Welcome to the e-Care Plan for People with Multiple Chronic Conditions (MCC) project page!
- To follow join our FHIR IG development meetings with the HL7 Patient Work Group please follow the link here.
- The project team is currently identifying data elements for long COVID and would appreciate any feedback you have. The link is in the Project Deliverables table below.
- The eCare Plan for People with Multiple Chronic Conditions Project presented at HIMSS2021. The HIMSS presentation can be viewed here.
- To hear an overview of the project visit the link here and to download our PowerPoint click MCC eCare Plan Overview 20200624 Final (1).pptx.
This project will involve the development of an open-source SMART on FHIR-based electronic (e-)care plan application to enable clinicians to better manage patients with MCC, including chronic kidney disease (CKD), type 2 diabetes (T2D), cardiovascular disease (CVD), pain and opioid use disorder (OUD). The application will be developed to align with emerging industry standards with the goal of creating publicly available, scale-able artifacts and services that could be used nationwide.
The Development of a SMART on FHIR e-Care Plan application, implementation guide and clinical information models for persons with multiple chronic conditions.
- Develop and test a SMART on FHIR e-care plan application
- Create clinical information models (CIM) using existing CKD data elements & standards
- Develop e-care plan application and implementation guide (IG) for point of care data review/entry
- Implement and evaluate the e-care plan application in diverse clinical settings in patients with MCC, including CKD
- Establish an e-care plan repository and development collaborative
- Expand the draft e-care plan application and IG to include cardiovascular disease (CVD), type 2 diabetes, chronic pain, and long COVID
- Expand the CKD data elements and CIMs to consider additional conditions
- Revise e-care plan application and IG to incorporate expanded DESS and pilot test feedback.
- Disseminate all project deliverable through open source channels
- Promote the interoperable collection, use, and sharing of comprehensive, person-centered health and social data across settings;
- Facilitate coordinated, person-centered care planning approaches that integrate the full care team (including the patient) across settings; and
- Build data capacity to conduct pragmatic Patient Centered Outcomes Research (PCOR).
Project Deliverable Timeline
|Deliverable||Description||Expected Start||Expected End||Status||Link|
|MCC Clinical Information Model for CKD||Clinical concept with identified and specified data elements, attributes, vocabularies, and FHIR mappings that will enable standardized transfer of CKD data across health settings||Q4 2019||Q2 2020||Complete||MCC Clinical Information Model (CIM) Analysis and Development|
|MCC Clinical Information Model for CVD, T2D, and OUD||Clinical concept with identified and specified data elements, attributes, vocabularies and FHIR mappings that will enable standardized transfer of CVD, T2D, OUD data across health settings||Q2 2021||Q3 2021||Complete|
|Data elements for long COVID||Clinical concept with identified and specified data elements, attributes, vocabularies and FHIR mappings that will enable standardized transfer of long COVID data across health settings||Q4 2021||Q2 2022||In Progress|
Symptoms related to long COVID analysis spreadsheet (Working Document)
Data element gathering spreadsheet for long COVID/PASC (Working Document with TEP)
|SMART on FHIR App||An open-source clinician and patient facing SMART on FHIR-based e-care plan application for managing persons with MCC||Q2 2020||Q3 2021||Completed (iterations may take place based on pilot feedback)||Patient and clinician facing app MccCareplan|
|Pilot Lessons Learned||A report that documents the results from testing the SMART on FHIR application including lessons learned and recommended app updates.||Q2 2021||Q3 2022||In progress||Link will be posted at a future date|
|Implementation Guide||An HL7 implementation guide for MCC starting with CKD value set||Q2 2020||Q3 2020||Complete|
Upcoming Testing Opportunities
Upcoming HL7 FHIR IG testing tracks
May 2022 Care Planning Track: 2022-05 Care Planning Track
Previous HL7 FHIR IG testing tracks
- January 2022 Care Planning Track: 2022-01 Care Planning Track
- January 2021 Care Coordination Track: 2021-01 Care Coordination Track
- September 2020 Care Coordination Track: 2020-09 Care Coordination Track
- May 2020 Care Coordination Track: 2020-05 Care Coordination Track
MCC Project RoadMap
|Jenna Norton||NIDDK Lead||NIH|
|Kevin Abbott||NIDDK COR||NIHemail@example.com|
|Arlene Bierman||AHRQ Lead||AHRQ||Arlene.Bierman@ahrq.hhs.gov|
|Janey Hsiao||AHRQ Health Research Lead||AHRQ|
|Steve Bernstein||AHRQ Technical Lead||AHRQ||Steve.Bernstein@ahrq.hhs.gov|
|Karen Bertodatti||EMI Advisors PM||EMI Advisors|
|Laura Marcial||RTI Pilot Lead||RTIfirstname.lastname@example.org|
|Beth Lasater||RTI Pilot PM||RTIemail@example.com|
|Sara Armson||RTI Pilot SME||RTIfirstname.lastname@example.org|
|David Dorr||RTI Pilot - OHSU Site Lead||OHSUemail@example.com|