Multiple Chronic Conditions (MCC) e-Care Plan Collaborative Site
Welcome!
This is the Collaborative Site for the Multiple Chronic Conditions (MCC) e-Care Plan Initiative ("MCC e-Care Plan Project"), a joint project between the Agency for Healthcare Research and Quality (AHRQ) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). To return to the project landing page, visit ecareplan.ahrq.gov.
Project Objectives
The MCC e-Care Plan Project aims to:
- 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).
Testing Opportunities
Upcoming HL7 FHIR IG testing tracks
- September 2022 Connectathon
Previous HL7 FHIR IG testing tracks
May 2022 Care Planning Track: 2022-05 Care Planning Track
- 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
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 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 | Complete | Symptoms related to long COVID analysis spreadsheet (Working Document) |
| 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) | |
| 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 2022 | Updates in progress |
Project Contacts
| Name | Title | Organization | |
|---|---|---|---|
| Jenna Norton | NIDDK Lead | NIH | |
| Kevin Abbott | NIDDK COR | NIH | kevin.abbott@nih.gov |
| 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 | RTI | lmarcial@rti.org |
| Beth Lasater | RTI Pilot PM | RTI | boverman@rti.org |
| Sara Armson | RTI Pilot SME | RTI | sarmson@rti.org |
| David Dorr | RTI Pilot - OHSU Site Lead | OHSU | dorrd@ohsu.edu |
