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Clinical Decision Support ![]() | Maturity Level: 4 | Trial Use | Security Category: Business | Compartments: No defined compartments |
This resource allows for the definition of various types of plans as a sharable, consumable, and executable artifact. The resource is general enough to support the description of a broad range of clinical and non-clinical artifacts such as clinical decision support rules, order sets, protocols, and drug quality specifications.
This resource is a definition resource from a FHIR workflow perspective - see Workflow, specifically Definition.
A plan definition is a pre-defined group of actions to be taken in particular circumstances, often including conditional elements, options, and other decision points. The resource is flexible enough to be used to represent a variety of workflows, as well as clinical decision support and quality improvement assets, including order sets, protocols, and decision support rules.
PlanDefinitions can contain hierarchical groups of action definitions, where each action definition describes an activity to be performed (often in terms of an ActivityDefinition resource), and each group defines additional behavior, relationships, and applicable conditions between the actions in the overall definition.
In addition to describing what should take place, each action in a plan definition can specify when and whether the action should take place. For when the action should be taken, the trigger
element specifies the action should be taken in response to some trigger occurring (such as a particular point in a workflow being reached, or as the result of a prescription being ordered). For whether the action should be taken, the condition
element can be used to provide an expression that evaluates to true or false to indicate the applicability of the action to the specific context.
The process of applying a PlanDefinition to a particular context typically produces request resources representing the actions that should be performed, grouped within a RequestOrchestration to capture relationships between the resulting request resources.
Each ActivityDefinition is used to construct a specific resource, based on the definition of the activity and combined with contextual information for the particular patient that the plan definition is being applied to.
As with the ActivityDefinition, a PlanDefinition may provide information about how to transform the activity to a specific intent resource, either by specifying a StructureMap that can be used to perform the transformation completely, or by specifying values for specific elements of the resulting resource using dynamicValue
elements in the action.
Note that these mechanisms are provided on both the ActivityDefinition and the PlanDefinition to allow both reusable transformation descriptions, as well as customization of those descriptions within specific contexts. As such, the transform descriptions specified on the PlanDefinition override transform descriptions defined on the ActivityDefinition.
Dynamic values within the definitions can be provided by specifying the expression directly, or by referencing an expression defined within a library. For more information on how to reference expressions within resources, refer to the Using Expressions topic.
As an example, the Low Suicide Risk example order set from the Clinical Decision Support Knowledge Artifact Specification can be represented using the PlanDefinition and ActivityDefinition structures: Low Suicide Risk Example Order Set.
In addition to the representation of PlanDefinitions, the $apply operation allows PlanDefinitions to be applied to a specific context such as a patient, practitioner, or institution. For Order Sets specifically, this operation is expected to place the orders defined by the order set, consistent with the service functional requirements defined by the Order Set specification .
Plan definitions also allow for the definition of goals. Actions in the plan definition can then reference these goals in order to indicate that the action should be taken in fulfillment of the goal. Note that the goal-relationship extension can be used to describe relationships between goal definitions, and the satisfies-requirement extension can be used to indicate that the goal satisfies a particular requirement.
The PlanDefinition resource is used to describe series, sequences, or groups of actions to be taken, while the ActivityDefinition resource is used to define each specific step or activity to be performed.
As the name implies, the PlanDefinition resource is strictly definitional. It does not represent the intention to take any action, nor does it represent that any actions have been taken. Rather, the resource provides a definition that can be applied in the appropriate circumstances. When the plan definition is applied, the result will in general be a set of actions that should be (or potentially even have been) performed.
Note that the PlanDefinition still has action-level information, as well as a reference to an ActivityDefinition. The action-level information defined in the PlanDefinition itself is used to describe how the actions are related to each other within the plan, where the ActivityDefinition contains only information about the activity itself. In addition, there is some overlapping information that allows the resources to be used independently, or in combination. See the Applying a PlanDefinition section for more information.
Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) , the spreadsheet version & the dependency analysis
Path | ValueSet | Type | Documentation |
---|---|---|---|
PlanDefinition.versionAlgorithm[x] | VersionAlgorithm | Extensible | Indicates the mechanism used to compare versions to determine which is more current. |
PlanDefinition.type | PlanDefinitionType | Extensible | The type of PlanDefinition. |
PlanDefinition.status | PublicationStatus | Required | The lifecycle status of an artifact. |
PlanDefinition.subject[x] | ParticipantResourceTypes | Extensible | All Resource Types that represent participant resources |
PlanDefinition.jurisdiction | JurisdictionValueSet | Extensible | This value set defines a base set of codes for country, country subdivision and region for indicating where a resource is intended to be used. Note: The codes for countries and country subdivisions are taken from ISO 3166 |
PlanDefinition.topic | DefinitionTopic | Example | High-level categorization of the definition, used for searching, sorting, and filtering. |
PlanDefinition.goal.category | GoalCategory | Example | Example codes for grouping goals to use for filtering or presentation. |
PlanDefinition.goal.description | SNOMEDCTClinicalFindings | Example | This value set includes all the "Clinical finding" SNOMED CT |
PlanDefinition.goal.priority | GoalPriority | Preferred | Indicates the level of importance associated with reaching or sustaining a goal. |
PlanDefinition.goal.start | GoalStartEvent | Example | Identifies types of events that might trigger the start of a goal. |
PlanDefinition.goal.addresses | ConditionProblemDiagnosisCodes | Example | Example value set for Condition/Problem/Diagnosis codes. |
PlanDefinition.goal.target.measure | LOINCCodes (a valid code from LOINC ![]() |
Example | This value set includes all LOINC codes |
PlanDefinition.actor.option.type | ActionParticipantType | Required | The type of participant for the action. |
PlanDefinition.actor.option.role | ActionParticipantRole ![]() |
Example | Either a practitioner role or a relationship type. Note from UTG import - may have been a temporary entry that subsequently disappeared from the FHIR source; unable to locate. Version set to 0.1.0 |
PlanDefinition.action.priority | RequestPriority | Required | Identifies the level of importance to be assigned to actioning the request. |
PlanDefinition.action.code | ActionCode | Example | Provides examples of actions to be performed. |
PlanDefinition.action.reason | ActionReasonCode | Example | Provides examples of reasons for actions to be performed. |
PlanDefinition.action.subject[x] | ParticipantResourceTypes | Extensible | All Resource Types that represent participant resources |
PlanDefinition.action.condition.kind | ActionConditionKind | Required | Defines the kinds of conditions that can appear on actions. |
PlanDefinition.action.relatedAction.relationship | ActionRelationshipType | Required | Defines the types of relationships between actions. |
PlanDefinition.action.relatedAction.endRelationship | ActionRelationshipType | Required | Defines the types of relationships between actions. |
PlanDefinition.action.participant.type | ActionParticipantType | Required | The type of participant for the action. |
PlanDefinition.action.participant.role | ActionParticipantRole ![]() |
Example | Either a practitioner role or a relationship type. Note from UTG import - may have been a temporary entry that subsequently disappeared from the FHIR source; unable to locate. Version set to 0.1.0 |
PlanDefinition.action.participant.function | ActionParticipantFunction | Example | The function performed by the participant for the action. |
PlanDefinition.action.type | ActionType | Extensible | The type of action to be performed. |
PlanDefinition.action.groupingBehavior | ActionGroupingBehavior | Required | Defines organization behavior of a group. |
PlanDefinition.action.selectionBehavior | ActionSelectionBehavior | Required | Defines selection behavior of a group. |
PlanDefinition.action.requiredBehavior | ActionRequiredBehavior | Required | Defines expectations around whether an action or action group is required. |
PlanDefinition.action.precheckBehavior | ActionPrecheckBehavior | Required | Defines selection frequency behavior for an action or group. |
PlanDefinition.action.cardinalityBehavior | ActionCardinalityBehavior | Required | Defines behavior for an action or a group for how many times that item may be repeated. |
PlanDefinition.asNeeded[x] | SNOMEDCTMedicationAsNeededReasonCodes | Example | This value set includes all clinical findings from SNOMED CT - provided as an exemplar value set. |
UniqueKey | Level | Location | Description | Expression |
![]() | Warning | (base) | Name should be usable as an identifier for the module by machine processing applications such as code generation | name.exists() implies name.matches('^[A-Z]([A-Za-z0-9_]){1,254}$') |
![]() | Rule | PlanDefinition.action.input | Input data elements must have a requirement or a relatedData, but not both | requirement.exists() xor relatedData.exists() |
![]() | Rule | PlanDefinition.action.output | Output data element must have a requirement or a relatedData, but not both | requirement.exists() xor relatedData.exists() |
![]() | Warning | PlanDefinition.url | URL should not contain | or # - these characters make processing canonical references problematic | exists() implies matches('^[^|# ]+$') |
![]() | Warning | (base) | goalid should reference the id of a goal definition | %context.repeat(action).where((goalId in %context.goal.id).not()).exists().not() |
![]() | Warning | (base) | targetId should reference the id of an action | %context.repeat(action).relatedAction.where((targetId in %context.repeat(action).id).not()).exists().not() |
The following diagram illustrates the relationship between the PlanDefinition and ActivityDefinition resources, as well as a typical realization to RequestOrchestration and Request-pattern resources. The resources depicted on the left side of the arrow are definition resources, while the ones on the right side of the arrow are request resources, with the arrow representing the $apply
operation:
The PlanDefinition and ActivityDefinition resources support the representation of a broad range of use cases including order sets, flow sheets, event-condition-action rules, clinical protocols, and research trials. To support this range of use cases, as well as the variability in capabilities of systems that use these types of artifacts, this specification is not prescriptive about exactly how these definitions are applied to produce request and event resources. However, the approach depicted above provides a general framework for the process, and the following steps provide more detail on the potential approach:
instantiatesCanonical
elementgoal
definitions in the PlanDefinitionaction
element of the PlanDefinitionProcessing for each action proceeds according to the following steps:
action
element in the RequestOrchestration. If the element has a linkId
, set the linkId>
element of the new action to the same value. Note that for legacy PlanDefinitions, this action linking was accomplished with the id
element, so for backwards compatibility, implementations may set the id
element of the newly created action as well.action
to the corresponding elements of the newly created action
in the RequestOrchestration such as title
, description
, textEquivalent
, timing
, and so ondefinition
element, but for the ones that specifically refer to another definitional resource, the behavior is:
resource
element of the action and add the resource as an entry in the overall result Bundle.intent
of the target resource to option so that it is clearly indicated as part of a RequestOrchestration. Note that the ActivityDefinition/$apply operation will not necessarily produce the resource with this status, so this is an important step.action
(see the section on Overlap below for details)resource
element of the action and add it as an entry in the overall result Bundle.intent
of the RequestOrchestration to option so that it is clearly indicated as part of a RequestOrchestration.action
such as title
, description
, and dynamicValue
.resource
element of the action to the Questionnaire, indicating that the activity to be performed is filling out the given questionnaire.The parameters to the $apply operation are available within dynamicValue CQL and FHIRPath expressions as context variables, accessible by the name of the parameter prefixed with a percent (%) symbol. For example, to access the subject given to the apply, use the expression %subject
. The value of the %subject context variable in a dynamicValue expression is determined using the current subject, as specified by the subject
element on the PlanDefinition, current PlanDefinition.action, or ActivityDefinition.
In addition to the $apply operation parameters, the context variable %action can be used within the path element of a dynamicValue to specify the current action target. For example, to specify the path to the description element of the current action, use %action.description
.
Note that result of this operation is transient (i.e. none of the resources created by the operation are persisted in the server, they are all returned as contained resources in the result). The result effectively represents a proposed set of activities, and it is up to the caller to determine whether and how those activities are actually carried out.
The ActivityDefinition resource may only specify Request resource types to facilitate considering user input as part of processing the result of any automated clinical reasoning processes. To support creation of event resources, such as Observations, RiskAssessments, and DetectedIssues, use a Task resource with the focus of the task set to the event resource to be created.
As noted in the Boundaries section, there is some overlap between the content that can be represented within the action
element of a PlanDefinition, and the elements of the ActivityDefinition resource. This overlap allows for both resources to be used independently, as well as in combination. For example, a PlanDefinition may be used without any supporting ActivityDefinitions to describe a particular workflow, where it is sufficient to describe the actions simply as textual descriptions of what needs to take place. On the other hand, the PlanDefinition may be used together with ActivityDefinition to provide a detailed structural representation of the activities to be performed.
In general, where there is overlap, the elements from the PlanDefinition provide overriding behavior. Specifically, the following elements of action
overlap with ActivityDefinition:
Element | Behavior |
---|---|
title | The title element in ActivityDefinition is the title of the activity "as defined", where the title element in PlanDefinition reflects the title in the scope of the plan. |
description | The description element in ActivityDefinition is the description of the activity "as defined", where the description element in PlanDefinition reflects the description in the scope of the plan. |
code | The code element in ActivityDefinition represents the meaning of the activity "as defined", where the code element in PlanDefinition represents the meaning in the scope of the plan. |
documentation | The documentation element in PlanDefinition represents additional documentation for the action specific to the scope of the plan, where the relatedArtifact element in ActivityDefinition provides documentation specific to the activity itself. |
timing | The timing element in ActivityDefinition represents timings associated within the activity itself, where the timing element in PlanDefinition represents the timing of the activity with respect to the plan and its other actions. When a timing is provided on both, the timing defined in the plan generally takes precedence. |
asNeeded | The asNeeded element allows pre-conditions to be associated with an action or activity. When asNeeded is specified on both, the value specified in the plan generally takes precedence. |
participant | The participant element in ActivityDefinition represents what type of actor is expected to perform the activity generally, where the participant element in PlanDefinition represents the type of actor that is expected to perform the activity in the context of the plan. |
transform | The transform element in ActivityDefinition describes the transformation of the definition to a request or event resource in general, where the transform element in PlanDefinition describes the transformation within the scope of the plan. When a transform is present in both, the transform in the plan takes precedence. |
dynamicValue | The dynamicValue element in ActivityDefinition defines values for elements of the target request or event resource in general, where the dynamicValue element in PlanDefinition defines values within the scope of the plan. When dynamic values are present in both, the dynamic values from the ActivityDefinition are applied first (in the order in which they appear on the ActivityDefinition), followed by the dynamic values from the PlanDefinition (in the order in which they appear on the PlanDefinition). |
Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
Name | Type | Description | Expression | In Common |
composed-of | reference | What resource is being referenced | PlanDefinition.relatedArtifact.where(type='composed-of').resource (Any) |
5 Resources |
context | token | A use context assigned to the plan definition | (PlanDefinition.useContext.value.ofType(CodeableConcept)) | 30 Resources |
context-quantity | quantity | A quantity- or range-valued use context assigned to the plan definition | (PlanDefinition.useContext.value.ofType(Quantity)) | (PlanDefinition.useContext.value.ofType(Range)) | 30 Resources |
context-type | token | A type of use context assigned to the plan definition | PlanDefinition.useContext.code | 30 Resources |
context-type-quantity | composite | A use context type and quantity- or range-based value assigned to the plan definition | On PlanDefinition.useContext: context-type: code context-quantity: value.ofType(Quantity) | value.ofType(Range) |
30 Resources |
context-type-value | composite | A use context type and value assigned to the plan definition | On PlanDefinition.useContext: context-type: code context: value.ofType(CodeableConcept) |
30 Resources |
date | date | The plan definition publication date | PlanDefinition.date | 31 Resources |
definition | reference | Activity or plan definitions used by plan definition | PlanDefinition.action.definition.ofType(canonical) | PlanDefinition.action.definition.ofType(uri) (SpecimenDefinition, MessageDefinition, Questionnaire, ObservationDefinition, PlanDefinition, ActivityDefinition) |
|
depends-on | reference | What resource is being referenced | PlanDefinition.relatedArtifact.where(type='depends-on').resource | PlanDefinition.library (Library, Any) |
5 Resources |
derived-from | reference | What resource is being referenced | PlanDefinition.relatedArtifact.where(type='derived-from').resource (Any) |
9 Resources |
description | string | The description of the plan definition | PlanDefinition.description | 29 Resources |
effective | date | The time during which the plan definition is intended to be in use | PlanDefinition.effectivePeriod | 12 Resources |
identifier | token | External identifier for the plan definition | PlanDefinition.identifier | 35 Resources |
jurisdiction | token | Intended jurisdiction for the plan definition | PlanDefinition.jurisdiction | 27 Resources |
name | string | Computationally friendly name of the plan definition | PlanDefinition.name | 28 Resources |
predecessor | reference | What resource is being referenced | PlanDefinition.relatedArtifact.where(type='predecessor').resource (Any) |
9 Resources |
publisher | string | Name of the publisher of the plan definition | PlanDefinition.publisher | 31 Resources |
status | token | The current status of the plan definition | PlanDefinition.status | 35 Resources |
successor | reference | What resource is being referenced | PlanDefinition.relatedArtifact.where(type='successor').resource (Any) |
5 Resources |
title | string | The human-friendly name of the plan definition | PlanDefinition.title | 28 Resources |
topic | token | Topics associated with the module | PlanDefinition.topic | 10 Resources |
type | token | The type of artifact the plan (e.g. order-set, eca-rule, protocol) | PlanDefinition.type | |
url | uri | The uri that identifies the plan definition | PlanDefinition.url | 34 Resources |
version | token | The business version of the plan definition | PlanDefinition.version | 32 Resources |