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Welcome!
This is the Collaborative Site for the Multiple Chronic Conditions (MCC) e-Care Plan Initiative ("MCC e-Care Plan Project"), a joint project between the Agency for Healthcare Research and Quality (AHRQ) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). To return to the project home page, visit ecareplan.ahrq.gov.
Project Objectives
The MCC e-Care Plan Project aims to:
- 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).
Testing Opportunities
The MCC IG undergoing STU Ballot as of August 2023 can be found here: MCC eCare Plan Implementation Guide
Previous HL7 FHIR IG testing tracks
- May 2023 Coordinating Care for Patients with Chronic Conditions Track: 2023-05 Coordinating Care for Patients with Chronic Conditions Track
May 2022 Care Planning Track: 2022-05 Care Planning Track
- January 2022 Care Planning Track: 2022-01 Care Planning Track
- January 2021 Care Coordination Track: 2021-01 Care Coordination Track
- September 2020 Care Coordination Track: 2020-09 Care Coordination Track
- May 2020 Care Coordination Track: 2020-05 Care Coordination Track
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 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 2021 | Complete | |
| Data elements for long COVID | Clinical concept with identified and specified data elements, attributes, vocabularies and FHIR mappings that will enable standardized transfer of long COVID data across health settings | Q4 2021 | Q2 2022 | Complete | |
| 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 2024 | In progress | |
| 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 | Complete | |
| Implementation Guide | An HL7 implementation guide for MCC starting with CKD value set | Q2 2020 | Q2 2024 | Updates in progress |
Project Contacts
| Name | Title | Organization | |
|---|---|---|---|
| Jenna Norton | NIDDK Lead | NIH | |
| Kevin Abbott | NIDDK COR | NIH | kevin.abbott@nih.gov |
| Arlene Bierman | AHRQ Lead | AHRQ | Arlene.Bierman@ahrq.hhs.gov |
| Rachael Boicourt | AHRQ Health Research Lead | AHRQ | Rachael.Boicourt@ahrq.hhs.gov |
| Jaime Zimmerman | AHRQ Health Research Lead | AHRQ | jaime.zimmerman@ahrq.hhs.gov |
| Evelyn Gallego | EMI Advisors Lead | EMI Advisors | evelyn.gallego@emiadvisors.net |
| Karen Bertodatti | EMI Advisors PM | EMI Advisors | |
| Laura Marcial | RTI Pilot Lead | RTI | lmarcial@rti.org |
| Jacqueline Bagwell | RTI Pilot PM/SME | RTI | jbagwell@rti.org |
| David Dorr | RTI Pilot - OHSU Site Lead | OHSU | dorrd@ohsu.edu |