201701 Care Plan

Return to January 2017 Proposals

Care Plan and Care Team

Coordinated with other related Connectathon tracks

• DAF-Core / US-Core IG and Argonaut
• Care Coordination Service (CCS) – TBD?

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.

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 DSTU-2 and STU-3 are welcome! Our primary objective is to engage implementers in discussion about use of FHIR for dynamic care planning. 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 include those organizations in this connectathon track. However, we also hope to test use of the new STU-3 resource for CareTeam. Including a mix of DSTU-2 and STU-3 participants will limit opportunities for interoperability testing, but all participants will benefit from discussions and comparing implementations of FHIR support for care plans and care coordination.

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

• VA – Dave Carlson
• HSPC – Dave Carlson
• InterSystems – Russ Leftwich MD
• Your organization here!

Questions for Discussion

• Review of existing FHIR profiles on CarePlan and CareTeam, including but not limited to:
  • US-Core CarePlan (formerly DAF CarePlan) -- TODO update with current link to published IG for January
  • IHE PCC Dynamic Care Plan
• ValueSet bindings – Note: work is underway to define these value sets, will add links prior to connectathon
  • 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.

Care Plan Responder

A responder FHIR server is expected to support the following resources for this track:

• Patient
• CarePlan
• CareTeam (if 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

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

• TODO link to an HSPC sandbox server with test data.
• TODO link to transaction Bundle files with test data that may be loaded into FHIR STU-3 servers

Care Plan Creator

• Generate a CarePlan from a ProcessDefinition 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

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

The following 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.

Chronic Conditions (DAM Section 3.4)

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 health issue thread (simplified) consists of four encounters, although in reality there could be many more encounters:

• Primary Care Physician Initial Visit
• Allied Health Care Provider Visits
• Hospital Admission
• Primary Care Follow-up Visits

Home Care (DAM Section 3.5)

The purpose of this care plan scenario on home-care 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 rehabilitation efforts for a patient recovering from a stroke. This health issue thread (simplified) consists of five encounters, although in reality there could be many more encounters:

• Hospital Discharge
• Ambulatory Rehabilitation Clinic Visit
• Home Health Visit
• Primary Care Visit
• Dietitian Visit