Announcements
Welcome to the e-Care Plan for People with Multiple Chronic Conditions (MCC) Project Page
The MCC eCare plan project had a kick-off on the Patient Care Work group call June 24, 2020 To get the information from the June 24th Stakeholder kick-off please follow the link here
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 & 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).
Project Deliverable Timeline
| 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 date |
| SMART on FHIR App | An open-source clinician-facing, SMART on FHIR-based e-care plan application for managing persons with MCC | Q2 2020 | Q3 2021 | In Progress | Link will be posted at once development starts |
| 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 | Planned | Link will be posted at a future date |
| Implementation Guide | An HL7 implementation guide for the SMART on FHIR application | Q2 2020 | Q3 2020 | In Progress |
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 | Title | Organization | |
|---|---|---|---|
| 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 Hicke | Cognitive PM | Cognitive Medical Systems | |
| Saira Haque | RTI Pilot Lead | RTI | shaque@rti.org |
| Alexa Ortiz | RTI Pilot PM | RTI | amortiz@rti.org |
| David Dorr | RTI Pilot- OHSU Site Lead | OHSU | dorrd@ohsu.edu |