Introduction
CMS requires and MU1 supports the exchange of a plan of care at the time of transfer from the hospital to the
principle care physician at discharge. We have analyzed the current standards and compared them to what
would be required to address the care planning needs of individuals with complex health issues. In this paper
we propose a series of steps to bring the current standards for the electronic exchange of care plans into line
with the requirements of a longitudinal plan of care.
The complexity of a plan of care increases as the number of issues requiring management increases.
Furthermore, because of the requirement for communication among providers of care, the complexity of
managing a plan of care increases exponentially with the number of health care providers who are engaged with
that individual. Both the number of active problems and the number of health care providers rise in parallel. As
a result, there is an eight-fold increase in the complexity of managing the care of the individual with two
problems and two providers compared with an individual with one issue and one provider.
5% of Medicare beneficiaries account for 70% of the care paid for by Medicare. In general, they have more than
three active health issues; five different clinicians involved in their care and take more than 10 medications. The
complexity of managing their care is 100-fold greater than managing the care of the individual with one
problem. Currently, when the care of such individuals is managed, one health care professional assumes
responsibility for coordinating care, improving communication among providers and clarification of the
individual’s goals of care.
Often, however, even intensive management processes are not sufficient to avoid interventions that are
conflicting, duplicative and potentially harmful. Every clinician can provide examples of meticulously crafted
care plans that fail. There are hundreds of ways in which these plans can fail, but most fail because of
inadequate communication among providers and failure to clarify the individual’s goals of care. Current health
information exchange standards have gaps and cannot fully support the range of information required to create,
amend and disseminate a complex plan of care.
Fortunately, some of the required components for care plans are in place. In the following sections we offer
preliminary suggestions for the components and functional requirements needed for care plans that we believe
are needed to support service delivery to medically complex and functionally impaired persons. We also submit
our preliminary analysis of the extent to which standards are available to support these requirements. propose
a model for longitudinal coordination of care, identify the categories of information required to support this
model, discuss gaps in the current information exchange standards and propose a series of steps to remedy
those gaps and provide the foundation for HIE assisted longitudinal coordination of care.
The following diagram highlights the keys components of the care planning process that will be described in the
balance of this paper.
Care Planning has been an integral component of the practice of nursing since …..
The lack of a single standard nomenclature for clninical processes in nursing has long been identified as a barrier to
effective communication. The Nursing Information and Data Set Evaluation Center (NIDSEC) of the American Nurses
Association (ANA) recognizes ten standardized vocabularies that support the documentation of nursing care and care
planning. (http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/HealthIT/StandardizedNursingLanguage.html#McCloskeyDochterman)
“Lillibridge55 found that when nurses were asked to list the type of data they would normally collect using
specific examination techniques, 23 percent provided nursing assessment details. It can be argued that if
nurses were provided with an explicit nursing framework (and language) to document and communicate
about their care that nurses and the interdisciplinary team members would more readily understand the
importance and impact of nursing care and patient outcomes. Others have also found that the care plans
typically do not reflect actual nursing practice.56, 57” http://www.ahrq.gov/qual/nurseshdbk/docs/KeenanG_DNCPP.pdf
This disconnect between care plans and nursing practice is of uncertain clinical significance. Given that care plans do
not typically inform care withn a clinical organization, it seems clear that the sharing of care plans across
organizations during a transition is even more uncommon. Additionally, clinical summary data coming from an
organization where care planning and coordination is not well integrated into clinical process is likely to underrepresent the sender plan of care to the receiver.
Measures of effective transitions of care are not well developed, however, nearly all interventions attempting to
improve transitions from Hospital to LTPAC measure the thirty day readmission rate. To date, there has been an
intense investment at informing transitions with clinical summary data through standardization of data, document
architecture, data exchange and system adoption. Implied in this strategy is that at the receiver site, this clinical
data would be inputted into a care planning process to improve start of care, reducing gaps in service created by the
lack of a transmitted care plan. However, given the current state of the practice of nursing described in the AHRQ
report, it is likely that the clinical summary data will not require sufficient information to effectively create a new
care plan at the receiving site.
Although the nomenclature of clinical nursing and care planning has not achieved professional adoption of a
single standard, the three major vocabularies most widely adopted (NANDA Classification,NIC,and NOC) each
identify three common elements to a care plan: Problems, Outcomes and Interventions. These concepts,
however, are not harmonized with the similar concept in the practice of medicine (Assessment and Plan).
Many of the terms in the care planning process are used ambiguously. For example, Goals and Outcomes are
often used interchangeably, however, it is clear that a person could achieve numerous desired outcomes from
interventions without achieving their overall health goals. In the domain of Interventions, the concept of
treatments, orders, and services are used imprecisely. Most effective interventions contain elements of all
three.
Care Plan problems are not synonymous with the concept of Problems as structured for inclusion in the
consolidated CDA. Care plan models vary. Some are described as “strength based” and others are “deficit
based”. While interventions to support retained capacity or a healthy lifestyle are well recognized, most
interventions in care plans are directed at correcting or compensating for a functional deficit or symptom
resulting from an illness, injury or accident or for preventing an adverse outcome from an identified risk factor
or factors. The S and I Framework endorses the concept of Health Concerns to inform the care plan process. In
turn, Health Concerns are informed by a number of sources, including the Problem template, multidisciplinary
assessment findings including risk assessments, patient reported concerns and evidence based practice
guidelines.
Orders is of particular concern. As its name implies, orders are intended to provide instructions from an
authorized entity based on scope of practice to a non-authorized entity. This non-authorized entity now
becomes responsible for outcomes. HITECH and other investments in technology have now created standards
for Order Entry Systems, however, the standards for nomenclature and structure of Order messages is only
defined for a small subset of orders including diagnostic testing (Clinical Laboratory and Diagnostic Imaging) and
Prescriptions. The care plan concept of Interventions is much broader and requires significantly more granular
information.It is essential to recognize that care planning is a process outputs care plans. The inputs are clinical
observations and judgments by multiple disciplines which were are not optimized for sharing across disciplines.
Some of the input data was not intended for inclusion in the care plan. For example, a Medication list is usually
the compiled list of Medication prescriptions, typlically sorted by Active (no stop date) or Inactive (with stop
date). Medication information required to inform a care plan requires administration instructions, special
precautions, potential side effects, duplicate therapy, and patient education requirements which are applied
during the care planning process. During the care planning process, associations are made between Health
Concerns, Interventions and Desired Outcomes to create a molecule of information supporting an Intervention.
The inputs are transformed by the process and fused into a single concept to create the plan.
To enable the creation of a care plan through technology, standards must be enhanced to include the core
elements in an unambiguous way. Health Concerns should be informed by every potential contributor to the
process. The component elements of Interventions beyond the elements defined for CPOE need to be
structured and coded. Goals and Desired outcomes require more granularity.
The care plan elements become molecules in a “many to one to many” fashion (see figure bill to do if desired).
In order to inform care delivery and future assessments, these care plan molecules must then be interpreted by
the systems supporting clinical assessments.
Given the lack of alignment of the information streams and the ambiguity of terminology to inform the care plan, the
lack of alignment between care plans and the clinical processes within health care organizations, the lack of
standardized architecture of the care plan and the lack of standards to support the functional requirements for the
care plan molecules, the exchange of care plans remains an elusive goal.
Add summary – of our “punch line” and table showing summary of what is in rules/Components needed
1 Background
The Health IT Policy Committee (HITPC) recommended that providers incented under Meaningful Use (MU)
record care plan information for transitions of care and team member information for their patients.1 Proposed
rules from CMS (MU Stage 2 NPRM) and the ONC (Standards and Certification NPRM) addressed these HITPC
recommendations by expanding requirements for the summary care record to incorporate care plan and team
member data elements.
The Standards & Interoperability Framework (S&I) Longitudinal Coordination of Care Workgroup (LCC WG)
applauds these efforts to move care plan content into interoperable health information exchange. Care plans
have long served a critical role in cataloguing patient needs and managing patient care in a wide array of
settings, including long-term and post-acute care (LTPAC). Persons with multiple chronic illnesses (CIs) and
functional impairments receive health and related services from a multitude of individual and organizational
providers, during single episodes of care and over time, and account for significant health care expenditures.
Timely and complete health information exchange (HIE) is expected to (i) improve quality and continuity of care,
and (ii) avoid unnecessary and costly hospitalizations and medical errors.
1.1 Care Plan Activities of S&I LCC WG
The S&I LCC WG is keenly interested in care plans and has activities focused on near-term, pragmatic workflow
solutions for the Home Health Plan of Care (HH POC) and long-term strategic visions for longitudinal,
coordinated care.
1
Department of Health & Human Services, Centers for Medicare and Medicaid Services. (2012). Medicare and Medicaid Programs NPRM;
Electronic Health Record Incentive Program—Stage 2. Page 13722.
Home Health Plan of Care - The HH POC is a process of care initiation and coordination between Home
Health Agencies and clinical professionals that provides certification of need, medical oversight (e.g.
physicians) and care management. The S&I LCC WG is engaged in the identification/creation of
standards for the iterative exchange of HH POC data elements and the contextual information required
to authorize or update a care and service plan. Support of this process introduces an element of care
coordination over time to the technical standards.
Longitudinal Care Plan - Care planning over time and across multiple settings and disciplines has long
challenged the health care community. The S&I LCC WG is engaged in the identification of the:
 , , Components/domains and other functional requirements needed for development of care
plans that fully engage patients, families and care providers;
 Interdependencies of these requirements in the identification of goals and specification of
outcome measures, and
 The health IT standards that are needed to support the interoperable exchange of care plans. .
1.2 Care Plans and the CMS/ONC NPRMs
Based on considerations to date, the S&I LCC WG believes that clearer and more complete specification of the
functional requirements for care plans and their exchange standards is needed to support the interoperable
exchange of care plans and the MU of care plan content in EHRs. The considerations by and recommendations
of the S&I LCC WG are presented below. The HITPC, CMS and ONC may find these remarks helpful as they
consider care plan requirements for the EHR MU Program.
2 Care Plans: Recommendations From HITPC and Proposed Requirements
from CMS and ONC
The following table summarizes the recommendations and proposed requirements related to care plans
provided by the HITPC, CMS and ONC.
Recommendations from
HITPC
Care Plan
Record care plan fields,
including goals and instructions,
for at least 10 percent of
transitions of care
CMS Proposed Rules
Preamble pgs 13716 and
13722:
The content of the care plan is
dependent on the clinical
context. We propose to
describe a care plan as the
structure used to define the
management actions for the
various conditions, problems, or
issues.
For purposes of meaningful use
measurement, we propose that
a care plan must include at a
minimum the following
components: Problem (the
ONC Proposed Rules
§ 170.314(b)(1) (Transitions of
care - incorporate summary care
record.)
. . . Electronically
incorporate, at a minimum . .
. care plan, including goals
and instructions;
§ 170.314(b)(2) (Transitions of
care—create and transmit
summary care record.)
. . . Electronically create a
summary care record
formatted according to the
standard adopted at §
Proposed Standards
Create Summary Care Record
§ 170.205(a)(3) (Consolidated
CDA)
Transmit Summary Care Record
§ 170.202(a)(1) (Applicability
Statement for Secure Health
Transport);
§ 170.202(a)(2) (XDR and XDM
for Direct Messaging);
§ 170.202(a)(3) (SOAP–Based
Secure Transport RTM version
1.0)
Recommendations from
HITPC
CMS Proposed Rules
focus of the care plan), goal
(the target outcome) and any
instructions that the provider
has given to the patient. A goal
is a defined target or measure
to be achieved in the process of
patient care (an expected
outcome).
ONC Proposed Rules
Proposed Standards
170.205(a)(3) and that
includes, at a minimum . . .
care plan, including goals
and instructions
Preamble pg. 13716:
We propose to require the
following information to be part
of the clinical summary for
Stage 2:
. . . Care plan field, including
goals and instructions
Preamble pg. 13720:
Therefore, in order to meet this
objective, the following
information must be made
available to patients
electronically within 4 business
days of the information being
made available to the EP:

. . . Care plan field,
including goals and
instructions
Preamble pg. 13722:
All summary of care documents
used to meet this objective
must include the following:

. . . Care plan field,
including goals and
instructions
Problem
Preamble pgs. 13716 and
13722:
For purposes of meaningful use
measurement, we propose that
a care plan must include at a
minimum the following
components: Problem (the
focus of the care plan)
Instructions
Record care plan fields, including
goals and instructions, for at
least 10 percent of transitions of
care
Preamble pgs 13716 and
13722:
. . . any instructions that the
provider has given to the
patient).
Preamble pg. 13716:
We propose to require the
following information to be part
of the clinical summary for
Stage 2:
§ 170.314(b)(1) (Transitions of
care - incorporate summary care
record.)
. . . Electronically
incorporate, at a minimum . .
. care plan, including goals
and instructions;
§ 170.314(b)(2) (Transitions of
care—create and transmit
summary care record.)
. . . Electronically create a
Create Summary Care Record
§ 170.205(a)(3) (Consolidated
CDA)
Transmit Summary Care Record
§ 170.202(a)(1) (Applicability
Statement for Secure Health
Transport);
§ 170.202(a)(2) (XDR and XDM
for Direct Messaging);
§ 170.202(a)(3) (SOAP–Based
Secure Transport RTM version
Recommendations from
HITPC
CMS Proposed Rules
. . . Care plan field, including
goals and instructions
Preamble pg. 13720:
Therefore, in order to meet this
objective, the following
information must be made
available to patients
electronically within 4 business
days of the information being
made available to the EP:

. . . Care plan field,
including goals and
instructions
ONC Proposed Rules
summary care record
formatted according to the
standard adopted at §
170.205(a)(3) and that
includes, at a minimum . . .
care plan, including goals
and instructions
Proposed Standards
1.0)
Preamble pg. 13722:
All summary of care documents
used to meet this objective
must include the following:

. . . Care plan field,
including goals and
instructions
Goals/Outcomes
Record care plan fields, including
goals and instructions, for at
least 10 percent of transitions of
care2
Preamble pgs 13716 and
13722:
. . . goal (the target outcome)
and any instructions that the
provider has given to the
patient. A goal is a defined
target or measure to be
achieved in the process of
patient care (an expected
outcome).
Preamble pg. 13716:
We propose to require the
following information to be part
of the clinical summary for
Stage 2:
. . . Care plan field, including
goals and instructions
Preamble pg. 13720:
Therefore, in order to meet this
objective, the following
information must be made
available to patients
electronically within 4 business
days of the information being
made available to the EP:

. . . Care plan field,
including goals and
instructions
Preamble pg. 13722:
All summary of care documents
§ 170.314(b)(1) (Transitions of
care - incorporate summary care
record.)
. . . Electronically
incorporate, at a minimum . .
. care plan, including goals
and instructions;
§ 170.314(b)(2) (Transitions of
care—create and transmit
summary care record.)
. . . Electronically create a
summary care record
formatted according to the
standard adopted at §
170.205(a)(3) and that
includes, at a minimum . . .
care plan, including goals
and instructions
Create Summary Care Record
§ 170.205(a)(3) (Consolidated
CDA)
Transmit Summary Care Record
§ 170.202(a)(1) (Applicability
Statement for Secure Health
Transport);
§ 170.202(a)(2) (XDR and XDM
for Direct Messaging);
§ 170.202(a)(3) (SOAP–Based
Secure Transport RTM version
1.0)
Recommendations from
HITPC
CMS Proposed Rules
ONC Proposed Rules
Proposed Standards
used to meet this objective
must include the following:

. . . Care plan field,
including goals and
instructions
Team Member
Record team member, including
primary care practitioner, for at
least 10 percent of patients
Preamble:
All summary of care documents
used to meet this objective
must include the following:

. . . Any additional known
care team members
beyond the referring or
transitioning provider and
the receiving provider.
§ 170.314(b)(1) (Transitions of
care - incorporate summary care
record.)
. . . Electronically
incorporate, at a minimum . .
. names and contact
information of any additional
care team members beyond
the referring or transitioning
provider and the receiving
provider;
§ 170.314(b)(2) (Transitions of
care—create and transmit
summary care record.)
. . . Electronically create a
summary care record
formatted according to the
standard adopted at §
170.205(a)(3) and that
includes, at a minimum . . .
names and contact
information of any additional
care team members beyond
the referring or transitioning
provider and the receiving
provider
Create Summary Care Record
§ 170.205(a)(3) (Consolidated
CDA)
Transmit Summary Care Record
§ 170.202(a)(1) (Applicability
Statement for Secure Health
Transport);
§ 170.202(a)(2) (XDR and XDM
for Direct Messaging);
§ 170.202(a)(3) (SOAP–Based
Secure Transport RTM version
1.0)
Table 1: Recommendations from HITPC and Proposed Requirements from CMS and ONC
2.1 CMS/ONC Proposed Care Plan Requirements: S&I LCC WG Comments
As described below, the S&I LCC WG believes that:
1. While the CMS and ONC proposed rules begin to advance the interoperable exchange of care plan
components at transition of care:
a. All care plan components identified for information exchange need to be clearly defined. The
rules do not define the following concepts:
i. The components of a care plan
ii. Problems
iii. Instructions
iv. Care team member
b. Some identified care plan components need to be refined such as:
i. “instructions” versus the broader concept of “interventions”
ii. “team member” in the HIT PC calls out PCP and in the CMS rule describes “referring and
receiving provider. However, there are many clinical disciplines that may serve as
team members and could be involved in establishing and implementing a care plan
c.
d. Some key care plan components are not included (i.e. “interventions”)
e. Proposed care plan requirements (i.e. inclusion of care plan, goals and instructions in a
summary of care record at transitions of care) are insufficient to support the robust care
planning process necessary for care planning across multiple providers and clinical disciplines
and over time. .
2. While the S&I LCC WG and a broader team of members from the S&I Transitions of Care WG, HL7
Structured Documents WG and HL7 Patient Care WG, support the use of the HL7 Consolidated CDA
standard, as described below further analysis is needed to assess:
a. Whether/how the Consolidated CDA can support, or be modified to support, the requirements
for interoperable exchange of the care plan and re-use of the care plan.
b. [is there something else from the Doug memo that is needed here?]
2.1.1 Recommended Care Plan Components, Terms & Definitions
Based on (i) discussions among the S&I POC HIT Squad; and (ii) an informal review of the literature for terms
related to care plan [see Appendix ___], the S&I LCC WG believes the following components are needed to
support the creation of care plans that will promote the timely initiation of care and service delivery to patients,
particularly as these individuals transition across care settings and experience “shared care” with multiple care
providers and clinicians.
Care Plan Term/
Component
Discussion
General Definition of “Care Plan”
Care Plan
Proposed Component/Definition
(footnote if appropriate)
Next Steps
From Susan’s Spreadsheet:
A document that identifies the patient's needs and
the ways of meeting them. A care plan is a
dynamic document initiated at admission and
subject to continuous reassessment and change.
Typically a care plan includes: diagnoses
(medical, nursing, etc.), orders, interventions, and
outcomes. Care plans can be written for an
individual patient, or be pre-printed or retrieved
from a computer and then individualized.
Care Plan “Problem” versus “Health Concern”
Problem
Health Concern
The POC HIT Squad believe
that care plans need to capture
and address the broad array of
“health concerns” such as:

Acute and Chronic Medical
Problems

Concerns such as injury,
illness, disease progression

Risk factors such as age,
family history, exposures/
lifestyles, environment,
treatment side effects
Care Plan “Decision Modifiers”
Decision Modifiers
From Bill’s spreadsheet:
Superset of conditions and problems
Note: The concept of “Health Concern” was
explored by the HL7 Patient Care
Committee.
http://wiki.hl7.org/index.php?title=Health_Co
ncern
?
Care Plan Term/
Component
Discussion
Proposed Component/Definition
(footnote if appropriate)
Next Steps
Care Plan “Interventions” versus “Patient Instructions”
Interventions
From Bill’s spreadsheet
Superset of actions, instructions, and
orders_______
Identify & evaluate
candidate standards (e.g.
Omaha, NIC, etc.)
Instructions
Care Plan “Goals” versus “Outcomes”
Goals
Outcome
Team Member
Team member
Table 2: Definitions of Key Care Plan Terms and Components
What is the relationship between table 2.1.1 and 2.1.2?
2.1.2 POC HIT Squad Analysis of Standards Needed to Support & Exchange Interoperable Care Plans
Care Plan Component
Care Plan
Health Concern
Decision Modifiers
Other things… risk factors…
Interventions
Instructions
Goals
Outcome
Team member
Interoperable Exchange/
transmission of the Care Plan
Consolidated
CDA Analysis
Comments
No “care plan”
document template.
Care plan section
level template.
Not reflected in CCDA as a section [or
data enty] level
template.
C-CDA reflects “problems.”
However, [p/u language from
Doug memo]
Recommendations and Activities
needed to assess the issue.
Recommendation: Collaborate with HL7 SDWG
and PC WG to modify the C-CDA to include a
“Care Plan” document type. [will need to
consider status of/impact on “care plan section
level template.]
Recommendation:
1. Collaborate with HL7 SDWG and PC
WG to modify the C-CDA:
a.
to include “Health Concern” as
a section-level/[data entry level]
template that could be used for
cares plans and other
documents/sections in the CCDA.
b. Describe the relationship
between “Health Concern” and
“problems”
Table 3: Analysis of Standards Needed to Support & Exchange Interoperable Care Plans
Care Plan Inputs
Plan Concepts
Governance
Health Concerns
Interventions
Team Members
Decision
Modifiers
Goals
Outputs
Care Plan
Coordinator
Roles and
Responsibiliies
Care Plan Process
Standards
Patient Instructions
Symptoms
(patient
reported
data)
Monitoring
and
Expectancy
Assessment
findings
Diagnostic
and
Prognostic
Testing
Medications
International
Classification of
Functioning, Health and
Disability
Nursing
Diagnoses
(N3)
Medical
Problem List
Treatment Plan
Plan of Care
Procedures
Skilled Nursing and
Rehabilitation
Consultation
Other
Care Plan
Standardized
Roles
Scope of
Practice
Standardized
Instructions
Interoperable Care
Plan
Patient
Choice
Prognosis
Global Goals
Advance Care
Documents
and Orders
Desired
Outcome
Intervention
Functional
Status
Clinical
Practice
Guildelines
Physiologic
Reserve
Milestones
Access
to Care
Duration
Affordability
Related
Interventions
Risks
Adverse
Event
History
Related
Conditions
3 Care Plan Activities of S&I LCC WG
3.1 Home Health Plan of Care Use Case
The S&I LCC WG, via work undertake by it’s Longitudinal Care Plan Sub-Workgroup (LCC LCP SWG), has focused
efforts on identifying requirements to support the interoperable exchange of the initial care plan between the
Home Health Agency (HHA) and the attending physicians. This use case focuses on a required component of the
HHA workflow because….
In addition, care plan supports more comprehensive and on-going care planning and assessment of the patient.
[once the care plan signed by the attending physician, the HHA may submit a claim for and payment from
Medicare for covered services provided to Medicare beneficiaries.]
Insert diagram of HHA care planning process
The S&I LCP WG HHA care plan work focuses on the care plan requirements previously required by CMS [and
extended/modified by VNS?]. In the past CMS required HHAs complete and obtain a physician signature
authorizing the HHA PoC (formerly known as the CMS 485 form). The HHA care plan components that will be
evaluated by SI are:
[list]
3.2 S&I LCC WG Considerations for Longitudinal Care Plan
BILL
The Longitudinal Care Plan subworkgroup charter was to document the gaps to technology enabled of sharing
care plans between health care entities. One major assumption was that there were common elements of a
care plan process and model which could be extended across these entities. An ongoing environmental scan of
care planning models revealed the following common clinical concepts: Problems, Interventions and Goals.
Terminology and hierarchy of the concepts in the care plans was variable, however. It became immediately
apparent that gaps not only impacted the ability to share care plans between organization, but more
importantly, there was extensive mal-alignment of the care plan with clinical information streams and
documentation systems and therefore the care delivery process itself was not well supported by current
technology and standards.
The subworkgroup has documented the inputs and outputs involved with the act of "care planning" which
results in artifact(s) of the care plan. A list of high level functional requirements (data objects and data elements)
for the care plan are defined. This list extends concepts previously identified requirements by S&I and HL7
Care plan concepts contained in MU stage 2 are being evaluated in the context of these functional
requirements. In addition, critical components of a Care Plan not yet represented in the proposed rules are
being identified. These gaps in information streams, semantics and care plan document architecture and the
functional requirements will then be used to evaluate the current Consolidated CDA documents and data
templates for their adequacy to communicate a complete care plan.
4 Next Steps
1. Validate LCC WG/ToC/Hl7 recommended functional requirements and standards assessment for I/O
exchange of care plan, including extend care plan considerations to persons who are transitioned to and
receive services in other LTPAC settings (e.g., IRFs, LTCHs, etc.) and receive LTSS.
2. Further assess the need for LCP as a matter of public policy and/or service delivery to patients,
particularly those who suffer from multiple chronic illnesses, are medically complex, and have functional
impairments.
3. If needed:
a. validate and refine the LCC WG assessment of the components/functional requirements of a
longitudinal care plan,
b. identify the availability of and gaps in standards to support the I/O exchange of the LCP and the
management and re-use of this document, and
c. identify additional activities that are needed to advance this concept.
4. Identify vocabulary standards
The activities described above will be undertaken, in part, by:
1. Extending the S&I LCC activities…
2. Convening a 2nd ONC roundtable to help validate assessments to date and need for and concepts in
these “longitudinal Care Plan”
3. Publishing an RFI to solicit comments on functional requirements (and standards) needed for the I/O
exchange of the longitudinal care plan.