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Welcome to the e-Care Plan for People with Multiple Chronic Conditions (MCC)

e-Care Plan

Project Page


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 & 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

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 Meetings

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

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 2022PlannedLink will be posted at a future date
SMART on FHIR AppAn open-source clinician-facing, SMART on FHIR-based e-care plan application for managing persons with MCCQ2 2020Q3 2021In ProgressLink will be posted at once development starts
Pilot Lessons LearnedA report that documents the results from testing the SMART on FHIR application including lessons learned and recommended app updates.Q2 2021Q3 2022PlannedLink will be posted at a future date
Implementation Guide An HL7 implementation guide for the SMART on FHIR applicationQ2 2020Q3 2020In Progress

HL7 MCC eCare plan page

Upcoming Testing Opportunities

The MCC eCare plan project plans to test at the HL7 34th Annual Plenary & Working Group Meeting in Baltimore, MD September 21-25 2020.

Stay tuned for more information.

MCC Project RoadMap 

Project Contacts

Name TitleOrganization Email
Jenna NortonNIDDK LeadNIH


Arlene BiermanAHRQ
Janey HsiaoAHRQ Health Research LeadAHRQ

Steve BernsteinAHRQ Technical
Tom HickeCognitive PMCognitive Medical Systems

Saira HaqueRTI Pilot
Alexa OrtizRTI Pilot
David DorrRTI Pilot- OHSU Site