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Short Description

This track will be hosted by the Multiple Chronic Conditions (MCC) eCare Plan project to continue testing of the MCC eCare plan FHIR IG, SMART on FHIR Apps (provider and patient-facing) and value sets defined for MCC clinical domains. The track builds on a successful series of connectathons testing specifications to support the development and exchange of FHIR based Care Plans and applying evidence-based clinical practice guidelines at the point of care to create and share person-centered care plans and to manage their ongoing care.

Long Description

Track Topic: This track will be hosted by the Multiple Chronic Conditions (MCC) eCare Plan project to evaluate and test goal-oriented care planning. The objectives for this track are to:

      • Demonstrate the purpose of using goals in care planning, where goals may be created by any member of the care team, including patients and caregivers.
      • Explore how care goals in practice can be both clinically useful and interoperable.
      • Explore the relationships between a goal, the conditions and/or assessment observations that it addresses, and outcome observations that document goal progress.
      • Explore the clinical workflow feasibility for creating FHIR Goal.description using coded terminology vs free text.
      • Examine the clinical workflow and challenges with creating measurable goals that reference specific codes, e.g. lab or vital sign LOINC code.
      • Evaluate the use of FHIR Goal to capture and track SMART goals, i.e. Specific, Measurable, Achievable, Relevant, and Time-Bound.
      • Evaluate and recommend updates to existing US Core Goal Search Parameters. 


Test an Implementation Guide

Submitting Work Group/Project/Accelerator/Affiliate/Implementer Group  

This track will be hosted by the Multiple Chronic Conditions (MCC) electronic Care Plan Project in collaboration with implementer communities testing several other FHIR IGs focus on and relevant to goal-oriented care planning, including: 

  • HL7 FHIR Gravity Social Determinants of Health in the Clinical Care Setting (sdoh-cc)
  • PACIO Functional Status Assessment IG and Cognitive Status Assessment IG
  • HL7 FHIR Electronic Long-Term Services and Supports (eLTSS)
  • IHE Dynamic Care Planning
  • Clinical Practice Guidelines (CPG)
  • US Core

Track Lead(s)

  • Dave Carlson -
  • Emma Jones -
  • Karen Bertodatti -
  • Savanah Mueller -

Track Lead Email(s);;;

Related Tracks

PACIO Integration of Post-Acute Care IGs

Gravity SDOH Exchange

Clinical Reasoning

US Core/USCDI v2

PCWG Clinicians on FHIR

FHIR Version

This track will use R4 version of FHIR.

Specification(s) this track uses

  • MCC IG:

  • US Core:

  • SDOH Clinical Care:

Artifacts of focus

FHIR Bundle resources containing scenario resources for Patricia Noelle are available on GitHub and also loaded into our track's FHIR sandbox.

Expected participants

Please sign up to participate in the Care Planning track so we can invite you to the track kick-off: Connectathon Track Participation Sign Up

Expected participants:

  • AHRQ
  • HHS - Administration for Children & Families (ACF)
  • EMI Advisors
  • Oregon Health & Science University (OHSU) - AHRQ Grant
  • Allscripts
  • MITRE - PACIO Project
  • RTI - eCare Plan and Gravity Projects
  • Epic (Public FHIR Sandbox)
  • Namaste Informatics
  • Clinical Cloud Solutions

Zulip stream

Track Kick Off Call

Track Orientation Call

  • Slide Deck:  
  • Recording:


We welcome your input on assembling our Track Report Out. Please contribute as necessary.

April 272:00-3:00 PM ET

Care Planning Track Orientation

May 39:30-10:00 AM ET

Track Kick-off

  • Make introductions and overview goals and purpose for the track.
May 310:00-10:50 AM ET

MCC eCare Plan FHIR IG Draft Walk Through

  • Walkthrough multiple chronic condition (MCC) eCare Plan FHIR IG and discuss IG redesign.
May 311:00 AM-12:30 PM ET

CQL use in Care Plan SMART on FHIR app demo

  • Demo and description of patient/caregiver SMART on FHIR app and its use of CQL to classify and filter data.
May 31:30-3:30 PM ET

Care planning process with PACIO, US Core, and Gravity/SDOH

  • Working session for care planning process (multiple providers, multiple care settings, etc.) in PACIO use cases with a focus on SDOH.
May 33:30-4:00 PM ET

Day 1 Wrap-up

  • Recap surfaced questions, accomplishments, and key learnings; contribute to report out.
May 49:30-10:00 AM ET

Track Check-in

  • Check-in for anyone with questions, comments, or feedback.
May 410:00 AM-12:00 PM ET

Open testing

  • 11-12 ET will be used for a demo/discussion from the Administration for Children and Families (ACF)
  • Requesting participation from Allscripts, Cerner, Epic and others.
May 41:00-2:00 PM ET

Open discussion & Day 2 Wrap-up

  • Further exploration of topics raised during the Connectathon i.e., deeper dive into CQL.
  • Recap surfaced questions, accomplishments, and key learnings; contribute to report out.
May 42:00-3:00 PM ET

Care Planning Track will be joining the Clinical Reasoning track for their session on PlanDefinition $apply.

May 43:30-3:40 PM ETTrack Highlights Presentation

Track Details

Testing Artifacts

FHIR Bundle resources containing scenario resources for Patricia Noelle are available on GitHub and also loaded into our track's FHIR sandbox.

Diabetes Diet Intervention Scenario

(This scenario is an extension on the May 2022 PCWG Clinician on FHIR use case)

The comprehensive use case illustrates a common scenario for patients with MCC and multiple interdependent interventions. These interventions for diabetic diet planning would be combined with SDoH interventions for food insecurity.

Patricia Noelle’s scheduled visit with her Primary Care Provider, Dr. John Carlson. Patricia is concerned about her weight, which is up 5 pounds, and her increased shortness of breath that comes on with minimal activity. Reviewing her diet and activity goals, she notes the pandemic has worsened her anxiety and caused her to eat more comfort food.

Patricia is at her quarterly checkup with Dr. John Carlson at her primary care clinic. Dr. Carlson captures these goals Patricia has identified for her diabetes control:

Goal #1 - 

  1. Stabilize hemoglobin A1c - HgbA1c <7% by over the next 6 months
    • Goal.description: Stabilize hemoglobin A1c
    • Goal.outcomeReference: observation with HgbA1c LOINC code (most recent) - 41995-2 Hemoglobin A1c [Mass/volume] in Blood

 Goal #2 - 

  1. Control blood sugars within 1-2 hours after eating to < 180 mg/dl
    • Goal.description: Control blood sugars within 1-2 hours after eating to <180 mg/dl

 Goal #3 -  Goal #2 - 4971000119101 

  1. Keep a carb consistent diet consuming 45-60 gms of carbohydrates per meal. 
    • Goal.description: Keep a carb consistent diet consuming 45-60 gms of carbohydrates per meal (LOINC estimated carbs/24 hrs)

[Note: Goal progress provides insight to the effectiveness of the related intervention(s). Use Goal.notes to record the progress on the goal. This would be notes recorded by patient, caregiver, care providers, etc.]

  • [For May 2022 - simple string in the note field for simple note]
  • Note: Goals are often evaluated using Observations

Topic 1: Notes on goals

Dr. Carlson captures the following (in the data source) on his goals for Patricia: [Capture as text notes]

  1. Patricia has been keeping a food diary logging what she eats at each meal. Generally for breakfast and dinner the carb count is within the desired limits. But the carb count at lunch is consistently above the desired limits.  Patricia likes to go out to lunch with her friends and does so 5-6 days a week. Patricia has a very limited income and has started attending events at the Senior Center many afternoons and finds there are snacks and treats often part of the afternoon activities. She is using these activities to access food she can eat as one of her meals for the day.
  2. Patricia's blood sugar logs show her blood sugar is well controlled after breakfast, but after lunch and dinner the values are inconsistent, and often high. And Patricia has begun experiencing low blood sugar events during the night. 

(Discussion Point: Would these notes be in goal.note or progress notes in a system that are handled with another resource element - e.g. documentReference?)

Resource: Goal.notes

Topic 2: Goal with related interventions

2a: Interventions associated with progression towards goals.

  • Intervention #1
    • Patricia is keeping a food diary [intervention]

(Connecthathon Question: is this a ServiceRequest when Patricia is instructed to start a food dairy with an active status and timing of daily?;  Does the serviceRequest remain active until its completed?; will it become a Procedure resource after the food diary is started? Which FHIR resources will be appropriate for sharing the food diary entries - Observation resource?)

      • Carb count is well controlled for breakfast and dinner [outcome]
        • (Procedure.outcome) 709014002 | Compliance with prescribed diet (finding) |SNOMED CT

      • Carb count is not well controlled for lunch [outcome]
        • (Procedure.outcome) 129832003 | Noncompliance with dietary regimen (finding) |SNOMED CT

  • Intervention #2
    • Attention and teaching needs to be done for the lunch meals and afternoon snacking [intervention]
      • (Procedure.outcome) 410114009 | Dietary compliance education (procedure) |SNOMED CT

2b. Use of extension to link interventions to goals

(Connecthathon Question: should an extension be used to link the "intervention" resource to goal? Such as Resource: resource.extension:resource-pertainsToGoal? OR should Goal reference the "intervention" resource using goal.addresses?) note: PCWG approved addition of Procedure to be included in the list of Goal.addresses referenced resources, See JIRA 28213)

Interventions needed to:

  • GOAL: Control blood sugars within 1-2 hours after eating to <180 mg/dl.
    • INTERVENTION: Monitor blood sugars 1-2 hours after meals
      • FHIR Resource: ServiceRequest; Procedure
        • Code: 698472009 | Blood glucose monitoring (regime/therapy) - SNOMED CT

  • FHIR Resource Linking Intervention and Goal:
    • procedure.extension:resource-pertainsToGoal reference GOAL: Control blood sugars within 1-2 hours after eating to <180 mg/dl
      • OR 
    • procedure.code - 698472009 | Blood glucose monitoring (regime/therapy) - SNOMED CT
  • GOAL: Understand (and apply to) meal planning - inherent carb count of foods
    • INTERVENTION: Education about carb counting, meal planning and its application to diabetes disease management
      • FHIR Resource: ServiceRequest; Procedure
        • Code: 6143009 | Diabetic education (procedure) - SNOMED CT

      • INTERVENTION: carb counting
        • FHIR Resource: ServiceRequest; Procedure
        • Code: 416576000 | Carbohydrate counting (regime/therapy) - SNOMED CT
  • FHIR Resource Linking Intervention and Goal:
    • procedure.extension:resource-pertainsToGoal reference GOAL: Understand (and apply to) meal planning - inherent carb count of foods
      • OR (Discussion Point) should Goal.addresses reference the procedure or ServiceRequest? 
    • procedure.code

Topic 3: Concerns/Observations addressed by the goal

Resource: Goal.addresses

Identified Concerns about Patricia:

    1. Diabetes Mellitus
      1. 73211009 | Diabetes mellitus (disorder) |SNOMED CT

    2. Personal diet = Eats highly processed foods because she has limited access to food [SDOH food insecurity concern]
      1. [SDOH food insecurity concern - 445281000124101 - Nutrition impaired due to limited access to healthful foods (finding) -SNOMED CT]

    3. Lack of understanding or coping strategies for food options in social situations 
      1. 18232000 | Difficulty coping (finding) |SNOMED CT

Identified Observations about Patricia:

    1. Patricia's knowledge level related to diabetic diet [Health Concern Education needs]
      1. 1148599007 | Knowledge level of diet regime (observable entity) 

    2. Diabetes poorly controlled
      1.   443694000 | Type II diabetes mellitus poorly (finding)
      2. due to
        1. 129832003 | Noncompliance with dietary regimen (finding) 

Topic 4a: Goal barriers

Resource: Goal.extension:Barrier

Barriers to Diet Control: the following are examples to use:

  • limited education/understanding of diet control for diabetes, carb content of foods;
  • not ready to make changes (willingness), personal diet preferences
  • lack of access to appropriate diet for diabetes,
  • family/situational support, psychological (upbringing - clean your plate;
  • value system (do not waste, what is good for you what is not);
  • emotional connection to food (comfort/stressor...);
  • age access/control of diet/food available; 
  • cognitive ability to manage diet;   
  • psychological fatigue related to dietary restrictions due to long term multiple chronic conditions.

Discussion Point: [Need to capture a barrier and tie it to a goal:

Note: can capture as Observations with relationship to the thing the barrier is on.

Plan to test new PCWG Barrier extension - extension can be Goal.barrier; ServiceRequest.Barrier; NutritionOrder.Barrier, etc.]

Topic 4b: Protective factors

Discussion Point: [What are protective factors?

Note: can capture as extension on goal and requestType resources.

Plan to test new PCWG ProtectiveFactor extension - extension can be Goal.protectiveFactor; ServiceRequest.protectiveFactor; NutritionOrder.protectiveFactor, etc.]

Topic 5: Goal related to other goals

Resource: Goal.extension:goal-relationship

Results in diabetic control goals:

  • Goal A: provider goal = keep A1C under 7.0; (86910-7 Hemoglobin A1c/ goal Blood - LOINC)  (Note: coded goal)
  • Goal B: patient goal of (carb consistent diet) meal carbohydrate count of 45 - 60 gms per meal; control blood sugars within 1-2 hours after eating to <180 mg/dl.; Understand and apply to meal planning the inherent carb count of foods;  (Note: text goal)
  • FHIR Resource Linking Goal and Goal:  
  • Discussion Points:
    • GoalRelationshipType valueset - PCWG planned changes to the valueset - See JIRA
    • Which direction is the linkage - for example:
      • which goal is the "target" goal?
      • is the target goal the goal that is referenced?

Care Team (For future use - edits in progress)

Patricia's Care Team

    1. Related Persons 
      1. Patricia lives with her oldest daughter
      2. Patricia's son provides assistance
      3. Patricia Granddaughter Kayla is coming to live with her because her mother (Patricia's youngest daughter) is incarcerated). 
        1. Kayla is Patricia's care giver - assist Patricia with preparing her meals and also assist Patricia with transportation 
    2. Practitioners

Kayla's Care Team

  1. Related Persons
    1. Patricia  - Kayla's grandmother - provides Formal Kinship Care for Kayla
  2. Providers
    1. Foster Care Agency of NJ (Social Services Organization) is a member of Kayla's care team 
      1. Provides monthly foster-care visits
      2. Provides transportation resources (transportation vouchers) for Kayla to get to her appointments
    2. Ob/Gyn specialist: Dr. Obi Ashwagandha
    3. Behavioral Health Specialist:
    4. Substance Use Disorder Teen Support (through AAA)
    5. Social worker or school guidance counselor 


Precondition: Success Criteria: 

Success Criteria:  

Bonus point:


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