eCare Plan Home
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
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.
The Development of a SMART on FHIR e-Care Plan application, implementation guide and clinical information models for persons with multiple chronic conditions.
- 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
- 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 HL& 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.
MCC Project RoadMap
|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||RTIfirstname.lastname@example.org|
|Alexa Ortiz||RTI Pilot PM||RTIemail@example.com|
|David Dorr||RTI Pilot- OHSU Site Lead||OHSUfirstname.lastname@example.org|