1. HL7 FHIR Connectathon Care Planning & Management Track
January 2019, San Antonio, TX
Track Lead: Dave Carlson (VA)

2. Care Planning on HL7 FHIR®
Goal for Care Planning
Create an electronic care plan that will enable patients and clinicians to record, change, access, create and receive key patient information, goals and preferences across settings.
Challenge
Care plans of the future must transition to an interdisciplinary approach reflecting communication and collaboration among all members of the care team (including patients and caregivers)
NIH CKD Care Plan Working Group and patient “persona”
programs/nkdep/working-groups/health-information-technology/development- electronic-ckd-care-plan
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3. Betsy Johnson – Person with Multiple Chronic Conditions (from NIH NIDDK)
60 y/o women
Springfield, IL
Betsy Johnson is a fictional “persona” who reflects some of the challenges we’ve heard from patients.
Betsy Johnson is a fictional “persona” who reflects some of the challenges heard from patients.

4. Patient-Centered Care Planning
Evidence-based Medicine
FHIR PlanDefinition
Primary Care
Create & share Care Plans
Specialist
Review & update plans
Create specialty plans
Clinical Decision Support
Medication Review
Risk Prediction
Integration Platform
Standards-based
Consent
Mgmt

5. Join the Community: Care Plans on FHIR
HL7 FHIR Connectathon: Care Planning and Management
Focusing on CKD care planning use case and Betsy Johnson patient persona
HIMSS 2019 Interoperability Showcase: Consumer-Centered Care Planning
Betsy Johnson goes to HIMSS! (patient renamed to Amy Jackson)
Open-source community project for Chronic Care Management on FHIR
Healthcare Services Platform Consortium (HSPC)
Planning a Chronic Care Management Project based on FHIR connectathon use case
Engage a larger community of providers, implementers, and professional societies
FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

6. Betsy Johnson: Sample FHIR Resources
Sample data have been created that are representative of Betsy Johnson’s persona, including realistic medications, labs, and vital sign observations
All data are currently for FHIR R3 (STU3)
These data have been used to support four HL7 FHIR connectathons
Project GitHub repository is expanding to include:
Clinical Quality Language (CQL) examples for CKD decision support
FHIR Questionnaires for standard assessments, based on LOINC panels
Wiki for project plans and resources
Primary focus on care planning for CKD with comorbidities
FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

7. Basic Components of a Care Plan
The 4 cornerstones of a care plan
Corresponding FHIR standards:
Care Plan
Condition
Goal
Request-type resources
ServiceRequest, MedicationRequest, etc.
Observation
Questionnaire & Response
Health Concern
Intervention
(care activity)
Milestone
Goal
Health Status Evaluation & Outcome
relates to / addresses
references / attains
references /
directs
references
(assess outcome)
Content:
Health concern(s)
Health goal(s)
Activity/intervention
Progress/outcome
and more …
Dynamic behavior:
Machine assisted care coordination
Vision Today
Source: HL7 Patient Care Work Group “Care Plan Standards Overview for ONC” April 19, 2017
FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

8. FHIR Care Plan Resource
FHIR R4
(as of October 2018)
Any of these activities may be assigned to Patient as the ‘performer’
‘reference’ or ‘detail’, not both
Inline copy instead of reference to Request resource
Or, structured activity description where no other resource exists
FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

9. FHIR Goal Resource
e.g. from Therapeutic goals panel, LOINC
Goal may be expressed by the Patient, a clinical Practitioner, or by a family caregiver.
Goal description also may be free-text provided by patient or care provider
Encourage goals to have quantified target measures for evaluating progress
FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

10. FHIR Service Request
Must be consistently coded with standard terminologies!
e.g. Renal care education, Blood pressure reading, etc.
FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

11. FHIR Service Request (cont.)
May be individual request or repeating, e.g. 2x per week, once each day, etc.
Request may be assigned to Patient as the performer, e.g. daily blood pressure.
Reason for this request, useful for filtering activities within a comprehensive care plan.
FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

12. Care Plans on FHIR Pulling it all together:
FHIR resources for data structure, discrete data elements
Terminology standards for coded data
FHIR service APIs to search for specific clinical records
Clinical Decision Support, using CQL and CDS Hooks
SMART application launch framework, using OAuth2 (SMART on FHIR apps)
= A powerful set of capabilities for innovation and patient engagement!
FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.