201704 Care Plan

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Return to April 2017 Value-Based Care FHIR Mini-Connectathon

Value-Based Care Plan

Summary presentation slides after conclusion of CarePlan track

Dedicated Zulip chat stream for this track.

Related Work

Submitting WG/Project/Implementer Group

Patient Care Workgroup

Healthcare Services Platform Consortium (HSPC)


This connectathon track explores the use of FHIR to provide inquiry and exchange of care plans that enhance the coordination between value-based care stakeholders involved in the management of chronic conditions and tracking progress toward outcome goals. Care plans, or fragments of plans, may be distributed across several provider systems and personal health repositories. A complete solution would need to collect, merge, and reconcile care plan content into a single comprehensive plan for use by patients and clinicians. Examples of value-based care stakeholders include:

  • the patient
  • the patient's caregivers
  • the patient's primary care provider
  • specialist providers
  • home health care team
  • case managers from both providers and payers

This track is intended to advance the maturity of FHIR resources for care planning (CarePlan, CareTeam, Goal, Condition, and others) and to document industry best practices for improving care coordination using shared care plans. This work will inform the development of more comprehensive implementation guides and profiles for care planning. FHIR Release 3, v3.0.0 published in March 2017, is the primary target for testing in this track. However, we recognize that there are organizations with DSTU-2 implementations (e.g. from the HL7 Argonaut Project) that are deploying support for CarePlan, and we'd like to invite those organizations to participate in this connectathon track and share lessons learned from implementation.

The U.S. Department of Health and Human Services (HHS) recently published an article that describes a vision for a Comprehensive Shared Care Plan (CSCP). HHS identifies these goals for a CSCP:

  • It should allow a clinician to electronically view information that is directly relevant to his or her role in the care of the person; to easily identify which clinician is doing what; and to update other members of an interdisciplinary team on new developments.
  • It should put the person’s goals (captured in his or her own words) at the center of decision-making and give that individual direct access to his or her information in the CSCP.
  • It should be holistic and describe both clinical and nonclinical (including home- and community-based) needs and services.
  • It should follow the person through high-need episodes (e.g., acute illness), as well as periods of health improvement and maintenance.

Track Leads

Dave Carlson – VA
E-mail: Dave.Carlson@BookZurman.com
Zulip: Dave Carlson

Expected participants

Participants using both FHIR STU-3 and DSTU-2 are welcome! Including a mix of FHIR versions will reduce opportunities for interoperability testing, but all participants will benefit from discussion and comparing implementations of FHIR support for care plans and care coordination. Test data prepared for this connectathon track will be based on the January 2017 published build of FHIR STU-3, including use of the the new STU-3 resource for CareTeam.

The following organizations have indicated an interest in participating in this track:

  • VA – Dave Carlson
  • HSPC – Dave Carlson
  • Allscripts
  • Datuit, LLC – Gordon Raup
  • Your organization here!

Questions for Discussion

  • ValueSet bindings – Note: work is underway by ONC and HL7 to define these value sets
    • CarePlan.category
    • CarePlan.detail.category
    • CarePlan.detail.code
    • CareTeam.type
    • CareTeam.participant.role


The roles outlined in this section describe the request, response, and creation of CarePlan and related FHIR resources. This track does not require or assume any transport mechanism or packaging of content, other than the FHIR core specification REST services for each resource. For some clinical use cases, e.g. the Patient Voice Scenario described below, care plan content may be transported using FHIR Compositions or Attachments; see the Attachments and C-CDA on FHIR connectathon tracks for more detail.

Care Plan Requestor (Client)

This connectathon track imposes few requirements for interested participants to evaluate and test retrieval of care plan and care team resources from servers. We wish to encourage discussion and testing that will lead to robust industry support for shared care plans. Thus, a requestor role could be fulfilled by a range of applications, such as the following:

  • Debug testing tools for RESTful services, e.g. Postman, that allow query of participating Responders using a variety of parameters such as plan category or date.
  • SMART on FHIR applications that embed Care Plan review and editing capabilities into any EHR system that supports these services.
  • SMART on FHIR mobile applications that enable patients to view, contribute to, or check off completed activities included in a care plan created by their care team member(s). A patient-centric mobile application could enable a patient to add personal Goals to a plan created by their primary care physician.
  • An EMR or Care Plan Management application may accept or request a Personal Advance Care Plan (PACP) FHIR bundle or document, as described in the Patient Voice Scenario described below.

Care Plan Responder (Server)

A responder FHIR server should support the following resources for this track:

  • Patient
  • CarePlan
  • CareTeam (when using STU-3)
  • Goal
  • Condition
  • Other resources as needed for value of CarePlan.activity.reference

For robust support of CareTeam, responder should also support:

  • Practitioner
  • RelatedPerson
  • Organization
  • Patient

Default responder service for testing, and sample data for loading into FHIR servers:

  • HSPC sandbox server, STU3 FHIR 1.9.0 (March 2017), contains all test resources for Diabetes storyboard scenario
  • See the Type II Diabetes Mellitus use case section below for a GitHub link to FHIR resource files with test data that may be loaded into FHIR STU-3 v1.9.0 or v3.0.0 servers.

Care Plan Creator

  • Generate a CarePlan from a PlanDefinition for protocols or care pathways, customized using the current Patient's context.
  • Using a SMART on FHIR application that enables care team members working within existing EHR systems to add/edit Goals, activity details, schedule, or other aspects of a Care Plan.
  • Generate a Personal Advance Care Plan (PACP) FHIR bundle or document, as described in the Patient Voice Scenario described below.

Basic Resource Scenarios

Two sets of scenarios are included in this connectathon track. The first Basic Resource Scenarios describe interactions with a FHIR server to support care planning and may be implemented on existing EHR systems or using generic FHIR servers. The second Use Case Scenarios describe more advanced and realistic interactions required for dynamic care planning and care coordination.

Search for all Care Plans for a patient

This is intended as a "getting started" scenario with minimal requirements for Requestors and Respondors.

Action: Server and Client support query of CarePlan based on patient.id using GET [base]/CarePlan?patient=[id]
Bonus point: Search for all of a patient's Care Plans with a specific category, e.g. cancer care plan
  • query CarePlan based on patient.id and category = "395082007" using GET [base]/CarePlan?patient=[id]&category=395082007

Display Care Plan goals, health conceras, and activity definitions

We are interested in implementer feedback on the two alternatives included for expressing care plan activities: as a reference to another resource (e.g. DiagnosticRequest, ProcedureRequest, etc.) or by describing the activity detail with schedule, performer, quantity, etc.

  • CarePlan.activity.reference
  • CarePlan.activity.detail

Use Case Scenarios

The track scenarios are based on the HL7 Care Plan Domain Analysis Model (DAM) documents dated 2015-11-04. They emphasize dynamic care planning clinical scenarios where the care plan is created, accessed, updated or used by multiple providers during the provision of healthcare.

Type II Diabetes Mellitus

The purpose of the chronic conditions care plan scenario is to illustrate the communication flow and documentation of a care plan between a patient, his or her primary care provider and the home health specialists involved in the discovery and treatment of a case of Type II Diabetes Mellitus. This storyboard is based on Section 3.4 of the HL7 Care Plan DAM. This health issue thread (simplified) consists of four encounters, although in reality there could be many more encounters:

  • Primary Care Physician Initial Visit
  • Dietitian
  • Podiatrist
  • Primary Care Follow-up Visits

Storyboard document and test data:

Maternity Care Coordination

Meghan is a post-9/11 Veteran who served in Afghanistan and is recovering from a Traumatic Brain Injury (TBI) and PTSD. Meghan recently became pregnant with her third child and is coordinating care plans between her primary care provider at VA and a community provider outside of VA for her prenatal care. Meghan has concerns about possible negative effects of her PTSD anti-anxiety medication on her new baby. The key actors in this scenario are:

  • Meghan
  • Dr. Francis, MD, primary care provider at VA
  • Dr.Beach, PsyD, VA Psychotherapist counselor for Meghan's PTSD and anxiety conditions
  • Vera, RN, the Maternity Care Coordinator (MCC) at VA helps manage Meghan's non-VA prenatal care
  • Dr. Rattle, OB/GYN from non-VA provider, responsible for Meghan's prenatal care plan

Patient Voice Scenario

The purpose of this care plan scenario on Patient Voice is to illustrate the communication flow and documentation of a care plan that is shared by a patient, his or her primary care provider or other care team members. A Personal Advance Care Plan (PACP) FHIR bundle or document may contain a patient's care goals, health concerns, preferences, and priorities with care team members so this information can be taken into consideration when creating or updating a care plan. This is beneficial in circumstance where the person can't communicate this information in person, or when automated and computable submission of the PACP is preferred. This scenario would be relevant for clinical situations, such as:

  • EMS Services
  • ER visit
  • Nursing Home
  • Primary Care
  • Post Acute Care
  • Palliative Care
  • Organ Donation