DEVELOPMENT OF AN ELECTRONIC CARE PLAN FOR PERSONS WITH MULTIPLE CHRONIC CONDITIONS (E-CARE)

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Through funding made available from the Department of Health and Human Services’ Patient-Centered Outcomes Research Trust Fund (PCOR TF), the NIDDK has partnered with the Agency for Healthcare Research and Quality (AHRQ) on the development and testing of a pilot suite of interoperable electronic (e-) care planning tools to facilitate aggregation and sharing of critical patient-centered data across home-, community-, clinic- and research-based settings for persons with multiple chronic conditions (MCC), including chronic kidney disease (CKD), type 2 diabetes mellitus (T2D), cardiovascular disease (CVD), chronic pain, and post-acute sequelae of SARS-CoV-2 infection (PASC). Care plans are a prominent part of multifaceted, care coordination interventions that reduce mortality and hospitalizations and improve disease management and satisfaction. In addition, proactive care planning promotes person-centeredness, improves outcomes, and reduces the cost of care. Development of care plans based on standardized data—leveraging standards such as Fast Healthcare Interoperability Resources (FHIR) and Substitutable Medical Apps, Reusable Technology (SMART) (https://smarthealthit.org/) on FHIR—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 missingness and improve quality of point-of-care data for use in pragmatic research. The NIDDK is leading the development component of the project, while real-world testing is being led by AHRQ.