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

Multiple Chronic Condition (MCC) FHIR Care Plan Profile

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.

MCC Condition

MCC Condition: This artifact is derived from the US Core Condition profile and has been constrained for use in the MCC Care Plan IG or other FHIR Care Plans. The MCC condition is 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)
• Conditon.extension:AssertedDate (Will be present after V5.0.0 Pub)

The MCC condition profile is directly constrained into the MCC Care Plan Profile where appropriate as identified in the MCC Care Plan profile and in the profile relationship diagram. A library of value sets appropriate for use within the MCC Condition profile can be found here <insert link>. <Possibly need to add descriptions of the type of value sets (Disorders, Findings, ICD and snomed and location e.g. condition.code, conditon.supporting evidence, etc - to be written after value set pages are developed)

Multiple Chronic Condition Care Plan Chronic Disease Conditions

This profile constrains US Core Condition to chronic disease conditions and supporting information for use in the MCC FHIR Care Plan or other FHIR Care Plans.

MCC Goal

MCC Goal: This artifact is derived from the US Core Goal and has been constrained for use in the MCC Care Plan IG. The MCC Goals is conformant to the US Core Goal with additional requirements for following elements:

• 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)

The MCC Goal profile is directly constrained into the MCC Care Plan Profile where appropriate as identified in the MCC Care Plan profile and in the profile relationship diagram. This initial version of the implementation guide has not developed a library of value sets for goals for use at Goal.description, the assumption being that in todays’ EHRs goals are currently most often captured as text. Use of code is not precluded.

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 Laboratory Result

MCC Laboratory Result: This artifacts is derived from the US Core Laboratory Result Observation profile that have been constrained for use in the MCC Care Plan IG or other FHIR Care Plans. 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.basedOn (Must Support) to encourage linking back Care Plan activities.

The MCC Goal profile is directly constrained into the MCC Care Plan Profile where appropriate as identified in the MCC Care Plan profile and in the profile relationship diagram. A library of value sets appropriate for use within the MCC Laboratory Result profile can be found here <insert link>. <Possibly need to add descriptions of the type of value sets (element location, LOINC etc - to be written after value set pages are developed)

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

MCC MedicationRequest: This artifacts are is derived from the US Core MedicationRequest profile that has been constrained for use in the MCC Care Plan IG or other FHIR IGs. The MCC MedicationRequest profile is conformant to the US Core MedicationRequest with additional requirements for following elements:

• MedicationRequest.extension:resource-pertainsToGoal (Must Support)
• 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.

The MCC MedicationRequest profile is directly constrained into the MCC Care Plan Profile where appropriate as identified in the MCC Care Plan profile and in the profile relationship diagram. A library of value sets appropriate for use within the MCC MedicationRequest profile can be found here <insert link>. <Possibly need to add descriptions of the type of value sets and element location etc., to be written after value set pages are developed>

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 Procedure

MCC Procedure: This artifacts is derived from the US Core Procedure profile and been constrained for use in the MCC Care Plan IG. All of the MCC procedure profiles are conformant to the US Core Procedure with additional requirements for following elements:

• Procedure.extension:resource-pertainsToGoal (Must Support)
• 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.

The MCC procedure profile is directly constrained into the MCC Care Plan Profile where appropriate as identified in the MCC Care Plan profile and in the profile relationship diagram. A library of value sets appropriate for use within the MCC Procedure profile can be found here <insert link>. <Possibly need to add descriptions of the type of value sets (code system and location etc., - to be written after value set pages are developed>

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 Radiology Report

MCC Radiology Report and Note: This artifact is all derived from the US Core Diagnostic Report profile and been constrained for use in the MCC Care Plan IG. The MCC Radiology Report profile is conformant to the US Core Diagnostic Report Profile with additional requirements for following elements:

• DiagnosticReport.extension:resource-pertainsToGoal (Must Support)
• DiagnosticReport.basedOn (Must Support) (Must Support) to encourage linking back Care Plan activities.

The MCC Radiology Report and Note profile is directly constrained into the MCC Care Plan Profile where appropriate as identified in the MCC Care Plan profile and in the profile relationship diagram. A library of value sets appropriate for use within the MCC Radiology Report and Note profile can be found here <insert link>. <Possibly need to add descriptions of the type of value sets (code system and location etc., - to be written after value set pages are developed>

Multiple Chronic Condition 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 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.

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.

Example: Example Instances

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
US-Core MCC example CareTeam	MCC Example of US Core Care Team
Parameters/expansion-parameters-mcc