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The National Institute of Health's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Agency for Healthcare Research and Quality (AHRQ) will drive, coordinate and advocate for the long term maintenance of this project.

Short Description:

 The MCC eCare Plan is a profile on the HL7 FHIR Care Plan Resource constrained to represent, query for, and aggregate  Health and Social Concerns, Goals, Interventions and Health Status/Outcomes of importance to patients with multiple chronic conditions.

The implementation guide provides representation of clinical and social data elements in the FHIR Care Plan format. The IG is focused on 4 common chronic conditions: 1) chronic kidney disease (CKD), 2) type 2 diabetes mellitus (T2DM), 3) cardiovascular diseases (specifically, hypertension, ischemic heart disease and heart failure), and 4) pain.Long Description:

  • What does the IG Do?
    • The implementation guide provides representation of clinical and social data elements in the FHIR format and defines where these elements should be represented within the FHIR Care Plan Resource. It describes the necessary operations and transactions needed to generate, aggregate and exchange care plans.
  • Who is the IG For?
    • The primary audience for this specification is EHR independent application developers and EHR developers of Care Plan modules and IT departments at implementation sites. A secondary target audience are consumers of structured Care Plan data such as researchers and payers.
  • What type of interoperability does it solve?
    • This implementation guide provides the rules and methods to achieve this aggregated view within a Care Plan structure pulling data from all systems where patients receive care, including patient provided data. Interoperability is often hamstrung by policy, technical, business and cultural challenges among EHRs to write back or pull data into their EHRs which is needed to provide a holistic picture of patients.

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