Orion Health Population Health Care Plan

{
  "$schema": "https://json-schema.org/draft/2020-12/schema",
  "$id": "https://schemas.orionhealth.com/population-health/care-plan.json",
  "title": "Orion Health Population Health Care Plan",
  "description": "Represents a care plan within the Orion Health Population Health Management platform, defining care goals, activities, and interventions for a patient enrolled in a care program.",
  "type": "object",
  "required": ["patientId", "programId", "status"],
  "properties": {
    "id": {
      "type": "string",
      "format": "uuid",
      "description": "Unique care plan identifier"
    },
    "patientId": {
      "type": "string",
      "description": "Patient identifier"
    },
    "programId": {
      "type": "string",
      "format": "uuid",
      "description": "Associated care program identifier"
    },
    "programName": {
      "type": "string",
      "description": "Name of the associated care program"
    },
    "status": {
      "type": "string",
      "enum": ["draft", "active", "on-hold", "completed", "revoked"],
      "description": "Current status of the care plan"
    },
    "intent": {
      "type": "string",
      "enum": ["proposal", "plan", "order"],
      "description": "Level of authority for the care plan"
    },
    "title": {
      "type": "string",
      "description": "Human-readable title for the care plan"
    },
    "description": {
      "type": "string",
      "description": "Summary of the care plan"
    },
    "period": {
      "type": "object",
      "properties": {
        "start": {
          "type": "string",
          "format": "date",
          "description": "Care plan start date"
        },
        "end": {
          "type": "string",
          "format": "date",
          "description": "Care plan end date"
        }
      },
      "required": ["start"]
    },
    "careTeam": {
      "type": "array",
      "description": "Members of the care team responsible for this plan",
      "items": {
        "type": "object",
        "properties": {
          "memberId": {
            "type": "string"
          },
          "name": {
            "type": "string"
          },
          "role": {
            "type": "string",
            "enum": ["primary-care-physician", "care-manager", "specialist", "nurse", "social-worker", "pharmacist", "dietitian", "behavioral-health"]
          },
          "organization": {
            "type": "string"
          },
          "phone": {
            "type": "string"
          },
          "email": {
            "type": "string",
            "format": "email"
          }
        },
        "required": ["memberId", "name", "role"]
      }
    },
    "conditions": {
      "type": "array",
      "description": "Conditions addressed by this care plan",
      "items": {
        "type": "object",
        "properties": {
          "code": {
            "type": "string",
            "description": "ICD-10 or SNOMED code"
          },
          "codeSystem": {
            "type": "string",
            "enum": ["icd-10", "snomed"]
          },
          "display": {
            "type": "string"
          },
          "clinicalStatus": {
            "type": "string",
            "enum": ["active", "recurrence", "relapse", "inactive", "remission", "resolved"]
          }
        },
        "required": ["code", "display"]
      }
    },
    "goals": {
      "type": "array",
      "description": "Care plan goals",
      "items": {
        "type": "object",
        "properties": {
          "id": {
            "type": "string",
            "format": "uuid"
          },
          "description": {
            "type": "string"
          },
          "status": {
            "type": "string",
            "enum": ["proposed", "planned", "accepted", "active", "on-hold", "completed", "cancelled", "entered-in-error", "rejected"]
          },
          "priority": {
            "type": "string",
            "enum": ["high", "medium", "low"]
          },
          "targetDate": {
            "type": "string",
            "format": "date"
          },
          "targetValue": {
            "type": "object",
            "properties": {
              "measure": {
                "type": "string",
                "description": "What is being measured (e.g., HbA1c, BMI, Blood Pressure)"
              },
              "targetValue": {
                "type": "number"
              },
              "unit": {
                "type": "string"
              },
              "currentValue": {
                "type": "number"
              },
              "currentValueDate": {
                "type": "string",
                "format": "date"
              }
            }
          },
          "achievedDate": {
            "type": "string",
            "format": "date"
          },
          "notes": {
            "type": "array",
            "items": {
              "type": "object",
              "properties": {
                "text": {
                  "type": "string"
                },
                "authorName": {
                  "type": "string"
                },
                "date": {
                  "type": "string",
                  "format": "date-time"
                }
              }
            }
          }
        },
        "required": ["description", "status"]
      }
    },
    "activities": {
      "type": "array",
      "description": "Planned care activities and interventions",
      "items": {
        "type": "object",
        "properties": {
          "id": {
            "type": "string",
            "format": "uuid"
          },
          "category": {
            "type": "string",
            "enum": ["medication", "procedure", "encounter", "observation", "education", "referral", "self-management", "assessment"]
          },
          "description": {
            "type": "string"
          },
          "status": {
            "type": "string",
            "enum": ["not-started", "scheduled", "in-progress", "on-hold", "completed", "cancelled"]
          },
          "frequency": {
            "type": "string",
            "description": "How often the activity should occur (e.g., daily, weekly, monthly)"
          },
          "scheduledDate": {
            "type": "string",
            "format": "date"
          },
          "completedDate": {
            "type": "string",
            "format": "date"
          },
          "assignedTo": {
            "type": "string",
            "description": "Care team member responsible"
          },
          "relatedGoalId": {
            "type": "string",
            "format": "uuid",
            "description": "Goal this activity contributes to"
          }
        },
        "required": ["category", "description", "status"]
      }
    },
    "riskAssessment": {
      "type": "object",
      "description": "Current risk assessment for the patient",
      "properties": {
        "riskLevel": {
          "type": "string",
          "enum": ["low", "moderate", "high", "critical"]
        },
        "riskScore": {
          "type": "number"
        },
        "model": {
          "type": "string"
        },
        "assessedDate": {
          "type": "string",
          "format": "date-time"
        }
      }
    },
    "createdAt": {
      "type": "string",
      "format": "date-time"
    },
    "updatedAt": {
      "type": "string",
      "format": "date-time"
    },
    "createdBy": {
      "type": "string"
    }
  }
}