Overview

The CarePlan has only one type of responsibility:

1. CareTeam - the practitioners who perform actions at the episode of care level.

Episode of Care responsibilities

The Episode of Care is in the eHealth infrastructure registered with three types of responsibilities:

1. ManagingOrganization - custodian of the patient's data

2. CareManagerOrganization - holds formal responsibility for the patient's episode of care

3. CareTeam - the practitioners who perform actions at the episode of care level.

Episode of Care ManagingOrganization

This organization is the custodian of the patient's data on the eHealth infrastructure and is responsible for data control, as required by GDPR.

This top-level organization controls the patient's data, is used for reporting and billing, and does not change. The Managing Organization remains the same even if a patient relocates. If a patient moves to a different region or municipality, a new Episode of Care must be created based on their new address.

The Managing Organization is typically a Region or a Municipality.

Usage in the eHealth Infrastructure

The managing organisation is used in e.g. communication resources, when they are created in the eHealth Infrastructure. See https://ehealth-dk.atlassian.net/l/cp/SSX623xA

RBAC - Access Control

The managing organisation is controlled as part of role-based access control for reporting. See https://ehealth-dk.atlassian.net/wiki/spaces/EDTW/pages/1695842461/Access+Control+in+eHealth+Services#Reports

CareManagerOrganization:

This organization holds formal responsibility for the patient's episode of care. The formal responsibility can only be changed when the receiving CareManagerOrganization accepts it.
Examples are:

1. A department in a hospital (usually a descendant of the ManagingOrganization)

2. or a General Practitioner.

Team:

The Team is the group of practitioners who perform actions at the episode of care level.
The practitioners have roles, like "behandlingsansvarlig" or "bestillingsansvarlig" and are related to the patient's episode of care through a CareTeam. Practitioners in the Team can work across different CarePlans.
Their actions involve:

1. assigning new CarePlans to the patient's episode of care,

2. closing or pausing existing CarePlans,

3. assigning new CareTeams to an active CarePlan.

CarePlan responsibilities

The CarePlan has only one responsibility: the CareTeam.

CareTeam

The CareTeam holds references to one or more CareTeams that have operational responsibility for the patient's CarePlan.
The practitioner's CareTeams are registered at the municipality and/or regional user management systems (IdP). The eHealth infrastructure automatically updates the CareTeam/Practitioner relation when a practitioner logs into the eHealth Infrastructure.
Practitioners with privileges can change the CareTeam at the CarePlan level.

Example

The following picture illustrates an example of the responsibility model.

Points of Interest:

• EpisodeOfCare.managingOrganization: This top-level organization controls the patient's data, is used for reporting and billing, and remains constant. For example, in the provided example, it's "Region Midt"

• EpisodeOfCare.careManagerOrganization: This organization has formal responsibility for the patient's care. It can change but typically stays within the same managing organisation. See Responsibility with General Practitioner as caremanagerOrganization for an example. In the example above the careManagerOrganization is “Lungemedicinsk Afdeling”.

• EpisodeOfCare.team: This administrative team consists of practitioners with the authority to assign new CarePlans to the Patient's EpisodeOfCare. The Team can be changed with the right permissions, and the responsibility history is stored in EpisodeOfCare.teamHistory. Examples are "Behandlingsansvarlig and Administrativt Personale”

• Careplan.careTeam: This operational team monitors the execution and progress of the patient's CarePlan. It also includes clinical practitioners who adjust plans and approve results for publishing. Operational teams can also involve practitioners with service and support roles. CareTeams on CarePlans can change, and their history is recorded in CarePlan.ehealth-teamHistory. Examples are “Sundhedsfaglig and Sundhedsfaglig monitoreringsansvarlig”