Definition

The specific list of actions that are planned to be applied to a specific target of care. Care Plans evolve as conditions evolve and responsibility for care is shared across clinical disciplines or even organizations. The description of planned services may address one or more health problems or issues and may involve coordinated care by more than one healthcare provider, supporting care givers and self care.

Types of plans are likely to evolve around chronic disease management programs as well as the more typical episodic care of today.

Synonyms

Care Plan,

Health Service Plan

EHRi Identifier

EHRi can only reflect the identifiers provided by the interfaced POS.

Definition References

HL7 Care Provision DMIM and Australian Model.

Rationale

The EHR is intended to support clinical services beyond the scope of a single health services provider. As the health system evolves, coordinated care planning is expected to become a major factor. While the EHRi is not intended to be an operational application managing care coordination, it is intended to reflect the changes in state of a health services plan over time and across organizations and disciplines.

The bolded statement is from the HL7 RIM. Qualifying statements are to clarify for EHRi purposes.

Business Process Implications

While the EHRi can provide access to a coordinated health services plan for all individuals authorized to view and update, the active management of identifiers and care teams is out of scope.

Most current clinical processes for shared care and managed care are not supported with automation. The ability to manage joint care plans, with each discipline or organization sub-unit retaining ownership of their own portion of joint care, will require significant business process development and standardized definitions.

Implementation Implications

As operational applications emerge that do coordinate care, the EHRi can increase the effectiveness of having a single view available to caregivers. In the near term, pass-through interactions can help coordinated across settings by providing secure access for participating integrated POS.

Attributes
Name	Type	Initial Value
Class Code
Derivation Espression
Ownership Level Code
Title

Relations
Name	Type	Begins	Ends
According To	association	Care Statement	Health Service Plan
	generalization	Health Service Plan	People Event