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Introduction

The HL7 Patient Care WG (PCWG) initiated a Care Plan domain Analysis Model (DAM) development project in 2011. This initiative resulted in the publication of the first release/revision of Care Plan DAM in 2015 (this artefact is hereon referred to as Care Plan DAM 1.0).

Clinical knowledge and technologies are evolving constantly. These changes, together with implementation experiences, impact on clinical practice, workflow and how care plans are used. The PCWG is committed to evolve and improve the Care Plan DAM and related standards in step with the changing clinical and technology landscapes.

This Care Plan DAM 2.0 project is initiated by the same dedicated Care Plan Project leadership and team who initiated the Care Plan DAM 1.0 with the goal of developing a new revision (Care Plan DAM 2.0) that takes in new knowledge, requirements and build on previous experiences.

Conference Calls

Frequency and time

    • The project conference calls are scheduled fortnightly on Wednesdays, at 5:00pm US Eastern time

Web sharing and audio information

Care Plan Domain Analysis Model 2.0

  • Link to Care Plan DAM - Key Building Blocks (Google Doc)
  • Social Determinants of Health (SDoH) stressors and relations to Care Plan standards
    • This collaborative Google Document provides a SDoH framework, defines the SDoH stressors that impact on health, and their relationships to Care Plan structure and function design in the context of Care Plan DAM 2.0

Link to Care Plan DAM 1.0 Resources


Care Plan DAM 2.0 Planning Document

Link to Care Plan DAM 2.0 planning document

FHIR Resources Analysis Spreadsheet

https://docs.google.com/spreadsheets/d/10TWWDbckDd_l--GmPTZ0eYXSljt9w-kLh2YT9ez6uxo/edit#gid=138542309

Gaps and inconsistency analysis on FHIR resources (contribution from Claude Nanjo)

Care Plan DAM 2.0 Conference Call Agenda and Minutes

To do:

Link to meeting notes pages to go to here


Leadership

NameAffliation
Laura Heermann LangfordInternmoutain Healthcare
Stephen ChuAustralian Digital Health Agency
Emma JonesAllscript
Russ LeftwichIntersystems
Mike Padula



Care Plan DAM 2.0 Project Activities and Schedule

Analysis and modelling new requirements

Allergy/Intolerance

Can be considered as a specialisation of condition/problem, hence can be represented as healthConcern in Care Plans

Analysis - to determine whether new attributes/properties need to be added to the healthConcern class in Care Plan model

Social Determinants of Health

Some of them can be considered as barriers to care? Which ones?

Some of them can be considered as healthConcerns? which ones?

How are they related to patient preferences? which ones?

Analysis - to determine whether there are new attributes/properties to existing barrier, healthConcern, and preference classes in Care Plan model

Orders and Order Sets

How to represent orders in Care Plans?

Order sets are represented in PlanDefinition resource

Individual order is represented as planActivity

Order in progress or completed is represented as 

Gaps in Care

Risks

Patient level risk

Population level risk stratification and where the patient fits in

Patient Instructions/Educations

Self-care Activities

How to represent self-care activities?

Can be represented as planActivity similar to Orders

Advance Directives

Some can be considered preferences / obligations

Some can be considered prohibitions

How are they related to healthConcerns?

How are they related to barriers of care?

How each of these represented in Care Plans?

Care Coordination - See July 25, 2018 Meeting Notes

How to represent care coordination in Care Plans?

Why is care coordination needed?

    • Assessed need/determination of assessed need
      • Include mental, psychological, cognitive, functional, safety and physical needs
    • Disease management
    • Pertinent Diagnosis
    • Difficulty accessing or managing care
    • Prevent complications/decline in health
    • Improve care quality and good outcomes 
    • Prevent waste of health care resources/decrease health care cost  
    • etc ...

What is being coordinated

    • Types of services, supplies, equipment, medical needs (meds, nutrition, , etc
    • Frequency and duration of encounters with the health care system
    • promote wellness

Who is being coordinated

Patient preferences/Barriers

Priority/urgency

Care plan Reconciliation

What structural components are required?

Incorporate relevant and related works

Health Concern

Latest Health Concern DAM content

Care Team

Care Team DAM

FHIR Care Team resource

Harmonisation and Consolidation

FHIM 

Care Plan component

FHIR

Care Plan Resource

Goal Resource

Patient Resource

Practitioner Resource

C-CDA IG

Health Concern template

Goal Template

Intervention Template

Observation/Outcome Template

Other templates?

Care Plan DAM 2.0 Modelling 

Conceptual model revision/update

Logical Model revision/Update

Care Plan DAM Specification

Contents update

Balloting

Notice of Intent to Ballot (NIB)

Date: TBD - based on ballot date

Ballot Date

Tentative: May 2019?






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