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cmext.ahrq.gov/confluence/pages/viewpage.action?pageId=114991038
October 26, 2021 - (s); used to inform, monitor, and optimize care plan and outcomes. 13 Condition Management Policy/ Procedure … preventive service coming due or possible OUD, or condition (e.g., out of range clinical parameter) … or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention and/or action … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence/display/PUB/Care+Delivery+Perspective
October 26, 2021 - (s); used to inform, monitor, and optimize care plan and outcomes. 13 Condition Management Policy/ Procedure … preventive service coming due or possible OUD, or condition (e.g., out of range clinical parameter) … or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention and/or action … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence//display/PUB/Care+Delivery+Perspective
October 26, 2021 - (s); used to inform, monitor, and optimize care plan and outcomes. 13 Condition Management Policy/ Procedure … preventive service coming due or possible OUD, or condition (e.g., out of range clinical parameter) … or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention and/or action … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence/download/temp/pdfexport-20230227-270223-1043-17/Care+Delivery+Perspective_c47e9f7ef81c464882bb25ec0b0faa17-270223-1043-18.pdf?contentType=application/pdf
(s); used to inform, monitor, and optimize care plan
and outcomes.
13 Condition
Manage
ment
Policy … as indicated preventive service coming due or possible OUD, or condition (e.
g., out of range clinical … parameter) or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan
is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence/download/export/pdfexport-20230320-200323-1144-211/Care+Delivery+Perspective_48af5cf7bd56404893da8b776426b788-200323-1144-212.pdf?contentType=application/pdf
(s); used to inform, monitor, and optimize care plan
and outcomes.
13 Condition
Manage
ment
Policy … as indicated preventive service coming due or possible OUD, or condition (e.
g., out of range clinical … parameter) or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan
is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence/download/export/pdfexport-20230424-240423-1211-2703/Care+Delivery+Perspective_32856957cf4242918fbda5342471f7e5-240423-1211-2704.pdf?contentType=application/pdf
(s); used to inform, monitor, and optimize care plan
and outcomes.
13 Condition
Manage
ment
Policy … as indicated preventive service coming due or possible OUD, or condition (e.
g., out of range clinical … parameter) or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan
is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence/download/export/pdfexport-20230703-030723-1236-83/Care+Delivery+Perspective_2a3fd3f3f18c48a6acc222fa55b9b589-030723-1236-84.pdf?contentType=application/pdf
(s); used to inform, monitor, and optimize care plan
and outcomes.
13 Condition
Manage
ment
Policy … as indicated preventive service coming due or possible OUD, or condition (e.
g., out of range clinical … parameter) or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan
is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence/download/export/pdfexport-20230731-310723-1149-23/Care+Delivery+Perspective_7f557e6f94334ede90a5a77f8feda6ce-310723-1149-24.pdf?contentType=application/pdf
(s); used to inform, monitor, and optimize care plan
and outcomes.
13 Condition
Manage
ment
Policy … as indicated preventive service coming due or possible OUD, or condition (e.
g., out of range clinical … parameter) or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan
is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249056&selectedPageVersions=41&selectedPageVersions=42
February 10, 2020 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Project Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical information … guide (IG) for point of care data review/entry Implement & evaluate the e-care plan application in diverse … clinical settings in patients with MCC, including CKD Establish an e-care plan repository and development … page 2 Clinical Care Model MCC Clinical Information Model (CIM) Analysis and Development 3 SMART on
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249064&selectedPageVersions=40&selectedPageVersions=41
February 06, 2020 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Project Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical information … guide (IG) for point of care data review/entry Implement & evaluate the e-care plan application in diverse … clinical settings in patients with MCC, including CKD Establish an e-care plan repository and development … page 2 Clinical Care Model MCC Clinical Information Model (CIM) Analysis and Development 3 SMART on
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249038&selectedPageVersions=39&selectedPageVersions=40
February 06, 2020 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Project Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical information … guide (IG) for point of care data review/entry Implement & evaluate the e-care plan application in diverse … clinical settings in patients with MCC, including CKD Establish an e-care plan repository and development … page 2 Clinical Care Model MCC Clinical Information Model (CIM) Analysis and Development 3 SMART on
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249073&selectedPageVersions=42&selectedPageVersions=43
February 10, 2020 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Project Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical information … guide (IG) for point of care data review/entry Implement & evaluate the e-care plan application in diverse … clinical settings in patients with MCC, including CKD Establish an e-care plan repository and development … page 2 Clinical Care Model MCC Clinical Information Model (CIM) Analysis and Development 3 SMART on
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249060&selectedPageVersions=38&selectedPageVersions=39
February 06, 2020 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Project Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical information … guide (IG) for point of care data review/entry Implement & evaluate the e-care plan application in diverse … clinical settings in patients with MCC, including CKD Establish an e-care plan repository and development … page 2 Clinical Care Model MCC Clinical Information Model (CIM) Analysis and Development 3 SMART on
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249063&selectedPageVersions=37&selectedPageVersions=38
February 06, 2020 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Project Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical information … guide (IG) for point of care data review/entry Implement & evaluate the e-care plan application in diverse … clinical settings in patients with MCC, including CKD Establish an e-care plan repository and development … page 2 Clinical Care Model MCC Clinical Information Model (CIM) Analysis and Development 3 SMART on
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249055&selectedPageVersions=36&selectedPageVersions=37
February 06, 2020 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Project Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical information … guide (IG) for point of care data review/entry Implement & evaluate the e-care plan application in diverse … clinical settings in patients with MCC, including CKD Establish an e-care plan repository and development … page 2 Clinical Care Model MCC Clinical Information Model (CIM) Analysis and Development 3 SMART
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cmext.ahrq.gov/confluence/exportword?pageId=114991038
(s); used to inform, monitor, and optimize care plan and outcomes.
13
Condition Management Policy … such as indicated preventive service coming due or possible OUD, or condition (e.g., out of range clinical … parameter) or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence/plugins/viewsource/viewpagesrc.action?pageId=114991038
(s); used to inform, monitor, and optimize care plan and outcomes. 13 Condition Management Policy/ Procedure … preventive service coming due or possible OUD, or condition (e.g., out of range clinical parameter) … or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention and/or action … care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides … The care plan is accessible on the portal, smartphone app, and/or paper.
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249068&selectedPageVersions=48&selectedPageVersions=49
February 17, 2020 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Project FAQs Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical … and implementation guide (IG) for point of care data review/entry Implement & evaluate the e-care plan … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan … page 2 Clinical Care Model In progress MCC Clinical Information Model (CIM) Analysis and Development
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249043&selectedPageVersions=49&selectedPageVersions=50
February 19, 2020 - multiple chronic condition conditions. … Project FAQs Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical … and implementation guide (IG) for point of care data review/entry Implement & evaluate the e-care plan … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan … page 2 Clinical Care Model Information Models In progress MCC Clinical Information Model (CIM) Analysis
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cmext.ahrq.gov/confluence/pages/diffpagesbyversion.action?pageId=109249072&selectedPageVersions=43&selectedPageVersions=44
February 12, 2020 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Project Project Objectives Develop & test a SMART on FHIR e-care plan application Create clinical information … guide (IG) for point of care data review/entry Implement & evaluate the e-care plan application in diverse … clinical settings in patients with MCC, including CKD Establish an e-care plan repository and development … page 2 Clinical Care Model In progress MCC Clinical Information Model (CIM) Analysis and Development