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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!


  • To follow join our FHIR IG development meetings with the HL7 Patient Work Group please follow the link here.
  • The project team is currently identifying data elements for long COVID and would appreciate any feedback you have. The link is in the Project Deliverables table below.
  • The eCare Plan for People with Multiple Chronic Conditions Project presented at HIMSS2021. The HIMSS presentation can be viewed here.
  • To hear an overview of the project visit the link here and 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 and 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 and 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 and IG to include cardiovascular disease (CVD), type 2 diabetes, chronic pain, and long COVID
    • Expand the CKD data elements and CIMs to consider additional conditions
    • Revise e-care plan application and 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 HL7 Patient Care Work Group Meetings

All upcoming MCC eCare plan HL7 work group meeting dates and information can be found here.

To get the information from the June 24, 2020 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 2022CompleteCurrent Version of MCC DESS
Data elements for long COVIDClinical concept with identified and specified data elements, attributes, vocabularies and FHIR mappings that will enable standardized transfer of long COVID data across health settingsQ4 2021Q2 2022In ProgressData element gathering spreadsheet for long COVID/PASC
SMART on FHIR AppAn open-source clinician and patient facing SMART on FHIR-based e-care plan application for managing persons with MCCQ2 2020Q3 2021Completed (iterations may take place based on pilot feedback)Patient 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 2022In progressLink will be posted at a future date
Implementation Guide An HL7 implementation guide for MCC starting with CKD value setQ2 2020Q3 2020Complete

HL7 MCC eCare plan FHIR IG page

Upcoming Testing Opportunities

Upcoming HL7 FHIR IG testing tracks

Previous HL7 FHIR IG testing tracks 

MCC Project RoadMap 

Project Contacts

Name TitleOrganization Email
Jenna NortonNIDDK LeadNIH

Kevin AbbottNIDDK
Arlene BiermanAHRQ
Janey HsiaoAHRQ Health Research LeadAHRQ

Steve BernsteinAHRQ Technical
Karen BertodattiEMI Advisors PMEMI Advisors 

Laura MarcialRTI Pilot 
Alexa OrtizRTI Pilot
David DorrRTI Pilot - OHSU Site