eCare Plan Joint NIH/NIDDK AHRQ Project

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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

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).

Project Deliverables

All project deliverables are open-source and freely available.

  1. Data elements, value sets, clinical information models (CIM), and FHIR mappings to enable standardized transfer of data across health and research settings for chronic kidney disease (CKD), type 2 diabetes (T2D), cardiovascular disease (CVD), chronic pain, and long-term COVID. 
  2. HL7® Fast Health Interoperability Resource (FHIR®) Implementation Guide based on defined use cases and standardized MCC data elements, balloted for trial use. The IG defines FHIR R4 profiles, structures, extensions, transactions, and value sets needed to represent, query for, and exchange Care Plan information to support care planning for people with multiple chronic conditions (MCC).

  3. Pilot tested SMART on FHIR eCare Planning Applications for clinicians, patients, and caregivers to use that integrate with the EHR to pull, share, and display key patient data to support care for people with multiple chronic conditions. The applications 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.

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.

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 

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 2020Complete
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 2021Complete
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 2022Complete
SMART on FHIR AppAn open-source clinician and patient facing SMART on FHIR-based e-care plan application for managing persons with MCCQ2 2020Q3 2024In progress


MyCarePlanner (patient/caregiver-facing)

eCarePlanner (clinician facing) 

Pilot Lessons LearnedA report that documents the results from testing the SMART on FHIR application including lessons learned and recommended app updates.Q2 2021Q3 2022Complete
Implementation Guide An HL7 implementation guide for MCC starting with CKD value setQ2 2020Q2 2024Updates in progress

Project Contacts

Name TitleOrganization Email
Jenna NortonNIDDK LeadNIH

Kevin AbbottNIDDK
Arlene BiermanAHRQ
Rachael BoicourtAHRQ Health Research
Jaime ZimmermanAHRQ Health Research
Evelyn GallegoEMI Advisors LeadEMI
Karen BertodattiEMI Advisors PMEMI Advisors 

Laura MarcialRTI Pilot 
Jacqueline BagwellRTI Pilot PM/
David DorrRTI Pilot - OHSU Site

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