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
- Coordination of Care Service (CCS) – TBD?
Submitting WG/Project/Implementer Group
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 a more comprehensive US Realm implementation guide and profiles for care planning based on FHIR release 3.
Participants using both FHIR DSTU-2 and STU-3 are welcome!
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
- 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 in this track may use:
- 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
- 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
1. 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
2. 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.
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
4. 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 storyboard 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:
- PrimaryCarePhysicianInitialVisit
- AlliedHealthCareProviderVisits
- Hospital Admission
- PrimaryCareFollow-upVisits
