MCC eCare Plan Draft Implementation Guide
0.1.0 - CI Build

MCC eCare Plan Draft Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions

Patient Story 1 Assumptions

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  • Covered and eligible for all medical/social services described in the use case
  • Capable of reading/comprehending at least at a high school level
  • Able to access the EHR/PHR, the electronic care plan application, a smart phone, and email
  • Able to grant consent to share data with selected Care Team members

Care Team Roles

  • Primary Care Physician (PCP) and specialists document clinical/social care planning activities in the EHR
  • Care Coordinator (triage nurse, social worker, discharge planning staff in inpatient units, community pharmacist) serves as care plan steward
    • Reviews and reconciles care plan changes
    • Reviews, manages, and monitors the action plan to address social needs

Technical Compliance

  • EHR is able to capture/document and store medical and social data using standardized medical terminologies (For Example, LOINC, SNOMED-CT, ICD-10, CPT)
  • EHR is able to connect and integrate with a SMART on FHIR App for care planning
  • EHR can transmit or expose care coordination data (e.g. referral, consult, care summary, care plan) using FHIR-based specifications
  • Care plan and EHR tie back to either 1) a single common database or 2) separate databases with common data elements and automated/near real-time integration
  • Care plan has a revision history and subscription process
    • Patient/Care Team are able to subscribe, define notifications, and designate recipients
    • Subscribers can identify what revisions were made, who made them, and why

Data Sharing Practices

  • Patient’s information is shared in compliance with privacy, security, and consent requirements

Care Plan Features

  • Provides necessary access and entry authorization protocols for users
  • Can identify and accommodate instances where different care team members access/edit the care plan at the same

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