Difference between revisions of "201801 Care Plan"

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| __TOC__
 
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=Care Plan=
+
=Care Management and Planning=
  
'''Dedicated [https://chat.fhir.org/#narrow/stream/connectathon.20mgmt/subject/C17.20Care.20Plan.20Track Zulip chat stream] for this track.'''
+
'''Dedicated [https://chat.fhir.org/#narrow/stream/connectathon.20mgmt/subject/Care.20Management.20and.20Planning Zulip chat stream] for this track.'''
  
==Submitting WG/Project/Implementer Group==
+
'''Connectathon Orientation and Track Overview'''
* [[Patient_Care | HL7 Patient Care Workgroup]]
+
* Presentation slides [http://wiki.hl7.org/images/a/a6/FHIR_Connectathon_Track_Orientation_-_Care_Management.pptx as PowerPoint]
* [http://hspconsortium.org Healthcare Services Platform Consortium (HSPC)]
+
 
 +
'''Summary presentation slides after conclusion of Care Management track'''
 +
* See Outcomes section below
 +
* Presentation slides TBD
  
 
'''Previous Care Plan Connectathons'''
 
'''Previous Care Plan Connectathons'''
Line 17: Line 20:
 
* [[201701 Care Plan]], January 2017, San Antonio, TX
 
* [[201701 Care Plan]], January 2017, San Antonio, TX
  
'''Summary presentation slides after conclusion of CarePlan track'''
+
==Submitting WG/Project/Implementer Group==
* Presentation slides TBD
+
* [[Patient_Care | HL7 Patient Care Workgroup]]
 +
* [http://hspconsortium.org Healthcare Services Platform Consortium (HSPC)]
 +
* Allscripts
  
 
==Justification==
 
==Justification==
 
<!--Why is this an important track to include in the connectathon - include implementer need, impact on ballot, FMM readiness of the resources, etc. -->
 
<!--Why is this an important track to include in the connectathon - include implementer need, impact on ballot, FMM readiness of the resources, etc. -->
This track is intended to advance the maturity of FHIR resources for care planning ([http://hl7.org/fhir/careplan.html CarePlan], [http://hl7.org/fhir/careteam.html CareTeam], [http://hl7.org/fhir/goal.html Goal], [http://hl7.org/fhir/condition.html Condition], and others) and definition of computable clinical protocols ([http://hl7.org/fhir/plandefinition.html PlanDefinition], [http://hl7.org/fhir/activitydefinition.html ActivityDefinition]), 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 [http://wiki.hl7.org/index.php?title=Clinicians_on_FHIR_-_Sept_2017,_San_Diego Clinicians on FHIR] where they focus on ''clinical interoperability'' and harmonizing differences between the technical and clinical perspectives of FHIR resources.
+
This track is intended to advance the maturity of FHIR resources for care management ([http://hl7.org/fhir/careplan.html CarePlan], [http://hl7.org/fhir/careteam.html CareTeam], [http://hl7.org/fhir/goal.html Goal], [http://hl7.org/fhir/condition.html Condition], and others), the definition of computable clinical protocols ([http://hl7.org/fhir/plandefinition.html PlanDefinition], [http://hl7.org/fhir/activitydefinition.html ActivityDefinition]), 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 management based on FHIR Release 3 (STU), which is the primary target for testing in this track. This connectathon track will be coordinated with the Chronic Conditions track at [http://wiki.hl7.org/index.php?title=Clinicians_on_FHIR_-_Jan_2018,_New_Orleans._LA Clinicians on FHIR] where they focus on ''clinical interoperability'' and harmonizing differences between the technical and clinical perspectives of FHIR resources.
  
In addition to advancing the maturity of FHIR resources for care planning, this track invites participation by clinicians and implementers who are interested in ''using'' these FHIR standards to achieve the vision of comprehensive shared care plans. As a first step toward this vision, we have included a new participant role, CDS Service Requestor, that begins to evaluate and demonstrate use of FHIR care planning resources for the active management of a patient's healthcare.
+
In addition to advancing the maturity of FHIR resources for care management, this track invites participation by clinicians and implementers who are interested in ''using'' these FHIR standards to realize the benefits of comprehensive shared care management coordinated across provider organizations. Two participant roles are included (Care Plan Protocol Creator & CDS Service Requestor) that engage the practitioner community to evaluate and demonstrate use of FHIR care management resources for the active management of a patient's healthcare.
  
 
==Proposed Track Lead==
 
==Proposed Track Lead==
Line 35: Line 40:
  
 
* Allscripts
 
* Allscripts
* Clinical Cloud Solutions, LLC
+
* Cerner
 +
* Clinical Cloud Solutions
 
* Healthcare Services Platform Consortium (HSPC)
 
* Healthcare Services Platform Consortium (HSPC)
 
* InterSystems
 
* InterSystems
Line 46: Line 52:
  
 
===Care Plan Server===
 
===Care Plan Server===
A FHIR server (version 3.0) should support the following resources for this track:
+
A FHIR server (version 3.0) should support the following resources for this role:
* CarePlan, CareTeam, Goal, Condition
+
* CarePlan, Condition, Goal, CareTeam, and other resources referenced by CarePlan.activity.reference
* Other resources as needed for value of CarePlan.activity.reference
 
  
 
A FHIR server is available for testing with sample data that represent one or more care plan scenarios.
 
A FHIR server is available for testing with sample data that represent one or more care plan scenarios.
 
* HSPC sandbox server (FHIR 3.0.1) at https://api-stu3.hspconsortium.org/careplantest/open
 
* HSPC sandbox server (FHIR 3.0.1) at https://api-stu3.hspconsortium.org/careplantest/open
* Test data JSON files are [https://github.com/clinical-cloud/sample-data available in a GitHub repository] that may be loaded into other FHIR v3.0 servers.
+
* Test data JSON files with several patient care plans are [https://github.com/clinical-cloud/sample-data available in a GitHub repository] that may be loaded into other FHIR v3.0 servers.
  
 
===Care Plan Requestor===
 
===Care Plan Requestor===
<!-- Provide a description of the capabilities this role will have within the connectathon -->
 
 
This connectathon track imposes few requirements for interested participants to evaluate and test retrieval of care plan resources from a Care Plan Server. 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:
 
This connectathon track imposes few requirements for interested participants to evaluate and test retrieval of care plan resources from a Care Plan Server. 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 Care Plan Server using a variety of parameters such as plan category or date.
 
* Debug testing tools for RESTful services, e.g. Postman, that allow query of participating Care Plan Server 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 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).
+
* SMART on FHIR mobile applications that enable patients to view, contribute to, or complete activities included in a care plan created by their care team member(s).
 +
 
 +
===Care Plan Protocol Creator===
 +
A FHIR server (version 3.0) should support the following resources for this role:
 +
* [http://hl7.org/fhir/plandefinition.html PlanDefinition] and [http://hl7.org/fhir/activitydefinition.html ActivityDefinition]
 +
** Bonus points for using CQL in conditional logic expressions for plan activities
 +
 
 +
* Create and share care protocol definitions via FHIR server endpoint
 +
** Care guidelines, e.g. for new diabetes diagnosis, or managing the progression of chronic kidney disease
 +
** Order set definitions that recommend modification of activities in existing care plans, e.g. modify medications based on vital sign or lab observation feedback; see CDS integration
  
 
===CDS Service Requestor===
 
===CDS Service Requestor===
* [[201709_CDS_Hooks]]
+
* Coordinate with  [[201801_CDS_Hooks]] track
 
* Invoke a [http://cds-hooks.org/ CDS Hooks Service] that guides a clinician or a patient toward fulfillment of a Care Plan's goals, or suggests additional activities based on clinical practice guidelines. The CDS Hooks Service provides real-time clinical decision support as a remote service, where the CDS Server is invoked on a desired hook and returns the decision support in the form of CDS cards.
 
* Invoke a [http://cds-hooks.org/ CDS Hooks Service] that guides a clinician or a patient toward fulfillment of a Care Plan's goals, or suggests additional activities based on clinical practice guidelines. The CDS Hooks Service provides real-time clinical decision support as a remote service, where the CDS Server is invoked on a desired hook and returns the decision support in the form of CDS cards.
** Evaluate progress toward care plan goals
 
*** Invoke 'patient-view' hook on all known CDS service endpoints
 
*** Query and analyze relevant Observations related to a Goal target measure (e.g. blood glucose, weight, etc.)
 
*** Notify care team members when insufficient progress
 
** Recommend additions to care plan activities
 
*** CDS service uses clinical practice guidelines for preventive care or chronic condition management
 
  
===Care Plan Protocol Creator===
+
==Scenarios==
* Create and share Care Plan protocol definitions via FHIR server endpoint ([http://hl7.org/fhir/plandefinition.html PlanDefinition], [http://hl7.org/fhir/activitydefinition.html ActivityDefinition]).
+
This track emphasizes dynamic care management scenarios where one or more care plans are created, accessed, or updated by one or more members of the care team during the provision of healthcare, and the care plans are used by a patient or his/her caregivers to review or perform plan activities. These scenarios illustrate communication flow of care plan(s) between a patient, his or her primary care provider, consulted specialists, home health care, telehealth care, and family caregivers involved in management of care for one or more health conditions.
** Protocol guidelines, e.g. for new diabetes diagnosis, prenatal care for new pregnancy
 
** Order set definitions that recommend modification of activities in an existing care plan, e.g. modify medications based on vital sign or lab observation feedback; see CDS integration
 
* Generate a CarePlan from a [http://hl7.org/fhir/plandefinition.html PlanDefinition] protocols, customized using the current Patient's context.
 
  
==Optional Roles==
+
===Chronic Care Management===
 +
Our recommended clinical use case is based on the [https://www.niddk.nih.gov/health-information/communication-programs/nkdep/working-groups/health-information-technology/development-electronic-ckd-care-plan NIH Chronic Kidney Disease (CKD) Care Plan project]. Because frequent transitions of care are common among patients with CKD, an electronic CKD care plan could potentially improve patient outcomes by helping to ensure that critical patient data are consistently available to both the patient and his/her providers.
 +
* Persona descriptions for patients with CKD and their provider care team members are available from the NIH site:
 +
** [https://www.niddk.nih.gov/-/media/Files/Health-Information/Communication-Programs/NKDEP/Patient_Personas_508.pdf?la=en Patient personas]; this track's sample data are based on Betsy Johnson's persona
 +
** [https://www.niddk.nih.gov/-/media/Files/Health-Information/Communication-Programs/NKDEP/Provider_Personas_508.pdf?la=en Provider personas] for six members of a CKD patient's care team
 +
* A draft set of data elements and terminology codes are also available for CKD care management, created by the NIH CKD Care Plan Working Group
 +
** [https://www.niddk.nih.gov/health-information/communication-programs/nkdep/working-groups/health-information-technology/development-electronic-ckd-care-plan#draftSet CKD Data Elements]
 +
* Example FHIR resource data were created for testing, based on these CKD patient and provider personas and data elements
 +
** JSON sample FHIR resource files for patient persona Betsy Johnson (contributions welcome!).  See https://github.com/clinical-cloud/sample-data/chronic-conditions
 +
** These sample data are also loaded into this track's HSPC sandbox FHIR server, https://api-stu3.hspconsortium.org/careplantest/open
  
* [[201709_FHIR_Subscriptions]]
+
===Scenario 1: Retrieve a patient's care plan(s)===
 +
Search for a patient's care plans(s) and associated resources (Conditions, Goals, activity references, CareTeam)
 +
* An end-user client application enables patients and/or care team members to search for and view care plans and their referenced resources.
 +
* A server-based application queries a patient's care plans and other clinical resources
 +
** e.g. a population health or analytics product vendor retrieves a patient's care plans and related resources for aggregation, analysis, and sharing with other care team members
 +
* Bonus points for demonstrating SMART on FHIR applications or other use of OAuth security that authorizes access to patient data
  
* [[201709_Provider_Directories_and_Scheduling]]
+
===Scenario 2: Create new care plan from protocol definition===
 +
* Generate a [http://hl7.org/fhir/careplan.html CarePlan] from a [http://hl7.org/fhir/plandefinition.html PlanDefinition] protocol, customized using the current [http://hl7.org/fhir/patient.html Patient]'s context
 +
** Use PlanDefinition [http://hl7.org/fhir/plandefinition-operations.html#apply $apply operation]
 +
** Save the resulting CarePlan resource on a FHIR server, making it available to participants of the other track roles and scenarios
  
 +
===Scenario 3: Request CDS 'patient-view' hook===
 +
* Invoke 'patient-view' hook on one or more CDS Hook service providers
 +
* Display returned cards
 +
** Cards may include any combination of information (for reading), suggested actions (to be applied if a user selects them), and links (to launch an app if the user selects them). The client application decides how to display cards, but CDS Hooks specification recommends displaying suggestions using buttons, and links using underlined text.
  
==Scenarios==
+
Example clinical scenarios for integrating CDS:
This track emphasizes dynamic care planning scenarios where the care plan is created, accessed, or updated by one or more members of the care team during the provision of healthcare, and the care plan is used by a patient or his/her caregivers to perform assigned activities.  These scenarios illustrate communication flow of care plan(s) between a patient, his or her primary care provider, consulted specialists, home health care, telehealth care, and family caregivers involved in management of care for one or more health conditions.
+
* Evaluate progress toward care plan goals
 +
** Query and analyze relevant Observations related to a Goal target measure (e.g. blood glucose, weight, etc.)
 +
** Return CDS Hook cards notifying care team members about lack of progress on goal targets
 +
* Recommend additions to care plan activities based on current Patient status or revised diagnoses
 +
** Return CDS Hook cards with information or suggestions based on clinical practice guidelines for chronic condition management
  
===Chronic Conditions===
+
==Outcomes==
This scenario is based on Section 3.4 of the [http://wiki.hl7.org/index.php?title=Care_Plan_Project_-_PCWG#Care_Plan_Domain_Analysis_Model_.28DAM.29_Documents HL7 Care Plan Domain Analysis Model (DAM)] documents dated 2015-11-04.
+
===Goal===
* Primary Care Plan
+
Advance the maturity of FHIR resources for care management ([http://hl7.org/fhir/careplan.html CarePlan], [http://hl7.org/fhir/careteam.html CareTeam], [http://hl7.org/fhir/goal.html Goal], [http://hl7.org/fhir/condition.html Condition], and others), the definition of computable clinical protocols ([http://hl7.org/fhir/plandefinition.html PlanDefinition], [http://hl7.org/fhir/activitydefinition.html ActivityDefinition]), 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 management based on FHIR Release 3 (STU), which is the primary target for testing in this track. This connectathon track will be coordinated with the Chronic Conditions track at [http://wiki.hl7.org/index.php?title=Clinicians_on_FHIR_-_Jan_2018,_New_Orleans._LA Clinicians on FHIR] where they focus on ''clinical interoperability'' and harmonizing differences between the technical and clinical perspectives of FHIR resources.
** Patient has a current care plan for one or more pre-existing condition (e.g. Hypertension, COPD, Depression, etc.)
+
===Participants===
* Diagnosis of a new condition (e.g. Diabetes)
+
* Academy of Nutrition and Dietetics
** Update the care plan to reference the new Condition, Goal(s) for care, and intervention activities
+
* Allscripts
** Add members to the care team, as needed
+
* Cerner
* Include patient-assigned goals and activities
+
* Clinical Cloud Solutions
** daily measurement of blood pressure, blood glucose, etc.
+
* Healthcare Services Platform Consortium (HSPC)
** daily or weekly exercise goals
+
* InterSystems
** scheduled follow-up appointments, or patient-assigned activities to schedule future appointment(s)
+
* Lantana Consulting Group
 
+
* SAMHSA
===Multi-Provider Care Coordination===
+
* Veterans Health Administration (VHA)
 
 
* Primary Care Physician (PCP)
 
** PCP manages care for existing conditions, as in the first scenario
 
* Specialist referral to a different provider organization
 
** e.g. referral to OB/GYN for prenatal care, or to physical therapist for rehab
 
* Specialist practitioner creates a new care plan using his/her organization's EHR system
 
* Coordinate and notify care plan updates between provider organizations
 
  
==Clinical Domain Scenarios==
+
===Notable Achievements===
These clinical scenarios are complementary to the general care planning and care coordination scenarios listed in the previous section. Each clinical scenario described below is based on contributions from communities interested in solutions using FHIR Care Plan.
+
* Successful collaboration with clinical use case based on the [https://www.niddk.nih.gov/health-information/communication-programs/nkdep/working-groups/health-information-technology/development-electronic-ckd-care-plan NIH Chronic Kidney Disease (CKD) Care Plan project]. Because frequent transitions of care are common among patients with CKD, an electronic CKD care plan could potentially improve patient outcomes by helping to ensure that critical patient data are consistently available to both the patient and his/her providers.
 +
* Successful results associating PlanDefinitions with applicable ActivityDefinition for a Diabetes care protocol and creating a recommended CarePlan for a specific patient.
 +
===Screenshots===
 +
[[Image:Care Plans using planDefinition.jpg|300px]]
 +
[[Image:CarePlan-clinFHIR-CKD.png|300px]]
 +
[[Image:CKD-patient-iPad-app.png|300px]]
  
===Maternity Care Coordination===
+
===Discovered issues===
This scenario is based on a [https://veteransaffairsuxguide.com/practice-areas/user-personas/ realistic Veteran Persona developed by the U.S. Department of Veterans Affairs], but may also represent coordination of care for any pregnancy. "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 OB/GYN and prenatal care. Meghan has concerns about possible negative effects from Teratogenic medications prescribed for her TBI-caused seizures and PTSD anxiety.
+
* Questions on use of clinFHIR to create and edit example FHIR resources for the CKD use case using a shared HSPC FHIR server. Successful and happy users after scheduling a breakout room review with David Hay.
 +
*What questions did you come away with?
 +
===Next Steps===
 +
* Illustrate benefits and use of distributing a library of care protocols using FHIR PlanDefinition, and applying those protocols to improve care management / care coordination by using:
 +
** CDS to create or update patient care plans
 +
** Provider directories to improve care coordination
 +
* Support use of evidence-based protocols for care planning with FHIR PlanDefinitions
 +
* Continue to expand comprehensive FHIR care planning example for Chronic Kidney Disease and other conditions
 +
** Document best practices and FHIR implementation guides for care managment

Latest revision as of 15:51, 29 January 2018

Return to Jan 2018 Proposals

Care Management and Planning

Dedicated Zulip chat stream for this track.

Connectathon Orientation and Track Overview

Summary presentation slides after conclusion of Care Management track

  • See Outcomes section below
  • Presentation slides TBD

Previous Care Plan Connectathons

Submitting WG/Project/Implementer Group

Justification

This track is intended to advance the maturity of FHIR resources for care management (CarePlan, CareTeam, Goal, Condition, and others), the definition of computable clinical protocols (PlanDefinition, ActivityDefinition), 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 management based on FHIR Release 3 (STU), which is the primary target for testing in this track. This connectathon track will be coordinated with the Chronic Conditions track at Clinicians on FHIR where they focus on clinical interoperability and harmonizing differences between the technical and clinical perspectives of FHIR resources.

In addition to advancing the maturity of FHIR resources for care management, this track invites participation by clinicians and implementers who are interested in using these FHIR standards to realize the benefits of comprehensive shared care management coordinated across provider organizations. Two participant roles are included (Care Plan Protocol Creator & CDS Service Requestor) that engage the practitioner community to evaluate and demonstrate use of FHIR care management resources for the active management of a patient's healthcare.

Proposed Track Lead

Dave Carlson – VHA
E-mail: dcarlson@ClinicalCloud.solutions
Zulip: Dave Carlson

Expected participants

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

  • Allscripts
  • Cerner
  • Clinical Cloud Solutions
  • Healthcare Services Platform Consortium (HSPC)
  • InterSystems
  • Veterans Health Administration (VHA)
  • Zynx Health
  • Your organization here!

Roles

Care Plan Server

A FHIR server (version 3.0) should support the following resources for this role:

  • CarePlan, Condition, Goal, CareTeam, and other resources referenced by CarePlan.activity.reference

A FHIR server is available for testing with sample data that represent one or more care plan scenarios.

Care Plan Requestor

This connectathon track imposes few requirements for interested participants to evaluate and test retrieval of care plan resources from a Care Plan Server. 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 Care Plan Server 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 complete activities included in a care plan created by their care team member(s).

Care Plan Protocol Creator

A FHIR server (version 3.0) should support the following resources for this role:

  • Create and share care protocol definitions via FHIR server endpoint
    • Care guidelines, e.g. for new diabetes diagnosis, or managing the progression of chronic kidney disease
    • Order set definitions that recommend modification of activities in existing care plans, e.g. modify medications based on vital sign or lab observation feedback; see CDS integration

CDS Service Requestor

  • Coordinate with 201801_CDS_Hooks track
  • Invoke a CDS Hooks Service that guides a clinician or a patient toward fulfillment of a Care Plan's goals, or suggests additional activities based on clinical practice guidelines. The CDS Hooks Service provides real-time clinical decision support as a remote service, where the CDS Server is invoked on a desired hook and returns the decision support in the form of CDS cards.

Scenarios

This track emphasizes dynamic care management scenarios where one or more care plans are created, accessed, or updated by one or more members of the care team during the provision of healthcare, and the care plans are used by a patient or his/her caregivers to review or perform plan activities. These scenarios illustrate communication flow of care plan(s) between a patient, his or her primary care provider, consulted specialists, home health care, telehealth care, and family caregivers involved in management of care for one or more health conditions.

Chronic Care Management

Our recommended clinical use case is based on the NIH Chronic Kidney Disease (CKD) Care Plan project. Because frequent transitions of care are common among patients with CKD, an electronic CKD care plan could potentially improve patient outcomes by helping to ensure that critical patient data are consistently available to both the patient and his/her providers.

Scenario 1: Retrieve a patient's care plan(s)

Search for a patient's care plans(s) and associated resources (Conditions, Goals, activity references, CareTeam)

  • An end-user client application enables patients and/or care team members to search for and view care plans and their referenced resources.
  • A server-based application queries a patient's care plans and other clinical resources
    • e.g. a population health or analytics product vendor retrieves a patient's care plans and related resources for aggregation, analysis, and sharing with other care team members
  • Bonus points for demonstrating SMART on FHIR applications or other use of OAuth security that authorizes access to patient data

Scenario 2: Create new care plan from protocol definition

  • Generate a CarePlan from a PlanDefinition protocol, customized using the current Patient's context
    • Use PlanDefinition $apply operation
    • Save the resulting CarePlan resource on a FHIR server, making it available to participants of the other track roles and scenarios

Scenario 3: Request CDS 'patient-view' hook

  • Invoke 'patient-view' hook on one or more CDS Hook service providers
  • Display returned cards
    • Cards may include any combination of information (for reading), suggested actions (to be applied if a user selects them), and links (to launch an app if the user selects them). The client application decides how to display cards, but CDS Hooks specification recommends displaying suggestions using buttons, and links using underlined text.

Example clinical scenarios for integrating CDS:

  • Evaluate progress toward care plan goals
    • Query and analyze relevant Observations related to a Goal target measure (e.g. blood glucose, weight, etc.)
    • Return CDS Hook cards notifying care team members about lack of progress on goal targets
  • Recommend additions to care plan activities based on current Patient status or revised diagnoses
    • Return CDS Hook cards with information or suggestions based on clinical practice guidelines for chronic condition management

Outcomes

Goal

Advance the maturity of FHIR resources for care management (CarePlan, CareTeam, Goal, Condition, and others), the definition of computable clinical protocols (PlanDefinition, ActivityDefinition), 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 management based on FHIR Release 3 (STU), which is the primary target for testing in this track. This connectathon track will be coordinated with the Chronic Conditions track at Clinicians on FHIR where they focus on clinical interoperability and harmonizing differences between the technical and clinical perspectives of FHIR resources.

Participants

  • Academy of Nutrition and Dietetics
  • Allscripts
  • Cerner
  • Clinical Cloud Solutions
  • Healthcare Services Platform Consortium (HSPC)
  • InterSystems
  • Lantana Consulting Group
  • SAMHSA
  • Veterans Health Administration (VHA)

Notable Achievements

  • Successful collaboration with clinical use case based on the NIH Chronic Kidney Disease (CKD) Care Plan project. Because frequent transitions of care are common among patients with CKD, an electronic CKD care plan could potentially improve patient outcomes by helping to ensure that critical patient data are consistently available to both the patient and his/her providers.
  • Successful results associating PlanDefinitions with applicable ActivityDefinition for a Diabetes care protocol and creating a recommended CarePlan for a specific patient.

Screenshots

Care Plans using planDefinition.jpg CarePlan-clinFHIR-CKD.png CKD-patient-iPad-app.png

Discovered issues

  • Questions on use of clinFHIR to create and edit example FHIR resources for the CKD use case using a shared HSPC FHIR server. Successful and happy users after scheduling a breakout room review with David Hay.
  • What questions did you come away with?

Next Steps

  • Illustrate benefits and use of distributing a library of care protocols using FHIR PlanDefinition, and applying those protocols to improve care management / care coordination by using:
    • CDS to create or update patient care plans
    • Provider directories to improve care coordination
  • Support use of evidence-based protocols for care planning with FHIR PlanDefinitions
  • Continue to expand comprehensive FHIR care planning example for Chronic Kidney Disease and other conditions
    • Document best practices and FHIR implementation guides for care managment