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201809 Care Plan

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Care Planning and Management

Dedicated Zulip chat stream for this track.

Previous Care Plan Connectathons

Submitting WG/Project/Implementer Group


This track is intended to advance the maturity of FHIR resources for care planning and 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 and clinical decision support. 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
  • Book Zurman
  • Clinical Cloud Solutions
  • Elsevier
  • InterSystems
  • Motive Medical Intelligence
  • Philips Research
  • Veterans Health Administration (VHA)
  • Your organization here!


FHIR Data Server

A FHIR server (version 3.0) should support the following resources for care planning, in addition to core clinical data (Patient, Observation, etc):

  • 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.

FHIR Knowledge Asset Server

A FHIR server (version 3.0) should support the following resources for knowledge-based care management:

  • PlanDefinition, ActivityDefinition, Library

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 201809_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.

Clinical 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 Kidney Disease 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.

Technical Scenarios

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

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

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