The purpose of this project was to develop and test a suite of electronic Care Plan (eCP) tools for adults with multiple chronic conditions (MCC), including an eCP implementation guide specifying data standards and value sets for key use case conditions and two open-source eCP apps (one for patients and one for clinicians). This joint initiative supported the work to develop and test these apps, which are intended to facilitate aggregation and sharing of critical patient-centered data across home-, community-, clinic-, and research-based settings by extracting data from point-of-care health systems and allowing transfer of those data across settings.

Contents

• Executive Summary
• 1. Introduction, Background, and Goals
  • 1.1. Multiple Chronic Conditions
  • 1.2. Care Coordination Around Multiple Chronic Conditions
  • 1.3. Vision and Scope of This Report
  • 1.4. Chronic Kidney Disease as a Case in Point
  • 1.5. Use of Standards to Improve Interoperability
• 2. Integration and Implementation of the eCare Plan Apps for Prototype Testing
  • 2.1. Clinician Facing
  • 2.2. Patient Facing
  • 2.3. Electronic Health Record Integration
  • 2.4. Development of a Training Approach
  • 2.5. Planning for Evaluation
• 3. Evaluation Methods
  • 3.1. Goal of the Evaluation
  • 3.2. Evaluation Framework and Questions
  • 3.3. Data Sources and Data Collection
• 4. Evaluation Analysis, Synthesis, and Results
  • 4.1. Analysis and Synthesis
  • 4.2. Evaluation Results
• 5. Conclusion
  • 5.1. Factors
  • 5.2. Limitations
  • 5.3. Key Lessons Learned (EQ5)
  • 5.4. Recommendations for Future Development
• Glossary
• References
• Appendix A. Protocols
• Appendix B. Training Materials
• Appendix C. Acronyms and Abbreviations

Disclaimer of Conflict of Interest

None of the investigators has any affiliations or financial involvement that conflict with the material presented in this report.

Acknowledgments

The authors wish to thank and recognize the following individuals and groups, without whom this work could not have been accomplished:

• Agency for Healthcare Research and Quality, and National Institute of Diabetes and Digestive and Kidney Diseases leadership teams
• Oregon Health & Science University
• Subcontractors Danny van Leeuwen and Dave Carlson
• RTI Project Team
• Health Level Seven, HL7^®, and FHIR

Suggested citation:

Implementation of an Electronic Care Plan for People With Chronic Conditions. Prepared under Contract No. 75P00120F37004. AHRQ Publication No. 23–0010. Rockville, MD: Agency for Healthcare Research and Quality; November 2022.This document is in the public domain and may be used and reprinted without permission in the United States unless materials are clearly noted as copyrighted in the document. No one may reproduce copyrighted materials without the permission of the copyright holders. Users outside the United States must get permission from AHRQ to reprint or translate this product. Anyone wanting to reproduce this product for sale must contact AHRQ for permission. Citation of the source is appreciated.