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eCare Plan Joint NIH/NIDDK AHRQ Project

eCare Plan Home


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

The eCare Plan for People with Multiple Chronic Conditions Project participated in their first connectathon

  • The eCare plan FHIR IG was tested for the first time at the HL7® FHIR® Connectathon 25 September 9-11, 2020
  • To view the track proposal page recording and presentation click here

To follow join our FHIR IG development meetings please follow the link here

Click here see the care coordination planning meeting material 

To hear an overview of the project visit the link here to download our powerpoint click MCC eCare Plan Overview 20200624 Final (1).pptx


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

To get the information from the June 24th Stakeholder kick-off please follow the link 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 and patient facing SMART on FHIR-based e-care plan application for managing persons with MCCQ2 2020Q3 2021In ProgressPatient and clinician facing app MccCareplan
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 FHIR IG page

Upcoming Testing Opportunities

The MCC eCare plan project plans to test at the HL7 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.

Tentative schedule



Meeting Materials
August 03, 2020

Care Coordination track planning kick-off.

Register for event and Care Coordination track
August 17, 2020

MCC SMART on FHIR App, Develop composite persona, finalize scenario and scene breakdown, and develop draft Care Plan.

August 24, 2020

Develop test scripts.

Confirm participation and track plan documentation.

Care Coordination Track Planning Meeting_August-24-2020.docx

HL7 Connectathon 25 Planning Meeting 20200824Final updated.pptx

August 31, 2020

Address emerging details, testing needs/assumptions, and track logistics.

Conduct pre-Connectathon testing

September, 9, 2020

Connectathon Testing Sept. 9th to 11th

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