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Creating Care Plans

Creating Care Plans

Technical description of how to create CarePlans by applying a PlanDefinition.

Applying a PlanDefinition to create CarePlan(s)

CarePlan resources are created by applying a PlanDefinition.

PlanDefinion are non-Patient. A PlanDefinition likely references a number of ActivityDefinition defining what activities in what order constitute the plan, possibly with default measurement ranges. On applying a PlanDefinition, Patient specific counterparts to the PlanDefinition and ActivityDefinition resources are created as CarePlan and ServiceRequest resources, respectively.

Patient-specific CarePlan and ServiceRequest resources and their linking to PlanDefinition and ActivityDefinition resources.

 

Finding The Appropriate PlanDefinition

Filtering applied on finding appropriate PlanDefinition could involve the following elements of PlanDefinition:

  • code

  • status set to active

  • ehealth-recommendation

  • ehealth-intendedAudience

  • useContext

 

Element in PlanDefinition

Example Value(s)

Element in PlanDefinition

Example Value(s)

status

active

ehealth-recommendation

Recommended

ehealth-intendedAudience

PlanDefinition intended for use in, say, Esbjerg Municipality

reference to FHIR Organization for Esbjerg Kommune (Esbjerg Municipality)

useContext

PlanDefinition intended for COPD in Telemedicine Solution TELMA:

 

Possibly, the following elements (and others) could be used as well:

  • title

  • version

  • publisher

Applying the PlanDefinition

A PlanDefinition is applied through the PlanDefinition$apply operation. This creates a number of CarePlan resources (typically one) and a ServiceRequest resource for each non-group action in the PlanDefinition.action (please note that PlanDefinition.action enables a recursive construct through its PlanDefinition.action.action).

The $apply operation have two modes. If used with POST, it will persist the CarePlan and ServiceRequest resources, and return the root CarePlan. If used with GET, it is transient, and will return a FHIR transaction bundle with the CarePlan and ServiceRequest resources.

The resources in the transaction bundle can be modified by the client, before being executed against the careplan service. It is also possible to add other requests to the transaction bundle. For example to create Goals.

The characteristics and values mentioned below are highlighting aspects of the created resources. It is not a complete description of all their values.

The resulting CarePlan(s) has:

  • a reference to its corresponding PlanDefinition through CarePlan.instantiatesCanonical.

  • status set to draft

 

The EpisodeOfCare passed as input to $apply is referenced from the CarePlan. The EpisodeOfCare can reference one or more Condition (through EpisodeOfCare.diagnosis.condition) while the CarePlan can reference one only (through CarePlan.addresses). At time of $apply, the infrastructure picks one Condition at random in case the EpisodeOfCare references more than one.

It is the responsibility of the user invoking $apply to ensure that the proper Condition is referenced from the CarePlan, and if needed, to replace the current through a CarePlan Update operation.

 

Each resulting ServiceRequest resource has:

  • a reference to its corresponding ActivityDefinition

  • status set to draft, with the following exception:

    • status is set to on-hold when the ServiceRequest is a depending ServiceRequest (see below)

  • a copy of the corresponding ActivityDefinition reuse criteria, if any

  • a copy of the corresponding ActivityDefinition sharing policy, if any

  • a copy of the corresponding ActivityDefinition document registering approval policy, if any

  • a copy of the corresponding ActivityDefinition measurement ranges, if any

  • an initial, relative measurement regime in ServiceRequest.occurrence[x] which is a copy of the measurement regime appearing for the action, if any. Note that the measurement regime in PlanDefinition.action.timing[x] takes precedence over ActivityDefinition.timing[x] for ActivityDefinition referenced in PlanDefinition.action.definition.

  • a copy of the includeAsExtra extension for the corresponding PlanDefinition.action . If the PlanDefinition.action does not contain the extension, and extension with value false is added to the ServiceRequest

 

At some point before a ServiceRequest has status set to active, its measurement regime must be defined with a starting date/time.

It is expected that a Telemedicine Solution in some form provides information about the intended time-wise layout of activities captured in the PlanDefinition and ActivityDefinition resources which the citizen’s plan is based on. This includes intention captured in:

  • PlanDefinition.action.timing[x] (which is copied to ServiceRequest.occurrence[x] initially, if present)

  • PlanDefinition.action.relatedAction (actionId, relationship and possible offset[x])

  • ActivityDefinition.timing[x] in ActivityDefinition referenced from ServiceRequest.instantiatesCanonical - This timing could specify a duration.

It is expected that a Telemedicine Solution intended for employees guides the user in setting ServiceRequest starting date/time even when initially set with status on-hold as is the case for a depending ServiceRequest. A depending ServiceRequest with status set to on-hold (as described below) can have its status changed automatically to active when its trigger conditions are met. See https://ehealth-dk.atlassian.net/wiki/spaces/EDTW/pages/538935313/Behind+the+Scenes#Automated-Processing-of-Triggering-Conditions for further details on this automatic change.

Action Triggers and Trigger Conditions

A PlanDefinition can contain one or more action trigger where each action trigger identifies the depending action/ActivityDefinition and the triggering action/ActivityDefinition (one or more) that it depends on. See https://ehealth-dk.atlassian.net/wiki/spaces/EDTW/pages/1696137281/Managing+Telemedicine+Packages#Setting-up-one-or-more-actions-as-trigger-for-an-action-in-PlanDefinition for how to define an action trigger, including how to specify trigger conditions, trigger behavior and reaction to perform when conditions are met.

In the PlanDefinition.action[i].actionTrigger (see https://ehealth.sundhed.dk/fhir/StructureDefinition-ehealth-plandefinition-definitions.html#PlanDefinition.action.extension:ehealth-actionTrigger )

  • a depending action is the action for which the actionTrigger is defined.

  • one or more triggering actions are those that the depending action is depending on and for which trigger conditions and behavior is defined in the trigger action.

 

When the PlanDefinition is applied to CarePlan and ServiceRequest resources, the action trigger and its trigger conditions manifest themselves in the ServiceRequest resources as follows:

  • A depending ServiceRequest (related to an ActivityDefinition which is a depending action) has

    • trigger-enablement set to TRIGGER_ENABLED.

  • A triggering ServiceRequest (related to an ActivityDefinition which is a triggering action) has

 

In the example below, a PlanDefinition containing an action trigger where activity “action[2]” has dependencies to “action[0]” and “action[1]” has been applied to a CarePlan and ServiceRequest resources:

  • The depending ServiceRequest SR2 (related to ActivityDefinition AD2, with has action trigger set) has trigger-enablement set to TRIGGER_ENABLED.

    • In this case, the action trigger for the action[2] (ActivityDefinition AD2) has trigger reaction set to “activation from on-hold to active”, which is why the ServiceRequest SR2 is initially with status set to on-hold.

  • The triggering ServiceRequest resources SR0 and SR1 have:

    • trigger-enablement set to NO_TRIGGER (because they themselves are not depending on others)

    • meta.tag set to trigger

 

CarePlan with trigger actions defined in the PlanDefinition. The ehealth-actionTrigger is a backbone element in PlanDefinition, not a resource on its own. The use of an action trigger is reflected in elements in the ServiceRequest resources.