8.10 Resource EpisodeOfCare - Content

8.10.1 Scope and Usage

The EpisodeOfCare Resource contains information about an association of a Patient 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 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

8.10.1.1 Multiple Organizations and Transfer of Care

Many organizations can be involved in an episode of care, however each organization will have its own EpisodeOfCare resource instance that tracks its responsibility with the patient.

When an Organization completes their involvement with the patient 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 is accepted, a CarePlan is often created.

8.10.2 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, 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.

8.10.3 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, 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.

8.10.3.1 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)

• Structure
• UML
• XML
• JSON
• Turtle
• R3 Diff
• All

Structure

Name	Flags	Card.	Type	Description & Constraints
EpisodeOfCare	TU		DomainResource	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 Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier		0..*	Identifier	Business Identifier(s) relevant for this EpisodeOfCare
status	?!Σ	1..1	code	planned | waitlist | active | onhold | finished | cancelled | entered-in-error EpisodeOfCareStatus (Required)
statusHistory		0..*	BackboneElement	Past list of status codes (the current status may be included to cover the start date of the status)
status		1..1	code	planned | waitlist | active | onhold | finished | cancelled | entered-in-error EpisodeOfCareStatus (Required)
period		1..1	Period	Duration the EpisodeOfCare was in the specified status
type	Σ	0..*	CodeableConcept	Type/class - e.g. specialist referral, disease management EpisodeOfCareType (Example)
diagnosis	Σ	0..*	BackboneElement	The list of diagnosis relevant to this episode of care
condition	Σ	1..1	Reference(Condition)	Conditions/problems/diagnoses this episode of care is for
role	Σ	0..1	CodeableConcept	Role that this diagnosis has within the episode of care (e.g. admission, billing, discharge …) DiagnosisRole (Preferred)
rank	Σ	0..1	positiveInt	Ranking of the diagnosis (for each role type)
patient	Σ	1..1	Reference(Patient)	The patient who is the focus of this episode of care
managingOrganization	Σ	0..1	Reference(Organization)	Organization that assumes care
period	Σ	0..1	Period	Interval during responsibility is assumed
referralRequest		0..*	Reference(ServiceRequest)	Originating Referral Request(s)
careManager		0..1	Reference(Practitioner)	Care manager/care coordinator for the patient
team		0..*	Reference(CareTeam)	Other practitioners facilitating this episode of care
account		0..*	Reference(Account)	The set of accounts that may be used for billing for this EpisodeOfCare
Documentation for this format

<EpisodeOfCare xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier(s) relevant for this EpisodeOfCare --></identifier>
 <status value="[code]"/><!-- 1..1 planned | waitlist | active | onhold | finished | cancelled | entered-in-error -->
 <statusHistory>  <!-- 0..* Past list of status codes (the current status may be included to cover the start date of the status) -->
  <status value="[code]"/><!-- 1..1 planned | waitlist | active | onhold | finished | cancelled | entered-in-error -->
  <period><!-- 1..1 Period Duration the EpisodeOfCare was in the specified status --></period>
 </statusHistory>
 <type><!-- 0..* CodeableConcept Type/class  - e.g. specialist referral, disease management --></type>
 <diagnosis>  <!-- 0..* The list of diagnosis relevant to this episode of care -->
  <condition><!-- 1..1 Reference(Condition) Conditions/problems/diagnoses this episode of care is for --></condition>
  <role><!-- 0..1 CodeableConcept Role that this diagnosis has within the episode of care (e.g. admission, billing, discharge …) --></role>
  <rank value="[positiveInt]"/><!-- 0..1 Ranking of the diagnosis (for each role type) -->
 </diagnosis>
 <patient><!-- 1..1 Reference(Patient) The patient who is the focus of this episode of care --></patient>
 <managingOrganization><!-- 0..1 Reference(Organization) Organization that assumes care --></managingOrganization>
 <period><!-- 0..1 Period Interval during responsibility is assumed --></period>
 <referralRequest><!-- 0..* Reference(ServiceRequest) Originating Referral Request(s) --></referralRequest>
 <careManager><!-- 0..1 Reference(Practitioner) Care manager/care coordinator for the patient --></careManager>
 <team><!-- 0..* Reference(CareTeam) Other practitioners facilitating this episode of care --></team>
 <account><!-- 0..* Reference(Account) The set of accounts that may be used for billing for this EpisodeOfCare --></account>
</EpisodeOfCare>

{
  "resourceType" : "EpisodeOfCare",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier(s) relevant for this EpisodeOfCare
  "status" : "<code>", // R!  planned | waitlist | active | onhold | finished | cancelled | entered-in-error
  "statusHistory" : [{ // Past list of status codes (the current status may be included to cover the start date of the status)
    "status" : "<code>", // R!  planned | waitlist | active | onhold | finished | cancelled | entered-in-error
    "period" : { Period } // R!  Duration the EpisodeOfCare was in the specified status
  }],
  "type" : [{ CodeableConcept }], // Type/class  - e.g. specialist referral, disease management
  "diagnosis" : [{ // The list of diagnosis relevant to this episode of care
    "condition" : { Reference(Condition) }, // R!  Conditions/problems/diagnoses this episode of care is for
    "role" : { CodeableConcept }, // Role that this diagnosis has within the episode of care (e.g. admission, billing, discharge …)
    "rank" : "<positiveInt>" // Ranking of the diagnosis (for each role type)
  }],
  "patient" : { Reference(Patient) }, // R!  The patient who is the focus of this episode of care
  "managingOrganization" : { Reference(Organization) }, // Organization that assumes care
  "period" : { Period }, // Interval during responsibility is assumed
  "referralRequest" : [{ Reference(ServiceRequest) }], // Originating Referral Request(s)
  "careManager" : { Reference(Practitioner) }, // Care manager/care coordinator for the patient
  "team" : [{ Reference(CareTeam) }], // Other practitioners facilitating this episode of care
  "account" : [{ Reference(Account) }] // The set of accounts that may be used for billing for this EpisodeOfCare
}

@prefix fhir: <http://hl7.org/fhir/> .


[ a fhir:EpisodeOfCare;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EpisodeOfCare.identifier [ Identifier ], ... ; # 0..* Business Identifier(s) relevant for this EpisodeOfCare
  fhir:EpisodeOfCare.status [ code ]; # 1..1 planned | waitlist | active | onhold | finished | cancelled | entered-in-error
  fhir:EpisodeOfCare.statusHistory [ # 0..* Past list of status codes (the current status may be included to cover the start date of the status)
    fhir:EpisodeOfCare.statusHistory.status [ code ]; # 1..1 planned | waitlist | active | onhold | finished | cancelled | entered-in-error
    fhir:EpisodeOfCare.statusHistory.period [ Period ]; # 1..1 Duration the EpisodeOfCare was in the specified status
  ], ...;
  fhir:EpisodeOfCare.type [ CodeableConcept ], ... ; # 0..* Type/class  - e.g. specialist referral, disease management
  fhir:EpisodeOfCare.diagnosis [ # 0..* The list of diagnosis relevant to this episode of care
    fhir:EpisodeOfCare.diagnosis.condition [ Reference(Condition) ]; # 1..1 Conditions/problems/diagnoses this episode of care is for
    fhir:EpisodeOfCare.diagnosis.role [ CodeableConcept ]; # 0..1 Role that this diagnosis has within the episode of care (e.g. admission, billing, discharge …)
    fhir:EpisodeOfCare.diagnosis.rank [ positiveInt ]; # 0..1 Ranking of the diagnosis (for each role type)
  ], ...;
  fhir:EpisodeOfCare.patient [ Reference(Patient) ]; # 1..1 The patient who is the focus of this episode of care
  fhir:EpisodeOfCare.managingOrganization [ Reference(Organization) ]; # 0..1 Organization that assumes care
  fhir:EpisodeOfCare.period [ Period ]; # 0..1 Interval during responsibility is assumed
  fhir:EpisodeOfCare.referralRequest [ Reference(ServiceRequest) ], ... ; # 0..* Originating Referral Request(s)
  fhir:EpisodeOfCare.careManager [ Reference(Practitioner) ]; # 0..1 Care manager/care coordinator for the patient
  fhir:EpisodeOfCare.team [ Reference(CareTeam) ], ... ; # 0..* Other practitioners facilitating this episode of care
  fhir:EpisodeOfCare.account [ Reference(Account) ], ... ; # 0..* The set of accounts that may be used for billing for this EpisodeOfCare
]

Structure

Name	Flags	Card.	Type	Description & Constraints
EpisodeOfCare	TU		DomainResource	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 Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier		0..*	Identifier	Business Identifier(s) relevant for this EpisodeOfCare
status	?!Σ	1..1	code	planned | waitlist | active | onhold | finished | cancelled | entered-in-error EpisodeOfCareStatus (Required)
statusHistory		0..*	BackboneElement	Past list of status codes (the current status may be included to cover the start date of the status)
status		1..1	code	planned | waitlist | active | onhold | finished | cancelled | entered-in-error EpisodeOfCareStatus (Required)
period		1..1	Period	Duration the EpisodeOfCare was in the specified status
type	Σ	0..*	CodeableConcept	Type/class - e.g. specialist referral, disease management EpisodeOfCareType (Example)
diagnosis	Σ	0..*	BackboneElement	The list of diagnosis relevant to this episode of care
condition	Σ	1..1	Reference(Condition)	Conditions/problems/diagnoses this episode of care is for
role	Σ	0..1	CodeableConcept	Role that this diagnosis has within the episode of care (e.g. admission, billing, discharge …) DiagnosisRole (Preferred)
rank	Σ	0..1	positiveInt	Ranking of the diagnosis (for each role type)
patient	Σ	1..1	Reference(Patient)	The patient who is the focus of this episode of care
managingOrganization	Σ	0..1	Reference(Organization)	Organization that assumes care
period	Σ	0..1	Period	Interval during responsibility is assumed
referralRequest		0..*	Reference(ServiceRequest)	Originating Referral Request(s)
careManager		0..1	Reference(Practitioner)	Care manager/care coordinator for the patient
team		0..*	Reference(CareTeam)	Other practitioners facilitating this episode of care
account		0..*	Reference(Account)	The set of accounts that may be used for billing for this EpisodeOfCare
Documentation for this format

UML Diagram (Legend)

XML Template

<EpisodeOfCare xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier(s) relevant for this EpisodeOfCare --></identifier>
 <status value="[code]"/><!-- 1..1 planned | waitlist | active | onhold | finished | cancelled | entered-in-error -->
 <statusHistory>  <!-- 0..* Past list of status codes (the current status may be included to cover the start date of the status) -->
  <status value="[code]"/><!-- 1..1 planned | waitlist | active | onhold | finished | cancelled | entered-in-error -->
  <period><!-- 1..1 Period Duration the EpisodeOfCare was in the specified status --></period>
 </statusHistory>
 <type><!-- 0..* CodeableConcept Type/class  - e.g. specialist referral, disease management --></type>
 <diagnosis>  <!-- 0..* The list of diagnosis relevant to this episode of care -->
  <condition><!-- 1..1 Reference(Condition) Conditions/problems/diagnoses this episode of care is for --></condition>
  <role><!-- 0..1 CodeableConcept Role that this diagnosis has within the episode of care (e.g. admission, billing, discharge …) --></role>
  <rank value="[positiveInt]"/><!-- 0..1 Ranking of the diagnosis (for each role type) -->
 </diagnosis>
 <patient><!-- 1..1 Reference(Patient) The patient who is the focus of this episode of care --></patient>
 <managingOrganization><!-- 0..1 Reference(Organization) Organization that assumes care --></managingOrganization>
 <period><!-- 0..1 Period Interval during responsibility is assumed --></period>
 <referralRequest><!-- 0..* Reference(ServiceRequest) Originating Referral Request(s) --></referralRequest>
 <careManager><!-- 0..1 Reference(Practitioner) Care manager/care coordinator for the patient --></careManager>
 <team><!-- 0..* Reference(CareTeam) Other practitioners facilitating this episode of care --></team>
 <account><!-- 0..* Reference(Account) The set of accounts that may be used for billing for this EpisodeOfCare --></account>
</EpisodeOfCare>

JSON Template

{
  "resourceType" : "EpisodeOfCare",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier(s) relevant for this EpisodeOfCare
  "status" : "<code>", // R!  planned | waitlist | active | onhold | finished | cancelled | entered-in-error
  "statusHistory" : [{ // Past list of status codes (the current status may be included to cover the start date of the status)
    "status" : "<code>", // R!  planned | waitlist | active | onhold | finished | cancelled | entered-in-error
    "period" : { Period } // R!  Duration the EpisodeOfCare was in the specified status
  }],
  "type" : [{ CodeableConcept }], // Type/class  - e.g. specialist referral, disease management
  "diagnosis" : [{ // The list of diagnosis relevant to this episode of care
    "condition" : { Reference(Condition) }, // R!  Conditions/problems/diagnoses this episode of care is for
    "role" : { CodeableConcept }, // Role that this diagnosis has within the episode of care (e.g. admission, billing, discharge …)
    "rank" : "<positiveInt>" // Ranking of the diagnosis (for each role type)
  }],
  "patient" : { Reference(Patient) }, // R!  The patient who is the focus of this episode of care
  "managingOrganization" : { Reference(Organization) }, // Organization that assumes care
  "period" : { Period }, // Interval during responsibility is assumed
  "referralRequest" : [{ Reference(ServiceRequest) }], // Originating Referral Request(s)
  "careManager" : { Reference(Practitioner) }, // Care manager/care coordinator for the patient
  "team" : [{ Reference(CareTeam) }], // Other practitioners facilitating this episode of care
  "account" : [{ Reference(Account) }] // The set of accounts that may be used for billing for this EpisodeOfCare
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .


[ a fhir:EpisodeOfCare;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EpisodeOfCare.identifier [ Identifier ], ... ; # 0..* Business Identifier(s) relevant for this EpisodeOfCare
  fhir:EpisodeOfCare.status [ code ]; # 1..1 planned | waitlist | active | onhold | finished | cancelled | entered-in-error
  fhir:EpisodeOfCare.statusHistory [ # 0..* Past list of status codes (the current status may be included to cover the start date of the status)
    fhir:EpisodeOfCare.statusHistory.status [ code ]; # 1..1 planned | waitlist | active | onhold | finished | cancelled | entered-in-error
    fhir:EpisodeOfCare.statusHistory.period [ Period ]; # 1..1 Duration the EpisodeOfCare was in the specified status
  ], ...;
  fhir:EpisodeOfCare.type [ CodeableConcept ], ... ; # 0..* Type/class  - e.g. specialist referral, disease management
  fhir:EpisodeOfCare.diagnosis [ # 0..* The list of diagnosis relevant to this episode of care
    fhir:EpisodeOfCare.diagnosis.condition [ Reference(Condition) ]; # 1..1 Conditions/problems/diagnoses this episode of care is for
    fhir:EpisodeOfCare.diagnosis.role [ CodeableConcept ]; # 0..1 Role that this diagnosis has within the episode of care (e.g. admission, billing, discharge …)
    fhir:EpisodeOfCare.diagnosis.rank [ positiveInt ]; # 0..1 Ranking of the diagnosis (for each role type)
  ], ...;
  fhir:EpisodeOfCare.patient [ Reference(Patient) ]; # 1..1 The patient who is the focus of this episode of care
  fhir:EpisodeOfCare.managingOrganization [ Reference(Organization) ]; # 0..1 Organization that assumes care
  fhir:EpisodeOfCare.period [ Period ]; # 0..1 Interval during responsibility is assumed
  fhir:EpisodeOfCare.referralRequest [ Reference(ServiceRequest) ], ... ; # 0..* Originating Referral Request(s)
  fhir:EpisodeOfCare.careManager [ Reference(Practitioner) ]; # 0..1 Care manager/care coordinator for the patient
  fhir:EpisodeOfCare.team [ Reference(CareTeam) ], ... ; # 0..* Other practitioners facilitating this episode of care
  fhir:EpisodeOfCare.account [ Reference(Account) ], ... ; # 0..* The set of accounts that may be used for billing for this EpisodeOfCare
]

Changes since DSTU2

EpisodeOfCare
EpisodeOfCare.referralRequest	Type changed from Reference(ReferralRequest) to Reference(ServiceRequest)

See the Full Difference for further information

This analysis is available as XML or JSON.

See R2 <--> R3 Conversion Maps (status = 1 test that all execute ok. All tests pass round-trip testing and all r3 resources are valid.). Note: these have note yet been updated to be R3 to R4

8.10.5 Status Management

8.10.5.1 History and Period

When an organization assumes responsibility for a patient, 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.

8.10.5.2 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

8.10.5.3 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.

8.10.5.4 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’d 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.

8.10.6 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