GP Chronic Condition Management Plan
0.1.0 - ci-build

GP Chronic Condition Management Plan, published by AEHRC CSIRO. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/aehrc/gpccmp-fhir-ig/ and changes regularly. See the Directory of published versions

## Home

Official URL: https://gpccmp.csiro.au/ig/ImplementationGuide/csiro.fhir.au.gpccmp | Version: 0.1.0
Draft as of 2026-01-28 | Computable Name: GPChronicConditionManagementPlan

### Introduction

This guide is provided to support the implementation of the FHIR GP Chronic Condition Management Plan (CCMP) form. CCMPs help eligible health professionals coordinate health care for patients with chronic or terminal medical conditions (Services Australia).

### Design Principles

The FHIR GP CCMP is represented as a Questionnaire resource and its technical design and function are guided by the Structured Data Capture specification. The data exchange requirements have been designed to align with AU Core to the greatest extent possible. AU Core describes a requester/responder paradigm of data access. Data exchange requirements described in this guide have significant overlap and derives much of its content from AU Core. The exchange of QuestionnaireResponse resources is in addition to those requirements.

The form content has been informed by requirements gathered from the Sparked Chronic Condition Management Clinical Focus Group. The key principles for this release are as follows: Insert principles

### Scope

The scope of this implementation guide includes the data exchange requirements to populate the form with existing data from a patient record and managing the completion of the form.

It does not include guidance on implementing the Structured Data Capture specification and supporting specific form behaviour.

### Actors

It is expected the GP CCMP will be available for use within the context of a patient management system. The following actors have been included to reflect this expectation:

1. CCMP Server The CCMP Server supports:
   - retrieval and provision of patient health information for the purposes of prepopulating the form
   - retrieval and storage of completed or partially completed forms.
2. CCMP Client The CCMP Client supports:
   - requesting and processing of patient health information for the purposes of prepopulating the form
   - requesting and production of completed or partially completed forms.

### Dependencies

IG | Package | FHIR | Comment
--- | --- | --- | ---
GP Chronic Condition Management Plan | csiro.fhir.au.gpccmp#0.1.0 | R4 |
HL7 Terminology (THO) | hl7.terminology.r4#7.0.1 | R4 | Automatically added as a dependency - all IGs depend on HL7 Terminology
FHIR Extensions Pack | hl7.fhir.uv.extensions.r4#5.2.0 | R4 |
AU Core Implementation Guide | hl7.fhir.au.core#2.0.0-preview | R4 |
HL7 Terminology (THO) | hl7.terminology.r4#7.0.0 | R4 |
AU Base Implementation Guide | hl7.fhir.au.base#6.0.0-preview | R4 |
SMART App Launch | hl7.fhir.uv.smart-app-launch#2.2.0 | R4 |
HL7 Terminology (THO) | hl7.terminology#5.5.0 | R4 |
FHIR Extensions Pack | hl7.fhir.uv.extensions.r4#1.0.0 | R4 |
International Patient Access | hl7.fhir.uv.ipa#1.1.0 | R4 |
HL7 Terminology (THO) | hl7.terminology.r4#6.2.0 | R4 |
SMART App Launch | hl7.fhir.uv.smart-app-launch#2.0.0 | R4 |
Structured Data Capture | hl7.fhir.uv.sdc#current | R4 |
HL7 Terminology (THO) | hl7.terminology.r4#6.5.0 | R4 |
FHIR Extensions Pack | hl7.fhir.uv.extensions.r4#5.3.0-ballot-tc1 | R4 |
FHIR Tooling Extensions IG | hl7.fhir.uv.tools.r4#0.9.0 | R4 | for example references

Package hl7.fhir.uv.extensions.r4#5.2.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Mon, Feb 10, 2025 21:45+1100+11:00)

Package hl7.fhir.au.base#6.0.0-preview This implementation guide is provided to support the use of FHIR®© in an Australian context. (built Wed, Nov 26, 2025 07:22+0000+00:00)

Package hl7.fhir.uv.extensions.r4#1.0.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sun, Mar 26, 2023 08:46+1100+11:00)

Package hl7.fhir.uv.ipa#1.1.0 This IG describes how an application acting on behalf of a patient can access information about the patient from an clinical records system using a FHIR based API. The clinical records system may be supporting a clinical care provider (e.g. a hospital, or a general practitioner), or a health data exchange, including a national health record system. (built Wed, Mar 19, 2025 14:34+0000+00:00)

Package hl7.fhir.au.core#2.0.0-preview This implementation guide is provided to support the use of FHIR®© in an Australian context, and defines the minimum set of constraints on the FHIR resources to create the AU Core profiles. This implementation guide forms the foundation to build future AU Realm FHIR implementation guides and its content will continue to grow to meet the needs of AU implementers. (built Thu, Nov 27, 2025 01:36+0000+00:00)

Package hl7.fhir.uv.extensions.r4#5.3.0-ballot-tc1 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sun, Aug 3, 2025 06:28+1000+10:00)

Package hl7.fhir.uv.sdc#current The SDC specification provides an infrastructure to standardize the capture and expanded use of patient-level data collected within an EHR. (built Wed, Oct 22, 2025 20:08+0000+00:00)

Package hl7.fhir.uv.tools.r4#0.9.0 This IG defines the extensions that the tools use internally. Some of these extensions are content that are being evaluated for elevation into the main spec, and others are tooling concerns (built Tue, Dec 16, 2025 23:18+1100+11:00)

This guide is also dependent on:

- Terminology published in Australia's National Clinical Terminology Service

### Usage

This document is a working specification that may be directly implemented by FHIR®© system producers.

FHIR®© connectathon events are key to the verification of the guide as being suitable for implementation. This implementation guide will be used as the basis for Australian connectathon events.

### How to read this guide

This guide is divided into several pages which are listed at the top of each page in the menu bar.

- Home: This page provides the introduction and scope for this guide.
- Guidance
  - General Requirements: This page documents how CapabilityStatements declare conformance to profiles and their FHIR interactions. It also defines the expectations for mandatory and Must Support elements.
- FHIR Artefacts: These pages provide detailed descriptions and formal definitions for all the FHIR artefacts defined in this guide.
  - Artefact Summary: This page lists all of the FHIR artefacts defined in this guide.
  - Questionnaires: This page lists all of the Questionnaire resources defined in this guide.
  - Profiles and Extensions: This page lists all of the StructureDefinition resources defined in this guide.
  - Capability Statements: This page lists all of the CapabilityStatement resources defined in this guide.
  - Actor Definitions: This page lists all of the ActorDefinition resources defined in this guide.
- Downloads: This page provides links to downloadable artefacts including the Smart Forms FHIR NPM package.

### Collaboration

This guide is the product of collaborative work undertaken with participants from:

- Sparked Chronic Condition Management Clinical Focus Group
- Australian FHIR Implementers Community