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Welcome to the Multiple Chronic Conditions (MCC) e-Care Plan Project Page
Overview
This project will involve 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
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| Deliverable Name | Description | Deliverable Status | Link to Deliverable |
|---|---|---|---|
| 1 Implementation Guide | In progress | HL7 MCC eCare plan page | |
| 2 Clinical Information Models | In progress | MCC Clinical Information Model (CIM) Analysis and Development | |
| 3 SMART on FHIR Application | Not started | TBD |
Upcoming Testing Opportunities
The MCC eCare plan project is planning 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 | Title | Organization | |
|---|---|---|---|
| Kevin Abott | COR | NIH | |
| Jenna Norton | PMO | NIH | jenna.norton@nih.gov |
| Saadia Miran | NIH | saadia.miran@nih.gov | |
| Tom Hicke | PM | Cognitive Medical Systems | thicke@cognitivemedicine.com |
Recent space activity
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