201709 Care Plan

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Care Plan

Dedicated Zulip chat stream for this track.

Submitting WG/Project/Implementer Group

Patient Care Workgroup

Healthcare Services Platform Consortium (HSPC)

Previous Care Plan Connectathons

• 201701 Care Plan, January 2017, San Antonio, TX
• 201704 Care Plan, April 2017, Chicago, IL

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 (STU), which is the primary target for testing in this track. This connectathon track will be coordinated with testing of CarePlan by Clinicians on FHIR where they focus on clinical interoperability and harmonizing differences between the technical and clinical perspectives of FHIR resources.

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 Lead

Dave Carlson – VA

E-mail: Dave.Carlson@BookZurman.com

Zulip: Dave Carlson

Expected participants

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

• VA – Dave Carlson
• HSPC – Dave Carlson
• Allscripts
• InterSystems
• Your organization here!

Roles

Care Plan Server

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

• CarePlan
• CareTeam
• Goal
• Condition
• Other resources as needed for value of CarePlan.activity.reference

A FHIR server is available for testing with sample data for several care plan scenarios:

• HSPC sandbox server, FHIR 3.0.1
  • https://api3.hspconsortium.org/vbcareplan/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 Requestor

This connectathon track imposes few requirements for interested participants to evaluate and test retrieval of care plan resources from FHIR 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).

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.

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 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:

• 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 Release 3 (v3.0.0, March 2017).

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