Submitted by mturchioe on
ANI's comment on USCDI v6: Care Plan
The Alliance for Nursing Informatics (ANI) supports the inclusion of this data element and adds our comments below. Please see previously submitted ANI comments for additional recommendations.
- Consider reframing to a “patient care plan” that is longitudinal, interdisciplinary, and dynamic.
- Include patient preferences, values, and goals explicitly, and how this connects to the “patient goals” data element.
- Clarify how the care plan is rendered, where it fits in messaging, and how it aligns with FHIR. Certified EHRs and hospitals have a variety of ways to meet the care plan requirements (i.e., discrete, both discrete and text, text only), which should be considered with the ability to transmit this data meaningfully. This is a potential technical challenge, and a challenge in sending meaningful data.
Submitted by rdillaire on
CMS-CCSQ Supports Care Plan's inclusion in USCDI v6
Recommendation: CMS CCSQ supports the inclusion of the Care Plan data element in USCDI v6 while still advocating for repurposing the Patient Summary and Plan data class to create a new Care Plan data class.
Rationale: CMS CCSQ continues to recommend a distinct Care Plan data class with a set of data elements (Care Plan Information, Assessment, Health Concerns, Goals, Interventions, and Outcomes/Evaluation). We define a Care Plan as a shared, dynamic, longitudinal plan representing all care team members (including patient/caregiver) prioritized concerns, goals, interventions, and evaluation/outcomes across health and social services settings. It can include a structured package of data elements that already exist in USCDI.
By adding Care Plan as a distinct class in the final USCDI v6, it would encompass all data elements relevant to patient care planning. We believe Patient Summary and Plan are distinct concepts, with the Patient Summary component more closely aligning with the Clinical Notes data class. Therefore, we propose repurposing the Patient Summary and Plan data class to the new Care Plan data class. Should this recommendation be adopted, we further recommend that the existing Assessment and Plan of Treatment (USCDI v6) data element, currently under the Patient Summary and Plan data class, be included in the new Care Plan data class.
Supporting information:
i. HL7® Multiple Chronic Condition (MCC) Care Plan Implementation Guide (IG) defines FHIR R4 profiles, structures, extensions, transactions and value sets needed to represent, query for, and exchange Care Plan information (Multiple Chronic Care Condition Care Plan - MCC eCare Plan Implementation Guide v1.0.0).
ii. electronic Long-Term Services and Supports (eLTSS) IG (IG Home Page - Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm v2.0.0).
iii. CarePlan is about to be exchanged in FHIR (CarePlan - FHIR v4.0.1).
1. Supporting extensions: CarePlan - FHIR v4.0.1
The draft definition of the Care Plan data element for the USCDI provides a strong foundation by outlining key components such as prioritized problems, health concerns, assessments, goals, and interventions. These components reflect the core elements common across different types of care plans, including nursing care plans, diabetic care plans, chronic condition care plans, and long-term services and support care plans. These elements are essential for coordinating care, tracking progress, and ensuring alignment across care teams.
However, there may be a need for further clarification regarding the specific details or granularity required for each of these components. For example, the definition mentions "prioritized problems" but does not specify whether this refers to clinical issues, psychosocial concerns, or other types of health challenges. Similarly, while it lists "goals" and "interventions," it would be helpful to clarify if these should be aligned with specific clinical outcomes, patient preferences, or evidence-based practices. Additionally, incorporating goals of care would enhance the definition, ensuring that care plans align with the patient’s values and priorities.
An important consideration is the longitudinal nature of care plans. For instance, a diabetic care plan may begin in the hospital but should follow the patient into PAC settings. The same care goals should persist across different care environments, but the plan must be adapted as necessary based on the site of care and any changes in the patient’s condition or goals.
Including a Care Plan data class with relevant data elements will improve communication and care coordination across care teams, enhance patient safety and experience, and provide access to patient- and caregiver-centric data.