Update (11/17): Updated sample with additional goal status information. Update (11/30): We have received initial feedback from partners and updated this proposal to add reference-id to tasks, and goals.
A number of partner use cases and scenarios have warranted us to create a type which stores a care plan. This type is targeted to help care institutions to provide tools for consumers to manage chronic conditions.
The care plan type would enable a user to track tasks and goals associated with a chronic condition as prescribed by their care manager. A number of care institutions already use care plan’s to manage chronic conditions, this type will facilitate structured storage in HealthVault platform.
Element
Type
Description
Occurrence
Notes
Name of the care plan e.g. insulin dependent diabetes
1..1
StartDate
Date at which this care plan started
Tasks
List of user tasks associated with this plan
0..n
Goals
List of goals associated with this plan
CareTeam
List of contacts associated with the care plan e.g. Care plan
CarePlanManager
Contact information for manager of this care plan
0..1
Status
Describes the status of the care plan – Active, In Active, Complete
Name
t-codable-value
Name of the task. E.g check glucose
No preferred vocab associated
string
Description of the task e.g. check glucose 4 times a day
d-approx-date-time
Date on which this task should be started.
Approx to be CCD complaint
EndDate
Date on which the task should end.
SequenceNumber
Non-negative Int
Sequence number which could be used to display the task in order.
Parity with CCD.
Contact
contact
Referral contact for this task e.g get procedure done with Lab X, get x-ray done from Bellevue imaging services
Recurrence
Choice between
recurrence expression from I-Cal format (RFC 2445 )
or HealthVault recurrence format (interval, times-in-interval)
Per-day, per-week, per-month
e.g <recurrence> <ical>FREQ=YEARLY;COUNT=1</ical> </recurrence>
or HealthVault recurrence format
<recurrence> <interval><text>daily</text></interval> <times-in-interval>6</times-in-interval> </recurrence>
We will use recurrence expression from i-cal format.
The interval element in HealthVault recurrence format is codable-value. We will define a vocabulary for it.
ThingType-Version
guid
Version ID of HealthVault type associated with this task.
e.g Exercise (GUID)
The type-id should be versioned type-id
ThingType-XPath
XPath of the details of thingtype-version field associated with this task.
/thing/data-xml/exercise[duration>30]
Occurrences
Name of the goal group. E.g Cholesterol
No preferred vocab
String
Description of the goal group e.g Total,LDL, HDL cholesterol goals.
Goal
Goals associated with the group
1..N
Name of the goal. E.g Weight should be 160 lbs
Description of the goal e.g Weight needs to be tracked daily.
Thing type associated with the goal.
ThingType-Value-XPath
Thing type xpath field for the goal. E,g
/thing/data-xml/weight/value/kg
ThingType-Display-XPath
Thing type display x-path associate with the goal e.g
/thing/data-xml/weight/display (?)
This is display value
Unit
Unit of the goal.
e.g Lbs
Conversion
double
Conversion value from Display path.
e.g 2.2
Goal start date
CompletionDate
Goal completion date
Range
Goal-range
Range of good, better, bad values for the type.
Note
Minimum-value
Range minimum value e.g 80
Maximum-value
Range maximum value e.g 120
Range-type
Range value corresponding to status of the range
We will define a preferred vocabulary for it.
There are number of discussion point which you as partners can help us give feedback on -
Following is an example of diabetes management plan authored with above type. The diabetes management plan following data elements
1. Plan Information (Diabetes Management Plan administered by Contoso Hospital) 2. Tasks (Measure blood glucose levels 6 times a day, Get dilated eye exam every year, Measure blood pressure) 3. Goals (Blood pressure should be less than 80mmHg diastolic, 130mmHg systolic; Blood Glucose should be in 70 – 240mg/dL range)
--
1: <care-plan>
2: <name>Diabetes management</name>
3: <start-date>
4: <date>
5: <y>2011</y>
6: <m>11</m>
7: <d>15</d>
8: </date>
9: </start-date>
10: <care-team>
11: <person>
12: <name>Health care provider</name>
13: <organization>Contoso health</organization>
14: <contact>
15: <address>
16: <street>123 Main st.</street>
17: <city>Redmond</city>
18: <postcode>98052</postcode>
19: <country>USA</country>
20: </address>
21: <phone>
22: <number>000-000-0000</number>
23: </phone>
24: <email>
25: <address>foo@bar.com</address>
26: </email>
27: </contact>
28: </person>
29: <person>
30: <name>Emergency contact</name>
31: <contact>
32: <address>
33: <street>123 Main st.</street>
34: <city>Redmond</city>
35: <postcode>98052</postcode>
36: <country>USA</country>
37: </address>
38: <phone>
39: <number>000-000-0000</number>
40: </phone>
41: <email>
42: <address>foo@bar.com</address>
43: </email>
44: </contact>
45: </person>
46: </care-team>
47: <careplanmanager>
48: <name>Health care provider</name>
49: <organization>Contoso health</organization>
50: <contact>
51: <address>
52: <street>123 Main st.</street>
53: <city>Redmond</city>
54: <postcode>98052</postcode>
55: <country>USA</country>
56: </address>
57: <phone>
58: <number>000-000-0000</number>
59: </phone>
60: <email>
61: <address>foo@bar.com</address>
62: </email>
63: </contact>
64: </careplanmanager>
65: <tasks>
66: <task>
67: <name>Measure blood glucose levels</name>
68: <description>Measure blood glucose levels 6 times a day</description>
69: <start-date>
70: <date>
71: <y>2011</y>
72: <m>11</m>
73: <d>15</d>
74: </date>
75: </start-date>
76: <end-date>
77: <date>
78: <y>2011</y>
79: <m>12</m>
80: <d>15</d>
81: </date>
82: </end-date>
83: <contact>
84: <name>Health care provider</name>
85: <organization>Contoso health</organization>
86: <contact>
87: <address>
88: <street>123 Main st.</street>
89: <city>Redmond</city>
90: <postcode>98052</postcode>
91: <country>USA</country>
92: </address>
93: <phone>
94: <number>000-000-0000</number>
95: </phone>
96: <email>
97: <address>foo@bar.com</address>
98: </email>
99: </contact>
100: </contact>
101: <recurrence>
102: <interval>
103: <text>daily</text>
104: </interval>
105: <times-in-interval>6</times-in-interval>
106: </recurrence>
107: <thing-type-version-id>879e7c04-4e8a-4707-9ad3-b054df467ce4</thing-type-version-id>
108: <thing-type-xpath>/thing/data-xml/blood-glucose/value/mmolPerL</thing-type-xpath>
109: </task>
110: <task>
111: <name>Get dilated eye exam</name>
112: <description>Get dilated eye exam every year</description>
113: <start-date>
114: <y>2011</y>
115: <m>11</m>
116: <d>15</d>
117: </start-date>
118: <recurrence>
119: <ical>FREQ=YEARLY;COUNT=1</ical>
120: </recurrence>
121: </task>
122: <task>
123: <name>Have your blood pressure checked at every diabetes visit.</name>
124: <description>Have your blood pressure checked at every diabetes visit.</description>
125: <start-date>
126: <y>2011</y>
127: <m>11</m>
128: <d>15</d>
129: </start-date>
130: </task>
131: </tasks>
132: <goals>
133: <goal-group>
134: <name>Blood pressure</name>
135: <description>Keep your blood pressure under control</description>
136: <goal>
137: <name>
138: <text>Systolic</text>
139: </name>
140: <description>Systolic should be below 130 mmHg</description>
141: <start-date>
142: <y>2011</y>
143: <m>11</m>
144: <d>15</d>
145: </start-date>
146: <thing-type-version-id>ca3c57f4-f4c1-4e15-be67-0a3caf5414ed</thing-type-version-id>
147: <thing-type-value-xpath>/thing/data-xml/blood-pressure/systolic</thing-type-value-xpath>
148: <unit>mmHg</unit>
149: <conversion>1</conversion>
150: <goal-ranges>
151: <goal-range>
152: <status-indicator>0</status-indicator>
153: <minimum-value>90</minimum-value>
154: <maximum-value>130</maximum-value>
155: </goal-range>
156: <goal-range>
157: <status-indicator>1</status-indicator>
158: <minimum-value>50</minimum-value>
159: <maximum-value>90</maximum-value>
160: </goal-range>
161: <goal-range>
162: <status-indicator>1</status-indicator>
163: <minimum-value>130</minimum-value>
164: <maximum-value>160</maximum-value>
165: </goal-range>
166: <goal-range>
167: <status-indicator>2</status-indicator>
168: <minimum-value>160</minimum-value>
169: <maximum-value>180</maximum-value>
170: </goal-range>
171: </goal-ranges>
172: </goal>
173: <goal>
174: <name>
175: <text>Diastolic</text>
176: </name>
177: <description>Diastolic should be below 80 mmHg</description>
178: <start-date>
179: <y>2011</y>
180: <m>11</m>
181: <d>15</d>
182: </start-date>
183: <thing-type-version-id>ca3c57f4-f4c1-4e15-be67-0a3caf5414ed</thing-type-version-id>
184: <thing-type-value-xpath>/thing/data-xml/blood-pressure/diastolic</thing-type-value-xpath>
185: <unit>mmHg</unit>
186: <conversion>1</conversion>
187: <goal-ranges>
188: <goal-range>
189: <status-indicator>0</status-indicator>
190: <minimum-value>60</minimum-value>
191: <maximum-value>80</maximum-value>
192: </goal-range>
193: <goal-range>
194: <status-indicator>1</status-indicator>
195: <minimum-value>35</minimum-value>
196: <maximum-value>60</maximum-value>
197: </goal-range>
198: <goal-range>
199: <status-indicator>1</status-indicator>
200: <minimum-value>80</minimum-value>
201: <maximum-value>100</maximum-value>
202: </goal-range>
203: <goal-range>
204: <status-indicator>2</status-indicator>
205: <minimum-value>100</minimum-value>
206: <maximum-value>120</maximum-value>
207: </goal-range>
208: </goal-ranges>
209: </goal>
210: </goal-group>
211: <goal-group>
212: <name>Glucose levels</name>
213: <description>Keep your glucose levels under control</description>
214: <goal>
215: <name>
216: <text>Glucose</text>
217: </name>
218: <description>Glucose measurement should be above 70 mg/dL and below 240 mg/dL</description>
219: <start-date>
220: <y>2011</y>
221: <m>11</m>
222: <d>15</d>
223: </start-date>
224: <thing-type-version-id>879e7c04-4e8a-4707-9ad3-b054df467ce4</thing-type-version-id>
225: <thing-type-value-xpath>/thing/data-xml/blood-glucose/value/mmolPerL</thing-type-value-xpath>
226: <thing-type-display-xpath>/thing/data-xml/blood-glucose/value/display</thing-type-display-xpath>
227: <unit>mg/dL</unit>
228: <conversion>18</conversion>
229: <goal-ranges>
230: <goal-range>
231: <status-indicator>0</status-indicator>
232: <minimum-value>3.88</minimum-value>
233: <maximum-value>13.33</maximum-value>
234: </goal-range>
235: </goal-ranges>
236: </goal>
237: </goal-group>
238: </goals>
239: </care-plan>
Please let us know your feedback.
We will appreciate any other use cases which this type can solve. Examples and appropriate data will help us as well.