Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions (North Carolina)

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The e-care plan applications that utilize interoperability standards have the potential to improve care management and care coordination for people with multiple chronic conditions across different healthcare settings.

Project Details - Ongoing


Care plans are a prominent part of multifaceted care coordination interventions designed to reduce mortality and hospitalizations, and improve disease management and satisfaction. The care plans that have been developed to date in healthcare settings in the United States remain largely paper-based; when they are electronic, they are not standardized and interoperable across care settings. Existing care plans are typically those focused on a single disease or care setting and do not meet the needs of patients with multiple chronic conditions (MCCs) or their providers. Development and use 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 data gaps and improve quality of point-of-care data for use in pragmatic research.

This research, led by RTI International, will support the development and testing of electronic care (e-care) plan applications and implementation guide as part of a joint project between the Agency for Healthcare Research and Quality (AHRQ) and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIDDK will develop two e-care plan applications (provider-facing and patient-facing) for managing persons with chronic kidney disease and at least one additional chronic condition, such as type 2 diabetes mellitus, cardiovascular disease, chronic pain, or opioid use disorder. Both e-care plan applications will be open-source, Substitutable Medical Applications Reusable Technologies (SMART®) on Fast Healthcare Interoperability Resources (FHIR®) applications. The e-care plan applications will be able to retrieve patient data and related resources from electronic health records and other health information technology (IT) systems for aggregation, analysis, and sharing with other healthcare team members. By including critical information across multiple settings of care, the resulting e-care plan will enable patient-centered outcomes research in answering critical questions.

The specific aims of the research are as follows:

  • Form stakeholder groups to provide input during NIDDK’s development of the e-care plan applications. 
  • Design and execute a plan for pilot-testing the e-care plan applications in a mix of ambulatory care settings (including primary care) that use different health IT systems to determine how well the applications enable the collection and sharing of standardized data across clinical and research settings. 

The overall goal of the research is to advance the use of e-care plans for people with MCCs across healthcare settings.