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eCare Plan Joint NIH/NIDDK AHRQ Project

eCare Plan Home

Welcome to the Multiple Chronic Kidney Disease e-Care Plan Project Page


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 Purpose

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

DateTimeTopicWebinar InformationRelevant Document or Links

Project Deliverable Timeline

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

Deliverable NameDescriptionDeliverable StatusLink to Deliverable 




Project Contacts

Name TitleOrganization Email
Kevin AbottCOR NIH

Jenna NortonPMONIH
Saadia Miran
Tom HickePMCognitive Medical Systems

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