for attainment of goals set and interventions planned to resolve the medical/physiological problems
Examples: absence of social support network; or lack of transport means Question: how should these barriers be modeled
o In paper care plans: These barriers are represented as problems or concerns independently
o In electronic care plans They need to be represented/modelled as co-dependencies between the barriers and
medical/physiological problems
Action item:o Jon Farmer to produce draft of 2-3 use cases and circulate to Laura, Stephen, Russ,
Kevin, etc for further inputso Use cases to be discussed at next meeting (31 october)
Microsoft Word Document
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Discussion Notes
Enrique presented a spreadsheet that contains breakdown of storyboard sentences into “subject-verb-object” predicates
Spreadsheet contents form the basis for modelling work Screen shot of spreadsheet – see next slide
Action item:o Enrique to continue work on decomposition and population of spreadsheeto Draft model to be circulated prior to next conference callo Continue discussion at next conference call
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Care Plan storyboard decomposition
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Care Plan Discussions
Similar and related concepts causing confusion:o Care Plano Plan of Careo Master care plano Clinical pathwayo Critical pathway
Links included in Baltimore WGM meeting slide deck by Susan Campbell provide useful information on some of these concepts
These links are in the next few slides extracted from the Susan Campbell slide deck
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From Susan Campbell slide deck (Baltimore WGM September 2012)
1. LCC Use Case. Outlines three scenarios for health information exchanges between: 1) an acute care hospital and home health agency (HHA); 2) a skilled nursing facility (SNF) and the Emergency Department (ED); and 3) a Physician and a HHA
Two of the scenarios center on the Home Health Plan of Care (HH-POC), based off CMS 485 form. The HH-POC supports the HHA in providing patient service via MD orders. The HHA and physician exchange information on patient’s evolving condition and needs, and the services the HHA will perform.
2. LCC Whitepaper. Meaningful Use Requirements For: Transitions of Care & Care Plans For Medically Complex and/or Functionally Impaired Persons. Includes a robust discussion of needs and issues regarding interoperable care plan collaboration and exchange.
A summary is also available here.
3. Preliminary Stage 3 MU Recommendations. Provided for July 16, 2012 meeting of Health IT Policy Committee Meaningful Use Subworkgroup #3 (includes comments on proposed Meaningful Use Stage 2 requirements related to care plans)
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From Susan Campbell slide deck (Baltimore WGM September 2012)
An animated Powerpoint presentation of this LCC vision of longitudinal care planning is available on the wiki here.
Definition, content,
sections, and standards of a collaborative care plan that can support
care planning for a variety of patient types over time –
interoperably.
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From Susan Campbell slide deck (Baltimore WGM September 2012)
Long Term and Post-Acute Care (LTPAC) Transitions of Care SWG: • Priority Transitions. Examined transitions to/from eleven providers• IMPACT Project Data Elements List. Updated and merged LCC Use
Case 1.0 Data Elements Five transitions of care data sets, all subsets of the LCC Use Case
Data Elements. The permanent transfer of care contains the entire set of data elements.
Patient Assessment Summary (PAS) SWG: • Balloted Functional Status, Cognitive Status, & Pressure Ulcer
templates for Consolidated CDA (May 2012)• Balloted Patient Questionnaire Assessment Summary
Implementation Guide for CDA Release 2 (September 2012)• Mapped the MDS, OASIS, CARE Tool, Massachusetts Universal
Transfer Form (IMPACT Dataset #5 with 328 data elements), and C83 data elements (prioritized by Beacon Community Affinity Group). (link)
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FUTURE MEETINGS• Conference calls between now and January 2013 – see wiki
• 90 min., Wednesday 5-6:30pm US Eastern, fortnightly (every 2 weeks)• Starting September 19
Next Agenda
• Meeting adjourned at 6:35pm US Eastern• Next meeting:
Wednesday 31 October 2012 at 5:00pm US Eastern
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Next meeting Agenda- October 31 (Lead: tentative: Laura)
Meeting Agenda To be announced
• Future topic
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APPENDIX