MCC eCare Plan Implementation Guide
1.0.0-ballot2 - ballot
MCC eCare Plan Implementation Guide
1.0.0-ballot2 - ballot
This page is part of the MCC eCare Plan Implementation Guide (v1.0.0-ballot2: STU 1 Ballot 2) based on FHIR R4. . For a full list of available versions, see the Directory of published versions 
Contents:
This page provides a list of the FHIR artifacts defined as part of this implementation guide.
The Multiple Chronic Condition (MCC) FHIR Care Plan Profile is the backbone or core profile of this of this implementation guide. All of the profiles defined in this IG are referred to from the MCC Care Plan profile.
| Multiple Chronic Care Condition Care Plan |
This profile constrains the FHIR Care Plan Resource to represent the requirements of a care plan for patients with multiple chronic conditions. |
| Multiple Chronic Condition Care Plan Caregiver Considerations Observation |
This profile constrains US Core Simple Observation for use in the MCC FHIR Care Plan or other FHIR Care Plans reflecting information about the caregiver. It is using Observation resource to record, search, and fetch Observations on issues or items that might effect the Caregiver’s ability to provide care to the patient. |
| MCCCareTeam |
This profile constrains US Core Care team for use in the MCC FHIR Care Plan or other FHIR Care Plans. It features a requirement for Patient and at least one caregiver to be part of the members of the team. |
| Multiple Chronic Condition Care Plan Chronic Disease Conditions |
This profile constrains US Core Condition Problems and Health Concerns Profile to encourage its use for chronic disease conditions for use in the MCC FHIR Care Plan or other FHIR Care Plans by linkages or references to goals and other resources.. |
| Multiple Chronic Condition Care Plan Clinical Impression |
This profile constrains ClinicalImpression for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Clinical Result Observation |
This profile constrains US Core Clinical Result Observation Profile for use in the MCC FHIR Care Plan or other FHIR Care Plans. It is using Observation resource to record, search, and fetch Observations where the Observation is neither a laboratory, imaging, vital sign, social history, sexual orientation, survey, SDOH assesment, nor a smoking status observation. ‘Echocardiogram’ is an example observation which would use the MCC Clinical Result profile. |
| Multiple Chronic Condition Care Plan Diagnostic Report and Note |
This profile constrains US Core Diagnostic Report and Note for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Document Reference to Patient's Personal Advance Care Plan (Advance Directive) |
This profile constrains US Core DocumentReference to reference, query for and retrieve Personal Advance Care Plans that exist for a patient. |
| Multiple Chronic Condition Care Plan Family History |
This profile constrains the FHIR Family Member History Resource for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Goal |
This profile constrains US Core Goal for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Immunization |
This profile constrains US Core Immunization Profile for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Laboratory Result Observation |
This profile constrains US Core Laboratory Result Observation Profile for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Medication Request |
This profile constrains US Core Medication Request for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Nutrition Order |
This profile constrains NutritionOrder for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Observation SDOH Assessment |
This profile constrains US Core Observation Screening Assessment Profile for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation |
This profile constrains US Core Simple Observation for use in the MCC FHIR Care Plan or other FHIR Care Plans. It is using Observation resource to record, search, and fetch Observations of the Patient or Caregivers feelings towards the status of patient conditions. The focus is on the conditions of interest and the performer element indicates weather this is the Patient or Caregiver’s feelings. This is similar to a clinical impression but is being made by a non-clinican. |
| Multiple Chronic Condition Care Plan Procedure |
This profile constrains US Core Procedure for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Questionnaire Response |
This profile constrains US Core QuestionnaireResponse Profile for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Service Request |
This profile constrains US Core Service Requst for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Simple Observation |
This profile constrains US Core Simple Observation for use in the MCC FHIR Care Plan or other FHIR Care Plans. It is using Observation resource to record, search, and fetch Observations on issues or items that are not appropriate for the other MCC FHIR Observation profiles. |
| Multiple Chronic Condition Care Plan Symptom Observation |
This profile constrains US Core Simple Observation creating a symptom profile for use in the MCC FHIR Care Plan or other FHIR Care Plans. |
| Multiple Chronic Condition Care Plan Clinical Imaging Observation |
This profile constrains US Core Clinical Result Observation Profile for use in the MCC FHIR Care Plan or other FHIR Care Plans. It is using Observation resource to record, search, and fetch the components of diagnostic imaging test results for a patient. |
The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.
| MCCServerCapabilityStatement |
This Section describes the expected capabilities of the MCC Server actor which is responsible for providing responses to the queries submitted by the MCC Requesters. See http://hl7.org/fhir/us/core/CapabilityStatement-us-core-server.html for specifics. Additionally, support for the extension ‘Pertains to Goal’ is indicated in the StructureDefinitions of MCC eCare Plan Implementation Guide, as well as other conformance artifacts of the MCC eCare Plan Implementation Guide. |
| MCCClientCapabilityStatement |
This Section describes the expected capabilities of the MCC Client actor. See http://hl7.org/fhir/us/core/CapabilityStatement-us-core-client.html for specifics. Additionally, support for the extension ‘Pertains to Goal’ is indicated in the StructureDefinitions of MCC eCare Plan Implementation Guide, as well as other conformance artifacts of the MCC eCare Plan Implementation Guide |
These define constraints on FHIR data types for systems conforming to this implementation guide.
| Change Pattern R5 backport |
Change in the status/pattern of a subject’s condition since previously assessed, such as worsening, improving, or no change. It is a subjective assessment of the direction of the change. |
| Custodian R5 backport |
Who is the designated responsible party. When populated, the custodian is responsible for the care plan. The care plan is attributed to the custodian. The custodian might or might not be a contributor. |
These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.
| Multiple Chronic Condition Care Plan Example |
A Multiple Chronic Condition Care Plan Example reflecting multiple chronic conditions and associated, goals, health concerns, interventions and outcomes as seen in the profile and profile relationship diagram. (NOTE: Only CKD examples present as of 2022-APR) |
| MCC Procedure Example - Dialysis |
MCC Procedure Example - Dialysis |
| MCC Diagnostic Report and Note Example |
MCC Diagnostic Report and Note Example |
| MCC Family Member History Example - Father |
MCC Family Member History Example - Father |
| MCC Document Reference to Advance Directives Example |
MCC Document Reference to Advance Directives Example |
| MCC Chronic Condition - CKD Example |
MCC Chronic Condition - CKD Example |
| MCC Goal Example - Weight Loss |
MCC Goal Example - Weight Loss |
| MCC Practitioner - Nephrologist |
US Core Conformant Practitioner Example For MCC - Nephrologist |
| MCC Practitioner - Nurse Practitioner |
US Core Conformant Practitioner Example For MCC - Nurse Practitioner |
| MCC Practitioner - Primary Care Provider |
US Core Conformant Practitioner Example For MCC - Primary Care |
| MCC Practitioner - Nephrologist Provider Role |
US Core Conformant Practitioner Role Example For MCC - Nephrologist |
| MCC Practitioner - Nurse Practitioner Role |
US Core conformant Practitioner Role example for MCC |
| MCC Practitioner - Primary Care Provider Role |
US Core Conformant Practitioner Role Example For MCC - Primary Care |
| MCC Lab Observation - BUN |
BUN Lab Observation |
| MCC Patient |
US Core Conformant Patient Example for MCC |
| Multiple Chronic Condition Care Plan Care Team |
MCC Example of US Core Care Team |
| MCC Goal Example - Normal Hypertension |
MCC Hypertension Goal Example |
| US-Core MCC Weight Example |
Weight Observation Example |
| MCC Medication Request Example |
MCC Medication Example |
| MCC Symptom Observation Example - Taste Sense Altered |
MCC Symptom Observation Example - Taste Sense Altered |
| Multiple Chronic Condition Care Plan Immunization Example |
Multiple Chronic Condition Care Plan Immunization Example |
| Multiple Chronic Condition Care Plan Nutrition Order Example |
Multiple Chronic Condition Care Plan Nutrition Order Example |
| Multiple Chronic Condition Care Plan Clinical Impression Example |
Multiple Chronic Condition Care Plan Clinical Impression Example |
| MCC Care Team Example |
MCC Care Team Example |
| Caregiver Example |
Caregiver Example |
| MCC QuestionnaireResponse Example |
MCC QuestionnaireResponse Example |
| Multiple Chronic Condition Care Plan Imagining Observation Example |
Multiple Chronic Condition Care Plan Imagining Observation Example |
| Expansion Parameters SNOMED US Version |
Parameter file |
| MCC Clinical Result Observation example |
MCC Clinical Result Observation example |
| MCC Caregiver Feelings on Condition Observation example |
MCC Caregiver Feelings on Condition Observation example |
| MCC SDOH assessment example Observation |
MCC SDOH assessment example Observation |
| Multiple Chronic Condition Service Request - Food Pantry |
Multiple Chronic Condition Service Request Food Pantry Example |
| Multiple Chronic Condition Care Plan Simple Observation Example |
Multiple Chronic Condition Care Plan Simple Observation Example |
| MCC Observation of Caregiver considerations example |
MCC Observation of Caregiver considerations example |
IG © 2020+ HL7 International - Patient Care WG. Package hl7.fhir.us.mcc#1.0.0-ballot2 based on FHIR 4.0.1. Generated 2023-07-28
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