MCC eCare Plan Implementation Guide
1.0.0 - STU1
MCC eCare Plan Implementation Guide
1.0.0 - STU1
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
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 US Core 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. |
| 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.. |
| 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. |
| 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 |
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. |
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.
| 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 |
IG © 2020+ HL7 International / Patient Care. Package hl7.fhir.us.mcc#1.0.0 based on FHIR 4.0.1. Generated 2024-08-13
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