HL7 Care Plan (CP) ProjectHealth Concerns – Risks – Goalsin Care Plans

April 2013

*Care Plan wiki: http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012

Dr Stephen Chu(Chief Clinical Informatician & Terminologist, NEHTA, Australia)

HL7 Patient Care Work Group

To join the meeting:

Phone Number: +1 770-657-9270Participant Passcode: 943377#

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Health condition, problems and goals

Condition/Diagnosis (e.g. Type 2 Diabetes Mellitus) [a diagnosis often results in one or more problems for the patient]

[Primary] Problem 1: inability to regulate blood glucose level

Problem 4: weight loss (resulting from inability to process calorie from foods)

Problem 5: polyphagia (resulting from hunger effect of increased insulin output to process high blood glucose)

Problem 6: lethargy (resulting from inability to utilise glucose effectively)

Problem 7: altered mental state (resulting from hyperglycaemia, ketoacidosis, etc) [agitation, unexplained irritability, inattention, or confusion]

Problem 2: urinary problems (resulting from hyperglycaemia) [polyuria, nocturia]

Problem 3: polydipsia (resulting from excessive urine output)

Goal 1: relief acute symptoms [polyuria polydipsia lethargy altered mental state …]

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Problems, Goals and Interventions

Diagnosis (e.g. Type 2 Diabetes Mellitus) [a diagnosis often results in one or more problems for the patient]

[Primary] Problem 1: inability to regulate blood glucose level

Problem 4: weight loss (resulting from inability to process calorie from foods)

Problem 5: polyphagia (resulting from hunger effect of increased insulin output to process high blood glucose)

Problem 6: lethargy (resulting from inability to utilise glucose effectively)

Problem 7: altered mental state (resulting from hyperglycaemia, ketoacidosis, etc) [agitation, unexplained irritability, inattention, or confusion]

Problem 2: urinary problems (resulting from hyperglycaemia) [polyuria, nocturia]

Problem 3: polydipsia (resulting from excessive urine output)

Goal 1: maintain effective blood glucose control [fasting = 4-6 mmol/litre]

Goal 2: maintain HbA1C level =< 7%

Intervention 1: diet control (diabetic diet)Intervention 2: medicationsIntervention 3: exercise (if overweight)

Outcome measuresdaily BSL measures: pre-prandial reading 4-7mmol/l post-prandial reading <8.5 mmol/lHBA1C 3 monthly reading =<7%

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Modelling Risks

• Types: Intrinsic extrinsic

• Intrinsic Risks that are consequential to a person’s health profile, condition

or problems

• Extrinsic Risks that are consequential to interventions designed to manage

a person’s condition

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Intrinsic Risks: consequential to condition/problem

Care Plans needs to model/include two types of risks:o Risks that are consequential to health concerns/problems that

trigger the instantiation of a care plano These are the risks healthcare providers treato Examples:

Poorly controlled hyperlipidaemia Poorly controlled hyperglycaemia Smoking (health concern/problem)

o Hyperlipidaemia as an intrinsic risk of Type 2 DM: Poorly controlled hyperlipidaemia in Type 2 DM significantly increased

risks of CVS of a person This risk becomes an outbound risk to another care plan(s)

instantiated to management the person with comorbidities such as hypertension and/or ischaemic heart disease

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Intrinsic Risks: consequential to problem

Diagnosis (e.g. Type 2 Diabetes Mellitus) [a diagnosis often results in one or more problems for the patient]

[Primary] Problem 1: inability to regulate blood glucose level

Problem 4: weight loss (resulting from inability to process calorie from foods)

Problem 5: polyphagia (resulting from hunger effect of increased insulin output to process high blood glucose)

Problem 6: lethargy (resulting from inability to utilise glucose effectively)

Problem 7: altered mental state (resulting from hyperglycaemia, ketoacidosis, etc) [agitation, unexplained irritability, inattention, or confusion]

Risk 1: poor wound healing (resulting from impaired WBC, poor circulation from thickened blood vessels) [high risk of foot/toe ulcers and gangrene] ← intrinsic risk (consequential to Type 2 DM)

Risk 2: increased infection (resulting from suppression of immune system from high glucose in tissues) [skin, urinary tract] ← intrinsic risk

Risk 3: hyperlipidaemia ← intrinsic risk (can create outbound risks, e.g. increase CVS risks to those with family history)

Risk 4: microangiopathy ← intrinsic risk

Problem 2: urinary problems (resulting from hyperglycaemia) [polyuria, nocturia]

Problem 3: polydipsia (resulting from excessive urine output)

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Extrinsic Risks: consequential to interventions

Extrinsic Risks: they are consequential to interventions implemented to treat/manage health concerns/problems

Examples:o Prolonged bleeding time (outside the optimal recommended range, e.g.

INR >3.0) caused by anticoagulant therapy increasing the risk of internal haemorrhage

o Lecukocytopenia caused by chemotherapy increasing the risk of infections

o Suppression of prostacyclin by Cox-2 Inhibitor NSAID used in treatment of arthritic pain increasing the risks of heart attacks and stroke

In care plans, these risks may represent outbound risks other care plan instantiated to manage other comorbidities will need to be aware ofo Arthritis care plan including Cox-2 inhibitor NSAID treatment presents

outbound risk for care plan instantiated to manage CVS comorbidity of the same person

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Extrinsic Risks: consequential to interventions

Diagnosis (e.g. Type 2 Diabetes Mellitus) [a diagnosis often results in one or more problems for the patient]

[Primary] Problem 1: inability to regulate blood glucose level

Risk 1: poor wound healing (resulting from impaired WBC, poor circulation from thickened blood vessels) [high risk of foot/toe ulcers and gangrene]

Risk 2: increased infection (resulting from suppression of immune system from high glucose in tissues) [skin, urinary tract]

Risk 3: cardiovascular complications [e.g. hypertension, ischaemia heart disease]

Risk 4: microangiopathy [e.g. retinopathy, nephropathy, peripheral neuropathy]

Risk 5: eye complications [e.g. cataract]

Is outbound CVS risks affecting CVS care plan for same person with CVS comorbidity (or increase CVS risk for those with positive family history of CVS problems)

Is an outbound risks affecting arthritis care plan for same person (esp when using cox-2 inhibitor analgesics

Is an outbound risks affecting renal infections management care plan of same person (or when need to use aminoglycoside antibiotics to treat infections)

Is an outbound risks for patient with increased exposure to sunlights [agriculture, forestry, fishing, construction industries]

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Inbound and Outbound risks

• An outbound risk of one care plan becomes inbound risks of another for the same person