About the eCare Plan for Multiple Chronic Conditions

The eCare Plan project aims to build care planning tools that will improve how we do research and provide healthcare for people with multiple chronic conditions (MCC). These tools include data standards and electronic care plan applications that allow all members of the healthcare team (including patients and caregivers) to see and share critical health data from multiple electronic health records (EHRs) across many healthcare settings. 

The eCare plan applications can also collect patient, caregiver, and clinician goals, as well as important information from the patient and caregivers, like healthcare preferences, functional status, and health-related social needs. The applications can than combine this information with EHR data from multiple healthcare settings to support patient-centered shared care planning, improve coordination of care, enhance research with real-world data, and support quality improvement.

Funded by the Assistant Secretary for Planning and Evaluation’s Patient-Centered Outcomes Research Trust Fund, the MCC eCare Plan project is a joint initiative between AHRQ and the National Institute of Diabetes and Digestive and Kidney Diseases. 

Need for the Project

There is a mismatch between the way healthcare is delivered and the needs of people at risk for or living with MCC. Nearly 1 in 3 American adults and nearly 4 in 5 Medicare beneficiaries live with MCC, accounting for more than 70 percent of all U.S. inpatient hospital stays, 71 percent of U.S. healthcare spending, and 93 percent of Medicare spending. By 2050, the number of Americans aged 65 years and older is expected to more than double, and the number aged 85 years and older may triple. As the U.S. population ages, the burden of MCC will continue to grow, impacting health systems, clinicians and their teams, patients, and caregivers. Preventing and managing MCC is critical for the well-being of all, and central to the sustainability of our health system.

People living with MCC have complex care needs. They often see multiple providers who may practice across many different settings of care. Their care is often fragmented and poorly coordinated, in part because important patient data do not easily move across different healthcare settings. This inability to share data also limits our ability to use real-world data for research, making it harder to understand how best to prevent and manage MCC.

To help address these challenges, the eCare Plan project was launched in 2019 to build capacity for pragmatic, patient-centered outcomes research (PCOR) by developing an interoperable electronic care plan to facilitate aggregation and sharing of critical patient-centered data across home-, community-, clinic-and research-based settings for people with MCC. 

Project Objectives and Impacts

Improve Capacity for Patient-Centered Outcomes Research

Collecting and aggregating healthcare data from different healthcare settings where patients receive care is key to having complete, comprehensive, real-world data for pragmatic research. However, currently, many EHRs are not interoperable and do not permit the movement of data across care settings. Therefore, data for real-world research on people living with MCC are often incomplete. The eCare Plan project developed data standards to allow transfer of healthcare data across settings for common chronic conditions as well as important information to inform care and assess outcomes, including health-related social needs, functional and cognitive status, and patient, caregiver, and clinician goals.

Facilitate Comprehensive Care Planning

Identifying a person’s healthcare goals and collecting their data from different settings can also produce actionable information that supports whole-person approaches to care for people living with MCC through comprehensive person-centered shared care planning. The eCare Plan project developed two apps (one for clinicians and one for patients/caregivers) that does just that: collects and shares clinical data from multiple EHRs, along with patient-reported outcomes and patient goals, to aid shared care planning at the point of care for people living with MCC. This collaborative process involves discussing patient and clinical goals of care and identifying, through shared decision making, strategies for clinical and self-management to achieve these goals based on evidence and patient preference. 

Support Quality Improvement 

Collecting and aggregating patient data from multiple sources also leads to more complete and comprehensive data for Quality Improvement (QI) efforts. Since the eCare Plan apps capture patient-reported goals and preferences, they also create the ability to better align QI targets and measures with patient goals/preferences. 

Project Contacts

NIDDK Co-lead: Jenna Norton (jenna.norton@nih.gov) 

AHRQ Co-lead: Arlene Bierman (arlene.bierman@ahrq.hhs.gov) 

For questions or comments, please contact eCarePlan@ahrq.hhs.gov. 

Select here for a list of past contributors to the project.