Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.

Data Element
Care Plan
Description (*Please confirm or update this field for the new USCDI version*)

Shared plan informed by members of a coordinated care team that details conditions, needs, and goals along with strategies for addressing them.

Usage notes: Includes prioritized problems, health concerns, assessments, goals, and interventions from across care settings.

Examples include nursing care plan, diabetic care plan, multiple chronic conditions care plan, and long term services and support care plan.
Submitted By: Julia Skapik / NACHC
Data Element Information
Rationale for Separate Consideration This is an overlaying data class that supports several intentional existing data elements in USCDI.
Use Case Description(s)
Use Case Description NACHC currently using the FHIR care plan to support data capture and exchange in mobile health ambassadors.
Estimate the breadth of applicability of the use case(s) for this data element 100,000 care team members
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC, HL7 C-CDA and FHIR
Additional Specifications N/A
Current Use In limited use in production environments
Supporting Artifacts Use in 6 FQHCs in the US.
Extent of exchange 4
Supporting Artifacts VA and Healthflow exchange use cases.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) The FHIR profile is preferred but C-CDA and FHIR versions should be linked to the use of the profile/standard.
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns to the extent that health data is
Estimate of Overall Burden Implementation burden should be overwhelmingly eclipsed by utility for care coordination
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

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