xCaliber healthCare Data Mesh

CarePlan

Overview

The CarePlan API empowers healthcare developers to seamlessly create, manage, and coordinate patient care plans, enhancing collaboration among healthcare professionals and improving patient outcomes within clinical workflows. By integrating this API, developers can optimize care coordination, ensure adherence to treatment plans, and foster effective communication across the healthcare ecosystem for comprehensive and patient-centered care.

Use Cases

  • Care Coordination - Create personalized care plans for patients across healthcare settings.
  • Condition Management - Build care plans addressing treatment goals and activities for specific conditions.
  • Patient Monitoring - Continuously update care plans as per changes in patient’s status and needs.
  • Integrated Care Teams - Share care plan data with all care team members involved in patient’s care.
  • Treatment Timelines - Map out detailed schedules of care activities and milestones in care plans.
  • Health Tracking - Include relevant vitals, observations required in care plan activities.
  • Patient Engagement - Surface care plan details on patient portals to improve adherence.
  • Population Analytics - Analyze care plans data to identify gaps and best practices.
  • Workflow Integration - Incorporate care plan activities like tasks into clinical workflows.
  • Referrals Management - Share specialist care plans for seamless transitions and coordination.

EHR Data Model

EHRSupported?Mapped Source Object
AthenaCCDA Patient Care Plan
ElationN/A
EpicN/A

Object Definition

{
  "resourceType": "CarePlan",
  "id": "example",
  "text": {
    "status": "additional",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n      <p> A simple care plan to indicate a patient taking their weight once a day because of obesity.</p>\n    </div>"
  },
  "contained": [
    {
      "resourceType": "Condition",
      "id": "p1",
      "clinicalStatus": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "active"
          }
        ]
      },
      "verificationStatus": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code": "confirmed"
          }
        ]
      },
      "code": {
        "text": "Obesity"
      },
      "subject": {
        "reference": "Patient/example",
        "display": "Peter James Chalmers"
      }
    }
  ],
  "identifier": [
    {
      "value": "12345"
    }
  ],
  "instantiatesUri": [
    "http://example.org/protocol-for-obesity"
  ],
  "basedOn": [
    {
      "display": "Management of Type 2 Diabetes"
    }
  ],
  "replaces": [
    {
      "display": "Plan from urgent care clinic"
    }
  ],
  "partOf": [
    {
      "display": "Overall wellness plan"
    }
  ],
  "status": "active",
  "intent": "plan",
  "category": [
    {
      "text": "Weight management plan"
    }
  ],
  "description": "Manage obesity and weight loss",
  "subject": {
    "reference": "Patient/example",
    "display": "Peter James Chalmers"
  },
  "encounter": {
    "reference": "Encounter/home"
  },
  "period": {
    "end": "2017-06-01"
  },
  "created": "2016-01-01",
  "author": {
    "reference": "Practitioner/example",
    "display": "Dr Adam Careful"
  },
  "careTeam": [
    {
      "reference": "CareTeam/example"
    }
  ],
  "addresses": [
    {
      "reference": "#p1",
      "display": "obesity"
    }
  ],
  "goal": [
    {
      "reference": "Goal/example"
    }
  ],
  "activity": [
    {
      "outcomeCodeableConcept": [
        {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "161832001",
              "display": "Progressive weight loss"
            }
          ]
        }
      ],
      "outcomeReference": [
        {
          "reference": "Observation/example",
          "display": "Weight Measured"
        }
      ],
      "detail": {
        "code": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "3141-9",
              "display": "Weight Measured"
            },
            {
              "system": "http://snomed.info/sct",
              "code": "27113001",
              "display": "Body weight"
            }
          ]
        },
        "status": "completed",
        "statusReason": {
          "text": "Achieved weight loss to mitigate diabetes risk."
        },
        "doNotPerform": false,
        "scheduledTiming": {
          "repeat": {
            "frequency": 1,
            "period": 1,
            "periodUnit": "d"
          }
        },
        "location": {
          "display": "Patient's home"
        },
        "performer": [
          {
            "reference": "Patient/example",
            "display": "Peter James Chalmers"
          }
        ]
      }
    }
  ],
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}

Data Fields

Data FieldTypeDescription
resourceTypeCarePlanThis is a CarePlan resource
ididThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
metaMetaThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRulesuriA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
languagecodeThe base language in which the resource is written.
textNarrativeA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
containedBackboneElementThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
extensionExtensionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
modifierExtensionExtensionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
identifierIdentifierBusiness identifiers assigned to this care plan by the performer or other systems which remain constant as the resource is updated and propagates from server to server.
instantiatesCanonicalcanonicalThe URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.
instantiatesUriuriThe URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.
basedOnReferenceA care plan that is fulfilled in whole or in part by this care plan.
replacesReferenceCompleted or terminated care plan whose function is taken by this new care plan.
partOfReferenceA larger care plan of which this particular care plan is a component or step.
statuscodeIndicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
intentcodeIndicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.
categoryCodeableConceptIdentifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc.
titlestringHuman-friendly name for the care plan.
descriptionstringA description of the scope and nature of the plan.
subjectReferenceIdentifies the patient or group whose intended care is described by the plan.
encounterReferenceThe Encounter during which this CarePlan was created or to which the creation of this record is tightly associated.
periodPeriodIndicates when the plan did (or is intended to) come into effect and end.
createddateTimeRepresents when this particular CarePlan record was created in the system, which is often a system-generated date.
authorReferenceWhen populated, the author is responsible for the care plan. The care plan is attributed to the author.
contributorReferenceIdentifies the individual(s) or organization who provided the contents of the care plan.
careTeamReferenceIdentifies all people and organizations who are expected to be involved in the care envisioned by this plan.
addressesReferenceIdentifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.
supportingInfoReferenceIdentifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc.
goalReferenceDescribes the intended objective(s) of carrying out the care plan.
activityBackboneElementIdentifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etc.
activity.idstringUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
activity.extensionExtensionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
activity.modifierExtensionExtensionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
activity.outcomeCodeableConceptCodeableConceptIdentifies the outcome at the point when the status of the activity is assessed. For example, the outcome of an education activity could be patient understands (or not).
activity.outcomeReferenceReferenceDetails of the outcome or action resulting from the activity. The reference to an "event" resource, such as Procedure or Encounter or Observation, is the result/outcome of the activity itself. The activity can be conveyed using CarePlan.activity.detail OR using the CarePlan.activity.reference (a reference to a “request” resource).
activity.progressAnnotationNotes about the adherence/status/progress of the activity.
activity.referenceReferenceThe details of the proposed activity represented in a specific resource.
activity.detailBackboneElementA simple summary of a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc.
activity.detail.idstringUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
activity.detail.extensionExtensionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
activity.detail.modifierExtensionExtensionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
activity.detail.kindcodeA description of the kind of resource the in-line definition of a care plan activity is representing. The CarePlan.activity.detail is an in-line definition when a resource is not referenced using CarePlan.activity.reference. For example, a MedicationRequest, a ServiceRequest, or a CommunicationRequest.
activity.detail.instantiatesCanonicalcanonicalThe URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan activity.
activity.detail.instantiatesUriuriThe URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan activity.
activity.detail.codeCodeableConceptDetailed description of the type of planned activity; e.g. what lab test, what procedure, what kind of encounter.
activity.detail.reasonCodeCodeableConceptProvides the rationale that drove the inclusion of this particular activity as part of the plan or the reason why the activity was prohibited.
activity.detail.reasonReferenceReferenceIndicates another resource, such as the health condition(s), whose existence justifies this request and drove the inclusion of this particular activity as part of the plan.
activity.detail.goalReferenceInternal reference that identifies the goals that this activity is intended to contribute towards meeting.
activity.detail.statuscodeIdentifies what progress is being made for the specific activity.
activity.detail.statusReasonCodeableConceptProvides reason why the activity isn't yet started, is on hold, was cancelled, etc.
activity.detail.doNotPerformbooleanIf true, indicates that the described activity is one that must NOT be engaged in when following the plan. If false, or missing, indicates that the described activity is one that should be engaged in when following the plan.
activity.detail.scheduledTimingTimingThe period, timing or frequency upon which the described activity is to occur.
activity.detail.scheduledPeriodPeriodThe period, timing or frequency upon which the described activity is to occur.
activity.detail.scheduledStringstringThe period, timing or frequency upon which the described activity is to occur.
activity.detail.locationReferenceIdentifies the facility where the activity will occur; e.g. home, hospital, specific clinic, etc.
activity.detail.performerReferenceIdentifies who's expected to be involved in the activity.
activity.detail.productCodeableConceptCodeableConceptIdentifies the food, drug or other product to be consumed or supplied in the activity.
activity.detail.productReferenceReferenceIdentifies the food, drug or other product to be consumed or supplied in the activity.
activity.detail.dailyAmountQuantityIdentifies the quantity expected to be consumed in a given day.
activity.detail.quantityQuantityIdentifies the quantity expected to be supplied, administered or consumed by the subject.
activity.detail.descriptionstringThis provides a textual description of constraints on the intended activity occurrence, including relation to other activities. It may also include objectives, pre-conditions and end-conditions. Finally, it may convey specifics about the activity such as body site, method, route, etc.
noteAnnotationGeneral notes about the care plan not covered elsewhere.

Extensions

NameURL

Operations & APIs

CarePlan-GET

CarePlan-POST

CarePlan ID-GET

CarePlan ID-PUT

CarePlan ID-DELETE