The eHealth Infrastructure uses the CareTeam resources in the following cases:

1. At Practitioner login to the infrastructure

2. For access control to resources like EpisodeOfCare, CarePlan, Communication and Task as well as related, other resources such as Observation, QuestionnaireResponse, Media and ClinicalImpression.

3. As a resource or entity describing which Practitioners are involved in working with which EpisodeOfCare, CarePlan and associated Communication and Task resources

Content

The CareTeam FHIR Resource profile

See the eHealth Implementation Guide for the model for the CareTeam complete resource profile: https://ehealth.sundhed.dk/fhir/StructureDefinition-ehealth-careteam.html

CareTeams are managed in the Organisation service or using the Clinical Administrative Application (Danish: KAM).

See https://ehealth.sundhed.dk/fhir/CapabilityStatement-organization.html

CareTeam focus area

The focus area(s) of the CareTeam is described in CareTeam.reasonCode which can be set to several CodeableConcept for conditions that the CareTeam takes care of, for instance, Coding for COPD:

CareTeam description

CareTeam participant

The CareTeam.participant lists the members of the CareTeam.

The members of CareTeams are managed in municipalities and regional user management systems.

If the Practitioner roles in the security token are bound the an existing CareTeam in the infrastructure, the eHealth Infrastructure automatically add Practioners as a CareTeam.participant.member during the login.

There is no effect and there is no need for an organization or user managing a CareTeam to add practitioners to the CareTeam participant list.

See also:

• Token Based Security

• Behind the Scenes | Handling at Login.

Creating a CareTeam

A CareTeam is created by performing CareTeam Create or creating the CareTeam using the Clinical Administrative Application.

As noted below, there are requirements for a CareTeam to be eligible for use at Practitioner login.

Managing a CareTeam

Changes to a CareTeam can be performed by CareTeam Update.

Setting the CareTeam Status

The CareTeam.status is changed by performing CareTeam Update.

The following diagram describes the status transition flow, for a CareTeam resource, which is implemented by the Clinical Administrative Application.

Open

CareTeam to be eligible for use at Practitioner login

For a CareTeam to be eligible for use at Practitioner login, it must have:

• status set to active

• period which is set where:

  • period.start is before or equal to the date and time of login

Prevent the use of a CareTeam at Practitioner login

To prevent the use of a CareTeam at Practitioner login, update:

• status to inactive

  • possibly set period.end to the current datetime

The Infrastructure currently does no automated inactivation of CareTeam upon reaching a CareTeam.period.end.

Best Practices

• Name:

  • Provide a meaningful name so easy the select the right CareTeam when needed. A good name for a CareTeam should reflect its purpose, focus, or role within the care process. Here are some tips and examples:

    • Be Specific: Include details like the patient, condition, or type of care provided.

    • Be Concise: The name should be clear and easy to understand.

    • Include Context: Reference the setting (e.g., hospital, home care) or role (e.g., surgical, palliative).

    • Avoid Ambiguity: Ensure the name is unique enough to prevent confusion with other teams.

    • Examples of CareTeam names (condition and location specific):

      • “Aarhus North Diabetes Team”

      • “Region South COPD team”

1. Document Timeframes

   • Use the period element to define the timeframe for the team’s activities. This is essential for tracking when the team is operational.

2. Status:

   • Specify the current state of the team using the status element (e.g., active, inactive, planned). This ensures clarity about the CareTeam’s validity.

3. Purpose or description

   • Specify the overall purpose of the CareTeam using the Note.text(see above for KAM use), such as managing a specific diagnosis or organisation citizens care.

4. Add intended telemedicine solution(s)/project(s).

   1. Populate useContext to specify which solutions on the eHealth infrastructure that the CareTeam is intended for (e.g. TELMA, K-PRO etc..

5. Add relevant metadata (focus area)

   • The focus area(s) of the CareTeam shall be described in CareTeam.reasonCode. This should be set to several CodeableConcept for conditions that the CareTeam takes care of.

6. Add Managing Organization

   • Populate managingOrganization to specify which organization oversees the team.

7. Add participating organizations

   • Populate participant.member to specify which organization (e.g. municipalities and regions) are participating in the team.