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.
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).
|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 HL7 FHIR IG testing tracks
- September 2022 Care Planning Track
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
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|