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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 is presented at HIMSS2021 August 11 at 2:30 PM - 3:30 PM PST
- To view the HIMSS presentation click here
To follow join our FHIR IG development meetings with the HL7 Patient Work Group please follow the link here. The project team is current reviewing the MCC DESS and would appreciate feedback. The link is in the Project Deliverables table below.
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||In Progress||Current Version of MCC DESS|
|SMART on FHIR App||An open-source clinician and patient facing SMART on FHIR-based e-care plan application for managing persons with MCC||Q2 2020||Q3 2021||Completed (iterations may take place based on pilot feedback)||Patient and clinician facing app MccCareplan|
|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||In progress||Link will be posted at a future date|
|Implementation Guide||An HL7 implementation guide for MCC starting with CKD value set||Q2 2020||Q3 2020||Complete|
MCC Project RoadMap
|Jenna Norton||NIDDK Lead||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|
|Gena Ford||Cognitive PM||Cognitive Medical Systems|
|Laura Marcial||RTI Pilot Lead||RTIemail@example.com|
|Alexa Ortiz||RTI Pilot PM||RTIfirstname.lastname@example.org|
|David Dorr||RTI Pilot- OHSU Site Lead||OHSUemail@example.com|