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Description

By supporting longitudinal coordination, communication, and collaboration across healthcare teams in diverse settings, e-care plans have potential to improve care safety and quality and reduce adverse events, diagnostic delays, and healthcare costs. Chronic kidney disease (CKD) is an ideal population in which to deploy and test an e-care plan, given the complexity of care, numerous transitions, need for interdisciplinary collaboration, and many comorbidities associated with the disease. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) is collaborating with experts from the nephrology and informatics communities via its CKD e-Care Plan Working Group to develop and implement a person-centered e-care plan incorporating data elements essential for CKD care. The Working Group conducted interviews with individuals living with CKD to understand their values, and developed patient and clinician personas to guide identification of data elements and corresponding data standards (i.e., LOINC, SNOMED-CT, ICD-10, CPT, RxNorm). These personas and data elements have been used during HL7 FHIR and C-CDA Care Plan standards related testing events, yielding C-CDA output and FHIR resources. Several challenges and lessons learned have been identified during development and testing that may be relevant to the creation of standardized and person-centered e-care plans for other chronic diseases.

Learning Objective 1: To understand strategies for and challenges to the development and implementation of person-centered electronic care plans designed to improve coordination of longitudinal care for patients with chronic conditions.

Learning Objective 2: To understand the benefits, drawbacks and trade-offs between use of HL7 C-CDA and FHIR standards in the development of person-centered electronic care plans designed to improve coordination of longitudinal care for patients with chronic conditions.

Authors:

Jenna Norton (Presenter)
National Institute of Diabetes and Digestive and Kidney Diseases

David Carlson (Presenter)
Clinical Cloud Solutions LLC,

Evelyn Gallego (Presenter)
EMI Advisors

Kaltun Ali, National Institute of Diabetes and Digestive and Kidney Diseases
Andrew Narva, National Institute of Diabetes and Digestive and Kidney Diseases
Theresa Cullen, Regenstrief Institute

Presentation Materials:

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