Multiple Chronic Conditions Dynamic Electronic Care Plan FHIR IG

Template Usage Information:

• Submit template change requests to PMO@HL7.org
• For Reaffirmations, please refer to the FAQ in  Hl7 Project Scope Statement Instructions for a list of which sections and fields should be completed

1. Project Name and ID

2. Sponsoring Group(s) / Project Team

2.a. Primary Sponsor/Work Group

2.b. Co-sponsor Work Group(s)

2.c. Project Team

All names should have confirmed their role in the project prior to submission to the TSC.

3. Project Definition

3.a. Project Scope

Initiated by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Agency for Healthcare Research and Quality (AHRQ), the multiple chronic conditions (MCC) Dynamic electronic care (eCare) Plan Project aims to develop, test, and pilot an interoperable ambulatory eCare plan that will provide a health information technology system agnostic framework for viewing and sharing of critical patient-centered data across home, community, clinic, and research-based settings for persons with MCC, initially focusing on chronic kidney disease (CKD), type 2 diabetes mellitus (T2D), cardiovascular disease (hypertension, ischemic heart disease and heart failure), and pain and expanding as needed to other chronic conditions as needed for an MCC Care Plan. The MCC Dynamic eCare Plan Project will:

1. Identify use cases to support the documentation and exchange of MCC eCare plan data within EHRs and other healthcare technology 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. Identify workflow processes required to support basic care coordination requirements such as processes defined in the IHE dynamic care planning technical profile
4. Develop, test, and ballot an HL7® Fast Health Interoperability Resource (FHIR®) Implementation Guide based on the defined use cases and MCC data elements.
5. The project team recognizes that over the five year project course that FHIR profiles will evolve.
6. Given the long project timelines alignment to changing profiles and resources will be maintained as required (e.g., provider specifications).
7. This FHIR implementation guide will use the US Core profiles. If this FHIR implementation guide is unable to use a US Core profile, we will request approval from the US Realm Steering Committee, and provide the US Realm Steering Committee an approved rationale for deviation in the implementation guide where applicable.
8. In latter part of the project:
   1. Examine requirements with respect to conflicts in care recommendations and/or care delivery which may exist between chronic conditions within the eCare plan and across systems
   2. If Plan definitions applied, examine requirements with respect to de-duplication in Plan Definitions applied
   3. Identify opportunities and challenges of data retrieval.   
9. Externally to the HL7 Project, the encompassing NIH/AHRQ project will develop and test an open-source clinician facing SMART on FHIR dynamic eCare plan application for managing persons with MCC; leveraging work done in previous FHIR Connectathon Care Planning and management tracks, FHIR Plan Definition and FHIR Clinical Guidelines.

3.b. Project Need

More than 25 percent of Americans have MCC, accounting for more than 65 percent 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 U.S. 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. 

3.c. Security Risks

3.d. External Drivers

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

3.e. Project Objectives / Deliverables / Target Dates

3.f.   Common Names / Keywords / Aliases

3.g. Lineage

3.h. Project Dependencies

3.i.   HL7-Managed Project Document Repository Location

Multiple Chronic Conditions (MCC) eCare Plan

3.j.   Backwards Compatibility

3.k. External Vocabularies

4. Products (check all that apply)

5. Project Intent (check all that apply)

5.a. Ballot Type (check all that apply)

5.b. Joint Copyright

Check this box if you will be pursuing a joint copyright.  Note that when this box is checked, a Joint Copyright Letter of Agreement must be submitted to the TSC in order for the PSS to receive TSC approval.

6. Project Logistics

6.a. External Project Collaboration

6.b. Realm

6.c. Stakeholders / Vendors / Providers

This section must be completed for projects containing items expected to be ANSI approved, as it is an ANSI requirement for all ballots

6.d. Project Approval Dates

Click here to go to HL7 Project Scope Statement Instructions#Appendix A for more information regarding this section.
Approvals are by simple majority vote of the approving body