Welcome to the e-Care Plan for People with Multiple Chronic Conditions (MCC) Project Page
We are seeking implementers or organizations to participate in the Care Coordination track that will be hosted by the AHRQ/NIDDK eCare plan for individuals The eCare Plan for People with Multiple Chronic Conditions Project . We strongly encourage EHR and HIE participation to help us test and validate these FHIR specifications.
The MCC eCare plan project plans to kick-off Connectathon Planning meetings call August 3, 2020.Click here to sign up to participate in the Care Coordination track and receive and invite for the kick-off meeting.
presented at HIMSS2021 August 11 at 2:30 PM - 3:30 PM PST
- To view the HIMSS presentation click here
To follow join our FHIR IG development meetings with the HL7 Patient Work Group please follow the link hereClick here see the care coordination planning meeting material . The project team is current reviewing the MCC DESS and would appreciate feedback. The link is in the Project Deliverables table below.
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.
The Electronic Long-Term Services and Supports (eLTSS) FHIR MCC eCare Plan Implementation Guide
- Develop & 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 & 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 & IG to include cardiovascular disease (CVD), type 2 diabetes & chronic pain
- Expand the CKD data elements & CIMs to consider additional conditions
- Revise e-care plan application & 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 2022||Planned||Link will be posted at a future dateIn Progress||Current Version of MCC DESS|
|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 2021In Progress||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||PlannedIn progress||Link will be posted at a future date|
|Implementation Guide||An HL7 implementation guide for the SMART on FHIR applicationMCC starting with CKD value set||Q2 2020||Q3 2020||In ProgressComplete|
The MCC eCare plan project plans to test at the HL7 Virtual FHIR Connectathon 25 September 9-11 2020.
We are seeking implementers or organizations to participate in the Care Coordination track that will be hosted by the AHRQ/NIDDK eCare plan for individuals with Multiple Chronic Conditions Project. We strongly encourage EHR and HIE participation to help us test and validate these FHIR specifications.
- Click here to sign up for Care Coordination track participation.
- Review our Care Coordination track proposal page for more details on the system actors, patient scenario and testing scenes.
Care Coordination track planning kick-off.Register for event and Care Coordination track
MCC SMART on FHIR App, Develop composite persona, finalize scenario and scene breakdown, and develop draft Care Plan.
Develop test scripts.
Confirm participation and track plan documentation.
Address emerging details, testing needs/assumptions, and track logistics.
Conduct pre-Connectathon testing
Connectathon Testing Sept. 9th to 11th
MCC Project RoadMap
View our previous HL7 FHIR IG testing tracks
- January 2021 Care Coordination Track: 2021-01 Care Coordination Track
- September 2020 Care Coordination Track: 2020-09 Care Coordination Track
MCC Project RoadMap
|Jenna Norton||NIDDK Lead||NIH||Saadia Miran||NIDDK PM||NIH|
|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|
|Tom HickeGena Ford||Cognitive PM||Cognitive Medical Systems|
|Saira HaqueLaura Marcial||RTI Pilot Lead||RTI||shaque@email@example.com|
|Alexa Ortiz||RTI Pilot PM||RTIfirstname.lastname@example.org|
|David Dorr||RTI Pilot- OHSU Site Lead||OHSUemail@example.com|