Maintaining CarePlan(s) and ServiceRequest(s)
- Erik Nielsen
- Alex Andbæk Nielsen
- Mikkel Maribo (Unlicensed)
Technical description of how to maintain CarePlan (status and involved care teams), and how to maintain ServiceRequest
- 1 Maintaining a CarePlan
- 2 Maintaining a ServiceRequest
- 2.1 Setting the ServiceRequest Sharing Approval Policy
- 2.2 Setting the ServiceRequest Measurement Regime
- 2.3 Managing offering ServiceRequest as extra activities
- 2.4 Maintaining ServiceRequest Status
- 2.5 Setting Measurement Ranges and possibly Reference Base
- 2.6 Controlling the Trigger Enablement
- 2.7 Setting the Document Sharing Approval Policy
Maintaining a CarePlan
Maintaining of a CarePlan involves or might involve:
setting the appropriate status
adjusting of involved CareTeam(s)
Maintaining the CarePlan Status
Over the lifecycle of a CarePlan, its status might change. Adjustment of CarePlan.status can be performed through CarePlan Update by:
Setting the
CarePlan.statusSetting the scheduled status changes in
CarePlan.ehealth-statusschedulescheduled changes are applied when the ApplyPlannedChangesJob is run.
Allowed status changes:
From draft to active, entered-in-error, revoked
From active to onhold, completed, revoked
From onhold to active, completed, revoked
Enforced constraints on the duration of scheduled status with value ‘on-hold’.
When setting scheduled status changes it is automatically enforced how long the CarePlan can be planned as paused. This is done to prevent patient plans from being forgotten in a paused state.
When setting CarePlan.ehealth-statusschedule:
If no further status changes are planned by the user, then the infrastructure will automatically insert a planned change back to ‘active’ 7 days after the start of ‘on-hold’
The maximum duration of a planned ‘on-hold’ status is 30 days.
CarePlan automatically maintains a status history CarePlan.statushistory:
The status history is maintained as a list of ehealth-statusHistory objects each containing:
A status.
The period the status was set.
The history is automatically updated when the status is (regardless of whether the status is set manually or is a scheduled change):
A new entry is added with the new status and an open-ended period that started at the time of the status change.
The
Period.endin the entry for the previous status is updated to be the same as the start of the new entry.One should consider the period to be exclusive-end to avoid confusion as the
Period.endof one historic status and thePeriod.startof the next have the same timestamp.
Maintaining the set of CareTeam(s) involved in a CarePlan
Over the lifecycle of a CarePlan, the set of CareTeam involved might change. Adjustment of CareTeam involved can be performed in several ways:
Through CarePlan Update
Setting the
CarePlan.careTeamSetting the scheduled team changes in
CarePlan.ehealth-teamscheduleThrough CarePlan$update-care-teams
Through EpisodeOfCare$update-care-teams (which also updates all CarePlan related to the EpisodeOfCare)
CareTeam Handover and Unhandled Tasks
When adjusting the involved CareTeams, consideration should be made as to the handling of Task resources about the CarePlan, its measurements or other resources related to the CarePlan. For employees, being part of a CareTeam involved in the CarePlan (and/or EpisodeOfCare) is a prerequisite to accessing the CarePlan, related measurements and so forth. Access to Task on the other hand is governed by being identified in the Task explicitly. Therefore, handover from one set of CareTeam to another could entail:
A period where both sets of CareTeam are involved in the CarePlan. In this period, both sets of CareTeam will be able to access CarePlan, measurements and so on as well as the related Task resources. The set of CareTeam parting involvement should handle Task resources created before the period.
Adjusting the CareTeam(s) designated as Task.taskResponsible for existing Task resources to include the set of CareTeam joining the CarePlan.
Maintaining a ServiceRequest
When maintaining a ServiceRequest, an employee must perform adjustment of:
ServiceRequest.occurrence[x]which must contain a measurement regime with a defined starting date/time.ServiceRequest.statuswhich must be set according to the situation, see below.
An employee should possibly consider (typically one-off) adjustment of:
Sharing policy in
ServiceRequest.ehealth-sharingPolicySharing Approval Policy in
ServiceRequest.ehealth-sharingApprovalPolicyReuse criteria in
ServiceRequest.ehealth-reuseCriteria
An employee should possibly consider continuous adjustment of:
The CareTeam(s) involved in daily monitoring etc. in
ServiceRequest.careTeamMeasurement ranges in
ServiceRequest.ehealth-referenceRangeAny reference value needed for triaging based on relative measurement range(s)
Setting the ServiceRequest Sharing Approval Policy
The Sharing Approval Policy of a ServiceRequest expresses whether the approval for registering documents is automated or done manually. It is defined in ServiceRequest.ehealth-sharingApprovalPolicy.
This extension is Optional. If set, it can have one of two values:
automatic- used when the approval of registering documents is wanted to be done automatically.manual- used when the approval of registering documents should be done manually.
The initial ServiceRequest.ehealth-sharingApprovalPolicy is a copy from the ActivityDefinition, made at the time of creation.
The sharing Approval Policy is set using a conceptMap
The ConceptMap http://ehealth.sundhed.dk/ConceptMap/activitydefinition-code-to-perform-sharing is used to determine if the Sharing Approval Policy should be set based on the ServiceRequests code: http://ehealth.sundhed.dk/vs/activitydefinition-code
The column “Activitydefinition-code-to-perform-sharing” is used to decide whether the Sharing Approval Policy should be set for the given activitydefinition code, by use of the ConceptMap.
Setting the ServiceRequest Measurement Regime
The measurement regime of a ServiceRequest expresses when the activity described in the ServiceRequest is supposed to take place. The measurement regime is defined in ServiceRequest.occurrence[x] by use of one of the alternatives:
occurrenceDateTime- used when the activity should be performed at a specific point in time, that is date and time.occurrencePeriod- used when the activity should be performed once during a period. The period may be open, that is, without the period end being specified.occurrenceTiming- used when the activity should be performed in a recurring manner, for instance, each week or at specific days or times of day.
The initial measurement regime in ServiceRequest.occurrence[x] is a copy from the PlanDefinition/ActivityDefintion made at the time of creation (see Creating Care Plans | Applying the PlanDefinition) and typically, it contains no starting date/time.
Timing expression copied from PlanDefinition/ActivityDefinition created in KAM
If recurring timing expression is copied from PlanDefinition/ActivityDefinition created in KAM the following transformation is needed for the infrastructure to resolve the timing:
For periodUnit wk (weekly)
If PlanDefinition.action[].timingTiming.repeat.periodUnit is wk (Week), apart from ServiceRequest.occurrenceTiming.repeat.boundsPeriod.start being mandatory, the following changes are required for the expression to be resolvable by the infrastructure:
Example
Expression from PlanDefinition.action[].timingTiming.repeat created in KAM. (Intention from KAM: Every second Monday at 10 AM, for 2 months)
"repeat": {
"frequency": 1,
"period": 2,
"periodUnit": "wk",
"dayOfWeek": [ "mon" ],
"timeOfDay": [ "10:00:00" ],
"boundsDuration": {
"unit": "mo",
"value": "2"
}
}Must be transformed to:
For periodUnit other than wk (weekly)
Expression from PlanDefinition.action[].timingTiming.repeat created in KAM. (Intention from KAM: Every third day at 10 AM, for 2 months)
"repeat": {
"duration": 2,
"durationUnit": "h",
"frequency": 1,
"period": 3,
"periodUnit": "d",
"timeOfDay": [ "10:00:00" ],
"boundsDuration": {
"unit": "mo",
"value": "2"
}
}Must be transformed to:
Managing offering ServiceRequest as extra activities
The extension includeAsExtra on ServiceRequest, is used to determine whether the ServiceRequest should be provided as an extra activity in the $get-patient-procedures result. The value for includeAsExtra is copied from the corresponding PlanDefinition.action during creation of the ServiceRequest ($apply operation), and the value can be updated on any individual ServiceRequest.
The value for includeAsExtra can be set through the TimingPicker. The default value for includeAsExtra is false when not scheduled or adhoc, and true when a schedule has been configured.
Maintaining ServiceRequest Status
Over the lifecycle of a ServiceRequest, its status might change. Adjustment of ServiceRequest.status can be performed through ServiceRequest Update by:
Setting the
ServiceRequest.statusSetting the scheduled status changes in
ServiceRequest.ehealth-statusschedulescheduled changes are applied when the ApplyPlannedChangesJob is run.
The status should be set according to the situation:
revokedwhen not to be performed for the particular Patienton-holdwhen depending on one or more submissions on another activity in the plan - this is the initial state when this is the case.activewhen any required device has been provided to the citizen and the measurement regime has been adjusted to contain the starting date/timecompletedwhen fully or adequately performed
Allowed status changes:
From draft to active, entered-in-error, revoked
From active to onhold, completed, revoked
From onhold to active, completed, revoked
From revoked to active, onhold
Setting Measurement Ranges and possibly Reference Base
See Creating and Maintaining Measurement Ranges.
Situation | FHIR ServiceRequest | FHIR ActivityDefinition (referenced by ServiceRequest) | FHIR Goal |
|---|---|---|---|
The absolute triaging rule used, no absolute measurement range defined in ServiceRequest | No The user should define an absolute measurement range (see Measurement Ranges | Absolute Measurement Ranges). |
The
| Not used (but can co-exist with the use of relative triaging rule/relative measurement range). |
The relative triaging rule used, no relative measurement range defined in ServiceRequest | No The user should define a relative measurement range (see Creating and Maintaining Measurement Ranges | Setting up Relative Reference Ranges and a Reference Base). |
The
| Possibly defined, otherwise see the row below. |
Relative triaging rule used, no reference base defined | At least one | The user should define a reference base (see Creating and Maintaining Measurement Ranges | Setting up Relative Reference Ranges and a Reference Base) |
Controlling the Trigger Enablement
In a PlanDefinition, action triggers can be added for the comprised activities as described in Managing Telemedicine Packages | Setting up one or more actions as trigger for an action in PlanDefinition. When the PlanDefinition is $apply'ed to a CarePlan, it is reflected in each of the resulting ServiceRequest whether it is depending on trigger conditions to be met, see Creating Care Plans | Action Triggers and Trigger Conditions. It is reflected in the ServiceRequest element triggerEnablement whether it is dependent or not. By default (at the time of $apply):
ServiceRequest.triggerEnablementis set toNO_TRIGGERwhen the ServiceRequest is not depending on trigger conditions. It may trigger other ServiceRequest, though.ServiceRequest.triggerEnablementis set toTRIGGER_ENABLEDif it depends on trigger conditions. TheServiceRequest.statusis set toon-hold.
When trigger conditions are fulfilled, a triggerEnablement of TRIGGER_ENABLED changes to TRIGGER_DONE automatically as described in Behind the Scenes | Automated Processing of Action Triggers and Trigger Conditions. At this point, even if the trigger conditions are fulfilled again, there will be no change.
It is possible to control, per ServiceRequest, whether it shall react to action triggers. The following manual changes of triggerEnablement are possible by ServiceRequest Update:
TRIGGER_ENABLEDchange toTRIGGER_DISABLED- to disable triggering of the depending ServiceRequest, for instance, if the citizen is on vacation.TRIGGER_DISABLEDchange toTRIGGER_ENABLED- to re-enable triggering of a depending ServiceRequest, for instance, if the citizen has returned from vacation.TRIGGER_DONEchange toTRIGGER_ENABLED- to re-enable triggering of a depending ServiceRequest even though it has been triggered already.
When re-enabling, it should be considered what is the appropriate status of the ServiceRequest. For a triggering behaviour such as activation, the ServiceRequest status should manually be set to on-hold.
Setting the Document Sharing Approval Policy
The document registering approval policy of a ServiceRequest set in ServiceRequest.ehealth-sharingApprovalPolicy expresses whether submitted measurement data (for instance measurements or questionnaire responses) for the activity shall be automatically approved for document sharing or whether manual approval is required.
When set, the value of ServiceRequest.ehealth-sharingApprovalPolicy controls how approval for document registering is handled per submitted measurement:
manual, a clinician must manually approve each submitted measurement for document registeringautomatic, the eHealth Infrastructure automatically creates the approval for document registering
If not set, the default behaviour is manual.