Development and Testing of an Interoperable e-care Plan for Person-Centered Care Planning for Multiple Chronic Conditions

Background: Multiple chronic conditions (MCC) the most common condition seen in practice are present in 33% of adults and 80% of individuals age > 65. Central tenets of primary care are essential to the delivery of effective MCC care: person & family-centered, comprehensive, equitable, team-based, collaborative, coordinated and integrated. Because people with MCC typically see multiple providers in multiple care settings often using different EHRs, critical information is difficult to obtain, leading to fragmented care, clinician and patient burden, and suboptimal outcomes. The emergence of FIHR enables the development of interoperable apps to facilitate comprehensive, shared care planning.

Settings & Participants: Primary Care, testing with clinicians, patients, caregivers

Methods: AHRQ, in partnership with NIDDK, through user-centered agile design, and a consensus-driven approach involving a Technical Expert Panel has developed an open standards clinician, patient, and caregiver facing electronic Careplans (eCare) app to support the documentation, exchange, and aggregation of EHR data for MCC. The apps can integrate with the EHR to pull, share, and display key patient data to support care planning across disparate systems of care and social services while keeping the person at the center of their care. The apps also collect patient reported data on goals, social needs, and functional status. The mixed methods evaluation includes focus groups, user testing, and surveys.

Results: The project developed and published standardized data elements and value sets for chronic kidney disease type 2 diabetes, cardiovascular disease, chronic pain, and long COVID. Data elements and applicable use cases were incorporated into the HL7 Fast Health Interoperability Resource (FHIR) MCC eCare Plan Implementation Guide. User testing of MCC eCareplan apps provided lessons learned across areas specific to patient-centeredness, effectiveness, fidelity, shareability, feasibility, scalability, and performance. The testing demonstrated patients’ and clinicians’ desire to have integrated clinical and patient-reported data available for care planning and management. Results of testing and evaluation will be presented.

Conclusions: The e-care plan has great potential to serve as a tool to support longitudinal, comprehensive, person-centered, shared care planning in primary care, improve team communication and care coordination, and to facilitate shared care with specialists.