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Announcements

Welcome to the

Multiple Chronic Conditions e-Care Plan Project Page

e-Care Plan for People with Multiple Chronic Conditions (MCC) project page!

Announcements

  • 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.



Overview 

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 and pain with OUD), pain and opioid use disorder (OUD). The application will be developed in a way that aligns to align with emerging industry standards with the goal of creating publicly available, scale-able artifacts and services that could be used nationwide. 

Project Purpose

The Development of an FHIR (electronic) a SMART on FHIR e-Care Plan , application, implementation guide and clinical information models for persons with chronic kidney disease and multiple chronic conditionconditions.


Project Objectives

  • 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

Project

Scope 
  • Identify use cases to support the documentation and exchange of MCC eCare Plan data within EHRs and related systems;
  • Identify, develop, and prioritize the necessary MCC data elements, clinical terminology standards, clinical information models (CIMS) , and HL7® Fast Health Interoperability Resource (FHIR®) mappings that will enable the standardized transfer of data across health settings;
  • Develop and test an open-source clinician facing SMART on FHIR eCare Plan application for managing persons with MCC; and

Develop, test, and ballot an HL7® FHIR® Implementation Guide based on the defined use cases and MCC data elements

Project Goals

  • 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).

Upcoming MCC eCare plan

WorkGroup

HL7 Patient Care Work Group Meetings

All upcoming MCC eCare plan HL7 workgroup work group meeting dates and information can be found here.

To get the information from the June 24, 2020 stakeholder kick-off please follow the link here.


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Project Deliverable Timeline

<Suggest the graphic from NIH Kick off presentation slide project overview>


RoadMap 

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DeliverableDescriptionDeliverable StatusLink to Deliverable 1 Implementation GuideHL7 PCWG eCare plan page2 Clinical Care Model3 SMART on FHIR App

Upcoming Testing Opportunities

The MCC eCare plan Project is planning to test at the 34th Annual Plenary & Working Group Meeting in Baltimore, MD September 21-25 2020.

Stay tuned for more information.

Expected StartExpected EndStatus Link
MCC Clinical Information Model for CKDClinical concept with identified and specified data elements, attributes, vocabularies, and FHIR mappings that will enable standardized transfer of CKD data across health settingsQ4 2019Q2 2020CompleteMCC Clinical Information Model (CIM) Analysis and Development
MCC Clinical Information Model for CVD, T2D, and OUDClinical concept with identified and specified data elements, attributes, vocabularies and FHIR mappings that will enable standardized transfer of CVD, T2D, OUD data across health settingsQ2 2021Q3 2021Complete

2021_MCC Data Element Spreadsheet with Value Sets_static

Data elements for long COVIDClinical concept with identified and specified data elements, attributes, vocabularies and FHIR mappings that will enable standardized transfer of long COVID data across health settingsQ4 2021Q2 2022In 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 AppAn open-source clinician and patient facing SMART on FHIR-based e-care plan application for managing persons with MCCQ2 2020Q3 2021Completed (iterations may take place based on pilot feedback)Patient and clinician facing app MccCareplan
Pilot Lessons LearnedA report that documents the results from testing the SMART on FHIR application including lessons learned and recommended app updates.Q2 2021Q3 2022In progressLink will be posted at a future date
Implementation Guide An HL7 implementation guide for MCC starting with CKD value setQ2 2020Q3 2022Updates in progress

HL7 MCC eCare plan FHIR IG page



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Testing
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Upcoming Testing Opportunities

Upcoming HL7 FHIR IG testing tracks

  • September 2022 Care Planning Track

Previous HL7 FHIR IG testing tracks 


MCC Project Timeline

2021-2024 Roadmap 

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Space contributors

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Project Contacts

Name TitleOrganization Email
Kevin AbottCOR NIH Jenna NortonNIDDK LeadNIH 

jenna.norton@nih.gov

Kevin AbbottNIDDK CORNIHkevin.abbott@nih.gov
Jenna NortonPMONIH jenna.norton@nih.gov
Saadia MiranNIHsaadia.miran@nih.gov
Tom HickePMCognitive Medical Systems thicke@cognitivemedicine.com

Recent space activity

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Arlene BiermanAHRQ LeadAHRQArlene.Bierman@ahrq.hhs.gov
Janey HsiaoAHRQ Health Research LeadAHRQ

Janey.Hsiao@ahrq.hhs.gov

Steve BernsteinAHRQ Technical LeadAHRQSteve.Bernstein@ahrq.hhs.gov
Karen BertodattiEMI Advisors PMEMI Advisors 

kbertodatti@emiadvisors.net 

Laura MarcialRTI Pilot LeadRTIlmarcial@rti.org 
Beth LasaterRTI Pilot PMRTIboverman@rti.org
Sara ArmsonRTI Pilot SMERTIsarmson@rti.org
David DorrRTI Pilot - OHSU Site LeadOHSUdorrd@ohsu.edu