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  1. Care Plan as knowledge asset (protocol, pathway, plan definition, guidelines, etc.) (1)
    1. pull a plan off the shelf and apply it Apply existing knowledge asset to a patient. 
      1. search manually
      2. plan suggested by system based on patient attributes
    2. Pull Apply multiple plans off the shelfto a patient; harmonize before applying to patientupdate or during application
    3. Update the patient care plan when the protocol changes.
      1. detect Detect change; alert appropriate person; record closure of issue
    4. pull a plan off the shelf and tailor it Tailor an existing knowledge asset for a patient.
        pull a plan off the shelf and apply it to
        1. Decline to apply some plan elements - annotate with rationale
      1. Tailor an existing knowledge asset for a patient who already has a plan.
      2. remove plan elements 
      3. authorAuthor/create new protocol? no; out of scope.
      4. clarify: this Clarification: application of plan assets to patients is going to involve clinician decision-making for the foreseeable future
    5. Care plan as a set of planned activities, + concerns, goals, completions, evaluations (2)
      1. See a patient. determine when the patient's plan comes into existence. establish a goal,
        1. Implicit plan exists at any time. CDA "plan" section contains planned interventions, goals, irrespective of explicit "plan" artifact.
        2. a.k.a. non-negotiated plan
      2. Establish a goal & intervention; intervene, evaluate, update plan
      3. Assess system-proposed goals, interventions based on a variety of patient characteristicsinclude non-negotiated plan
    6. Care planning as the process of planning, negotiation, agreement, reconciliation (3, 5)
      1. establish a goal, secure consensus, record
      2. establish a goal, disagree, modify, agree, propose intervention, intervene, evaluate, update plan
      3. subscribe to plan information providers
    7. care coordination: relevant parts of record for communicating with other providers (4, 6)
      1. Of providers, of plans
      2. create plan, communicate referral, illustrate how what second provider gets differs from ccd
        1. automated suggestions for relevance
        2. sending provider approval or modification
    8. Care Plan support for CDS
      1. Detect gaps in care (At trigger event, identify gaps based on source protocol, on payor plan, other asset)
      2. Assess confidence in diagnosis (number of providers in agreement; by experience level)
      3. Identify referrals not completed

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