This wiki has undergone a migration to Confluence found Here

Care Plan Project - PCWG

From HL7Wiki
Revision as of 20:55, 15 March 2017 by Michael padula (talk | contribs)
Jump to navigation Jump to search

Return to: Patient Care

  • Go to Care Plan project archived wiki pages:
- Care Plan Project 2012
- Care Plan Initiative project 2011
- Care Plan Topic project (Project contents prior to 2011)


Care Plan has been balloted in 2007 as DSTU. However, a number of ballot issues were not resolved satisfactorily and consequently the balloted contents did not reach DSTU status.

The project plan initiated in 2011 is to first develop a Domain Analysis Model (DAM) for the Care Plan, and then decide on follow on activities. The HDF 1.5 (HL7 development framework) approach will be followed. HL7 PC will work together with various groups including HL7 Work Groups (e.g. EHR, Structured documents), IHE, NEHTA, Canada Health Infoway, and others.

The Care Plan DAM project concluded in 2014 after complete resolution of informative ballot 2 comments.

Post Care Plan DAM publication: the PCWG care plan project moves into the following areas of activities:

(1) Harmonization of the Care Plan model with FHIR care plan model
(2) Harmonization of the Care Plan model with C-CDA R2 care plan templates

Project Co-Leaders

Laura Heermann Langford
Intermountain Healthcare, USA
Phone: 801.290.6888
Stephen Chu, MD
Phone: +61.416.960.333

Meeting Information

Meeting Schedule: Fortnightly Wednesday at:

Call Time Region Call Time Region
17h00 NA / US Eastern 23h00 UK
16h00 NA / US Central 22h00 Europe Central
15h00 NA / US Midwest
14h00 NA / US Pacific 07h00 Australia Eastern Standard

Call Logistics:

Call number Audio PIN Web conference
770-657-9270 943377# See HL7 conference call notice emails

Meeting Agendas and Minutes

Agendas and Minutes

Care Plan Domain Analysis Model (DAM) Documents

Current Care Plan DAM

  • November 2015 - Pre-publication Draft Care Plan DAM specification
~ The pre-publication draft of Care Plan DAM specification is intended to be a "preview" of what the contents of the specification are likely to be
~ A number review and revision changes are anticipated to be applied to the document before it is released for final publication as HL7 Informative document:
- Storyboard 8: how care plans are used and exchanged within the case management/disease management perspectives
- Restructuring of the contents: it is planned that all storyboards (which are contextual and supportive in nature) will be moved into the appendix section and not being placed in the main body of the document
- Note - due to the (2MB) file size limitation of the HL7 wiki, the draft document has been split into two parts. Consequently, the section and line numbers be disrupted

- Care Plan DAM Spec - Pre-Publication Draft - 2015-11-04 Part 1 (pdf)
- Care Plan DAM Spec - Pre-Publication Draft - 2015-11-04 Part 2 (zip)

Care Plan Models and Related Projects

Care Team Definition Project


The US ONC (Office of National Coordination for Health IT) is supporting an initiative to review the FHIR Care Team resource and to define what constitutes a care team, the types of care team, and code values required for supporting the implementation of the CareTeam resource in various care settings.
This initiative has attracted the participation and contributions from domain experts and industry stakeholders. The group meets weekly via conference calls on Friday at 4:00pm US Eastern.
As of Friday 3 March 2017, the ONC Care Team definition project has been consolidated into the HL7 Learning Health Systems (LHS) Care Team Domain Analysis Project (see link to the LHS project in the subsection below)

Reference/Resource Documents

A number of artefacts/documents have been produced as the analysis and discussions progress over time. These documents are uploaded to the ONC CareTeam Definition Confluence page. Interested parties outside this group may not be able to access these documents.

At a PCWG conference call, it was discussed and agreed that it is highly useful for these documents to be made available to the HL7 PCWG members. Members from the PCWG who contribute to the ONC CareTeam definition initiative agrees to make the documents they created also available on the PCWG Care Plan wiki.

Learning Health Systems Project

Essential Information for Children with Special Healthcare Needs Project

Care Plan Models Harmonization

Care Plan Mode - FHIR Harmonization

  • Contents to go into here

Care Plan Model - C-CDA Care Plan Template harmonization

  • Placeholder for C-CDA care plan templates harmonization work

  • PCWG Care Plan Model and C-CDA R2.x Care Plan templates Collaborative

~ PCWG and Structured Document Workgroup have collaborated closely to harmonize the PCWG care plan models and the C-CDA R2.x care plan templates. The collaboration activities are continuing.

~ C-CDA R2.x includes a set of sections and entry templates to support care plan exchanges.
- These templates were developed in parallel to the Care Plan DAM informative ballot 1 contents.
- Also in scope for exploration/discussion is the terminology/code sets required to support Care Plan implementations

~ The Care Plan DAM has since gone through the second cycle of informative ballot, which results in further changes to the original DAM design.
~ It is anticipated that there may be differences between the care plan model as published in the DAM informative ballot 2 document and the C-CDA R2 care plan templates.
~ The harmonization activities are intended to address these differences such that the two sets of artefacts are as closely aligned as possible

  • Place holder for Care Plan Model - C-CDA R2.x harmonization contents

C-CDA R2.x Case Management/Disease Management Care Plan Implementation:

- The need to use Care Plan in chronic conditions case management/disease management was raised as ballot comments in response to the first informative Care Plan DAM ballot in 2013.
- The PCWG Care Plan team received storyboard contributions on case management/disease management which was balloted and finalised through ballot comments reconciliation processes. This storyboard is scheduled for publication in the final Care Plan DAM specification before October 2015 WGM
- A project has been initiated to implement case management/disease management care plan as C-CDA R2.x compliant documents
Project documents are available via the following wiki link:
* Case Management/Disease Management C-CDA R2.x Project Documents

Important Discussion Topics

During the development of the Care Plan models and related work, a number of topics continue to attract numerous inputs and debates.

They include:

  • Types of Plan: The concepts "Care Plan", "Plan of Care" and "Treatment/management Plan" attracted extensive debates over a long period of time. Summary of the discussions and final resolution/decision is available on this wiki page:
Types of Plan - Differentiation and Definitions (This topic replaces previous topic: Care Plan Definition)

  • Health Concern: The Health Concern is one of the important components/concept in care plan
This topic has been extensively debated on a number of HL7 Workgroup mailing lists.
PCWG has a Health Concern project with the objectives of clearing defining this topic and related concepts, and how these concepts are used in patient care. Information on the Health Concern project can be access through this wiki:
Health Concern
How the Health Concern and Concern Tracking topics are related to the "Health Concern", "Health Goal", "Care Activity", etc concepts identified in the Care Plan Domain Analysis Model will also be addressed by the Health Concern project

  • Care Team: The composition of Care Team has also be discussed quite extensively and evolves over time. It is anticipated that this will continue to attract discussions and will continue to evolve.
Currently, the following is a list of roles/professional roles that is considered as care team members:
- Medical Practitioners (including all specialties and sub-specialties)
- Nurses
- Allied Health Practitioners (including Physiotherapist, Occupational Therapist, Speech Therapist, Psychologist, Pharmacist, etc)
- Social workers
- Care Managers, Disease Managers, Care Coordinators
- Patient
- Nominated patient family members
- Care givers/carers

Care Plan DAM Project Resource Documents

Project Scope Statement

  • Care Plan Clinical Model - draft project scope statement:
- Care Plan clinical model draft PSS - updated: 2014-12-19

Care Plan DAM Previous Drafts

  • April 2015 Version
- Please note the following:
- Due to file size limitation imposed by HL7 wiki, the complete Care Plan DAM draft specification has been split into 3 parts
- As the result of the split, the numbering sequence of Sections and Subsections in Part 2 and Part 3 are out of syn with the complete document
- The documents are working drafts. Editing of the full document is still in progress. Hence the contents should not be taken as final
- Care Plan DAM Spec - 2015-04-06 edits - Part 1
- Care Plan DAM Spec - 2015-04-06 edits - Part 2
- Care Plan DAM Spec - 2015-04-06 edits - Part 3

Care Plan DAM Informative Ballot 1 Document

Other Useful Resources

Comparison of International Care Plan Structure as at 2011:

  • Coordinated Care Services Specification:

Older documents

Related and Relevant Activities/Projects

2016 List of Care Plan Topics

Topic Source/Owner Comments
HL7 Care Plan Domain Analysis Model PCWG (generic care plan standards)
HL7 C-CDA 2.1 Care Plan Document Template SDWG (generic care plan [C-CDA templates] standards)
HL7 FHIR Care Plan Resource PCWG (generic care plan standards)
CCDA on FHIR Care Plan SDWG (generic care plan standards)
IHE PCC Dynamic Care Planning Profile IHE - PCC (generic care planning standards)
HL7 Care Coordination Services (CCS) functional model; OMG CCS Technical Specification PCWG, SOA (generic care planning and coordination standards)
IHE QRPH Early Hearing Detection and Intervention (EHDI) Plan of Care IHE - QRPH (use case specific care plan standards)
HL7 Clinical Oncology Treatment Plan and Summary SDWG (use case specific care plan standards)
Survival-ship plan SDWG - master grid - family = CDA
NCPDP/HL7 Pharmacist Care Plan NCPDP, HL7 Pharm (use case specific care plan standards)
HL7 CDA R2 Personal Advanced Care Plan Document SDWG (use case specific care plan standards)
Payers unstructured care plan HL7 Payers (use case specific care plan standards)
Care team DAM project Learning Health Systems WG (model the relationship between care team members and the patient and between other members of the team)
Care team members definition update project ONC (define care team types, roles and members)
x---x x---x
DAF (Data Access Framework): minimum mandatory requirements for recording, searching for, and fetching patient information ONC (includes ONC 2015 Certification Criteria for the Common Clinical Data Set (CCDS) for Assessment and Plan of Treatment, e.g. Condition, Care Team, Goal ...
xx xx

Care Coordination

  • The IHE Patient Care Coordination Technical Committee has published an IHE Technical Framework supplement:
- IHE - Reconciliation of Clinical Content and Care Providers profile
- This document is open for public comment in the period from June 6 through July 5, 2014
- More details about comments submission can be obtained from this IHE link:
- IHE comment spreadsheet:
o IHE - Reconciliation profile comment spreadsheet
o Comments can be emailed to:

Care Coordination Services Project details:

ONC/LCC Project website:

Other related parties of the Care Plan Topic

To be updated.

Collaborating with Agreement status Comments
IMIA-NI Existing
IHE Existing
CEN Existing Swedish Care Plan project

Download CEN materials from Sweden here:

See also the reference material wiki page (link above)