Clinical Workflow Questions How do I use order sets when planning care? How does care plans identify what protocol it’s adhering to? How can I use best practices or clinical practice guidelines while planning care? How do I close-the-loop? How do I know a request or an order has been satisfied? How does an event or a result point to the order that authorized it? How do I know who the patient care team members are?

Protocol/Template/orderSets First Line Monotherapy Metformin HCL 500 mg ….. description: Metformin HCl 500 MG Oral Tablet; TAKE one TABLET Twice daily with meals; 60 tablet; 2 refills purpose: Defines a guideline supported prescription for the treatment of DM Type II usage: This activity definition is used as part of Diabetes Mellitus, Type 2, Adult +MU care guides approvalDate: 04/28/2017 lastReviewDate: 05/04/2017 effectivePeriod: 05/04/2017 --> 05/04/2018 ActivityDefinition Alternative Monotherapy Glimepiride 1 MG Oral ….. description: Glimepiride 1 MG Oral Tablet; one TABLET QD WITH BREAKFAST.; Qty: 30; Tablet; Days Supply: 30; Refill: 2 purpose: Defines a guideline supported prescription for the treatment of DM Type II usage: This activity definition is used as part of Diabetes Mellitus, Type 2, Adult +MU care guides approvalDate: 04/28/2017 lastReviewDate: 05/04/2017 effectivePeriod: 05/04/2017 --> 05/04/2018 ActivityDefinition library Protocol/Template/orderSets PlanDefinition e.g. DM Type II definition basedOn Patient specific Care Plan HealthConcern identifies addresses HealthGoal fulfils Activity Request e.g. ProcedureRequest initiates Activity Event – uses action resources e.g. Procedure

actionDefintion (group) ActivityDefinition PlanDefinition actionDefintion (group) First Line Monotherapy Metformin HCL 500 mg ….. description: Metformin HCl 500 MG Oral Tablet; TAKE one TABLET Twice daily with meals; 60 tablet; 2 refills purpose: Defines a guideline supported prescription for the treatment of DM Type II usage: This activity definition is used as part of Diabetes Mellitus, Type 2, Adult +MU care guides approvalDate: 04/28/2017 lastReviewDate: 05/04/2017 effectivePeriod: 05/04/2017 --> 05/04/2018 ActivityDefinition library Protocol/Template/orderSets PlanDefinition e.g. DM Type II definition Patient specific basedOn Care Plan Diet Recommendation – follow a 1500 calories diabetic diet ….. description: Diabetes diet, specified calories; Follow a diabetic diet with 1500 calories. purpose: Defines a guideline supported patient instructions for the treatment of DM Type II usage: This activity definition is used as part of Diabetes Mellitus, Type 2, Adult +MU care guides approvalDate: 04/28/2017 lastReviewDate: 05/04/2017 effectivePeriod: 05/04/2017 --> 05/04/2018 ….. HealthConcern identifies addresses HealthGoal Activity Request e.g. ProcedureRequest fulfils initiates Activity Event – uses action resources e.g. Procedure

Plan & Activity Definitions PlanDefinition PlanDefinition maps to CarePlan and/or request group PlanDefinition Actions are activities, i.e. ActivityDefinition PlanDefinition aggregate activity definitions so they are implementable, i.e. library of activity definitions ActivityDefinition ActivityDefinition referenced from PlanDefinition ActivityDefinition.kind uses request type resources ActivityDefinition, i.e. definition of an activity Actions are generated from the activityDefinition so they are used in a CarePlan ActivityDefinitions can be based on best practices, CPG

Care Team Members How can I use PlanDefintion to derive care team members? PlanDefinition.action.definition reference activityDefinition ActivityDefinition.participant.type defines the practitioner | patient |relatedPerson This person can be included in the care team planDefinition need linkage to care team at 1) entire definition level (for coordination purposes) as well as support of teams in team and 2) at the activity level – where individuals that have accountability and responsibility