xShare Project CarePlan
0.1.0-ci - ci-build 150

xShare Project CarePlan, published by xShare Project. This guide is not an authorized publication; it is the continuous build for version 0.1.0-ci built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/xshare-careplan/ and changes regularly. See the Directory of published versions

Care Plan Business overview

The business domain describes the overview and business use cases in research that will rely on the IPS+.

The context

The European Health Data Space (EHDS) represents a transformative step toward a unified European framework for the primary and secondary use of electronic health data. By establishing common rules, standards and infrastructures for cross-border data exchange, EHDS aims to improve continuity of care, strengthen patient rights, enhance healthcare quality and enable innovation across Member States.

A central instrument for achieving interoperability within EHDS is the European Electronic Health Record Exchange Format (EHRxF). The EHRxF defines priority categories of electronic health data to be exchanged across borders under Article 5 and Annex I of the EHDS Regulation. These categories include patient summaries, ePrescriptions, laboratory results, medical imaging reports and discharge reports.

However, while these categories cover essential clinical documentation, they do not explicitly address structured, longitudinal and coordinated care planning as a distinct Health Information Domain (HID). Care Plans, which organise goals, interventions, responsibilities and follow-up across time and care settings, are fundamental to modern healthcare delivery, particularly in the management of chronic conditions and complex multimorbidity.

Across Europe, healthcare systems are increasingly characterised by:

  • A growing burden of chronic diseases
  • Multidisciplinary and cross-sectoral care pathways
  • Greater emphasis on outcome-based and value-based care
  • Stronger patient involvement and shared decision-making

These developments require care coordination mechanisms that are structured, interoperable and capable of computational support. Narrative or locally defined care planning approaches are insufficient to support cross-border exchange, systematic quality measurement or digital decision support.

Within the xShare project, the ambition is to expand and operationalise the European EHRxF to support effective and meaningful exchange of health data in the EHDS context. As part of this work, Deliverable 3.4 proposes the definition of a new Health Information Domain for Care Plans.

The core conceptual position of this deliverable is that:

A Care Plan HID should be defined as a structured, standardised, guideline-informed, machine-readable and interoperable model for coordinated patient care.

This implies that Care Plans are not merely narrative documents, but structured and semantically defined constructs capable of supporting:

  • Coordinated care across providers and sectors
  • Transparent linkage to evidence-based clinical guidance
  • Rule-based, machine readable and verifiable decision support
  • Cross-border continuity of care
  • Secondary use for research, monitoring and quality improvement

Business Use Cases

Actors

Care Plan Business ActorsCare Plan Business ActorsPatientHC ProfessionalClinicianNurseHC Provider (Org)RelativesCaregiver

Patient

Care Plan Patient Use CaseCare Plan Patient Use CaseCare Plan ServicesSearch & see care planShare care planExecute & record actionsSee the care planPatient«include»

Health Care Professional

Care Plan Patient Use CaseCare Plan Patient Use CaseCare Plan ServicesSearch & see care planShare care planExecute & record actionsDefine care planCare plan mgmt. & executionUpdate care planSee the care planMonitor care plan(outcomes)HC ProfessionalClinicianNurse«include»«include»«include»«include»

Caregiver

Care Plan Caregiver Use CaseCare Plan Caregiver Use CaseCare Plan ServicesSearch & see care planShare care planExecute & record actionsSee the care planMonitor care plan(outcomes)Caregiver«include»

Relatives

Care Plan Relative Use CaseCare Plan Relative Use CaseCare Plan ServicesSearch & see care planExecute & record actionsSee the care planRelatives«include»

Organization

Care Plan HC Provider Use CaseCare Plan HC Provider Use CaseCare Plan ServicesSearch & see care planMonitor care plan(outcomes)HC Provider (Org)UC_See«include»

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