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Alternative Schedule for week of September 14-18

(Monday = PCWG Co-Chair call)


Tues 5- 6:30 ET-

Overview of all tracks 1.5 hours (30 min each)

  • 5:00-5:30 Care coordination
  • 5:30-6:00 Complex condition
  • 6:00-6:30 Multiple Procedures

Wed 5 -6:30 ET

Launch meetings for each track (30 min meetings each)

  • 5:00-5:30 Care coordination
  • 5:30-6:00 Complex condition
  • 6:00-6:30 Multiple Procedures (MP teaching 4-7)

Thurs 5 - 6:30 ETWork day - could have individual calls set up for each topic...

Fri 5-6:30 ET

Synchronous report outs for all tracks/discussion (1.5 hours, 30 minutes for each topic)

  • 5:00-5:30 Care coordination
  • 5:30-6:00 Complex condition
  • 6:00-6:30 Multiple Procedures

Below is planning-in-progress


  1. Applying evidence-based clinical practice guidelines at the point of care to create and share individualized patient care plans and to manage their ongoing care
    1. Patient and person-level information sharing across acute, ambulatory, post-acute care settings, community-based organizations, and patient digital mobile devices. 
    2. Alignment across multiple care paradigms.
    3. Coordination across multi-functional groups (patient/caregivers; providers; community care; etc)
    4. Management of  health and social needs
    5. Sharing multiple assessments, outcomes, barriers, preferences, etc - based on need (i.e. need to know)
    6. Ability to provide the "big picture" ensuring the right information  
    7. Support  secondary uses of care planning and management information 
    8. The role of the "empowered patient/caregiver"
  •  Specific clinical scenarios are provided for Hypertension care management and COVID-19 ED severity risk assessment, but participants are invited to share work on use of clinical guidelines for other care management scenarios.
  • Assess clinical and functional validity (workflows, clinical use cases, clinical information, etc. ) and alignment of care coordination FHIR-based initiatives. The primary focus is not on the "how" but more on the "what" the clinical/functional need is. 

Discussion Topics: 

Specific questions/discussions based on observances at the Technical Connectathon and other previous experiences.  

CarePlan Resource (R5 Current)

  • Need for Care Plan owner/monitor/custodian
  • Need for various elements available in CarePlan.activity.detail to be used when using activtyReference instead

Identified Issues

  1. JIRAs submitted by Gay
    1. Care Plan custodian or owner is needed
      1. Per Gay, Zulip discussion with Lloyd - Lloyd agrees and suggest that author be renamed to Custodian (responsible party). However, what if the author is a device, how will custodian be represented?
      2. Stephen agrees that author and custodians are different elements conceptually. 
    2. Goal element is needed with Activity when using reference
    3. Reason.reference element is needed to be able to be used within Activity when using activity outcome reference:
  2. MCC is not balloting until Sept 2022. Some of the changes have been made in the continuous build. 
  3. CarePlan.activity need a reference to Goal (similar to activity.detail.goal) - have a current work-around. 
    1. Suggested Resolution: 
      1. move goal and reason elements up to activity


Care Coordination/Care Management Scenarios

  1. Acute Patient Admission 
  2. Payer Case Management and Disease Management
  3. Rehab Admission 
  4. Discharge To Home  
    1. Home Health Care 
    2. Community care
    3. Personal care
  1. Care Team management 

    1. Payer Disease Management/Case Management Team Transactions
    2. Rehabilitation Care Team Transactions 
    3. Out Patient Community Care Team Transactions 
    4. Patient Care Planning

Longitudinal Care Planning 

             Longitudinal Care Team, Long term cross incident and condition care planning and oversight 

NameRoleRelationship to the PatientClinical WorkflowExpected Outcomes Associated Encounter (Episode of Care) Steps (workflow) FHIR Resource NeededComments


Care Providers

-- Care Team members

Payer Care Manager/Disease Manager

(Scenario - e.g. Inpatient setting) -
NameRole Relationship to Patient Clinical WorkflowExpected Outcomes Associated Encounter (Episode of Care) Steps (workflow) FHIR Resource NeededComments

(Scenario - e.g. Care Coordination) 

RoleRelationship to PatientClinical WorkflowExpected OutcomesAssociated EncounterSteps FHIR ResourceComments

(Scenario - e.g. Rehabilitation Care Team)

         Care Team engaged during Pat's transfer to and during on site rehabilitation stay 

NameRole Relationship to PatientClinical WorkflowExpected OutcomesAssociated EncounterStepsFHIR ResourceComments

(Scenario - e.g. Outpatient /Community Care Team)

       Care Team engaged on Pat's discharge to home 

NameRoleRelationship to Patient Clinical WorkflowExpected OutcomesAssociated EncounterSteps FHIR ResourceComments

Care Team Management


  1. CQF - FHIR Clinical Guidelines - See examples

Patient Preferences

Resources/Workflow Issues

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