MCC eCare Plan Implementation Guide
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MCC eCare Plan Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-mcc/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Multiple Chronic Condition (MCC) FHIR Care Plan

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 US Core FHIR Care Plan Resource to represent the requirements of a care plan for patients with multiple chronic conditions.

MCC CaregiverConsiderationsObservation

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.

MCC CareTeam

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.

MCC Chronic Condition and Health Concern Profile

MCC Chronic Condition and Health Concern Profile

This profile constrains US Core Condition Problems and Health Concerns Profile to encourage its use for chronic condition and health concerns for use in the MCC FHIR Care Plan or other FHIR Care Plans by linkages or references to goals and other resources..

MCC Clinical Impression

Multiple Chronic Condition Care Plan Clinical Impression

This profile constrains ClinicalImpression for use in the MCC FHIR Care Plan or other FHIR Care Plans.

MCC Clinical Result Observation

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.

MCC Diagnostic Report and Note

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.

MCC Document Reference

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.

MCC Family Member History

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.

MCC Goal

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.

MCC Immunization

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.

MCC Laboratory Result

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.

MCC Medication Request

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.

MCC Nutrition Order

Multiple Chronic Condition Care Plan Nutrition Order

This profile constrains NutritionOrder for use in the MCC FHIR Care Plan or other FHIR Care Plans.

MCC Observation SDOH Assessment

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.

MCC PatientCaregiverConditionStatus

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.

MCC Procedure

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.

MCC QuestionnaireResponse

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.

MCC Service Request

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.

MCC Simple Observation

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.

MCC Symptom Observation

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.

MCC Imaging Observation

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.

MCC Long COVID Bundle

long-covid-and-ckd-bundle

Long COVID and CKD Collection Bundle

observation-moca

MOCA new result showing improvement

questionnnaire-res-moca

MOCA new questionnaire response

obs-response-moca

MOCA new converted observation from question

observation-moca-original

MOCA initial result showing impairment

questionnnaire-res-moca-original

MOCA initial questionnaire response

obs-response-moca-original

MOCA converted original observation from question

dialysis-request

Referral for dialysis

dialysis-for-bundle

Dialysis Procedure

dialysis-for-bundle2

Dialysis Procedure

dialysis-for-bundle3

Dialysis Procedure

ckd-app-education

Education on CKD app

dietitian-referral

Dietitian Referral

dietitian-consult

Dietitian consult

better-diet

Observation by caregiver (daughter) of improvement in diet

long-covid-request

Long Covid Clinic Referral serviceRequest

med-for-chilblains

Treatment for chilblains

pt-3x-wk

PT 3x per week

counseling-1x-wk

Counseling 1x per week

meditation-7x-wk

Meditation 7x per week

careplan-for-bundle

Long COVID and CKD Careplan for Long COVID Bundle

daughter1

Rose Noelle, Daughter

practitionerMCC-V

Dr Vince Jones, Nephrologist

dr-vince-jones

Nephrologist Role, served by Dr Vince Jones

practitionerMCC-3v

Dr John Carlson, Primary Care Physician

careCoordinator1

Julie Smith, Care-coordinator

funding1

Example of Organization for Long COVID bundle

communitysite

Example of Location for Long COVID bundlee

careCoordinator-1

Care-coordinator, served by Julie Smith

careteam-for-bundle

Example of CareTeam for Long COVID bundle

patient-health-concern-1

Patient Health Concern: Worry that Long Covid symptoms will effect CKD

patient-health-concern-2

Patient Health Concern: Hard to exercise due to pain

patient-health-concern-3

Patient Health Concern: Struggles to manage her diet and find affordable healthy food choices under her financial strain

patient-health-concern-4

Patient Health Concern: Poor appetite for healthy CKD appropriate foods, likes cola, cake and chips

careTeam-concerns-1

CareTeam Health Concern: Imbalanced Nutrition

careTeam-concerns-2

CareTeam Health Concern: Dyspnea

careTeam-concerns-3

CareTeam Health Concern: Pain in Legs

careTeam-concerns-4

CareTeam Health Concern: Pain in Hands

careTeam-concerns-5

CareTeam Health Concern: Pain in arms

problem-list-1

Finding: Food aversion and cravings

problem-list-2

Diagnosis: Metabolic acidosis

encounter-diag-1

Long COVID

arterial-blood-gas-panel

Example of Observation for Long COVID bundle

ph-lab-observation

Example of Observationfor Long COVID bundle

hco3-arterial-observation

Example of Observation for Long COVID bundle

pCO2-arterial-observation

Example of Observation for Long COVID bundle

pO2-arterial-observation

Example of Observation for Long COVID bundle

serum-lactate-observation

Example of Observation for Long COVID bundle

blood-ketones-observation

Example of Observation for Long COVID bundle

serum-electrolytes-panel

Example of Observation for Long COVID bundle

sodium-serum-observation

Example of Observation for Long COVID bundle

potassium-serum-observation

Example of Observation for Long COVID bundle

chloride-serum-observation

Example of Observation for Long COVID bundle

bicarbonate-serum-observation

Example of Observation for Long COVID bundle

carbon-dioxide-serum-observation

Example of Observation for Long COVID bundle

anion-gap-serum-observation

Example of Observation for Long COVID bundle

protein-serum-observation

Example of Observation for Long COVID bundle

albumin-serum-observation

Example of Observation for Long COVID bundle

glomerular-filtration-observation

Example of Observation for Long COVID bundle

symptom2

Long Covid symptom: Dyspnea

symptom3

Long Covid symptom: Pain in Legs

symptom4

Long Covid symptom: Pain in hands

symptom5

Long Covid symptom: Pain in arms

symptom6

Long Covid symptom: Brain Fog - Intermittent confusion

symptom7

Long Covid symptom: Brain Fog - Memory impairment

symptom8

Long Covid symptom: Covid Toes - Toe swelling

symptom9

Long Covid symptom: Covid Toes - Pustular chilblain

chilblain-found

Long Covid related condition: Pustular chilblain found

chilblain-resolved

Long Covid related condition: Pustular chilblain resolved

lower-pain-minimal-opioids

Lower pain with minimal opioids

reduced-pain

Outcome example. Caregiver's observed thoughts on pain

appetite-to-normal

Return appetite to normal

electrolyte-protein-normal-range

Get Electrolyte and proteins back to normal

bmi-normal-range

Get BMI into healthy range

access-affordable-healthy-food

Improve access to affordable, healthy food

Behavior: Capability Statements

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.

MCCClientCapabilityStatement

This Section describes the expected capabilities of the MCC Client actor. See http://hl7.org/fhir/us/core/STU6.1/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

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/STU6.1/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.

Structures: Extension Definitions

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.

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

Caregiver Example

Caregiver Example

Expansion Parameters SNOMED US Version

Parameter file

MCC Care Team Example

MCC Care Team Example

MCC Caregiver Feelings on Condition Observation example

MCC Caregiver Feelings on Condition Observation example

MCC Chronic Condition - CKD Example

MCC Chronic Condition - CKD Example

MCC Clinical Result Observation example

MCC Clinical Result Observation example

MCC Diagnostic Report and Note Example

MCC Diagnostic Report and Note Example

MCC Document Reference to Advance Directives Example

MCC Document Reference to Advance Directives Example

MCC Family Member History Example - Father

MCC Family Member History Example - Father

MCC Goal Example - Normal Hypertension

MCC Hypertension Goal Example

MCC Goal Example - Weight Loss

MCC Goal Example - Weight Loss

MCC Lab Observation - BUN

BUN Lab Observation

MCC Medication Request Example

MCC Medication Example

MCC Observation of Caregiver considerations example

MCC Observation of Caregiver considerations example

MCC Patient

US Core Conformant Patient Example for MCC

MCC Practitioner - Nephrologist

US Core Conformant Practitioner Example For MCC - Nephrologist

MCC Practitioner - Nephrologist Provider Role

US Core Conformant Practitioner Role Example For MCC - Nephrologist

MCC Practitioner - Nurse Practitioner

US Core Conformant Practitioner Example For MCC - Nurse Practitioner

MCC Practitioner - Nurse Practitioner Role

US Core conformant Practitioner Role example for MCC

MCC Practitioner - Primary Care Provider

US Core Conformant Practitioner Example For MCC - Primary Care

MCC Practitioner - Primary Care Provider Role

US Core Conformant Practitioner Role Example For MCC - Primary Care

MCC Procedure Example - Dialysis

MCC Procedure Example - Dialysis

MCC QuestionnaireResponse Example

MCC QuestionnaireResponse Example

MCC SDOH assessment example Observation

MCC SDOH assessment example Observation

MCC Symptom Observation Example - Taste Sense Altered

MCC Symptom Observation Example - Taste Sense Altered

Multiple Chronic Condition Care Plan Care Team

MCC Example of US Core Care Team

Multiple Chronic Condition Care Plan Clinical Impression Example

Multiple Chronic Condition Care Plan Clinical Impression Example

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)

Multiple Chronic Condition Care Plan Imagining Observation Example

Multiple Chronic Condition Care Plan Imagining Observation Example

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 Simple Observation Example

Multiple Chronic Condition Care Plan Simple Observation Example

Multiple Chronic Condition Service Request - Food Pantry

Multiple Chronic Condition Service Request Food Pantry Example

US-Core MCC Weight Example

Weight Observation Example