Multiple Chronic Conditions (MCC) Dynamic Electronic Care Planning and Management FHIR IG (PSS in Confluence)

Project Name
Multiple Chronic Conditions (MCC) Dynamic Electronic Care Planning and Management FHIR IG (PSS in Confluence)

Project Number
1618

Project Type

Product Family

Products
FHIR Implementation Guide; FHIR Profile

Project Intent
Implementation Guide

Ballot Type

Project Need

More than 25% of Americans have MCC, accounting for more than 65% of U.S. health care spending. These individuals have complex health needs handled by diverse providers, across multiple settings of care. As a result, their care is often fragmented, poorly coordinated and inefficient. Therefore, data aggregation is particularly important and challenging for people with MCC. These challenges will increasingly strain the U.S. health system, with the aging of the US population. Projections suggest numbers of adults aged 65 and older will more than double and numbers of those aged 85 and older will triple by 2050.

Care plans are a prominent part of multifaceted, care coordination interventions that reduce mortality and hospitalizations and improve disease management and satisfaction. In addition, proactive care planning promotes person-centeredness, improves outcomes, and reduces the cost of care. By design, care plans take a patient-centered approach, both by making comprehensive health data available across providers and settings and through the incorporation of data elements that have not traditionally been included in health IT systems (e.g., social determinants of health [SDH], patient health and life goals, patient preferences). While Care Plans have been developed, they remain paper-based in many U.S. healthcare settings and are not standardized and interoperable across care settings when electronic. While care plans focused on a single disease or condition are unlikely to be tenable for patients with MCC or their providers, existing care plans infrequently address individuals with MCC. The development of care plans based on structured data has been proposed as a method for enabling electronic systems to pull together and share data elements automatically and dynamically. Such aggregated data would not only provide actionable information to identify and achieve health and wellness goals for individuals with MCC, but also would reduce missingness and improve quality of point-of-care data for use in pragmatic research.

The Fast Healthcare Interoperability Resources (FHIR) specification is an open-source standard for exchanging healthcare information electronically based on emerging industry approaches. The FHIR workflow specification includes a CarePlan request resource that may facilitate the transfer of data for an e-care plan across healthcare settings. SMART (https://smarthealthit.org/) and SMART on FHIR standards include open specifications to integrate applications with health IT systems and may enable the development of an e-care plan application that can integrate with a variety of electronic health record (EHR) systems.

Objectives and Deliverables
Clinical Information Model Analysis Mapping and definition (to existing profiles and resources) - Target: March 2020 Connectathon 0 (Investigation and informal testing) - Target: May 2020 CKD and related Draft Value Set Definitions (not for all chronic conditions) - Target: June 2020 Care Planning, Plan Definition, Care Team, Care Coordination and Clinical Guidelines Framework for MCC eCare Plan - Target: June 2020 Draft IG (non -balloted, ready for testing) - Target: September 2020 SMART on FHIR App v1.0 (ready for testing) - Target: September 2020 Connectathon 1 - Target: September 2020 Connectathon 2 - Target: January 2021 Connectathon 3 - Target: May 2021 Connectathon 4 - Target: Sept 2021 Connectathon 5 - Target: January 2022 Connectathon 6 - Target: May 2022 Submit for STU ballot - Target: September 2022 Complete STU Reconciliation - Target: February 2023 Request STU Publication - Target: February 2023 STU Publication Date - Target: May 2023? Submit for Normative Ballot - Target: September 2025 Complete Normative Reconciliation - Target: February 2026 Submit Publication Request - Target: March 2026

Project Document Repository
https://confluence.hl7.org/display/PC/Multiple+Chronic+Conditions+Dynamic+Electronic+Care+Plan+FHIR+IG HTTP://Multiple Chronic Conditions (MCC) eCare Plan

Collaboration Efforts
For projects that have some of their content already developed: Joint initiative with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the Agency for Healthcare Research and Quality (AHRQ), and the Assistant Secretary for Planning and Evaluation (ASPE). https://ecareplan.ahrq.gov/ https://www.niddk.nih.gov/health-information/communication-programs/nkdep/working-groups/health-information-technology/development-electronic-ckd-care-plan

Dependencies
Care Plan Domain Analysis Model: FHIR Care Plan Resource: http://hl7.org/fhir/R4/careplan.html Care Team Resource: http://hl7.org/fhir/R4/careteam.html US Core Care Team: https://build.fhir.org/ig/HL7/US-Core-R4/StructureDefinition-us-core-careteam.html IHE Dynamic Care Planning Profile: https://wiki.ihe.net/index.php/Dynamic_Care_Planning FHIR Clinical Guidelines: http://build.fhir.org/ig/HL7/cqf-recommendations/artifacts.html Plan Definition Resource: https://www.hl7.org/fhir/plandefinition.html FAST Shared Care Planning Use Case: https://oncprojectracking.healthit.gov/wiki/display/TechLabSC/Ecosystem+Use+Case+Tiger+Team#ecosystem FHIR Clinical Guidelines:http://build.fhir.org/ig/HL7/cqf-recommendations/artifacts.html Plan Definition Chronic Kidny Disease Risk Screening: http://build.fhir.org/ig/HL7/cqf-recommendations/PlanDefinition-ckd-risk-screening.html Chronic Kidny Disease Ambulatory Plan: http://build.fhir.org/ig/HL7/cqf-recommendations/PlanDefinition-cc-cpg-plan-ckd.html

Stakeholders
Immunization Registries, Quality Reporting Agencies, Regulatory Agency, Standards Development Organizations (SDOs), Payors,Healthcare Institutions (hospitals, long term care, home care, mental health),Pharmaceutical; EHR, PHR; Equipment; Health Care IT; Clinical Decision Support Systems

Implementers
1) RTI - leading multiple implementers 2) AHRQ ACTION III Networks https://www.ahrq.gov/research/findings/factsheets/translating/action3/actionIIIpartners.html

External Drivers
National Institutes of Health (NIH) Statement of Work Requirements and Timelines.

Common Names
eCare Plan, Dynamic Care Plan, Multiple Chronic Condition Care Plan, Shared Care Plan, Comprehensive Care Plan, Care Planning and Management

Lineage

External Vocabularies
Yes

Backwards Compatibility
N/A

Joint Copyright
No