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Work In Progress: Care Plans

Work-in-progress toward goals outlined on this Care Plan toolset overview page include applications that address three interrelated use cases that are illustrated by two current AHRQ-supported research projects described on this page. The use cases are:

  • Patient engagement in care planning as part of daily life activities
  • Shared decision making between patients and their primary care team
  • Shared care planning with specialty care teams, especially for patients with Multiple Chronic Conditions (MCC)

Two AHRQ-supported research projects are described below, along with description on how they support the three use cases:

  • MyPreventiveCare Project
  • NIDDK/AHRQ e-Care Plan for Multiple Chronic Conditions Project

MyPreventiveCare Project

Evidence-based preventive and chronic care offer profound health benefits, yet Americans receive only half of indicated care. Patient portals from EHR vendors can help patients to schedule appointments, communicate with their doctor, see their test results, and even see what care is overdue. However, the functionality of current portals does not fully utilize the technology’s potential. Fairfax Family Practice Centers, in collaboration with Virginia Commonwealth University, has been developing an application called MyPreventiveCare that can be integrated into patient portals to engage patients more deeply in health promotion. It builds on a model for designing patient-centered health information technology that we have been promoting nationally (350). MyPreventiveCare collects patient-reported information; extracts information from the electronic medical record; translates clinical information into lay language; provides patients with guideline-based clinical recommendations and detailed personalized patient education; anticipates patient decisions and information needs; and facilitates patient and clinician action through decision aids and resource links (351,352). This can make it easier for care teams to make sure that patients get the right care at the right time.
Despite these successes, MyPreventiveCare has required a custom integration to implement the system in new settings, which has been time intensive for health systems informatics staff. This has largely been due to lack of accepted standards for data transfer and application integration. Fortunately, SMART on FHIR has emerged as a new viable and functional standard. The 21st Century Cures Act and 2020 Final Rule from the ONC made SMART a certification requirement and all EHRs have adapted their systems to support these functions. This requires all EHRs to allow patients to download their data in a standardized format on request and to be able to “talk” to each other and to third-party apps, including MyPreventiveCare.
We have created a standards-based MyPreventiveCare demonstration application for four cancer screening services (Breast, Colorectal, Lung, and Prostate) based on published USPSTF guidelines. It uses Epic’s standard FHIR API and allows any patient from an Epic health system to request their data and run the MyPreventiveCare demonstration app using their MyChart username and password.

Functions of Digital Health

Information systems should be able to…

  1. Anticipate patient decisions
  2. Send patient educational information and care planning tools prior to an encounter
  3. Prepare patient to participate in decision-making process
  4. Collect information about where the patient is with decision journey and share with clinician
  5. Support the patient in creating a care plan

MyPreventiveCare Application Screenshots

Add narrative that ties back to patient journey and use cases.

NIDDK/AHRQ e-Care Plan for Multiple Chronic Conditions Project

Build capacity for pragmatic, patient-centered outcomes research (PCOR) by developing an interoperable electronic care plan to facilitate aggregation and sharing of critical patient-centered data across home-, community-, clinic-and research- based settings for people with multiple chronic conditions (MCC) --

AHRQ-NIDDK Project Deliverables:

  1. Data elements, value sets, clinical information models, and FHIR mappings to enable standardized transfer of data across health & research settings for kidney disease, diabetes, cardiovascular disease, chronic pain & long COVID
  2. Pilot tested patient-, clinician- and caregiver-facing e-care plan applications that integrate with the EHR to pull, share & display key patient data
  3. HL7® Fast Health Interoperability Resource (FHIR®) Implementation Guide based on defined use cases and standardized MCC data elements, balloted for trial use  

MCC e-Care Plan Data Flow

A FHIR server will pull together data from numerous, distinct settings of care. Three SMART on FHIR e-care plan applications (a patient-facing application, a clinician-facing application, and a caregiver-facing application) will pull and display aggregated data from the FHIR server. The apps will also collect person-centered data not typically available in the EHR. These novel data will be provided to the FHIR server, where they will be available (along with aggregated EHR data from multiple settings) to clinical and research settings.

MCC e-Care Plan IG (Development in Progress) 

High Level Dynamic Care Plan Process Diagram

Multiple Chronic Condition FHIR Care Plan Profile Relationship Diagram

MCC e-Care Plan Applications (Development in Progress)

Provider Application Demo:  

Patient Application

MCC e-Care Plan Roadmap (2019-2024)

Other Related Initiatives

Gravity Project

Social determinants of health (SDoH) data are essential to care planning in context of patient needs. Yet, SDoH lack well defined/widely implemented data standards. The Gravity Project ( was initiated in November 2018 by SIREN with funding from the Robert Wood Johnson Foundation to convene broad stakeholder groups in identifying and harmonizing social risk factor data for interoperable electronic health information exchange. To date, Gravity has focused on the following key SDoH domains:

Food insecurity 
Housing Instability / Homelessness
Inadequate Housing
Transportation Insecurity
Financial Insecurity
Material Hardship
Employment Status / Educational Attainment / Veteran Status
Social Connection
Intimate Partner Violence
Elder Abuse