HL7 WGM Madrid May 2017 Care Plan Standards Update Laura Heermann Langford, PCWG co-chair Emma Jones, PCWG co-chair Dr Stephen Chu, PCWG co-chair

Projects related to Care Plan HL7 C-CDA 2.1 Care Plan Document Template HL7 CDA R2 Personal Advanced Care Plan Document CCDA on FHIR Care Plan IHE QRPH Early Hearing Detection and Intervention (EHDI) Plan of Care IHE PCC Dynamic Care Planning Profile IHE PCC Care Team Profile – Dynamic Care Team HL7 Care Plan Domain Analysis Model HL7 Care Coordination Services (CCS) functional model HL7 FHIR Care Plan Resource HL7 Clinical Oncology Treatment Plan and Summary NCPDP/HL7 Pharmacist Care Plan 11/17/2018

HL7 C-CDA 2.1 Care Plan Document Template - Lisa Nelson We continue to explore the use of this document. Most of the recent questions have to do with wanting to include additional information in the Care Plan.  Healthix Pilot has developed their own IG to explain how to include other relevant information in additional sections.  The issue is being debated. Some argue that a Care Plan Document was only intended to have these 4 sections and no more.  Others argue the template is open and exists to demonstrate the special relationship between these 4 sections, but feel it would make sense to augment by adding in other sections such as Assessments Section and Advance Directives Section to name a few.  Others identified have included Allergies and Intolerances, Procedures, and others present in a CCD document. These are sections the Care Plan piloters felt include information which may be needed for care planning. The idea is to share that all the information within a Care Plan document, as a way of exchanging the relevant and pertinent information in a single document. Also, there continues to be debate about the overall understanding of the Care Plan as being only “prospective”. Some argue it can include completed interventions, completed goals, etc.  and should provide a retrospective as well as a prospective view of the information.   There will be a Care Plan Track at the June 22 Virtual CDA Implementation-A-Thon.  People with active solutions working in this space should plan on attending to contribute to this conversation. 11/17/2018

HL7 C-CDA 2.1 Care Plan Document Template - Lisa Nelson – Cont. The C-CDA world has yet to embrace any of the work on nested care plans that BCBSA initiated over a year ago.  There is nothing preventing a C-CDA Care Plan document from doing any of the “advanced” things I showed to create a plan within a plan or to add “plan meta information” about the enrollment in the plan. Nor has any implementer embraced the techniques demonstrated to separate the care plan information from the sections used to record the lists of health concerns, goals, interventions, health status evaluations and outcomes.  This technique created a care plan that was designed to “IDENTIFIED GAPS IN CARE”.  This is a CPC+ requirement.  I’m concerned that we are not doing enough to leverage prior learning.  We need stronger efforts to keep others informed on the details of HOW to create Care Plan documents.  We are missing opportunities to keep everyone progressing as quickly as possible.   The CDA Examples Task Force has approved a Care Team Section Template that aligns with all the work we have been doing in the LHS WG on the FHIR CareTeam Resource and Vocabulary requirements.  The new Care Team Section template will be reviewed by SDWG on 5/4 and hopefully will be approved and will be added to the set of C-CDA templates coming out in the new C-CDA R2.1 Volume 3. The HIMSS Health Story Project is working on some materials about CDA and C-CDA which help to explain the different document types and their intended uses.  The presentation/resource being developed should help shed additional insight on the difference and relationships between care summary documents and care plan documents.  The materials are expected to be available before by the end of June. 11/17/2018

HL7 CDA R2 Personal Advanced Care Plan Document - Lisa Nelson Great uptake of the PACP standard by ADVault.  Their system now enables consumers to download their advance directives as a PACP document not just as a pdf, but with 3 different levels to support interoperability:  Unstructured CDA, Level-2 PACP, or Level-3 PACP.  They also have demonstrated interoperability for a person’s health goals, treatment preferences, and priorities by providing patient generated health data (PGHD) as a standard CDA PACP document (with Cerner at HIMSS2017) and using FHIR APIs to generate a FHIR-based PACP document (with ZeOmega at FHIR Connectathon14).   More work is being done to demonstrate how clinical care summary documents and care plan documents can reference a person’s Personal Care Plan document to inform goals set by and treatment choices made by clinicians. The examples will also show how to reference an external document. This is very import because implementers need clear guidance to REMIND them that there never was an intention for document to start replicating other documents inside.  We are at risk of the industry misunderstanding this point which could lead to unnecessary (and risky) data duplication that could make records less accurate because they hold stale information. The safer approach is to point out to the source of the information so that when needed, the right version of the information can be referenced. This needs to be made clear so that we don’t lose anyone down the wrong path.  The work on clarifying the difference and practical relationship between a static snapshot of a care plan and a dynamic care plan continues to be VERY IMPORTANT. 11/17/2018

CCDA on FHIR Care Plan – Lisa Nelson Mapping between the FHIR Composition Resource and CDA documents has been developed and is being finalized in Madrid (Rick Geimer is heading up that effort). The mappings will be documented in the FHIR documentation available in the mappings area for the Composition Resource. Lisa Nelson, Ken Lord, and others are working on a more detailed mapping from each C-CDA entry template to the various US Core Profiles and FHIR Resources. This is early work and there are many thorny issues to wrestle. Best way to get involved is to attend the C-CDA on FHIR Project team meetings on Thursday afternoons at 3:00pm ET  (posted as a SDWG Conference Call on the HL7 Calling Center) 11/17/2018

QRPH Early Hearing Detection and Intervention (EHDI) Plan of Care- Lisa Nelson Inquiries would need to be directed through Xidong Deng on the CDC Team.  They did not move forward with Document Template revisions that would reform the document into a set of templates that would better align with the templates used by C-CDA Care Plan Documents. For example, the EHDI Hearing Plan of Care Document (HPoC)  includes a Problems Section and a Risk Assessment Section, but does not include a Health Concerns Section.  It includes a Procedures Section and a Results Section, but does not include an Interventions Section.  The Procedures Section and Results sections hold retrospective information about procedures and tests that have been completed.  It includes a Plan of Treatment Section that includes the planned interventions. These changes would be very straight forward to address as the mapping between HPoC Content and C-CDA Care Plan Document is straightforward.  Bottom line: the HPoC document is a GREAT EXAMPLE of the issues we are up against in straightening all this out for the sake of INTEROPERABILITY.  It is a great example of a “Condition Focused” care plan that would need to be taken into consideration with other condition focused (heart or vision problems) care plans and other specialty plans (like for nutrition) in order to create a comprehensive Care Plan focused on Coordination of Care for one little baby so that Mom and Dad can get a handle on all the care being provided to help give their child the best chance at life.   At the CDA virtual Implementation-A-Thon Care Plan Track I will be attempting to include examples for all three types of focus – Care Coordination , Condition (hearing, kidney disease), and Specialty(Pharmacy) .  11/17/2018

IHE PCC Dynamic Care Planning Profile Currently available for trial implementation Did not get tested at Jan 2017 IHE Technical connecthathon 11/17/2018

IHE PCC Care Team Profile – Dynamic Care Team Management Will be available for public comment in the next few weeks 11/17/2018

HL7 Care Plan Domain Analysis Model Included in presentation to ONC Will be going back to fix identified gaps Need alignment with FHIR carePlan 11/17/2018

HL7 Care Coordination Services (CCS) functional model Published and available on list of standards grid 11/17/2018

HL7 FHIR Care Plan Resource Need alignment with CP DAM Need alignment with C-CDA 11/17/2018

HL7 Clinical Oncology Treatment Plan and Summary Contact Jeff Brown 11/17/2018

NCPDP/HL7 Pharmacist Care Plan 11/17/2018

Questions and Discussion 11/17/2018

11/17/2018