eCare Plan Resources and Publications

All products are open-source and freely available.

eCare Plan Apps

eCare Plans support seamless care coordination, communication, and collaboration among members of the care team (patients, caregivers, and healthcare professionals) to address the full spectrum of a patient’s needs across home-, community-, clinic-, and research-based settings. The MCC eCare Plan project created and pilot-tested two SMART®-on-FHIR (Fast Healthcare Interoperability Resources) apps, one for providers (“eCarePlanner”) and one for patients/caregivers (“MyCarePlanner”), that integrate with EHRs and other available FHIR servers to pull, share, collect, and display key patient data to help with person-centered care planning.

• For patients/caregivers: MyCarePlanner* |  For clinicians: eCarePlanner
• Review a live demo of the MyCarePlanner app.

*U.S. Department of Health and Human Services 2015 Stakeholder Panel | Baker, et al. Making the Comprehensive Shared Care Plan a Reality. NEJM Catalyst. 2016.

eCare Plan Implementation Guide and Plain Language Summary

HL7, or Health Level Seven International, creates standards to allow information to be shared between hospitals, doctors’ offices, and laboratories. The HL7 FHIR MCC eCare Plan implementation guide defines FHIR R4 profiles, structures, extensions, transactions, and value sets needed to represent, query for, and exchange care plan information. This initial version focuses on chronic kidney disease, type 2 diabetes mellitus, common cardiovascular diseases (hypertension, ischemic heart disease, and heart failure), chronic pain, and Long COVID. 

The MCC eCare Plan implementation guide was balloted as a standard for trial use in the September 2023 ballot cycle and is currently undergoing reconciliation. The implementation guide includes a new (experimental) section with a Plain Language Summary—the first of its kind that may become standard in future HL7 FHIR implementation guides.

Partnering With HL7

The standards development components of the project were developed together with HL7. The project is sponsored by the Patient Care Work Group, and co-sponsored by the Clinical Decision Support Work Group and the Learning Health System Work Group. Learn more about our activities with HL7 on the HL7 MCC eCare Plan page.

Data Elements and Value Sets

To help with standardized transfer of health data across various settings for people with chronic kidney disease, diabetes, cardiovascular disease, chronic pain, and/or Long COVID, we worked with patients, caregivers, clinicians, researchers, and informaticians to identify important pieces of information to include in the care plan and built corresponding value sets using common clinical terminologies such as LOINC, SNOMED-CT, and ICD-10. The value sets include chronic conditions, clinical tests, goals, laboratory results, medications, social determinant of health assessments, procedures, and symptoms relevant to the five use case conditions. The value sets are published in the National Library of Medicine’s Value Set Authority Center under the “HL7 Patient Care WG Steward” and available from the value set library in our HL7 FHIR implementation guide. 

Pilot Testing Lessons Learned (Round 1)

The Implementation of an eCare Plan for People With MCC Final Report (PDF, 4.7 MB) documents the results from single site implementation of the SMART on FHIR app, including lessons learned and recommended app updates. Testing focused on usability and was conducted in two phases: the first phase in the test environment at Oregon Health & Science University, with clinicians accessing test patient data using each eCare Plan app, and the second in the production environment, with patients accessing their own data in the MyCarePlanner app. During testing, the eCare Plan apps enabled standards-based sharing of some data and revealed areas for additional work, demonstrating the feasibility of a solution for electronic shared care planning and care coordination for patients with MCC. 

Multisite, Real-world Implementation and Usability Testing (Round 2) 

The Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions Final Report, Version 2 (PDF, 2.3 MB) broadly outlines the development of the eCare Plan apps, highlighting the efforts that went into the testing and evaluation of the apps as well as sharing lessons learned implementing the eCP apps (myCareplanner and eCareplanner) in real-world settings to aid other researchers and developers as they undertake similar efforts. It provides evaluation information from the patient and provider perspective. It also provides lessons learned by the team to help other researchers undertaking similar SMART-on-FHIR app development.

Person-Centered Care Planning for Persons with Multiple Chronic Conditions Reports

• Baseline Scan:
  • Person-Centered Care Planning for Persons with Multiple Chronic Conditions: Current Approaches and Models (PDF, 2 MB); Appendices (PDF, 430 KB):
  • This baseline scan provides a summary of the approaches and models of person-centered care planning (PCCP) for people living with or at risk of developing multiple chronic conditions (MCC) with the goal of developing care plans aligned with an individual’s goals to optimize health and well-being.
• Rapid Scan:
  • Measures of implementation of Person-Centered Care Planning for people at risk for or living with Multiple Chronic Conditions (PDF, 602 KB):
  • This rapid scan examined implementation measures to assess implementation of PCCP to help health systems and providers increase the uptake of PCCP for individuals at risk for and living with multiple chronic conditions in order to improve their health and prevent avoidable adverse outcomes.
• Rapid Scan:
  • Connecting Community-Based Human and Social Service Organizations and Health Care Organizations (PDF, 1 MB):
  • This rapid scan assessed approaches used by health-care organizations to collaborate with human and social service organizations to better address the needs of individuals at risk for or living with multiple chronic conditions in order to improve their health and prevent avoidable adverse outcomes.

Publications

Establishing Data Elements and Exchange Standards to Support Long COVID Healthcare and Research.

Mobile Health Applications, Family Caregivers, and Care Planning: A Scoping Review.

Assessing Progress Toward the Vision of a Comprehensive, Shared Electronic Care Plan: Scoping Review.

Transforming Care for People With Multiple Chronic Conditions: Agency for Healthcare Research and Quality's Research Agenda.