To join the meeting:
Phone Number: +1 770-657-9270
Participant Passcode: 943377#
HL7 Care Plan (CP) Project
Health Concerns – Risks – Goals
in 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
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 2: urinary problems (resulting from hyperglycaemia)
[polyuria, nocturia]
Problem 3: polydipsia (resulting from excessive urine output)
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]
Goal 1: relief acute symptoms
[polyuria
polydipsia
lethargy
altered mental state …]
Page 2
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 2: urinary problems (resulting from hyperglycaemia)
[polyuria, nocturia]
Problem 3: polydipsia (resulting from excessive urine output)
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]
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: medications
Intervention 3: exercise (if overweight)
Outcome measures
daily BSL measures: pre-prandial reading 4-7mmol/l
post-prandial reading <8.5 mmol/l
HBA1C 3 monthly reading =<7%
Page 3
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
Page 4
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 plan
o These are the risks healthcare providers treat
o 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
Page 5
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 2: urinary problems (resulting from hyperglycaemia)
[polyuria, nocturia]
Problem 3: polydipsia (resulting from excessive urine output)
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
Page 6
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 of
o Arthritis care plan including Cox-2 inhibitor NSAID treatment presents
outbound risk for care plan instantiated to manage CVS comorbidity of
the same person
Page 7
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]
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
Risk 4: microangiopathy [e.g. retinopathy, nephropathy, peripheral neuropathy]
Is an outbound risks affecting renal infections management care plan of same person
(or when need to use aminoglycoside antibiotics to treat infections)
Risk 5: eye complications [e.g. cataract]
Is an outbound risks for patient with increased exposure to sunlights
[agriculture, forestry, fishing, construction industries]
Page 8
Inbound and Outbound risks
• An outbound risk of one care plan becomes inbound
risks of another for the same person
Page 9