Nursing Process (ADPIE)

Will broadly following Nursing Processes ADPIE.

(note: when we go into the detail/later stages probably a diagram like this may be better https://build.fhir.org/ig/HL7/physical-activity/workflow.html#physical-activity-care-planning)

Like actual implementation of care process (below), the project will be iterative and continue to evolve (see End to End process section for more details). Starting small, initially focusing on simple assessments & care plans (e.g. vital signs and ReSPECT) and then moving to more advanced assessments and care plans.

SOAP Note (Encounter Documentation)

The Nursing process will include many Encounters which will occur at each process stage. We will be using the SOAP Note (https://en.wikipedia.org/wiki/SOAP_note) as a base description of what happens in individual encounters - the process.

The SOAP Note was originally designed as a method of recording information and aiding interoperability at a human level, i.e. writing patient notes in a similar way makes it easier for other clinicians to read. The SOAP Note has evolved over time, for example Section Headings in PRSB Standards (https://theprsb.org/standards/) are newer versions of the original SOAP Note Headings. These are often in

Pathways Definitions

The Nursing Process is a generalised description. More detailed descriptions can be found in Clinical Pathways which help define the Patients Journey across health and care. They also provide a tool for defining and standardising Clinical Process.

For example, in the diagram below we have created an example diabetes prevention pathway based on definitions and pathway elaboration from:

• National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk/
• NHS England Getting It Right First Time (GIRFT) https://gettingitrightfirsttime.co.uk/
• FuturesNHS https://future.nhs.uk/
• Diabetes UK

Note: Frameworks will not define pathways, any diagrams shown are for illustration purposes only

Clinical Pathways will often involve several providers, all working on the same problem (e.g. reduce risk of diabetes). The interactions to coordinate the delivery of care is called workflow and this will be covered within this project.

Example Wellness Pathway (Health Prevention Programme)

It starts with a NHS Health check assessment and may result in a patient completing an online diabetes type 2 risk assessment.

Dependent on the identified concerns or risks these can lead to referrals to a VCSE Physical Activity provider (Social Prescribing) and/or NHS Diabetes Prevention Programme.

The implementation of the interventions is recorded as Observations (step counts, weight, etc).

On completion both interventions should send a Discharge/Intervention report back to the referrer.

Sources:

• Advancing our health: prevention in the 2020s – consultation document
• NHS Health Check
• NICE: Quality statement 1: Advice for adults during NHS Health Checks

Example Health Pathway (Type 2 Diabetes)

Pathways continue for a patient journey. For example a patient that goes onto develop Type 2 Diabetes can expect to be following several pathways as mentioned in NICE Type 2 diabetes in adults: management guidelines. This also shows the same ADPIE process for Blood Glucose Management this mentions

Assessments

• Driver and Vehicle Licensing Agency (DVLA)'s Assessing fitness to drive: a guide for medical professionals
• Annual Type 2 Diabetes Assessment

Planning

• HbA1c levels targets/goals
• Lifestyle and Drug Therapy activities

Implementation

• Measuring HbA1c levels
• Self Monitoring of Blood Glucose
• Continuous glucose monitoring

Evaluation

• Is reviewed every 3 to 6 months
• This process pattern is also present in NHS England Getting It Right First Time - Diabetes

Example Community Pathway (Wound Care)

How these services are configured to deliver care is not currently know but it is expected to include a mix of health and care providers (and wider?) and so we know these pathways require interoperability standards support. For example a (Diabetes) Foot Care Management pathway has been elaborated by NHS England SE in conjunction with Hampshire and Isle of Wight ICB. In the diagram below the Medication Therapy is likely to be supported by Electronic Prescription Service (EPS). Note this pathway may follow on from pathways in other care settings (see NICE Diabetic foot problems: prevention and management)

Technical Support for Clinical Pathways

We believe ADPIE together with Clinical Pathway description provides very useful documentation for understanding interoperability requirements. This still supports domain or care setting data standards BUT interoperability appears to be better focused on support interactions and sharing records rather than implementing the data standards.

For example the diabetes use cases we have shown, are implementing https://theprsb.org/standards/diabetesstandards/ but this model is collected as required along several diabetes pathways. This is also true for https://theprsb.org/standards/social-prescribing-standard/ one of these, Physical Activity is also an early diabetes intervention (in the Wellness section).

We are seeing zero evidence that care providers solve either data standard with a single set of interoperability standards. In most cases are acutally solved with a mix of frameworks and interaction standards.

We are recommending the way interoperability supports health and care, this will be based around the clinical processes (ADPIE) and encounters (SOAP), this is a replacement to the existing approach based on exchanging data standards. This still supports delivering the data standard but we are breaking this down into components.

The high level view is:

• Encounters are recorded in EPR/EHR systems (out of scope for interoperability standards) and they are shared via Shared Care Records.
• Clinical Process is supported by Care Coordination and so is focused on patient journeys and pathways.

We will refer to both Care Coordination and Shared Care Records as Frameworks.

Data Standards (e.g. UK Core) will be used by these frameworks (note: this excludes EHR/EPR data model standards).