Patient-Centered Care Management Home

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Computable care guidelines and pathways help deliver actionable knowledge at the point-of-care and support evidence-based care planning and coordination among all participants in a patient’s care team. This project provides pragmatic implementation guidance that leverages the strengths of both HL7 FHIR Clinical Guidelines IG and OMG BPM+ Health standards to deliver evidence-based care recommendations integrated into the clinical workflow. This work will also align with and contribute to development of the HL7 FHIR eCare Plan IG for shared care plans that support patients with multiple chronic conditions. By translating the recommendations in clinical practice guidelines into computable versions to stand alongside their narrative versions, timely translation will be streamlined to improve consistent, evidence-informed care across all providers in a patient’s care team. Unnecessary and unintentional variations as a result of duplicative translation efforts may also be prevented with a standard, computable version that is ready to implement. The ultimate goal of this project is for scientific evidence to reach patient care more easily, quickly, accurately, and consistently.

We will improve patient-centered care management by:

  • Creating patient-specific care recommendations based on applicable clinical practice guidelines and care pathways, delivered at the point-of-care to clinicians and patients.

  • Creating or updating a patient-specific care plan to coordinate care between primary care and specialists, different provider organizations, and with patients and caregivers.

  • Supporting use of clinical practice guidelines (CPGs) and clinical pathways for patients diagnosed with multiple chronic health conditions.

  • Supporting pilot projects that aim to improve care coordination between Primary Care Provider (PCP), specialists, community care providers, patients, and caregivers.

  • Publishing case study summaries for prototypes and clinical pilot projects that are based on these principles and guidance for Patient-Centered Care Management.

This project is open to all interested organizations and individuals. We welcome your participation and contributions to develop and promote use of implementation guides that apply interoperability standards to improve patient-centered care management.

Solution Architecture

Clinical Use Cases

Implementation Guidance