EpisodeOfCare

Introduction

Scope and Usage

The EpisodeOfCare Resource contains information about an association of a Patient/Group with a Healthcare Provider for a period of time under which related healthcare activities may occur.

In many cases, this represents a period of time where the Healthcare Provider has some level of responsibility for the care of the patient(s) regarding a specific condition or problem, even if not currently participating in an encounter.

These resources are typically known in existing systems as:

• EpisodeOfCare: Case, Program, Problem, Episode
• Encounter: Visit, Contact

Multiple Organizations and Transfer of Care

Many organizations can be involved in an EpisodeOfCare; however each organization will have its own EpisodeOfCare resource instance that tracks its responsibility with the patient(s).

When an Organization completes their involvement with the patient(s) and transfers care to another Organization. This is often in the form of a referral to another Organization (or Organizations).

When an incoming referral is received a new EpisodeOfCare may be created for this organization. The initial step(s) in the intake workflow for the referral often involve some form of assessment(s), eligibility, capacity, care levels, which could take some time.
Once the intake process is completed and the patient/group is accepted, a CarePlan is often created.

Boundaries and Relationships

The primary difference between the EpisodeOfCare and the Encounter is that the Encounter records the details of an activity directly relating to the patient(s), while the EpisodeOfCare is the container that can link a series of Encounters together for problems/issues.
The Example scenarios below give some good examples as to when you might want to be using an EpisodeOfCare.

This difference is a similar difference between the EpisodeOfCare and a CarePlan. The EpisodeOfCare is a tracking resource, rather than a planning resource.
The EpisodeOfCare usually exists before the CarePlan. You don't need a CarePlan to use an EpisodeOfCare.

Background and Context

Systems collect a coherent group of activities (such as encounters) related to a patient's health condition or problem often referred to as a Care Episode. Information about an episode is often shared across systems, and in some cases organizational and disciplinary boundaries. An EpisodeOfCare contains details about the purpose of the care and can exist without any activities.
The minimal information that would be required in an episode of care would be a patient/group, organization and a reason for the ongoing association. Other reasons for creating an EpisodeOfCare could be for tracking the details required for government reporting or billing.

Expected Implementations

• Chronic Disease Management Systems
• Community Care Systems
  • Tracking progress of a specific condition
  • Tracking government funding
• Problem based General Practice systems
• Disability Support Systems
• Aged Care Systems (Community and Residential)

Notes

Status Management

History and Period

When an organization assumes responsibility for a patient/group, then the EpisodeOfCare is created and a start date entered to show when it has begun.
As the organization's responsibility changes, so does the status of the EpisodeOfCare.
This is described via an example below for an intake workflow.

Leave Handling

With long term care there is often a concept of the provision of care being suspended for various reasons. Many systems have extensive Leave Management/Tracking solutions which consider the complexities of this space, however this EpisodeOfCare resource is NOT intended to provide this level of tracking.
Extension(s) may be used on the status/status history to track the on-hold reason, which can facilitate the processing.

A more complete Leave Management solution may have to deal with:

• Leave Types
• Leave Entitlements
• Billing/Funding implications while on different types of leave

Example Intake Workflow

This example sequence demonstrates some status transitions and how other resources interact.
The context could be in a Community/Aged Care/Disability/Mental Health setting.

• ServiceRequest received
• intake clerk processes referral and decides that the first level eligibility has been met
  (e.g. Have capacity in the facility for the patient, the patient is covered by VA)
• EpisodeOfCare created with status of planned which is allocated as fulfilling the ServiceRequest
• Further assessment of needs is scheduled to be taken, a care manager is probably allocated at this point
• Assessment Practitioner sees the Patient and completes a series of relevant Questionnaires to rank the patient
• The assessments are reviewed and a formal CarePlan is created
• The EpisodeOfCare is updated to be marked as active, and the CareTeam is likely filled in
• The provision of care is then managed through the care plan, with all activities will also being linked to the EpisodeOfCare
• The patient is admitted to hospital for some procedures, and the EpisodeOfCare is marked as on hold
  Some of the services on the CarePlan (or scheduled appointments) would be reviewed to determine if they can be performed without the patient (e.g., home maintenance), or if they should be suspended while the patient is on hold.
• The patient returns from the hospital and the EpisodeOfCare is marked as active again (and services reviewed again)
• Patient wished to move to another area to be closer to family
• Organization creates an outgoing ServiceRequest to a new Organization to continue the care
• The EpisodeOfCare is closed

In some jurisdictions an Organization may be funded by a government body for the days that a patient is under their care. These are known as "active days". This does not mean that they are actively receiving a service (an encounter), but that the organization is responsible for managing their care.
This monthly reporting value can be easily extracted from the status history as described above.
The actual provision of services may also be funded separately, and this would be via the Encounters.

EpisodeOfCare Outcomes Review

An Organization may perform analytics on their EpisodeOfCare resources to have an understanding of how their business is performing.
Observing that there was a 60/40 split of episodes being finished/cancelled is not very informative. The organization would prefer to know the reason why the episodes are completing so that they can plan their business effectively.
They would be more interested in knowing whether it was due to services hitting their mandatory end date, client passing away, client transitioning to a higher level of services provided by them or to another provider etc.

Currently there are no attributes on this resource to provide this information. This would be very specific to each implementation and usage, so it would be recommended to use extensions to achieve this functionality.

Example Scenarios

A General Practitioner wants to review how well his patient is managing his diabetes over time from information within his clinic and also the regional community care organization's system(s).

The EpisodeOfCare enables the practitioner to easily separate the diabetes activities from the mental health problem's activities.

A Community Care organization wants to track all activities that occur with a patient relating to their disability to simplify the reporting to the government to receive funding to care for the patient

StructureDefinition

Elements (Simplified)

• EpisodeOfCare [0..*]: - An association of a Patient with an Organization and Healthcare Provider(s) for a period of time that the Organization assumes some level of responsibility
• EpisodeOfCare.identifier [0..*]: Identifier Business Identifier(s) relevant for this EpisodeOfCare
• EpisodeOfCare.status [1..1]: code required:episode-of-care-status planned | waitlist | active | onhold | finished | cancelled | entered-in-error
• EpisodeOfCare.statusHistory [0..*]: BackboneElement Past list of status codes (the current status may be included to cover the start date of the status)
• EpisodeOfCare.statusHistory.status [1..1]: code required:episode-of-care-status planned | waitlist | active | onhold | finished | cancelled | entered-in-error
• EpisodeOfCare.statusHistory.period [1..1]: Period Duration the EpisodeOfCare was in the specified status
• EpisodeOfCare.type [0..*]: CodeableConcept example:episodeofcare-type Type/class - e.g. specialist referral, disease management
• EpisodeOfCare.reason [0..*]: BackboneElement The list of medical reasons that are expected to be addressed during the episode of care
• EpisodeOfCare.reason.use [0..*]: CodeableConcept example:encounter-reason-use What the reason value should be used for/as
• EpisodeOfCare.reason.value [0..*]: CodeableReference example:encounter-reason Medical reason to be addressed
• EpisodeOfCare.diagnosis [0..*]: BackboneElement The list of medical conditions that were addressed during the episode of care
• EpisodeOfCare.diagnosis.condition [0..*]: CodeableReference example:condition-code The medical condition that was addressed during the episode of care
• EpisodeOfCare.diagnosis.use [0..*]: CodeableConcept preferred:encounter-diagnosis-use Role that this diagnosis has within the episode of care (e.g. admission, billing, discharge …)
• EpisodeOfCare.subject [1..1]: [Reference(Patient](/Reference(Patient), Group)) The patient/group who is the focus of this episode of care
• EpisodeOfCare.managingOrganization [0..1]: Reference(Organization) Organization that assumes responsibility for care coordination
• EpisodeOfCare.period [0..1]: Period Interval during responsibility is assumed
• EpisodeOfCare.referralRequest [0..*]: Reference(ServiceRequest) Originating Referral Request(s)
• EpisodeOfCare.careManager [0..1]: [Reference(Practitioner](/Reference(Practitioner), PractitionerRole)) Care manager/care coordinator for the patient
• EpisodeOfCare.careTeam [0..*]: Reference(CareTeam) Other practitioners facilitating this episode of care
• EpisodeOfCare.account [0..*]: Reference(Account) The set of accounts that may be used for billing for this EpisodeOfCare

Mappings

• EpisodeOfCare Mappings — 21 mapping entries

Resource Packs

list-EpisodeOfCare-packs.xml

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

<List xmlns="http://hl7.org/fhir">
  <id value="EpisodeOfCare-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>

Search Parameters

• care-manager — reference — Care manager/care coordinator for the episodeOfCare — EpisodeOfCare.careManager.where(resolve() is Practitioner)
• diagnosis-code — token — Conditions/problems/diagnoses this episode of care is for (coded) — EpisodeOfCare.diagnosis.condition.concept
• diagnosis-reference — reference — Conditions/problems/diagnoses this episode of care is for (resource reference) — EpisodeOfCare.diagnosis.condition.reference
• reason-code — token — Reference to a concept (coded) — EpisodeOfCare.reason.value.concept
• reason-reference — reference — Reference to a resource (resource reference) — EpisodeOfCare.reason.value.reference
• date — date — The provided date search value falls within the episode of care's period — EpisodeOfCare.period
• identifier — token — Business Identifier(s) relevant for this EpisodeOfCare — EpisodeOfCare.identifier
• incoming-referral — reference — Incoming Referral Request — EpisodeOfCare.referralRequest
• organization — reference — The organization that has assumed the specific responsibilities of this EpisodeOfCare — EpisodeOfCare.managingOrganization
• subject — reference — The patient/group who is the focus of this episode of care — EpisodeOfCare.subject
• patient — reference — The patient who is the focus of this episode of care — EpisodeOfCare.subject.where(resolve() is Patient)
• status — token — The current status of the Episode of Care as provided (does not check the status history collection) — EpisodeOfCare.status
• type — token — Type/class - e.g. specialist referral, disease management — EpisodeOfCare.type

Full Search Parameters

Examples

• episodeofcare-example — episodeofcare-example
• episodeofcare-examples-header — episodeofcare-examples-header
• example — episodeofcare-example — Episode of Care example

Full Examples

Mapping Exceptions

episodeofcare-event-mapping-exceptions.xml

Divergent Elements

• Event.identifier → EpisodeOfCare.identifier
  • summary | reason=Unknown | pattern=true
  • shortUnmatched | reason=Unknown | pattern=Business identifier for episode of care | resource=Business Identifier(s) relevant for this EpisodeOfCare
  • definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this episode of care by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server. | resource=The EpisodeOfCare may be known by different identifiers for different contexts of use, such as when an external agency is tracking the Episode for funding purposes.
  • commentsUnmatched | reason=Unknown | pattern=Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
  • requirementsUnmatched | reason=Unknown | pattern=Allows identification of the episode of care as it is known by various participating systems and in a way that remains consistent across servers.
• Event.basedOn → EpisodeOfCare.referralRequest
  • missingTypes | reason=Unknown | pattern=Reference(Request)
  • extraTypes | reason=Unknown
  • summary | reason=Unknown | pattern=true
  • shortUnmatched | reason=Unknown | pattern=Fulfills plan, proposal or order | resource=Originating Referral Request(s)
  • definitionUnmatched | reason=Unknown | pattern=A plan, proposal or order that is fulfilled in whole or in part by this episode of care. | resource=Referral Request(s) that are fulfilled by this EpisodeOfCare, incoming referrals.
  • requirementsUnmatched | reason=Unknown | pattern=Allows tracing of authorization for the episode of care and tracking whether proposals/recommendations were acted upon.
• Event.status → EpisodeOfCare.status
  • shortUnmatched | reason=Unknown | pattern=preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown | resource=planned | waitlist | active | onhold | finished | cancelled | entered-in-error
  • definitionUnmatched | reason=Unknown | pattern=The current state of the episode of care. | resource=planned | waitlist | active | onhold | finished | cancelled.
  • commentsUnmatched | reason=Unknown | pattern=A nominal state-transition diagram can be found in the (Event pattern documentation

Unknown does not represent "other" - one of the defined statuses must apply. Unknown is used when the authoring system is not sure what the current status is. | resource=This element is labeled as a modifier because the status contains codes that mark the episode as not currently valid.

• Event.code → EpisodeOfCare.type
  • shortUnmatched | reason=Unknown | pattern=What service was done | resource=Type/class - e.g. specialist referral, disease management
  • definitionUnmatched | reason=Unknown | pattern=A code that identifies the specific service or action that was or is being performed. | resource=A classification of the type of episode of care; e.g. specialist referral, disease management, type of funded care.
• Event.subject → EpisodeOfCare.subject
  • shortUnmatched | reason=Unknown | pattern=Individual service was done for/to | resource=The patient/group who is the focus of this episode of care
  • definitionUnmatched | reason=Unknown | pattern=The individual or set of individuals the action is being or was performed on. | resource=The patient/group who is the focus of this episode of care.
  • requirementsUnmatched | reason=Unknown | pattern=Links the episode of care to the Patient context. May also affect access control.
• Event.occurrence[x] → EpisodeOfCare.period
  • missingTypes | reason=Unknown | pattern=dateTime, Timing
  • shortUnmatched | reason=Unknown | pattern=When episode of care occurred/is occurring | resource=Interval during responsibility is assumed
  • definitionUnmatched | reason=Unknown | pattern=The date, period or timing when the episode of care did occur or is occurring. | resource=The interval during which the managing organization assumes the defined responsibility.
  • commentsUnmatched | reason=Unknown | pattern=This indicates when the activity actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this {{event}} is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds. .
• Event.performer.actor → EpisodeOfCare.managingOrganization
  • missingTypes | reason=Unknown | pattern=Reference(Practitioner, PractitionerRole, CareTeam, Patient, Device, RelatedPerson)
  • shortUnmatched | reason=Unknown | pattern=Who performed episode of care | resource=Organization that assumes responsibility for care coordination
  • definitionUnmatched | reason=Unknown | pattern=Indicates who or what performed the episode of care. | resource=The organization that has assumed the specific responsibilities for care coordination, care delivery, or other services for the specified duration.
• Event.performer.actor → EpisodeOfCare.careManager
  • missingTypes | reason=Unknown | pattern=Reference(Organization, CareTeam, Patient, Device, RelatedPerson)
  • summary | reason=Unknown | pattern=true
  • shortUnmatched | reason=Unknown | pattern=Who performed episode of care | resource=Care manager/care coordinator for the patient
  • definitionUnmatched | reason=Unknown | pattern=Indicates who or what performed the episode of care. | resource=The practitioner that is the care manager/care coordinator for this patient.
• Event.performer.actor → EpisodeOfCare.careTeam
  • missingTypes | reason=Unknown | pattern=Reference(Practitioner, PractitionerRole, Organization, Patient, Device, RelatedPerson)
  • summary | reason=Unknown | pattern=true
  • shortUnmatched | reason=Unknown | pattern=Who performed episode of care | resource=Other practitioners facilitating this episode of care
  • definitionUnmatched | reason=Unknown | pattern=Indicates who or what performed the episode of care. | resource=The list of practitioners that may be facilitating this episode of care for specific purposes.
• Event.reason → EpisodeOfCare.reason.value
  • shortUnmatched | reason=Unknown | pattern=Why was episode of care performed? | resource=Medical reason to be addressed
  • definitionUnmatched | reason=Unknown | pattern=Describes why the episode of care occurred in coded or textual form or Indicates another resource whose existence justifies this episode of care. | resource=The medical reason that is expected to be addressed during the episode of care, expressed as a text, code or a reference to another resource.
  • commentsUnmatched | reason=Unknown | pattern=Textual reasons can be captured using reasonCode.text.
• Event.reason → EpisodeOfCare.diagnosis.condition
  • shortUnmatched | reason=Unknown | pattern=Why was episode of care performed? | resource=The medical condition that was addressed during the episode of care
  • definitionUnmatched | reason=Unknown | pattern=Describes why the episode of care occurred in coded or textual form or Indicates another resource whose existence justifies this episode of care. | resource=The medical condition that was addressed during the episode of care, expressed as a text, code or a reference to another resource.
  • commentsUnmatched | reason=Unknown | pattern=Textual reasons can be captured using reasonCode.text.

Unmapped Elements

• Event.partOf — Unknown
• Event.reported — Unknown
• Event.relevantHistory — Unknown
• Event.location — Unknown
• Event.statusReason — Unknown
• Event.performer.function — Unknown
• Event.note — Unknown
• Event.category — Unknown
• Event.encounter — Unknown
• Event.recorded — Unknown
• Event.product — Unknown
• Event.performer — Unknown
• Event.researchStudy — Unknown

episodeofcare-fivews-mapping-exceptions.xml

Divergent Elements

• FiveWs.what[x] → EpisodeOfCare.reason.value
• FiveWs.what[x] → EpisodeOfCare.diagnosis.condition

Unmapped Elements

• FiveWs.recorded — Unknown
• FiveWs.author — Unknown
• FiveWs.actor — Unknown
• FiveWs.cause — Unknown
• FiveWs.version — Unknown
• FiveWs.witness — Unknown
• FiveWs.where — Unknown
• FiveWs.context — Unknown
• FiveWs.why — Unknown
• FiveWs.source — Unknown
• FiveWs.who — Unknown
• FiveWs.grade — Unknown
• FiveWs.planned — Unknown
• FiveWs.done — Unknown