Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions

Care plans are a prominent part of multifaceted, care coordination interventions designed to reduce mortality and hospitalizations and improve disease management and patient satisfaction. The care plans that have been developed to date in U.S. healthcare settings remain largely paper-based; when they are electronic, they are not standardized nor 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 healthcare providers. Development and use of care plans based on structured data has been proposed as a method for enabling electronic systems to automatically integrate and share data elements across providers. These data provide actionable information to identify and achieve health and wellness goals and improve the quality of point-of-care data used in pragmatic research.

This research, led by RTI International, informed the development and testing of electronic care (e-care) plan applications and the creation of an Health Level Seven International (HL7®) implementation guide (IG) as part of a joint project between the Agency for Healthcare Research and Quality (AHRQ) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIDDK developed the IG and two e-care plan applications, one provider-facing and one patient-facing, for managing those 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 are open-source, using Substitutable Medical Applications Reusable Technologies (SMART®) on Fast Healthcare Interoperability Resources (FHIR®) standards. The e-care plan applications retrieves 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 enables patient-centered outcomes research in answering critical questions.

The specific aims of the research were 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 by using the IG 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.

This research demonstrated the feasibility of implementing applications to enable standards-based sharing of some patient data and revealed areas where current standards are insufficient or incompletely implemented. The research also demonstrated patients’ and clinicians’ desires to have patient-reported data available for tracking over time and to find a way to incorporate the generation and review of these data in day-to-day routines and workflows.