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Purpose and Overview

This storyboard adapts and extends the patient persona for Betsy Johnson, created by the Electronic CKD Care Plan Working Group of the National Institutes of Health’s (NIH) National Institute of Diabetes and Digestive and Kidney Diseases, to address challenges with the transfer of health information and transitions of care for patients with chronic kidney disease (CKD)Electronic care plans are intended to facilitate longitudinal transfer of key patient data across settings, providing access to the patient and all health care professionals who provide care to the patient. Because frequent transitions of care are common among patients with CKD, an electronic person-centered care plan, based on FHIR standards, could potentially improve patient outcomes by helping to ensure that critical patient data are consistently available to all members of her care team.

Although the NIH working group efforts do not directly address the formation and management of care teams for multidisciplinary and multi-provider care, the patient and provider personas illustrate a realistically complex scenario for care team analysis. The personas, including Betsy Johnson, are fictitious individuals whose stories are based on interviews with actual patients and care providers, plus the challenges and barriers they face while managing chronic health conditions.  Key elements from Betsy's persona are summarize in this document, but see the original NIH persona description for more context on the perspectives of each care team member.

Patient Profile: Betsy Johnson


  • Type 2 diabetes mellitus (DM), onset 20 years ago
  • Progressive chronic kidney disease (CKD), onset 10 years ago
  • Diabetic retinopathy with visual loss, onset 6 years ago
  • Sedentary lifestyle, onset 5 years ago
  • Dyslipidemia and peripheral vascular disease, onset 4 years ago
  • Congestive heart failure (CHF), onset 2 years ago
  • Anxiety, onset nearly 1 year ago

Care Team

The NIH CKD care plan working group created personas for six core members of Betsy's care team. They are included in this summary table, along with a few additional members of the multidisciplinary care team, e.g. the care coordinators, community service organizations, and home health care providers. These care teams and members are not a complete picture for a patient like Betsy, who is living with three chronic conditions. The care team for nephrology was expanded to illustrate a specialty care team from a different provider organization. However a similar care team for diabetic care is not included here, e.g. to include an ophthalmologist and podiatrist along with their organizational teams.

Member NameRoleRelationship to BetsyComment

Betsy Lives with

Lives in another city
Debra SmithCare Coordinator
Rose Valley Primary Care
Dr. John CarlsonPrimary Care Provider
Rose Valley Primary Care
Maria Gonzalez, RDNutritionist
Rose Valley Primary Care
Dr. Vince JonesNephrologist
Nephrology Clinic
Sarah KingCare Coordinator
Nephrology Clinic
Multidisciplinary Care Team

Nephrology Clinic
Meals-on-Wheel (To Be added)

Community Services
Home health ServicesHome health aid service (SNOMED 385781007) 
Home health agency


These use case scenarios were created by Motive Medical Intelligence in support of HL7 FHIR connectathons for care planning and care management. The scenarios illustrate interactions among Betsy Johnson's care team members during routine care and office visits.

Wednesday, November 1, 2017 – Periodic System Run (Day 1)