Attendance Page

Submitting WG/Project/Implementer Group

Track Orientation

A webinar will be hosted on TBD date to share further participation information about this track.

This track will use R4 version of FHIR.

Justification and Objectives

This track continues a successful series of connectathons since January 2017 with steady growth of interest in applying evidence-based clinical practice guidelines at the point of care to create and share individualized patient care plans and to manage the ongoing care for patients with chronic disease.  Care Planning is a clinical process, not a single artifact, and Care Management requires integration of FHIR resources for patient care (CarePlan, CareTeam, Goal, Condition, and others) with the definition of computable clinical guidelines and protocols (PlanDefinition, ActivityDefinition) guided by clinical decision support using CQL. This track will be coordinated with the Dynamic Care Planning & Care Coordination track at Clinicians on FHIR where they focus on clinical interoperability and harmonizing differences between the technical and clinical perspectives of FHIR resources.

In addition to advancing the maturity of FHIR resources for evidence-based care planning and care management, this track invites participation by clinicians and implementers who are interested in using these FHIR standards to realize the benefits of comprehensive shared care management coordinated across provider organizations. Two technical scenarios are included that engage the practitioner community to evaluate and demonstrate use of FHIR care management resources for the active management of a patient's healthcare.

This track includes several interrelated use cases:

Related tracks

Recent Care Planning Connectathons

Track Lead

Dave Carlson,

Expected participants

Clinical Scenarios

This track emphasizes a realistically complex care situation where our track participants are progressively creating and organizing a comprehensive suite of test materials that are based on clinical requirements. This scenario illustrates the flow of care plan creation and management with supporting clinical practice guidelines between a patient, his or her primary care provider, consulted specialists, home health care, telehealth care, and family caregivers involved in management of care for one or more health conditions.

Chronic Kidney Disease Care Management

Our track's clinical use case is based on the NIH Chronic Kidney Disease (CKD) Care Plan project. Because frequent transitions of care are common among patients with CKD, an electronic CKD care plan could potentially improve patient outcomes by helping to ensure that critical patient data are consistently available to both the patient and his/her providers. It is also very common for patients with CKD to require care planning for comorbidities; our example patient is also diagnosed with hypertension, diabetes and congestive heart failure.

electronic Long-Term Services and Supports (eLTSS)

The primary objectives of the eLTSS Initiative are: 1) to identify components or data elements needed for the electronic creation and interoperable exchange of person-centered service plans by health care and HCBS providers, payers and the individuals they serve; and 2) to field test these data elements within participating organizations’ electronic systems. The eLTSS data is currently and primarily used by LTSS service providers and care managers and resides in case management systems and LTSS provider systems. This IG is designed to streamline the ability to exchange and make this data available to all members participating in the care of the beneficiary (patient) including clinical and non-clinical care providers as well as the beneficiary and their representative(s).

eLTSS participation at the connectathon will be to test the eLTSS FHIR IG. We will tie into the CKD project as time allows and will leverage the relevant pieces of the CKD patient personas.

Test FHIR Servers

Technical Scenarios

Create a new care plan from guideline definitions

Retrieve a patient's care plan(s) and clinical data

Search for a patient's care plans(s) and associated resources (Conditions, Goals, activity references, CareTeam)

System Roles

Clinical Practice Guideline Provider

Share standards-based, computable care protocol definitions, including:

A FHIR server (version R4) should support the following resources for care plan creation and care management

Care Plan Creator

Care Plan Consumer

Clinical Data Provider

A FHIR server (version R4) should support the following resources for care planning:

A FHIR server is available for testing with sample data that represent one or more care plan scenarios.