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Co-sponsor Work Group(s):

(Enter co-sponsor approval dates in Section 6.d Project Approval Dates)


Learning Health System (FHIR Plan Definition and FHIR Clinical Guidelines?

Indicate the level of involvement that the co-sponsor will have for this project:
 Request formal content review prior to ballot
 Request periodic project updates. Specify periodat WGMs
 Other Involvement. Specify details here: 

Interested Parties:

  • CIMI
  • CBCP
  • Public Health
  • O&O
  • EHR


Care plans are a prominent part of multifaceted, care coordination interventions that reduce mortality and hospitalizations and improve disease management and satisfaction. In addition, proactive care planning promotes person-centeredness, improves outcomes, and reduces the cost of care. By design, care plans take a patient-centered approach, both by making comprehensive health data available across providers and settings and through the incorporation of data elements that have not traditionally been included in health IT systems (e.g., social determinants of health [SDH], patient health and life goals, patient preferences). While Care Plans have been developed, they remain paper-based in many U.S. healthcare settings and are not standardized and interoperable across care settings when electronic. While care plans focused on a single disease or condition are unlikely to be tenable for patients with MCC or their providers, existing care plans infrequently address individuals with MCC. Development The development of care plans based on structured data has been proposed as a method for enabling electronic systems to pull together and share data elements automatically and dynamically. Such aggregated data would not only provide actionable information to identify and achieve health and wellness goals for individuals with MCC, but also would reduce missingness and improve quality of point-of-care data for use in pragmatic research. 

The Fast Healthcare Interoperability Resources (FHIR) specification is an open-source standard for exchanging healthcare information electronically based on emerging industry approaches. The FHIR workflow specification includes a CarePlan request resource that may facilitate the transfer of data for an e-care plan across healthcare settings. SMART ( and SMART on FHIR standards include open specifications to integrate applications with health IT systems and may enable the development of an e-care plan application that can integrate with a variety of electronic health record (EHR) systems. 


Clinical Information Model Analysis Mapping and definition (to existing profiles and resources)March 2020
Value Set Definitions June 2020
Care Planning, Plan Definition and Clinical Guidelines Framework for MCC eCare PlanJune 2020
Draft IG (non -balloted, ready for testing)

September 2020

SMART on FHIR App v1.0 (ready for testing)

September 2020

Connectathon 1

September 2020

Connectathon 2January 2021
Connectathon 3May 2021
Connectathon 4Sept 2021
Connectathon 5January 2022
Connectathon 6May 2022

Submit for STU ballot

Target Date:

September 2022

Complete STU Reconciliation

February 2023

Request STU PublicationFebruary 2023
STU Publication DateMay 2023?

Submit for Normative Ballot

September 20232025

Complete Normative Reconciliation

February 20242026

Submit Publication Request

March 2026

February 2024Example: STU Period – 24 months

Example: Submit for Normative Ballot

Example: Complete Normative Reconciliation

Example: Submit Publication Request

Example: Receive ANSI Approval

Project End Date (all objectives have been met)

Enter Project End Date


eCare Plan, Dynamic Care Plan, Multiple Chronic Condition Care Plan, Shared Care Plan
, Comprehensive Care Plan

3.g. Lineage

If your project creates a Post-Release 1 version; indicate the name of the prior product and if it is supplanting, replacing or coexisting with a previous release: