Announcements
Welcome to the e-Care Plan for People with Multiple Chronic Conditions (MCC)
Project PageWe 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
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- 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), 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).
| Anchor | ||||
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| 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 | Planned | Link will be posted at a future date | 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 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 2020In Progress2022 | Updates in progress |
| Anchor | ||||
|---|---|---|---|---|
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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.
Tentative schedule
Date
Agenda
Care Coordination track planning kick-off.
Register for event and Care Coordination trackNIDDK Care Coordination Kick-off Meeting 03Aug20.docx
HL7 Connectathon 25 Planning Meeting Kickoff 2020080Final.pptx
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
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 Timeline
2021-2024 Roadmap
Project Contacts
| Name | Title | Organization | |
|---|---|---|---|
| Jenna Norton | NIDDK Lead | NIH | |
| Saadia MiranKevin Abbott | NIDDK PMCOR | NIH | saadiakevin.miran@nihabbott@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 |
| Tom Hicke | Cognitive PM | Cognitive Medical Systems | |
| Saira HaqueKaren Bertodatti | EMI Advisors PM | EMI Advisors | |
| Laura Marcial | RTI Pilot Lead | RTI | shaque@rtilmarcial@rti.org |
| Alexa OrtizBeth Lasater | RTI Pilot PM | RTI | amortiz@rtiboverman@rti.org |
| Sara Armson | RTI Pilot SME | RTI | sarmson@rti.org |
| David Dorr | RTI Pilot - OHSU Site Lead | OHSU | dorrd@ohsu.edu |
