Health New Zealand Te Whatu Ora Shared Care FHIR API
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: Template for Remote Monitoring Heart Failure Care Plan - XML Representation

Active as of 2023-07-25

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<PlanDefinition xmlns="http://hl7.org/fhir">
  <id value="RemoteMonitoringHeartFailureCarePlanTemplate"/>
  <language value="en-NZ"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-NZ" lang="en-NZ"><p class="res-header-id"><b>Generated Narrative: PlanDefinition RemoteMonitoringHeartFailureCarePlanTemplate</b></p><a name="RemoteMonitoringHeartFailureCarePlanTemplate"> </a><a name="hcRemoteMonitoringHeartFailureCarePlanTemplate"> </a><a name="RemoteMonitoringHeartFailureCarePlanTemplate-en-NZ"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Language: en-NZ</p></div><p><b>url</b>: <a href="PlanDefinition-RemoteMonitoringHeartFailureCarePlanTemplate.html">PlanDefinition Template for Remote Monitoring Heart Failure Care Plan</a></p><p><b>identifier</b>: RemoteMonitoringHeartFailureCarePlanTemplate (use: official, )</p><p><b>version</b>: 0.1.6</p><p><b>name</b>: RemoteMonitoringHeartFailureCarePlanTemplate</p><p><b>title</b>: Template for Remote Monitoring Heart Failure Care Plan</p><p><b>subtitle</b>: Care in the Community plans to handle heart failure patients remotely in an ongoing capacity</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/plan-definition-type order-set}">Order Set</span></p><p><b>status</b>: Active</p><p><b>experimental</b>: true</p><p><b>subject</b>: <span title="Codes:{http://hl7.org/fhir/resource-types Patient}">Patient</span></p><p><b>date</b>: 2023-07-25</p><p><b>publisher</b>: Te Whatu Ora</p><p><b>contact</b>: Te Whatu Ora: <a href="https://www.tewhatuora.govt.nz/">https://www.tewhatuora.govt.nz/</a>, David Grainger: <a href="mailto:david.grainger@middleware.co.nz">david.grainger@middleware.co.nz</a></p><p><b>description</b>: </p><div><p>This careplan designed to support ongoing monitoring of long term conditions (heart failure) in primary care.</p>
</div><p><b>jurisdiction</b>: <span title="Codes:{urn:iso:std:iso:3166 NZ}">New Zealand</span></p><p><b>purpose</b>: </p><div><p>This careplan designed to support ongoing monitoring of long term conditions (heart failure) in primary care</p>
</div><p><b>usage</b>: Allows monitoring and tracking of progress of a self serve remote Heart failure patient.</p><p><b>lastReviewDate</b>: 2022-08-04</p><p><b>effectivePeriod</b>: 2022-08-04 --&gt; 2023-08-04</p><p><b>topic</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/definition-topic treatment}">Treatment</span></p><p><b>author</b>: HNZ RPM Project: </p><p><b>editor</b>: HNZ RPM Project: </p><p><b>reviewer</b>: HNZ RPM Project: </p><p><b>endorser</b>: Alastair Kenworthy: CinC Fit for Future Project</p><blockquote><p><b>goal</b></p><blockquote><p><b>id</b></p>heart-failure-monitoring</blockquote><p><b>category</b>: <span title="Codes:">Heart Failure Monitoring</span></p><p><b>description</b>: <span title="Codes:">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.</span></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/goal-priority medium-priority}">Medium Priority</span></p><p><b>start</b>: <span title="Codes:">Assessed as suitable</span></p></blockquote><blockquote><p><b>action</b></p><blockquote><p><b>id</b></p>1</blockquote><p><b>prefix</b>: 1.</p><p><b>title</b>: Daily Symptom Survey</p><p><b>description</b>: Daily Symptom Survey</p><p><b>textEquivalent</b>: Daily Survey to gather any symptoms experianced by a patient</p><p><b>priority</b>: Routine</p><p><b>goalId</b>: heart-failure-monitoring</p><p><b>subject</b>: <span title="Codes:{http://hl7.org/fhir/resource-types Patient}">Patient</span></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/action-type create}">Create</span></p><p><b>requiredBehavior</b>: Must</p><p><b>precheckBehavior</b>: Yes</p><p><b>cardinalityBehavior</b>: Multiple</p><p><b>definition</b>: <a href="https://simplifier.net/resolve?scope=fhir.org.nz.ig.base@3.0.0&amp;canonical=http://fhir.org.nz/ig/base/{{API_URL}}/Questionnaire?identifier=RemoteMonitoringHeartFailureSymptomSurveyQuestionnaire">{{API_URL}}/Questionnaire?identifier=RemoteMonitoringHeartFailureSymptomSurveyQuestionnaire</a></p></blockquote><blockquote><p><b>action</b></p><blockquote><p><b>id</b></p>2</blockquote><p><b>prefix</b>: 2.</p><p><b>title</b>: Weekly Feedback Survey</p><p><b>description</b>: Weekly Feedback Survey</p><p><b>textEquivalent</b>: A weekly survey giving an opportunity for patients to provide feedback towards their experiance with the program</p><p><b>priority</b>: Routine</p><p><b>goalId</b>: heart-failure-monitoring</p><p><b>subject</b>: <span title="Codes:{http://hl7.org/fhir/resource-types Patient}">Patient</span></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/action-type create}">Create</span></p><p><b>requiredBehavior</b>: Must</p><p><b>precheckBehavior</b>: Yes</p><p><b>cardinalityBehavior</b>: Multiple</p><p><b>definition</b>: <a href="https://simplifier.net/resolve?scope=fhir.org.nz.ig.base@3.0.0&amp;canonical=http://fhir.org.nz/ig/base/{{API_URL}}/Questionnaire?identifier=RemoteMonitoringFeedbackSurveyQuestionnaire">{{API_URL}}/Questionnaire?identifier=RemoteMonitoringFeedbackSurveyQuestionnaire</a></p></blockquote><blockquote><p><b>action</b></p><blockquote><p><b>id</b></p>3</blockquote><p><b>prefix</b>: 3.</p><p><b>title</b>: Observation Activity</p><p><b>description</b>: Take an obervation</p><p><b>priority</b>: Routine</p><p><b>goalId</b>: heart-failure-monitoring</p><p><b>subject</b>: <span title="Codes:{http://hl7.org/fhir/resource-types Patient}">Patient</span></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/action-type create}">Create</span></p><p><b>requiredBehavior</b>: Must</p><p><b>precheckBehavior</b>: Yes</p><p><b>cardinalityBehavior</b>: Multiple</p><p><b>definition</b>: <a href="https://simplifier.net/resolve?scope=fhir.org.nz.ig.base@3.0.0&amp;canonical=http://fhir.org.nz/ig/base/{{API_URL}}/ActivityDefinition?identifier=RemoteMonitoringObservationRequest">{{API_URL}}/ActivityDefinition?identifier=RemoteMonitoringObservationRequest</a></p></blockquote></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="David Grainger"/>
    <telecom>
      <system value="email"/>
      <value value="david.grainger@middleware.co.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="{{API_URL}}/ActivityDefinition?identifier=RemoteMonitoringObservationRequest"/>
  </action>
</PlanDefinition>