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201809 Care Plan

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Care Planning and Management

Dedicated Zulip chat stream for this track.

Previous Care Planning 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 Leads

Dave Carlson
Zulip: Dave Carlson
Sean Muir

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
  • ONC/CMS eLTSS Initiative
  • Philips Research
  • Veterans Health Administration (VHA)
  • Your organization here!


This diagram illustrates roles and participants in the track this weekend. See the Clinical Scenarios section below for additions description.

Care Planning track roles and participants

Also as PDF: File:Care Planning Track Diagram.pdf

Clinical Data Provider

A FHIR server (version 3.0) should support the following resources for care planning:

  • CarePlan, Condition, Goal, CareTeam, and other resources referenced by CarePlan.activity.reference
  • Patient data needed for management and decision support, including: Observation (labs and vitals), MedicationRequest, etc.

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

Care Protocol Knowledge Asset Provider

Share standards-based, computable care protocol definitions, including:

  • Clinical practice 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

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

Care Plan Creator

  • Provide SMART on FHIR app that:
    • Supports clinician to select and apply recommended care protocol, as PlanDefinition, to a specific patient's new diagnosis.
    • Creates new CarePlan resource or modifies an existing CarePlan resource based on selected PlanDefinition and current patient's clinical data.

Care Plan Consumer

  • Provide SMART on FHIR app that:
    • Supports clinicians and/or patients to review the selected patient's current care plan(s) and associated clinical data.

For additional information see IHE PCC DCP

FHIR Server Endpoints

All of the following FHIR servers are open endpoints that don't require OAuth2, at least during the connectathon. All are running FHIR STU3.

Perspecta Health Concourse FHIR:

These four servers were created to represent roles in our clinical scenario and will be populated during the weekend:

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.

  • Persona descriptions for patients with CKD and their provider care team members are available from the NIH site:
  • 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
  • Example FHIR resource data were created for testing, based on these CKD patient and provider personas and data elements

Technical Scenarios

Retrieve a patient's care plan(s) and clinical data

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

  • A client application enables patients and/or care team members to search for and view care plans and their referenced resources.
  • An integration server queries a patient's care plans and other clinical data 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

  • Coordinate with 201809_CDS_Hooks track
  • 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

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