<?xml version="1.0" encoding="UTF-8"?>

<PlanDefinition xmlns="http://hl7.org/fhir">
  <id value="RPMHeartFailureCarePlanTemplate"/>
  <language value="en-NZ"/>
  <text>
    <status value="extensions"/><div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-NZ" lang="en-NZ">
<div>
    <table class="grid dict">
        
        <tr>
            <th scope="row"><b>Id: </b></th>
            <td style="padding-left: 4px;">RPMHeartFailureCarePlanTemplate</td>
        </tr>
        

        
        <tr>
            <th scope="row"><b>Url: </b></th>
            <td style="padding-left: 4px;"><a href="PlanDefinition-RPMHeartFailureCarePlanTemplate.html">Template for Remote Monitoring Heart Failure Care Plan</a></td>
        </tr>
        

        
        <tr>
            <th scope="row"><b>Version: </b></th>
            <td style="padding-left: 4px;">0.1.6</td>
        </tr>
        

        
        <tr>
            <th scope="row">
                <b>
                    
                        Official
                    
                </b>
            </th>
            <td style="padding-left: 4px;">
                
                <p style="margin-bottom: 5px;">
                    <span>RemoteMonitoringHeartFailureCarePlanTemplate</span>
                </p>
                
            </td>
        </tr>
        

        
        <tr>
            <th scope="row"><b>Title: </b></th>
            <td style="padding-left: 4px;">Template for Remote Monitoring Heart Failure Care Plan</td>
        </tr>
        

        
        <tr>
            <th scope="row"><b>Subtitle: </b></th>
            <td style="padding-left: 4px;">Care in the Community plans to handle heart failure patients remotely in an ongoing capacity</td>
        </tr>
        

        

        
        <tr>
            <th scope="row"><b>Experimental: </b></th>
            <td style="padding-left: 4px;">true</td>
        </tr>
        

        
        <tr>
            <th scope="row"><b>Type: </b></th>
            <td style="padding-left: 4px;">
                
                    
                        
                        <p style="margin-bottom: 5px;">
                            <b>system: </b> <span><a href="http://terminology.hl7.org/6.5.0/CodeSystem-plan-definition-type.html">http://terminology.hl7.org/CodeSystem/plan-definition-type</a></span>
                        </p>
                        
                        
                        <p style="margin-bottom: 5px;">
                            <b>code: </b> <span>order-set</span>
                        </p>
                        
                        
                        <p style="margin-bottom: 5px;">
                            <b>display: </b> <span>Order Set</span>
                        </p>
                        
                    
                
                
            </td>
        </tr>
        

        
        <tr>
            <th scope="row"><b>Subject: </b></th>
            
            <td style="padding-left: 4px;">
                
                    
                        
                        <p style="margin-bottom: 5px;">
                            <b>system: </b> <span><a href="http://hl7.org/fhir/R4/codesystem-resource-types.html">http://hl7.org/fhir/resource-types</a></span>
                        </p>
                        
                        
                        <p style="margin-bottom: 5px;">
                            <b>code: </b> <span>Patient</span>
                        </p>
                        
                        
                        <p style="margin-bottom: 5px;">
                            <b>display: </b> <span>Patient</span>
                        </p>
                        
                    
                
                
            </td>
            
            
        </tr>
        

        
        <tr>
            <th scope="row"><b>Date: </b></th>
            <td style="padding-left: 4px;">2023-07-25</td>
        </tr>
        

        
        <tr>
            <th scope="row"><b>Publisher: </b></th>
            <td style="padding-left: 4px;">Te Whatu Ora</td>
        </tr>
        

        
        <tr>
            <th scope="row"><b>Description: </b></th>
            <td style="padding-left: 4px;"><div><p>This careplan designed to support ongoing monitoring of long term conditions (heart failure) in primary care.</p>
</div></td>
        </tr>
        

        

        

        

        
        <tr>
            <th scope="row"><b>Jurisdiction: </b></th>
            <td style="padding-left: 4px;">NZ</td>
        </tr>
        

        
            <tr>
                <th scope="row"><b>Topic: </b></th>
                <td style="padding-left: 4px;">treatment</td>
            </tr>
        

        
        <tr>
            <th scope="row"><b>Purpose: </b></th>
            <td style="padding-left: 4px;"><div><p>This careplan designed to support ongoing monitoring of long term conditions (heart failure) in primary care</p>
</div></td>
        </tr>
        

        
        <tr>
            <th scope="row"><b>Usage: </b></th>
            <td style="padding-left: 4px;">Allows monitoring and tracking of progress of a self serve remote Heart failure patient.</td>
        </tr>
        

        

        

        
        <tr>
            <th scope="row"><b>Effective Period: </b></th>
            <td style="padding-left: 4px;">2022-08-04..2023-08-04</td>
        </tr>
        

        

        

        
        <tr>
            <th scope="row"><b>Actions: </b></th>
            <td style="padding-left: 4px;">
                <table class="grid-dict">
                    
                    <tr>
                        <td>
                            
                            Daily Survey to gather any symptoms experianced by a patient
                            
                            <br/>
                            
                            
                            
                            
                            <b>Then:</b> <i>Definition:</i> <code>{{API_URL}}/Questionnaire?identifier=RemoteMonitoringHeartFailureSymptomSurveyQuestionnaire</code><br/>
                            
                            
                            
                        </td>
                    </tr>
                    
                    <tr>
                        <td>
                            
                            A weekly survey giving an opportunity for patients to provide feedback towards their experiance with the program
                            
                            <br/>
                            
                            
                            
                            
                            <b>Then:</b> <i>Definition:</i> <code>{{API_URL}}/Questionnaire?identifier=RemoteMonitoringFeedbackSurveyQuestionnaire</code><br/>
                            
                            
                            
                        </td>
                    </tr>
                    
                    <tr>
                        <td>
                            
                            <b>3. Observation Activity:</b> Take an obervation
                            
                            <br/>
                            
                            
                            
                            
                            <b>Then:</b> <i>Definition:</i> <a href="ActivityDefinition-RPMObservationRequest.html">Vital Signs Observation Service Request</a><br/>
                            
                            
                            
                        </td>
                    </tr>
                    
                </table>
            </td>
        </tr>
        
    </table>
</div>
</div>
  </text>
  <url value="https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/PlanDefinition/RemoteMonitoringHeartFailureCarePlanTemplate"/>
  <identifier>
    <use value="official"/>
    <value value="RemoteMonitoringHeartFailureCarePlanTemplate"/>
  </identifier>
  <version value="0.1.6"/>
  <name value="RemoteMonitoringHeartFailureCarePlanTemplate"/>
  <title value="Template for Remote Monitoring Heart Failure Care Plan"/>
  <subtitle value="Care in the Community plans to handle heart failure patients remotely in an ongoing capacity"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/plan-definition-type"/>
      <code value="order-set"/>
      <display value="Order Set"/>
    </coding>
    <text value="Order Set"/>
  </type>
  <status value="active"/>
  <experimental value="true"/>
  <subjectCodeableConcept>
    <coding>
      <system value="http://hl7.org/fhir/resource-types"/>
      <code value="Patient"/>
      <display value="Patient"/>
    </coding>
    <text value="Patient"/>
  </subjectCodeableConcept>
  <date value="2023-07-25"/>
  <publisher value="Te Whatu Ora"/>
  <contact>
    <name value="Te Whatu Ora"/>
    <telecom>
      <system value="url"/>
      <value value="https://www.tewhatuora.govt.nz/"/>
    </telecom>
  </contact>
  <contact>
    <name value="Te Whatu Ora Integration Team"/>
    <telecom>
      <system value="email"/>
      <value value="integration@tewhatuora.govt.nz"/>
      <use value="work"/>
    </telecom>
  </contact>
  <description value="This careplan designed to support ongoing monitoring of long term conditions (heart failure) in primary care."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="NZ"/>
      <display value="New Zealand"/>
    </coding>
  </jurisdiction>
  <purpose value="This careplan designed to support ongoing monitoring of long term conditions (heart failure) in primary care"/>
  <usage value="Allows monitoring and tracking of progress of a self serve remote Heart failure patient."/>
  <lastReviewDate value="2022-08-04"/>
  <effectivePeriod>
    <start value="2022-08-04"/>
    <end value="2023-08-04"/>
  </effectivePeriod>
  <topic>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/definition-topic"/>
      <code value="treatment"/>
      <display value="Treatment"/>
    </coding>
    <text value="Treatment"/>
  </topic>
  <author>
    <name value="HNZ RPM Project"/>
  </author>
  <editor>
    <name value="HNZ RPM Project"/>
  </editor>
  <reviewer>
    <name value="HNZ RPM Project"/>
  </reviewer>
  <endorser>
    <name value="Alastair Kenworthy"/>
    <telecom>
      <system value="other"/>
      <value value="CinC Fit for Future Project"/>
    </telecom>
  </endorser>
  <goal id="heart-failure-monitoring">
    <category>
      <text value="Heart Failure Monitoring"/>
    </category>
    <description>
      <text value="Activities in the Remote Monitoring Careplan for Cardiac Heart Failure are intended to support the person and whanau managing their heart failure through capturing and sharing information relating to their needs and experience, symptoms and observations. These activities are in alignment with the NZ Health pathways base heart failure pathway."/>
    </description>
    <priority>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/goal-priority"/>
        <code value="medium-priority"/>
        <display value="Medium Priority"/>
      </coding>
      <text value="Medium Priority"/>
    </priority>
    <start>
      <text value="Assessed as suitable"/>
    </start>
  </goal>
  <action id="1">
    <prefix value="1."/>
    <title value="Daily Symptom Survey"/>
    <description value="Daily Symptom Survey"/>
    <textEquivalent value="Daily Survey to gather any symptoms experianced by a patient"/>
    <priority value="routine"/>
    <goalId value="heart-failure-monitoring"/>
    <subjectCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/resource-types"/>
        <code value="Patient"/>
        <display value="Patient"/>
      </coding>
      <text value="Patient"/>
    </subjectCodeableConcept>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/action-type"/>
        <code value="create"/>
        <display value="Create"/>
      </coding>
      <text value="Create"/>
    </type>
    <requiredBehavior value="must"/>
    <precheckBehavior value="yes"/>
    <cardinalityBehavior value="multiple"/>
    <definitionCanonical value="{{API_URL}}/Questionnaire?identifier=RemoteMonitoringHeartFailureSymptomSurveyQuestionnaire"/>
  </action>
  <action id="2">
    <prefix value="2."/>
    <title value="Weekly Feedback Survey"/>
    <description value="Weekly Feedback Survey"/>
    <textEquivalent value="A weekly survey giving an opportunity for patients to provide feedback towards their experiance with the program"/>
    <priority value="routine"/>
    <goalId value="heart-failure-monitoring"/>
    <subjectCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/resource-types"/>
        <code value="Patient"/>
        <display value="Patient"/>
      </coding>
      <text value="Patient"/>
    </subjectCodeableConcept>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/action-type"/>
        <code value="create"/>
        <display value="Create"/>
      </coding>
      <text value="Create"/>
    </type>
    <requiredBehavior value="must"/>
    <precheckBehavior value="yes"/>
    <cardinalityBehavior value="multiple"/>
    <definitionCanonical value="{{API_URL}}/Questionnaire?identifier=RemoteMonitoringFeedbackSurveyQuestionnaire"/>
  </action>
  <action id="3">
    <prefix value="3."/>
    <title value="Observation Activity"/>
    <description value="Take an obervation"/>
    <priority value="routine"/>
    <goalId value="heart-failure-monitoring"/>
    <subjectCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/resource-types"/>
        <code value="Patient"/>
        <display value="Patient"/>
      </coding>
      <text value="Patient"/>
    </subjectCodeableConcept>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/action-type"/>
        <code value="create"/>
        <display value="Create"/>
      </coding>
      <text value="Create"/>
    </type>
    <requiredBehavior value="must"/>
    <precheckBehavior value="yes"/>
    <cardinalityBehavior value="multiple"/>
    <definitionCanonical value="https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/ActivityDefinition/RemoteMonitoringObservationRequest"/>
  </action>
</PlanDefinition>