Overview 

<Suggest using the text from the e-care plan project description>

Development of an FHIR (electronic) e-Care Plan, application, and clinical models for persons with chronic kidney disease and multiple chronic conditions

Project Purpose

This project will involve development of an open-source SMART on FHIR-based e-care plan application to enable clinicians to better manage patients with MCC, including CKD, T2D, CVD and pain with OUD. The application will be developed in a way that aligns to emerging industry standards with the goal of creating publicly available, scale-able artifacts and services that could be used nationwide.

Project Objectives

<Suggest using the text from NIH Kick off presentation slide AHRQ- NIDDk project objectives>

1.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

2.Establish an e-care plan repository and development collaborative

3.Expand the draft e-care plan application & IG to include cardiovascular disease (CVD), type 2 diabetes & chronic pain

1. –Expand the CKD data elements & CIMs to consider additional conditions
2. –Revise e-care plan application & IG to incorporate expanded DESS and pilot test feedback.

4.Disseminate all project deliverable through open source channels

Project Scope 

• Identify use cases to support the documentation and exchange of MCC eCare Plan data within EHRs and related systems;
• Identify, develop, and prioritize the necessary MCC data elements, clinical terminology standards, clinical information models (CIMS) , and HL7® Fast Health Interoperability Resource (FHIR®) mappings that will enable the standardized transfer of data across health settings;
• Develop and test an open-source clinician facing SMART on FHIR eCare Plan application for managing persons with MCC; and

Develop, test, and ballot an HL7® FHIR® Implementation Guide based on the defined use cases and MCC data elements

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 eCare Plan WorkGroup Meetings

Project Deliverable Timeline

<Suggest the graphic from NIH Kick off presentation slide project overview>

RoadMap 

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Project Contacts