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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 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
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 |
