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eCare Plan Joint NIH/NIDDK AHRQ Project

eCare Plan Home


Welcome to the Multiple Chronic Conditions (MCC) 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 condition

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 MCC eCare plan WorkGroup Meetings

All upcoming MCC eCare plan HL7 workgroup meeting dates and information can be found here

Project Deliverable Timeline

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

Deliverable NameDescriptionDeliverable StatusLink to Deliverable 
1 Implementation Guide

HL7 MCC eCare plan page
2 Clinical Care Model

MCC Clinical Information Model (CIM) Analysis and Development

Upcoming Testing Opportunities

The MCC eCare plan project is planning to test at the HL7 34th Annual Plenary & Working Group Meeting in Baltimore, MD September 21-25 2020.

Stay tuned for more information.

MCC Project RoadMap 

Project Contacts

Name TitleOrganization Email
Kevin AbottCOR NIH

Jenna NortonPMONIH
Saadia Miran
Tom HickePMCognitive Medical Systems

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