MCC eCare Plan Draft Implementation Guide
0.1.0 - CI Build

MCC eCare Plan Draft Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions

IG Cornerstone: MCC FHIR eCare Plan Profile Design

Previous Page - Structure and Design Considerations

A Care Plan is a consensus-driven dynamic plan that represents a patient’s and Care Team Members’ prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers, and providers), to guide the patient’s care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions. A Care Plan may represent one or more Care Plans and serves to reconcile and resolve conflicts between the various plans developed for a specific patient by different providers. It supports the following use cases:

  • Query for patient data across providers and compile into a consolidated care plan representation.
  • Encourage capture of and communication of a patient’s health concerns and related goals, interventions, and outcomes.
  • Gather and aggregate patient data for uses beyond the point of care (e.g. public health, population health, quality measurement, risk adjustment, quality improvement, and research.)

Standards Supported Care Planning and Coordination Process

The vision of this implementation guide (IG), with the FHIR Care Plan profile as its framework, is to define a profile on the FHIR Care Plan resource that describes how it can be implemented and leveraged to support machine assisted care coordination between systems. It is assumed that SMART on FHIR Apps can be designed off of this guide to achieve that goal. The IG will also inform EHR systems on how to implement a structured encoded Care Plan.

The dynamic care plan process diagram shows Care Plan Cornerstones as they exist within the clinical world and elements and attributes from the FHIR Care Plan resource structure that support the process. In order to encourage reuse and dynamic, machine assisted care coordination, the Care Plan profile design leverages referrencing profiles wherever possible, especially within CarePlan.Activity.

High Level Dynamic Care Plan Process Diagram

This profile on the FHIR Care Plan Resource describes rules, contraints to record, search, and fetch care plan data associated with a patient with multiple chronic conditions. It identifies which profiles, core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile. Care plan data may or may not be tagged in an EHR as part of a care plan, but is also useful to retrieve data such as goals, problems, medications etc. and their time stamps from EHRs and other health system records to bring into an aggegated plan. This includes care plans that may be authored by a patient.

Multiple Chronic Condition FHIR Care Plan Profile Relationship Diagram

Supporting Machine Assisted Dynamic Care Coordination/Planning with the FHIR Care Plan Resource and FHIR Goal Resource

The machine assisted dynamic care planning/coordination is supported in FHIR by leveraging together the Care Plan resource, the Goal resource, resource referencing and available extensions within those resources to “link together the health concern or problem, and it’s associated goals, interventions and outcomes. The intention is to re-use data entered in the EHR, whether it is in a Care Plan Application, or elsewhere in the EHR or other information system, rather than having a care plan be a double documentation burden. For example, if a procedure is ordered and performed and the health concern or problem reason for that procedure is asserted in the ordering workflow or documentation workflow - this information can be pulled into the Care Plan. If a goal is asserted for a patient outside of a care plan, along with the reason for that goal, this also can be pulled into a care plan. The Care Plan profile relies on referencing of profiles rather than “in-line” representation or documentation to enable a dynamic workflow and to be able to pull in and aggregate care coordination activities from disparate systems to provide a comprehensive care coordination view for patients

CarePlan.Activity” is a Backbone element. It identifies an action that has occurred or is a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring that has occurred, education etc., within which in R4 can be OutcomeCodeableConcept, OutcomeReference, Progress Note when using activity.reference.

OUTCOME REFERENCE (aka PERFORMED ACTIVITY reference: to be renamed in R5 to “CarePlan.performedActivity”. Please see OutcomeReference is not only an outcome but rather an action such as Procedure or an Encounter that was made or occurred or an Observation. Within CarePlan.performedActivity, the extension, “resource-pertainsToGoal” SHALL be used to reference this activity’s related goal. Within the resource referenced within performedActivity, “Procedure.reason” SHALL be used to reference the health concern or problem for which the activity is done.

ACTIVITY REFERENCE (aka PLANNED ACTIVITY reference: to be renamed in R5 to “PlannedActivityReference”. Please see Within plannedActivityReference, the extension, “resource-pertainsToGoal” SHALL be used to reference this activity’s request’s related goal. “xxx.Request.reason” SHALL be used to reference the health concern or problem for which the activity is done. Within the referenced Goal resource, goal.address SHALL be used to reference the goal’s related Condition, Observation, MedicationStatement, NutritionOrder, ServiceRequest or RiskAssessment. Within the referenced Goal resource, Goal.outcomeReference, references the outcome (e.g observations related to the goal).

Health Concerns represented with:

  • CarePlan.addresses
  • CarePlan.suppportingInfo
  • CarePlan.addresses (from within referenced goal)
  • Goal.addresses
  • activity.reason.reference

Goals represented with:

  • CarePlan.goal (for entire plan)
  • resource-pertainsToGoal

Interventions represented with:

  • CarePlan.plannedActivityReference (aka activity.reference)
  • CarePlan.performedActivityReference (aka activity.outcome.reference)

Outcomes represented with:

  • CarePlan.ActivityOutcome
  • Goal.outcome.reference

Instanciated FHIR Supported Dynamic Care Planning and Coordination

Next Page - Library of Profiles vs Explicit Reference Constraints