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201801 Care Plan

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Return to Jan 2018 Proposals

Care Management and Planning

Dedicated Zulip chat stream for this track.

Previous Care Plan Connectathons

Summary presentation slides after conclusion of Care Management track

  • Presentation slides TBD

Submitting WG/Project/Implementer Group


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
Zulip: Dave Carlson

Expected participants

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

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


Care Plan Server

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

  • CarePlan, CareTeam, Goal, Condition
    • Other resources as needed for value of CarePlan.activity.reference
  • PlanDefinition and ActivityDefinition
    • Bonus points for use of CQL as part of the plan definition

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 check off completed activities included in a care plan created by their care team member(s).

Care Plan Protocol Creator

  • Create and share care protocol definitions via FHIR server endpoint (PlanDefinition, ActivityDefinition)
    • 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
  • Generate a CarePlan from a PlanDefinition protocol, customized using the current Patient's context

CDS Service Requestor

  • 201801_CDS_Hooks
  • 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.
    • 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 PlanDefinition protocols for preventive care or chronic condition management


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 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.

Chronic Care Management

This scenario is based on the NIH Chronic Kidney Disease (CKD) Care Plan project.

  • Summarize...