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Announcements

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 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.

project page!

Announcements

  • To follow join our FHIR IG development meetings with the HL7 Patient Work Group please follow the link here
Click here see the care coordination planning meeting material 
  • .
  • 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

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), 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. 

Project Purpose

The Development of a SMART on FHIR e-Care Plan application, implementation guide and clinical information models for persons with multiple chronic conditions. 


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 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 24th Stakeholder 24, 2020 stakeholder kick-off please follow the link here.


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Projectdeliverables
Projectdeliverables
Project Deliverable Timeline


DeliverableDescriptionExpected 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 2022PlannedLink will be posted at a future dateIn 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 2021In ProgressCompleted (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 2022PlannedIn progressLink will be posted at a future date
Implementation Guide An HL7 implementation guide for the SMART on FHIR applicationMCC starting with CKD value setQ2 2020Q3 2020In Progress2022Updates in progress

HL7 MCC eCare plan FHIR IG page

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Testing
Testing
Upcoming Testing Opportunities

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.

Tentative schedule

Date

Agenda

Meeting MaterialsAugust 03, 2020

Care Coordination track planning kick-off.

Register for event and Care Coordination track

NIDDK Care Coordination Kick-off Meeting 03Aug20.docx

HL7 Connectathon 25 Planning Meeting Kickoff 2020080Final.pptx

August 17, 2020

MCC SMART on FHIR App, Develop composite persona, finalize scenario and scene breakdown, and develop draft Care Plan.

August 24, 2020

Develop test scripts.

Confirm participation and track plan documentation.

August 31, 2020

Address emerging details, testing needs/assumptions, and track logistics.

Conduct pre-Connectathon testing

September, 9, 2020

Connectathon Testing Sept. 9th to 11th

MCC Project RoadMap 

Image RemovedUpcoming 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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Project Contacts

Name TitleOrganization Email
Jenna NortonNIDDK LeadNIH 

jenna.norton@nih.gov

Saadia MiranKevin AbbottNIDDK PMCORNIHsaadiakevin.miran@nihabbott@nih.gov
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
Tom HickeCognitive PMCognitive Medical Systems 

thicke@cognitivemedicine.com

Saira HaqueKaren BertodattiEMI Advisors PMEMI Advisors 

kbertodatti@emiadvisors.net 

Laura MarcialRTI Pilot LeadRTIshaque@rtilmarcial@rti.org 
Alexa OrtizBeth LasaterRTI Pilot PMRTIamortiz@rtiboverman@rti.org
Sara ArmsonRTI Pilot SMERTIsarmson@rti.org
David DorrRTI Pilot - OHSU Site LeadOHSUdorrd@ohsu.edu