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The eCare Plan for People with Multiple Chronic Conditions Project presented at HIMSS2021 August 11 at 2:30 PM - 3:30 PM PST

Visit our project confluence page to learn more and access the powerpoint:

The HL7 MCC eCare Plan public collaborative meets on Care Plan Weekly calls on alternating Wednesdays at 5 pm ET:

  • Call Info: Phone:   +1 669 900 6833 US (San Jose), +1 929 436 2866 US (New York) Meeting ID: 532 857 1160
  • Webmeeting Info:
  • To see the meeting schedule and notes from our past meeting click here

We are currently walking through the MCC DESS with value sets which can found here: MCC Clinical Information Model (CIM) Analysis and Development

Join the project listserv:

Interested in learning more about other care plan related projects visit this page here


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 SDOH, 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 transfer of data for an e-care plan across healthcare settings. SMART ( 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. 

MCC eCare Plan Overview .pptx

Project Scope

Initiated by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Agency for Healthcare Research and Quality (AHRQ) with funding from the Assistant Secretary for Planning and Evaluation’s (ASPE) Patient-Centered Outcomes Research (PCOR) Trust Fund, the electronic care (eCare) plan for people with multiple chronic conditions (MCC) project aims to develop, test, and pilot an interoperable eCare plan that will facilitate aggregation and sharing of critical patient-centered data across home, community, clinic, and research-based settings for persons with MCC, including chronic kidney disease (CKD), type 2 diabetes mellitus (T2DM), cardiovascular disease (CVD), and pain with opioid use disorder (OUD). The HL7 based activities of the MCC eCare Plan Project will:

  1. Identify use cases to support the documentation and exchange of MCC eCare plan data within EHRs and related systems;
  2. Identify, develop and prioritize the necessary MCC data elements and clinical terminology standards, clinical information models (CIM), and FHIR® mappings that will enable the standardized transfer of data across health settings;
  3. Develop and test an open-source clinician facing SMART on FHIR eCare plan application for managing persons with MCC; and
  4. Develop, test, and ballot an HL7® Fast Health Interoperability Resource (FHIR®) Implementation Guide based on the defined use cases and MCC data elements.

Additional non-HL7 related activities of the MCC eCare Plan project will be facilitated through the AHRQ eCare Plan Project Confluence.

Project objectives will be accomplished through bi-weekly one-hour virtual meetings facilitated under the current PCWG Care Plan Meeting Schedule.

The HL7 Project Scope Statement (PSS) is available here: PSS

HL7 FHIR IG Proposal: MCC FHIR IG Proposal

Upcoming MCC eCare Plan Project Meeting

DateTimeTopicMeeting InformationHomework Documents & Links


5:00 - 6:00 pm ET

MCC eCare Plan Project

Please join the meeting from your computer, table or smart phone.

Zoom Meeting URL

Dial by your location

        +1 669 900 6833 US (San Jose)

        +1 929 436 2866 US (New York)

Find your local number:

Meeting ID: 532 857 1160

MCC Meetings agenda are posted here

To view the full patient care schedule click here

Project Timeline

 Project Contacts 

Jenna NortonFederal 
Arlene BiermanFederal 
Gena FordProject ManagerCognitive Medical Systems

Jerry GoodnoughTechnical ArchitectCognitive Medical 
Joe BormelCIM Technical LeadCognitive Medical 
Evelyn GallegoSDO Liaison & CoordinationEMI Advisors 
Katiya ShellSDO Liaison & CoordinationEMI Advisors 


  • MCC eCare Plan Overview for PCWG January 22, 2020


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