I am organizing a continuation and update of the successful FHIR Care Plan track from the January HL7 FHIR® Connectathon, this time held as part of the HL7 Value-Based Care FHIR Summit in Chicago, on April 11-12, 2017. The Value-Based Care Plan track emphasizes patient-centered care for managing chronic conditions using standards-based FHIR service APIs that enable all members of the care team to work from the same care plans.

Patient-centered, team-based care is an essential capability needed to implement value-based care processes that maximize value for patients by achieving the best outcomes at the lowest cost. Achieving value-based care requires heathcare providers, and their EHR systems, to follow patients across services, sites, and time for the full lifecycle of care including hospitalization, outpatient visits, testing, physical therapy, and other interventions. Data are aggregated around patients, not departments, units, or locations[1].

The Office of the National Coordinator (ONC) for Health Information Technology (HIT) is offering a proposed vision[2] for how health IT can support a paradigm shift over the next few years to facilitate effective health management by individuals, their caregivers, and their health care teams. By 2020, ONC envisions that:

The power of each individual is developed and unleashed to be active in managing their health and partnering in their health care, enabled by information and technology.

The U.S. Department of Health and Human Services (HHS) recently published an article that integrates many of these ideas for a comprehensive shared care plan (CSCP)[3]. They identify these goals for a CSCP:

  • It should allow a clinician to electronically view information that is directly relevant to his or her role in the care of the person; to easily identify which clinician is doing what; and to update other members of an interdisciplinary team on new developments.
  • It should put the person’s goals (captured in his or her own words) at the center of decision-making and give that individual direct access to his or her information in the CSCP.
  • It should be holistic and describe both clinical and nonclinical (including home- and community-based) needs and services.
  • It should follow the person through high-need episodes (e.g., acute illness), as well as periods of health improvement and maintenance.

I believe that we can achieve these goals by working together as a community of clinicians and implementers, and that the HL7 FHIR Care Plan standards (CarePlan, CareTeam, Goal, Condition, and others) define the best path forward to get there. I am working on a prototype iOS mobile app that integrates use of these FHIR Care Plan standards with a recently released open source library for Apple’s CareKit®. Watch more more blog posts soon describing Mobile Care Plans.

[1] “The Strategy That Will Fix Health Care,” Harvard Business Review, October 2013, https://hbr.org/2013/10/the-strategy-that-will-fix-health-care

[2] ONC Person at the Center, https://www.healthit.gov/policy-researchers-implementers/person-center

[3] HHS Comprehensive Shared Care Plans, http://catalyst.nejm.org/making-the-comprehensive-shared-care-plan-a-reality/