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Multiple Chronic Conditions e-Care Plan Project

The Multiple Chronic Conditions (MCC) electronic care (e-)Care Plan Initiative is a joint project between AHRQ and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Funded by the Assistant Secretary for Planning and Evaluation (ASPE) and the Department of Health and Human Services’ Patient-Centered Outcomes Research Trust Fund (PCOR-TF), the MCC e-Care Plan project aims to build capacity for pragmatic, patient-centered outcomes research by developing an interoperable electronic care plan to facilitate aggregation and sharing of critical patient-centered health data across various settings for people living with multiple chronic conditions.

Project Collaborative Site

The work of the MCC e-Care Plan project requires contributions from many stakeholders including the HL7 Patient Care Work Group, various Technical Expert Panels, the Contract Monitoring Board, the Federal Partners Meeting, and both the development and evaluation project teams. To facilitate this coordination, a Collaborative Site was created to share meeting materials, project documents, presentations, and working deliverables.

All deliverables are open-source and freely available. Visit the Collaborative Site to see the latest.

Project Background

More than 25% of Americans have multiple chronic conditions, accounting for more than 65% of U.S. health care spending. These individuals have complex health needs handled by diverse providers, across multiple settings of care. As a result, their care is often fragmented, poorly coordinated and inefficient, making data aggregation particularly important and challenging for people with MCC. These challenges will increasingly strain the U.S. health system, with the aging of the U.S. population. Projections suggest numbers of adults aged 65 and older will more than double and numbers of those aged 85 and older will triple by 2050.

Development of electronic care plans based on structured data has been proposed as a method for enabling electronic systems to pull together and share data elements automatically and dynamically. Such aggregated data would not only provide actionable information to identify and achieve health goals for individuals with MCC, but also would reduce missingness and improve quality of point-of-care data for use in pragmatic research. E-care plans support seamless care coordination, communication, and collaboration among members of the care team–patients, caregivers, and providers–to address the full spectrum of a patient’s needs across home-, community-, clinic-, and research-based settings and over time.

Project Deliverables

The MCC e-Care Plan project deliverables include:

  • Data elements, value sets, and Fast Healthcare Interoperability Resources® (FHIR®) mappings to enable standardized transfer of health data across various settings for chronic kidney disease, diabetes, cardiovascular disease, chronic pain, and long-term COVID conditions.
  • Pilot-tested e-care planning SMART-on-FHIR applications for providers, patients, and caregivers that integrate with EHRs and other available FHIR servers to pull, share, and display key patient data.
  • An HL7 FHIR Implementation Guide based on use cases and standardized MCC data elements, balloted for trial use.

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Agency for Healthcare Research and Quality

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