201701 Care Plan

Return to January 2017 Proposals

Care Plan and Care Team

Coordinated with other related Connectathon tracks

• Resource Subscription - Roles: FHIR Subscription Client, Subscription Notification Receiver
• Clinical Reasoning - Role: Knowledge Artifact Consumer

Dedicated Zulip chat stream for this track.

Summary presentation slides after conclusion of CarePlan track

• Presentation slides as PDF, or as PowerPoint

Submitting WG/Project/Implementer Group

Patient Care Workgroup

Healthcare Services Platform Consortium (HSPC)

Justification

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 based on FHIR release 3. The January 2017 published build of FHIR STU-3 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.

This connectathon track will be coordinated with testing of CarePlan by HL7 Clinicians on FHIR where they focus on clinical interoperability and harmonizing differences between the technical and clinical perspectives of FHIR resources. Clinicians on FHIR has met at each HL7 WGM since May 2014 and has the following objectives:

• to test the accuracy, validity and usability of clinical resources
• to identify any issues arising from clinical use of clinical resources tested
• to provide recommendations to enhance/improve the clinical resources tested
• to identify lessons learnt such that future FHIR resources development methodology and processes may be improved

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.

Proposed Track Leads

Dave Carlson – VA

E-mail: Dave.Carlson@BookZurman.com

Zulip: Dave Carlson

Russ Leftwich MD – InterSystems (Clinical Lead)

E-mail: Russell.Leftwich@intersystems.com

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
• InterSystems – Russ Leftwich MD (clinical)
• Allscripts – Emma Jones (clinical)
• HarmonIQ Health Systems Corporation
• A|D Vault, Inc.
• ZeOmega, Inc.
• Janie Appleseed powered by MaxMD

• Your organization here!

Questions for Discussion

• Review of existing FHIR profiles on CarePlan and CareTeam, including but not limited to:
  • US-Core IG profiles (formerly DAF-Core profiles)
  • IHE PCC Dynamic Care Plan
• 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

Roles

Care Plan Requestor

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.
• Provider EMR or Care Plan Management solution that allows a provider to request and/or accept information from a patient that can be used when creating or updating the person's care plan. (Patient Voice Scenario)

Care Plan Responder

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

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

For robust support of CareTeam, responder should also support:

• Practitioner
• RelatedPerson
• Organization
• Patient (See Patient Voice Scenario)

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

• HSPC sandbox server, STU3 FHIR 1.8.0, contains all test resources for Diabetes storyboard scenario
  • https://api3.hspconsortium.org/fhirconnect14/open
• See the Type II Diabetes Mellitus use case section below for a GitHub link to FHIR transaction Bundle files with test data that may be loaded into FHIR STU-3 v1.8.0 servers.
  • Type II Diabetes Mellitus storyboard as PDF

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 document that permits a patient to share his or her care goals, preferences and priorities with with care providers so this information can be taking into consideration when making a care plan in circumstance when the person can't communicate this information for his or herself.

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

Search for all Care Teams for a patient

This is another "getting started" scenario with minimal requirements for Requestors and Respondors.

Action: Server and Client support query of CareTeam based on patient.id using GET [base]/CareTeam?patient=[id]

Precondition: Server implements FHIR STU-3.

Search for all Care Plans where the given Practioner is a member of the Care Team

Action: Search CarePlan (TODO: example of search parameters)

Bonus point: Filter Care Plans to include only those for a given Condition, e.g. Diabetes

Display Care Plan 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

This track is coordinating test scenarios with Clinicians on FHIR CarePlan testing that will occur on Friday following the connectathon at HL7. Participants should study the planning notes on that wiki page and be prepared to provide technical input experience on those topics. The track scenarios are also 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:

• A storyboard for the Type II Diabetes Mellitus scenario was prepared to guide Connectathon participants.
• Test data JSON files for this storyboard are available in a GitHub repository based on FHIR v1.8.0, the Jan 2017 build prepared for this Connectathon.

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 between a patient, his or her primary care provider or other care team members. Specifically we show how information generated by the patient about their health goals, care preferences and priorities can be shared so that the patient’s voice can be included in the care plans created by care team members. This scenario would be relevant for:

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