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

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.