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

Artifacts Summary

Contents:

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

Multiple Chronic Condition (MCC) FHIR Care Plan Profile and chronic condition foci.

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. This draft, focuses on Chronic Kidney Disease (CKD) as the first of several chronic conditions that the IG will focus on. Therefore, CKD is also considered a core profile. The CKD profile contains or refers to several profiles especialy significant to CKD.

Multiple Chronic 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.
Chronic Kidney Disease Condition

This profile constrains US Core Condition to chronic kidney disease conditions and supporting information.

Conditions

MCC Conditions Library: These artifacts are all derived from the US Core Condition profile and have been constrained for use in the MCC Care Plan IG. All of the MCC conditions are conformant to the US Core Condition Profile with additional requirements for following elements:

  • Goal.extension:resource-pertainsToGoal (Must Support)
  • Condition.onset (Must Support)
  • Condition.recordedDate (Must Support)

These are not directly constrained into the MCC Care Plan Profile - but are considered a library of conditions from which to select to query for, fetch or record. These profiles may be used wherever the US Core Condition profile is bound within the MCC FHIR Care Plan.

Please see Library of Profiles vs Explicit Reference Constraints for additional discussion on this topic.

Alcohol Abuse Conditions

This profile constrains US Core Condition to alcohol abuse conditions.
Alkaline Phosphatase Deficiency Conditions

This profile constrains US Core Condition to alkaline phosphatase deficiency conditions.
Anemia Conditions

This profile constrains US Core Condition to anemia conditions.
Anxiety Conditions

This profile constrains US Core Condition to anxiety conditions.
Arthritis Disorders

This profile constrains US Core Condition to arthritis conditions.
Bipolar Conditions

This profile constrains US Core Condition to bipolar conditions.
Chronic Kidney Disease Type or Cause

This profile constrains US Core Condition to causes or types of chronic kidney conditions.
Chronic Pain Conditions

This profile constrains US Core Condition to chronic pain conditions.
Cognitive health and Impaired Memory Disorders

This profile constrains US Core Condition to cognitive health and impaired memory conditions.
Coronary Artery Disease Conditions

This profile constrains US Core Condition to coronary artery conditions.
Depression Conditions

This profile constrains US Core Condition to depression conditions.
Diabetic Neuropathy Conditions

This profile constrains US Core Condition to diabetic neuropathy conditions.
Diabetic Retinopathy Conditons

This profile constrains US Core Condition to diabetic retinopathy conditions.
End Stage Renal Disease Conditions

This profile constrains US Core Condition to end stage renal conditions.
Heart Failure

This profile constrains US Core Condition to heart failure conditions.
Hematuria Conditions

This profile constrains US Core Condition to hematuria conditions.
Hepatitis B Condition

This profile constrains US Core Condition to hepatitis B conditions.
Hepatitis C Conditions

This profile constrains US Core Condition to hepatitis C conditions.
Human Immunodeficiency Virus (HIV) Disease

This profile constrains US Core Condition to XX conditions.
Hypercalcemia Conditions

This profile constrains US Core Condition to hypercalcemia conditions.
Hyperkalemia Conditions

This profile constrains US Core Condition to hyperkalemia conditions.
Hyperlipidemia Conditions

This profile constrains US Core Condition to hyperlipidemia conditions.
Hyperparathyroidism Condition

This profile constrains US Core Condition to hyperparathyroidism conditions.
Hyperphosphatemia Conditions

This profile constrains US Core Condition to Hyperphosphatemia conditions.
Hypertension Conditions

This profile constrains US Core Condition to hypertension conditions.
Hyperuricemia Conditions

This profile constrains US Core Condition to hyperuricemia conditions.
Hypoalbuminemia Conditions

This profile constrains US Core Condition to hypoalbuminemia conditions.
Hypocalcemia Conditions

This profile constrains US Core Condition to hypocalcemia conditions.
Insomnia Disorders

This profile constrains US Core Condition to Insomnia conditions.
Metabolic Acidosis Conditions

This profile constrains US Core Condition to metabolic acidosis conditions.
Obesity Conditions

This profile constrains US Core Condition to obesity conditions.
Peripheral Vascular Disease

This profile constrains US Core Condition to peripheral vascular conditions.
PostTraumatic Stress Disorder PTSD

This profile constrains US Core Condition to post traumatic stress disorder PTSD conditions.
Preeclampsia Disorders

This profile constrains US Core Condition to preeclampsia conditions.
Schizophrenia or Psychotic Disorder

This profile constrains US Core Condition to schizophrenia or psychotic conditions.
Sleep Apnea Disorders

This profile constrains US Core Condition to sleep apnea conditions.
Substance Abuse Disorder

This profile constrains US Core Condition to substance abuse disorder conditions.
Tuberculosis Disorders

This profile constrains US Core Condition to tuberculosis conditions.
Type 1 Diabetes Diagnosis

This profile constrains US Core Condition to type 1 diabetes conditions.
Type 2 Diabetes Diagnosis

This profile constrains US Core Condition to type 1 diabetes conditions.
Uremic Pruritus Conditions

This profile constrains US Core Condition to uremic pruritus conditions.
Valvular Heart Disease

This profile constrains US Core Condition to valvular heart conditions.
Vitamin D Deficiency Conditions

This profile constrains US Core Condition to vitamin D deficiency conditions.

Goals

MCC Goal Library: These artifacts are all derived from the US Core Goal that have been constrained for use in the MCC Care Plan IG. All of the MCC Goals are conformant to the US Core Goal with additional requirements for following elements:

  • Goal.measure (Required) Bound to it’s relevant goal target value set
  • Goal.expressedBy (Must Support)
  • Goal.addresses (Must Support)
  • Goal.outcomeReference (Must Support)
  • Goal.extension:goal-acceptance (Must Support)
  • Goal.extension:reasonRejected (Must Support)
  • Goal.extension:goal-relationship (Must Support)

These are not directly constrained into the MCC Care Plan Profile - but are considered a library of goals from which to select to query for, fetch or record. These profiles may be used wherever the resource-pertainsToGoal extension is used to relate a resource to its goal.

Please see Library of Profiles vs Explicit Reference Constraints for additional discussion on this topic.

Albumin Level Target

This profile constrains US Core Goal to focus on goals for serum albumin levels.
Bicarbonate Level Target

This profile constrains US Core Goal to focus on goals for serum bicarbonate levels.
Blood Pressure Diastolic Target

This profile constrains US Core Goal to focus on goals for diastolic blood pressure.
Blood Pressure Systolic Target

This profile constrains US Core Goal to focus on goals for systolic blood pressure.
Body Weight Target

This profile constrains US Core Goal to focus on goals for body weight.
Calcium Level Target

This profile constrains US Core Goal to focus on goals for calcium levels.
Dietary Goal

This profile constrains US Core Goal to focus on goals for dietary intake for modified cholesterol, fat, phosphorous, protein, potassium and sodium diets.
Ferritin Level Target

This profile constrains US Core Goal to focus on goals for ferritin levels.
Hemogobin A1C Target

This profile constrains US Core Goal to focus on goals for A1C.
Hemogobin Level Target

This profile constrains US Core Goal to focus on goals for hemogobin levels.
Intact Parathyroid Hormone Level Target

This profile constrains US Core Goal to focus on goals for intact parathyroid hormone levels.
Iron Saturation Level Target

This profile constrains US Core Goal to focus on goals for iron saturation levels.
Low Density Lipoprotein Level Target

This profile constrains US Core Goal to focus on goals for low density lipoprotein levels.
Phosphorus Level Target

This profile constrains US Core Goal to focus on goals for phosphorus levels.
Physical Activity Target

This profile constrains US Core Goal to focus on goals for physical activity level from light through strenuous levels.
Potasssium Level Target

This profile constrains US Core Goal to focus on goals for potasssium levels.
VitaminD Level Target

This profile constrains US Core Goal to focus on goals for vitamin D levels.

Laboratory Results

MCC Laboratory Results Library: These artifacts are all derived from the US Core Laboratory Result Observation profile that have been constrained for use in the MCC Care Plan IG. All of the MCC laboratory result profiles are conformant to the US Core Laboratory Result Observation with additional requirements for following elements:

  • Observation.extension:resource-pertainsToGoal (Must Support)
  • Observation.code (Must Support) Bound to it’s relevant laboratory result value set
  • Observation.basedOn (Must Support) to encourage linking back Care Plan activities.

These are not directly constrained into the MCC Care Plan Profile - but are considered a library of laboratory results from which to select to query for, fetch or record. These profiles may be used wherever the US Core Laboratory Observation profile is bound within the MCC FHIR Care Plan.

Please see Library of Profiles vs Explicit Reference Constraints for additional discussion on this topic.

Anion Gap

This profile constrains US Core Laboratory Result Observation to anion gap results.
Blood Urea Nitrogen

This profile constrains US Core Laboratory Result Observation to blood urea nitrogen results.
Complete Blood Count

This profile constrains US Core Diagnostic Report Lab to a Complete Blood Count Panel.
Corrected Calcium

This profile constrains US Core Laboratory Result Observation to corrected calcium results.
Cystatin C

This profile constrains US Core Laboratory Result Observation to Cystatin C results.
Erythrocyte Distribution Width

This profile constrains US Core Laboratory Result Observation to erythrocyte distribution width results.
Estimated Average Glucose

This profile constrains US Core Laboratory Result Observation to estimated average glucose results.
EstimatedGlomerularFiltrationRate

This profile constrains US Core Laboratory Result Observation to estimated glomerular filtration rate results.
Ferritin

This profile constrains US Core Laboratory Result Observation to Ferritin results.
Hematocrit

This profile constrains US Core Laboratory Result Observation to hematocrit results.
Hemoglobin

This profile constrains US Core Laboratory Result Observation to hemoglobin results.
Hemoglobin A1C

This profile constrains US Core Laboratory Result Observation to hemoglobin A1C results.
High Density Lipoprotein

This profile constrains US Core Laboratory Result Observation to high density lipoprotein results.
Intact Parathyroid Hormone

This profile constrains US Core Laboratory Result Observation to intact parathyroid hormone results.
Iron Saturation

This profile constrains US Core Laboratory Result Observation to iron saturation results.
KT/V Hemodialysis Ratio

This profile constrains US Core Laboratory Result Observation to KT/V hemodialysis ratio results.
Low Density Lipoprotein

This profile constrains US Core Laboratory Result Observation to low density lipoprotein results.
Mean Corpuscular Hemoglobin Concentration

This profile constrains US Core Laboratory Result Observation to Mean Corpuscular Hemoglobin Concentration results.
Mean Corpuscular Volume

This profile constrains US Core Laboratory Result Observation to mean corpuscular volume results.
Platelet Count

This profile constrains US Core Laboratory Result Observation to Platelet Count results.
Platelet Distribution Width

This profile constrains US Core Laboratory Result Observation to platelet distribution width results.
Platelet Mean Volume

This profile constrains US Core Laboratory Result Observation to Platelet Mean Volume results.
Red Blood Cell (Erythrocyte) Count

This profile constrains US Core Laboratory Result Observation to red blood cell (erythrocyte) count results.
Serum Albumin

This profile constrains US Core Laboratory Result Observation to serum albumin results.
Serum Creatinine

This profile constrains US Core Laboratory Result Observation to serum creatinine results.
Serum Bicarbonate

This profile constrains US Core Laboratory Result Observation to serum bicarbonate results.
Serum Chloride

This profile constrains US Core Laboratory Result Observation to serum chloride results.
Serum Phosphorus

This profile constrains US Core Laboratory Result Observation to serum phosphorus results.
Serum Potassium

This profile constrains US Core Laboratory Result Observation to Serum Potassium results.
Serum Sodium

This profile constrains US Core Laboratory Result Observation to serum sodium results.
Total Cholesterol

This profile constrains US Core Laboratory Result Observation to total cholesterol results.
Triglyceride

This profile constrains US Core Laboratory Result Observation to triglyceride results.
Urinalysis

This profile constrains US Core Diagnostic Report for Labs profile, to urinalysis results associated with a patient.
Urine Albumin Creatinine Ratio

This profile constrains US Core Laboratory Result Observation to urine albumin creatinine ratio results.
Urine Sediment

This profile constrains US Core Laboratory Result Observation to urine sediment results.
Urine Urea Nitrogen

This profile constrains US Core Laboratory Result Observation to urine urea nitrogen results.
Vitamin D Level

This profile constrains US Core Laboratory Result Observation to vitamin D level results.
White Blood Cell (Leukocytes) Count

This profile constrains US Core Laboratory Result Observation to white blood cell (leukocytes) count results.

Medication Request

MCC MedicationRequest Library: These artifacts are all derived from the US Core MedicationRequest profile that have been constrained for use in the MCC Care Plan IG. All of the MCC laboratory result profiles are conformant to the US Core MedicationRequest with additional requirements for following elements:

  • MedicationRequest.extension:resource-pertainsToGoal (Must Support)
  • MedicationRequest.medication (Must Support) Bound to it’s relevant medication value set
  • Medication.reasonReference (Must Support) to encourage linking back to the health concern, problem or observation it was ordered for.

These are not directly constrained into the MCC Care Plan Profile - but are considered a library of medications from which to select to query for, fetch or record. These profiles may be used wherever the US Core MedicationRequest profile is bound within the MCC FHIR Care Plan.

Please see Library of Profiles vs Explicit Reference Constraints for additional discussion on this topic.

ACE and ARB Medication Request

This profile constrains US Core Medication Request to ACE and ARB Medications.
Erythropoiesis Stimulating Agent

This profile constrains US Core Medication Request to Erythropoiesis Stimulating Agent Medications.
Iron Supplements Medication Request

This profile constrains US Core Medication Request to Iron Supplement Medications.
Phosphate Binders Medication Request

This profile constrains US Core Medication Request to Phosphate Binder Medications.
Vitamin D Medication Request

This profile constrains US Core Medication Request to Vitamin D Formulation Medications.

Procedures

MCC Procedure Library: These artifacts are all derived from the US Core Procedure profile that have been constrained for use in the MCC Care Plan IG. All of the MCC laboratory result profiles are conformant to the US Core Procedure with additional requirements for following elements:

  • Procedure.extension:resource-pertainsToGoal (Must Support)
  • Procedure.code (Must Support) Bound to it’s relevant procedure value set
  • Procedure.reasonReference (Must Support) to encourage linking back to the health concern, problem, procedure, report or observation it was ordered for.

These are not directly constrained into the MCC Care Plan Profile - but are considered a library of procedures from which to select to query for, fetch or record. These profiles may be used wherever the US Core Procedure is bound within the MCC FHIR Care Plan.

Please see Library of Profiles vs Explicit Reference Constraints for additional discussion on this topic.

Kidney Biopsy Procedure

This profile constrains US Core Procedure to Kidney Biopsy procedures.
Renal Dialysis

This profile constrains US Core Procedure to renal dialysis procedures.
RenalTransplant

This profile constrains US Core Procedure to renal transplant procedures.
Upper Limb Vein Ultrasound

This profile constrains US Core Procedure to upper limb veinography procedures.
Vascular Access for Dialysis

This profile constrains US Core Procedure to dialysis vascular access procedures.

Radiology Reports

MCC Radiology Report Library: These artifacts are all derived from the US Core Diagnostic Report profile that have been constrained for use in the MCC Care Plan IG. All of the MCC Radiology Report profiles are conformant to the US Core Diagnostic Report Profile with additional requirements for following elements:

  • DiagnosticReport.extension:resource-pertainsToGoal (Must Support)
  • DiagnosticReport.code (Must Support) Bound to it’s relevant procedure value set
  • DiagnosticReport.basedOn (Must Support) (Must Support) to encourage linking back Care Plan activities.

These are not directly constrained into the MCC Care Plan Profile - but are considered a library of diagnostic radiology reports from which to select to query for, fetch or record. These profiles may be used wherever the US Core DiagnosticReport is bound within the MCC FHIR Care Plan.

Please see Library of Profiles vs Explicit Reference Constraints for additional discussion on this topic.

Bone Density Report

This profile constrains US Core Diagnostic Report Note to Diagnostic Reports about bone density studies.
Bone Survey Xrays

This profile constrains US Core Diagnostic Report Note to Diagnostic Reports about bone survey xrays.

Miscellaneous

These artifacts are MCC profiles on existing resources that are contained to meet need of a multiple chronic conditon care plan. In each case the extension:resource-pertainsToGoal is included in the profile as a “Must Support” element.

Document Reference Personal Advance Care Plan (PACP)

This profile constrains US Core DocumentReference to reference, query for and retrieve Personal Advance Care Plans that exist for a patient.
Family History of Chronic Kidney disease

This profile constrains the FHIR Family Member History Resource to chronic kidney disease conditions.

Example: Example Instances

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

US Core Patient Patricia Noelle Example

The MCC Care Plan references US Core Patient that carries the patient information for the Care Plan. This is a valid US Core Patient example.
Chronic Kidney Disease Example

This example is a conformant US Core Condition example representing Chronic Kidney Disease. Condition due to is represented, as well as examples of referring to profiles instances that represent “evidence”.
Estimated Glomerular Filtration Rate Example

US Core laboratory result observation profile compliant example representing an estimated glomerular filtration rate result
MCC FHIR Care Plan Example

This is a basic example of an Multiple Chronic Condition (MCC) FHIR Care Plan with extensive commenting to guide implementers.
US-Core example CareTeam Example

The MCC Care Plan references US Core Care Team that carries the Care team information for the Care Plan. This is a valid US Core Care Team example.
US Core Practitioner Example

The MCC Care Plan references US Core Practitioner that carries practitioner information for the Care Plan. This is a valid US Core practtioner example.
US Core PractitionerRole Example

The MCC Care Plan references US Core PractitionerRole that carries practitionerRole information for the Care Plan. This is a valid US Core practitionerRole example.
Personal Advanced Care Plan Document Reference Example

A conformant example of a US Core Document reference seeking Personal advance care plan that may reside in a patient’s record.
Renal Transplant Example

US Core compliant Renal Transplant Procedure Example.
Chronic Pain Condition Example

US Core compliant Chronic Pain Condition for MCC Care Plan example
Phophate Binder Medication Request Example

US Core compliant MedicationRequest phosphate binder medication example for MCC Care Plan example
Family Member Hx CKD Example

Family Member History of CKD Example
BoneSurvey Radiology Report Example

A US Core compliant Diagnostic Report for Bone Survey for MCC Care Plan example
Weight Goal Example

US Core compliant Weight Goal for MCC Care Plan example.