Dr. William Goossen Co-chair HL7 international Patient Care WG Results 4 Care b.v. Stichting HL7 Nederland

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1 Het Care Provision model in de diabeteszorg Dr. William Goossen Co-chair HL7 international Patient Care WG Results 4 Care b.v. Stichting HL7 Nederland

2 Opbouw presentatie Nictiz e-diabetes project HL7 v3 Care Provision: verwijzing, overdracht, ketenzorg Toepassingen in e-diabetes Profile queries via LSP Detailed Clinical Models en vertaling naar HL7 templates Conclusie

3 Doelen Nictiz Betere zorg door betere informatie Kernactiviteiten Nictiz: AORTA Standaarden voor toepassingen. Kwalificeren en certificeren voor LSP. Agendavoorbereiding platform ICT en innovatie: behoeften en mogelijkheden Ondersteuning invoering toepassingen Monitoren (inter)nationale ontwikkelingen, best practices en mogelijkheden. december 08 Stichting HL7 Nederland 3

4 Nictiz en Care Provision Care Provision is ontstaan uit Nictiz project perinatologie Hergebruikt in CVA zorg Orientatie voor Prica GGZ Hergebruikt voor JGZ Hergebruikt voor Masterplan Perinatologie Hergebruikt voor e-diabetes december 08 Stichting HL7 Nederland 4

5 Keten denken De route van de patiënt volgen van start probleem, via multidisciplinair afgestemde interventies tot gewenste (of onafwendbare) resultaten. Doorbreken heilige huisjes en eilandjes denken Dit betekent samen delen van gegevens Veelal via elektronische uitwisseling (via LSP)

6 Nictiz e-diabetes huidige en aankomend patienten Nederlandse Diabetes Federatie Richtlijnen & financiering zorg / zorggroepen Basis Data Set diabeteszorg Om elektronische gegevensuitwisseling voor de diabeteszorg op landelijke schaal mogelijk te maken, ontwikkelt het programma e-diabetes standaarden december 08 Stichting HL7 Nederland 6

7 Architectuur e- Diabetes, Fase 1: gegevensuitwisseling tussen zorgverleners, versie 0.8. Leidschendam, Nictiz, 2008 e-diabeteszorg

8 Hoofdonderdelen Care Provision Storyboards & interaction diagrams D-MIM Care Provision (DSTU) Care Structures topic (DSTU) Care Record structure (DSTU) Care Record query (DSTU) Care Transfer topic (DSTU) Concern Tracker (DSTU) Allergies and Intolerance topic (DSTU) Draft items: Assessment Scales R2 (in ballot DSTU Dec 2008) Care Plan (Plan May 2009 in ballot DSTU) Canada specific items (Plan 2009)

9 Storyboard: Courtesy of Isobel Frean, Australia Activities: Adam Everyman arrives at GHH ER and is seen by Dr. Eric Emergency who stabilizes him and assesses when he is ready to be checked-out. Dr. Emergency writes a summary of the encounter and sends this to Dr. Patricia Primary, providing details of the assessment, treatment provided and follow up care required [Interaction: Complete Care Provision]. Dr. Emergency also sends a referral for Adam Everyman for a follow-up visit to Dr. Penny Puffer [Interaction: Care Transfer Request ].

10 HL7 v3 Care Provision model summary 2 Person Target Participation 1 Care Provision EntryPoint 3 Care Statement Choice Observation Procedure 4 Patient orrelated orprovider 5 Provider Participation Medication Person Person Encounter

11 HL7 v3 Care Provision jan 09 ballot DSTU

12 Mood codes request RQO (verzoek) (wil je?) promise PRMS (belofte) (ja ik zal) event EVN (gebeurtenis) (uitgevoerd) definition DEF (definitie) (protocol) intention INT (intentie) (klinisch pad / plan) proposal PRP (voorstel) (suggestie) goal GOL (doel) (wat wil je bereiken?)

13 Care Transfer: Verwijzing

14 Query voor een record

15 Care Record

16 Concern tracking: overzicht Concern: b.v. diabetes (txt) Subconcern via component oogproblemen (txt) Subconcern via component voetproblemen (txt)

17 Zorgplan : continuïteit Care Plan R-MIM Version: ( ) Last Version: ( ) RIM Version: 2.08 Changes - Changed CarePlan WorkingListEvent to CareProvisionIntent - Changed Guideline WorkingListDefinition to CareProvisionDefinition - Changed participant participation to verifier and aligned attributes with CareProvision in DMIM - Added DataEnterer participation - Removed default value for modecode in Author - Replaced CareStatement with PlannedCare choice containing acts with only INT mood - Added fulfillment AR from PlannedCare to CareStatement which is constrained to exclude INT moods - Add constraint to Guideline components to not allow fulfillment ARs - Added finalgoal of CarePlan - Added CareReview and CarePlanReview - Added Reason AR from PlannedCare to Condition - Added CarePlan responsibleparty participation - Added CarePlan performer participation - Added PlannedCare responsibleparty participation - Added hasgoal of PlannedCare - Added PatientInstructions procedure - Added CareDefinition choice to compose a guideline from Acts in DEF mood instead of INT mood - Added conditional criterion to PlannedCare and DefinedCare Issues - Ensure that Author of CareProvision in DMIM can be an AssignedEntity - Criterion may need classcode to be broadened to include SubstanceAdministration, Procedures, encounters and Acts in general. CarePlan (REPC_RM000200) 0..1 scopedrolename CMET: (ASSIGNED) R_AssignedPerson [universal] (COCT_MT090100) 0..1 scopedrolename CMET: (ASSIGNED) R_AssignedProvider [care provision] (REPC_MT090001) Note: Not a device 0..1 scopedrolename CMET: (ASSIGNED) R_AssignedEntity [universal] (COCT_MT090000) Note: Phases of a care plan component2 typecode*: <= COMP contextconductionind: BL [0..1] 0..* careplan 0..* assignedperson dataenterer typecode*: <= ENT contextcontrolcode*: CS CNE [1..1] <= ContextControl "OP" time: TS [0..1] (Time of signature) modecode: CE CWE [0..1] <= ParticipationMode "ELECTRONIC" signaturecode: CE CNE [0..1] <= ParticipationSignature signaturetext: ED [0..1] 0..* assignedentity author 0..1 assignedperson * responsibleparty typecode*: <= RESP contextcontrolcode: CS CNE [0..1] <= ContextControl "OP" time: IVL<TS> [0..1] 0..* assignedperson verifier typecode*: <= VRF contextcontrolcode*: CS CNE [1..1] <= ContextControl "OP" notetext: ED [0..1] time*: TS [0..1] (Time of signature) modecode: CE CWE [0..1] <= ParticipationMode signaturecode: CE CNE [0..1] <= ParticipationSignature signaturetext: ED [0..1] 0..* assignedprovider performer typecode*: <= PRF contextcontrolcode*: CS CNE [1..1] <= ContextControl "OP" time: IVL<TS> [0..1] modecode: CE CWE [0..1] <= ParticipationMode "PHYSICAL" 1..1 assignedentity * author1 typecode*: <= AUT contextcontrolcode*: CS CNE [1..1] <= ContextControl "OP" notetext: ED [0..1] time*: TS [1..1] (time of signiture) modecode*: CE CWE [1..1] <= ParticipationMode signaturecode*: CE CNE [1..1] <= ParticipationSignature signaturetext: ED [0..1] CarePlan classcode*: <= PCPR moodcode*: <= INT id*: II [0..1] code: CD CWE [0..1] <= ActCode derivationexpr: ST [0..1] title: ST [0..1] statuscode: CS CNE [0..1] <= ActStatus effectivetime*: IVL<TS> [0..1] definition typecode*: <= INST contextconductionind: BL [1..1] "false" Guideline classcode*: <= PCPR moodcode*: <= DEF id*: II [0..1] code: CD CWE [0..1] <= ActCode derivationexpr: ST [0..1] title: ST [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime*: IVL<TS> [0..1] component typecode*: <= COMP contextconductionind*: BL [0..1] "false" sequencenumber: INT [0..1] component1 typecode*: <= COMP contextconductionind: BL [0..1] sequencenumber: INT [0..1] 0..* patientinstructions component3 typecode*: <= COMP contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" 0..* conditiontracking reason typecode*: <= RSON contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" 0..* observationgoal finalgoal typecode*: <= OBJF contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" subjectof2 typecode*: <= SUBJ contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" 0..* plannedreview subjectof1 typecode*: <= SUBJ contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" 0..* annotation 0..1 guideline 0..* definedcare PatientInstructions CMET: (COND) A_ConditionTracking [universal] (REPC_MT000300) ObservationGoal classcode*: <= OBS moodcode*: <= GOL code*: CD CWE [1..1] <= ActCode effectivetime*: IVL<TS> [1..1] (Goal vakue target date) value*: ANY [1..1] (Goal value) PlannedReview 0..* plannedcare classcode*: <= PROC moodcode*: <= EVN id: SET<II> [0..*] code: CD CWE [0..1] <= ActCode (Instruction type) text: ED [0..1] (Text instructions) effectivetime: TS [0..1] (Time of education) classcode*: <= REV moodcode*: <= INT effectivetime*: GTS [0..1] (Reassessment date) Annotation classcode*: <= ACT moodcode*: <= EVN code*: CD CWE [1..1] <= ActCode text*: ST [1..1] (Notes) statuscode*: CS CNE [1..1] <= completed author 0..* performer1 0..* performer 0..* ObservationIntent PlannedCare classcode*: <= OBS moodcode*: <= INT id: SET<II> [0..*] code*: CD CWE [1..1] <= ObservationType negationind: BL [0..1] derivationexpr: ST [0..1] text: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime: GTS [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality "N" repeatnumber: IVL<INT> [0..1] uncertaintycode: CE CNE [0..1] <= ActUncertainty languagecode: CS CNE [0..1] <= HumanLanguage value: ANY [0..1] interpretationcode: SET<CE> CWE [0..*] methodcode: SET<CE> CWE [0..*] targetsitecode: SET<CD> CWE [0..*] SubstanceAdministrationIntent classcode*: <= SBADM moodcode*: <= INT id*: SET<II> [1..*] code: CD CWE [0..1] <= ActCode negationind: BL [0..1] text: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime*: GTS [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality repeatnumber: IVL<INT> [0..1] routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [0..*] <= ActSite dosequantity: IVL<PQ> [0..1] ratequantity: IVL<PQ> [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] administrationunitcode: CE CWE [0..1] <= AdministrableDrugForm ProcedureIntent classcode*: <= PROC moodcode*: <= INT id*: SET<II> [1..*] code: CD CWE [0..1] negationind: BL [0..1] text: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime*: IVL<TS> [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality uncertaintycode: CE CNE [0..1] <= ActUncertainty languagecode: CS CNE [0..1] <= HumanLanguage methodcode: SET<CE> CWE [0..*] approachsitecode: SET<CD> CWE [0..*] targetsitecode: SET<CD> CWE [0..*] EncounterIntent classcode*: <= ENC moodcode*: <= INT id*: SET<II> [1..*] code: CD CWE [0..1] <= ActEncounterCode text: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime: IVL<TS> [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality ActIntent classcode*: <= ACT moodcode*: <= INT id*: SET<II> [1..*] code*: CD CWE [1..1] <= ActCode negationind: BL [0..1] text*: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime*: IVL<TS> [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality uncertaintycode: CE CNE [0..1] <= ActUncertainty languagecode: CS CNE [0..1] <= HumanLanguage 0..* criterion conditions typecode*: <= ActRelationshipConditional contextcontrolcode: CS CNE [0..1] <= ContextControl "ON" contextconductionind*: BL [0..1] "false" conjunctioncode*: CS CNE [0..1] <= RelationshipConjunction "AND" 0..* criterion reason Note: classcode may need to be broaden for additional planned acts such as procedures, encounters, substanceadmin., etc Constraint: CareStatement invariant( x) { x.moodcode!= INT; } 0..* conditiontracking typecode*: <= RSON contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" 1..1 manufacturedproduct * consumable1 typecode*: <= CSM precondition Material CMET: (COND) A_ConditionTracking [care provision] (REPC_MT000300) ManufacturedProduct 0..1 classcode*: <= MANU id: SET<II> [0..*] Criterion classcode*: <= OBS moodcode*: <= EVN.CRT code: CD CWE [0..1] <= ObservationType negationind*: BL [1..1] "false" text*: ED [0..1] value*: ANY [1..1] interpretationcode*: CE CWE [1..1] <= ObservationInterpretation typecode*: <= PRCN contextcontrolcode*: CS CNE [0..1] <= ContextControl "ON" contextconductionind*: BL [0..1] "false" conjunctioncode*: CS CNE [0..1] <= RelationshipConjunction "AND" 1..1 manufacturedmaterial classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= MaterialEntityClassType name: EN [0..1] fulfillment typecode*: <= FLFS contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" 0..* carestatement Note: Fulfilment Acts can be related by reference or related by value. 0..* observationgoal goal typecode*: <= GOAL contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" subjectof2 typecode*: <= SUBJ contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" 0..1 plannedreview 0..* assignedprovider responsibleparty typecode*: <= RESP contextcontrolcode*: CS CNE [0..1] <= ContextControl "OP" time: IVL<TS> [0..1] subjectof1 typecode*: <= SUBJ contextcontrolcode*: CS CNE [1..1] <= ContextControl "AN" contextconductionind*: BL [1..1] "true" 0..* annotation CMET: (ACT) A_CareStatement [universal] (REPC_MT000100) ObservationGoal PlannedReview 0..1 scopedrolename CMET: (ASSIGNED) R_AssignedProvider [care provision] (REPC_MT090001) Annotation DefinedCare ObservationDefinition classcode*: <= OBS moodcode*: <= DEF id: SET<II> [0..*] code*: CD CWE [1..1] <= ObservationType negationind: BL [0..1] derivationexpr: ST [0..1] text: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime: GTS [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality "N" repeatnumber: IVL<INT> [0..1] uncertaintycode: CE CNE [0..1] <= ActUncertainty languagecode: CS CNE [0..1] <= HumanLanguage value: ANY [0..1] interpretationcode: SET<CE> CWE [0..*] methodcode: SET<CE> CWE [0..*] targetsitecode: SET<CD> CWE [0..*] SubstanceAdministrationDefinition classcode*: <= SBADM moodcode*: <= DEF id*: SET<II> [1..*] code: CD CWE [0..1] <= ActCode negationind: BL [0..1] text: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime*: GTS [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality repeatnumber: IVL<INT> [0..1] routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [0..*] <= ActSite dosequantity: IVL<PQ> [0..1] ratequantity: IVL<PQ> [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] administrationunitcode: CE CWE [0..1] <= AdministrableDrugForm consumable ProcedureDefinition classcode*: <= PROC moodcode*: <= DEF id*: SET<II> [1..*] code: CD CWE [0..1] negationind: BL [0..1] text: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime*: IVL<TS> [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality uncertaintycode: CE CNE [0..1] <= ActUncertainty languagecode: CS CNE [0..1] <= HumanLanguage methodcode: SET<CE> CWE [0..*] approachsitecode: SET<CD> CWE [0..*] targetsitecode: SET<CD> CWE [0..*] EncounterDefinition classcode*: <= ENC moodcode*: <= DEF id*: SET<II> [1..*] code: CD CWE [0..1] <= ActEncounterCode text: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime: IVL<TS> [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality ActDefinition classcode*: <= ACT moodcode*: <= DEF id*: SET<II> [1..*] code*: CD CWE [1..1] <= ActCode negationind: BL [0..1] text*: ED [0..1] statuscode*: CS CNE [0..1] <= ActStatus effectivetime*: IVL<TS> [0..1] availabilitytime: TS [0..1] prioritycode: CE CWE [0..1] <= ActPriority confidentialitycode: SET<CE> CWE [0..*] <= Confidentiality uncertaintycode: CE CNE [0..1] <= ActUncertainty languagecode: CS CNE [0..1] <= HumanLanguage 0..* criterion conditions 1..1 manufacturedproduct *

18 Use Cases e-diabetes Architectuur e-diabetes, Fase 1: gegevensuitwis seling tussen zorgverleners, versie 0.8. Leidschendam december 08 Stichting HL7 Nederland 18, Nictiz, 2008

19 Use cases e-diabetes Gebruiken nagenoeg het hele scala van verwijs, acceptatie, query en care record Query is profile based: vragen aanpassingen die nog niet in internationale ballot zitten Query is autorisatie gebonden LSP koppeling vroeg specifieke uitwerking Voorlopig autorisatie om interacties te mogen uitvoeren december 08 Stichting HL7 Nederland 19

20 e-diabetes informatieuitwisseling Architectuur e-diabetes, Fase 1: gegevensuitwisseling tussen zorgverleners, versie 0.8. Leidschendam, Nictiz, 2008 december 08 Stichting HL7 Nederland 20

21 Query Profile december 08 Stichting HL7 Nederland 21

22 Profielen e-diabetes december 08 profiel 1 Inzien Diabetes Patiëntengegevens profiel 2 Inzien Diagnose Diabetes profiel 3 Inzien Medische basisgegevens profiel 4 Inzien Diabetes Risicoprofiel profiel 5 Inzien diabetes streefwaarden profiel 6 Inzien Medicatieprofiel profiel 7 Inzien Diabetes Contactmomenten profiel 8 Inzien Verwijzingen Diabetes profiel 9 Inzien Voetonderzoek Diabetes profiel 10 Inzien Oogonderzoek Diabetes profiel 11 Inzien Voeding Diabetes profiel 12 Inzien Laboratoriumonderzoek Diabetes profiel 13 Inzien Zelfzorgdossier Diabetes profiel 17 Inzien Diabetes Bloedglucosemeter Stichting HL7 Nederland

23 Interacties per profiel Use Case Storyboard interactie heen 1 Opvragen REPC_ST812210NL Get Care Record Diabetes Diabetes Patiëntengegevens Patiëntengegeve ns Profile Query TemplateId REPC_TM810001NL01 2 Diabetes REPC_ST812210NL Get Care Record Diagnose Profiel TemplateId REPC_TM810002NL01 3 Medische REPC_ST812210NL Basisgegevens bij Diabetes TemplateId 4 Diabetes Risicoprofiel REPC_TM810003NL01 REPC_ST812210NL Diabetes Diagnose Profile Query Get Care Record Medische Basisgegevens Profile Query QUPC_IN NL interactie terug Get Care Record Event Profile Query Response QUPC_IN814 Get Care Record 322NL Event Profile Query Response QUPC_IN NL Get Care Record Event Profile Query Response QUPC_IN UV QUPC_IN UV QUPC_IN UV Get Care Record QUPC_IN814 Get Care Record Diabetes 355NL Event Profile Risicoprofiel Query Response Profile Query TemplateId REPC_TM NL01 december 08 en Stichting HL7 Nederland 23 REPC_TM NL01 QUPC_IN UV

24 Detailed Clinical Model Opknippen van de grote hoeveelheid gegevens in de zorg in kleine hapklare en herbruikbare virtuele informatieblokjes. Best practice, evidence based, gebruik gestandaardiseerde terminologieën en technische specificatie Dit helpt technische implementatie in bericht en EPD, omdat er een brug geslagen wordt tussen vakinhoud en techniek Harmonisatie HL7 v3 templates en archetypes

25 DCM: hartslag in HL7 v3, gewicht in UML Hartslag (UUDD_RMnnnnnn) Description Hartslag classcode*: <= OBS moodcode*: <= EVN code: CD CWE [0..1] <= ActCode "LOINC " derivationexpr: ST [0..1] effectivetime: GTS [0..1] value: INT [0..1] interpretationcode: SET<CE> CWE [0..*] <= ObservationInterpretation methodcode: SET<CE> CWE [0..*] <= ObservationMethod

26 Query Profile & Template & DCM Query profile geeft per profiel de bijbehorende data uit de BDS mapping e-diabetes Elk profiel krijgt een HL7 template ID Elk profiel bestaat uit 1 n Detailed Clinical Models (b.v. bloeddruk, gewicht, voetonderzoek). Opvragen via interactie met speciaal nummer Retour gegevens profiel volgens template spec Care Provision internationaal mist template in query => 2009 inleveren als wijzigingsvoorstel. december 08 Stichting HL7 Nederland 26

27 e-diabetes in BDS en voorlopige architectuur 2008 Implementatiehandleiding HL7 v3 CP en mapping BDS 2009 specificaties e-diabetes voor zorgaanbieders en softwareleveranciers 2009 detailed clinical models e-diabetes / HL7 v3 templates 2009 architectuur zelfzorgdossier voor patiënten 2009 architectuur elektronisch rapporteren architecturen en specificaties testen, aanpassingen.

28 Thank you for your attention dr. W.T. F. Goossen Results 4 Care B.V. Amersfoort E: results4care@cs.com M: W: