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201801 Care Plan

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Return to Jan 2018 Proposals

Care Plan

Dedicated Zulip chat stream for this track.

Previous Care Plan Connectathons

Summary presentation slides after conclusion of CarePlan track

  • Presentation slides TBD

Submitting WG/Project/Implementer Group

Justification

This track is intended to advance the maturity of FHIR resources for care planning (CarePlan, CareTeam, Goal, Condition, and others) and 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 planning based on FHIR Release 3 (STU), which is the primary target for testing in this track. This connectathon track will be coordinated with evaluation of CarePlan by 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 realize the benefits of comprehensive shared care plans. Two participant roles are included (CDS Service Requestor & Care Plan Protocol Creator) that engage the practitioner community to evaluate and demonstrate use of FHIR care planning 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
  • 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 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 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).

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 clinical practice guidelines for preventive care or chronic condition management

Care Plan Protocol Creator

  • Create and share Care Plan protocol definitions via FHIR server endpoint (PlanDefinition, ActivityDefinition)
    • Care guidelines, e.g. for new diabetes diagnosis, or 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 PlanDefinition protocol, customized using the current Patient's context


Scenarios

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.

Chronic Conditions

This scenario is based on Section 3.4 of the HL7 Care Plan Domain Analysis Model (DAM) documents dated 2015-11-04.

  • Primary Care Plan
    • Patient has a current care plan for one or more pre-existing condition (e.g. Hypertension, COPD, Depression, etc.)
  • Diagnosis of a new condition (e.g. Diabetes)
    • Update the care plan to reference the new Condition, Goal(s) for care, and intervention activities
    • Add members to the care team, as needed
  • Include patient-assigned goals and activities
    • daily measurement of blood pressure, blood glucose, etc.
    • daily or weekly exercise goals
    • scheduled follow-up appointments, or patient-assigned activities to schedule future appointment(s)

Multi-Provider Care Coordination

  • 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

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.

Maternity Care Coordination

This scenario is based on a 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.

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