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{
  "resourceType": "ImplementationGuide",
  "id": "hl7.fhir.us.mcc",
  "meta": {
    "versionId": "438",
    "lastUpdated": "2022-11-18T22:06:06.137+00:00",
    "source": "#hiorUqksM4PhnfX4"
  },
  "text": {
    "status": "extensions",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h2>MCCeCarePlan</h2><p>The official URL for this implementation guide is: </p><pre>http://hl7.org/fhir/us/mcc/ImplementationGuide/hl7.fhir.us.mcc</pre><div><h3>Introduction</h3>\n<p>This HL7® Multiple Chronic Condition (MCC) Care Plan Implementation Guide (IG) defines FHIR R4 profiles, structures, extensions, transactions and value sets needed to represent, query for, and exchange Care Plan information. It defines how to represent coded content used to support the care planning activities focusing on the needs of patients with multiple chronic conditions. This initial version focuses on Chronic Kidney Disease Type 2 diabetes mellitus, common cardiovascular disease (hypertension, ischemic heart disease and heart failure), chronic pain and Long Covid.The profiles defined within this IG were based on data elements of importance identified by the National Institute of Health's (NIH) National Institute of Diabetes and Digestive and Kidney Disease technical expert panels.</p>\n<p>A Care Plan is a consensus-driven dynamic plan that represents a patient’s and Care Team Members’ prioritized concerns, goals, planned and actual interventions and the resultant care outcomes. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers, and providers), to guide the patient’s care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions. A Care Plan may represent one or more Care Plans and serves to reconcile and resolve conflicts between the various plans developed for a specific patient by different providers. It supports the following use cases:</p>\n<ol>\n<li>\n<pre><code>    Query for patient data across providers and compile into a consolidated care plan representation.\n</code></pre>\n</li>\n<li>\n<pre><code>    Encourage capture of and communication of a patient's health concerns and related goals, interventions, and outcomes.\n</code></pre>\n</li>\n<li>\n<pre><code>    Gather and aggregate patient data for uses beyond the point of care (e.g. public health, population health, quality measurement, risk adjustment, quality improvement, and research.)\n</code></pre>\n</li>\n</ol>\n<p>This FHIR IG addresses the needs of multiple audiences. It provides technical artifacts that assist programmers when implementing standards-based FHIR application program interfaces (APIs) for specific purposes. It provides instructive material that explains how FHIR is used to accomplish specific use cases. It also provides general information that helps business analysts and technology decision-makers understand the use cases and benefits associated with achieving specific data exchange capabilities. A FHIR IG is as much a business planning tool as it is an educational resource and a technical specification.</p>\n<h3>How to Read this Guide and Cautions</h3>\n<p>This Guide is divided into several pages which are listed in the navigation bar at the top each page. The contents of each page are listed in a yellow &quot;Contents&quot; box at the top right of each page.</p>\n<h3>Value Set Library</h3>\n<p>Rather than creating nearly 1000 profiles covering important concepts for chronic care coordination for use within the MCC FHIR Care Plan profile, we have created 21 foundation profiles which conform to US Core Profiles (where available) adding constraints or extensions pertinent to their representation within a dynamic FHIR care plan and then creating libraries of value sets pertinent to the base profiles for representing chronic conditions, and their related interventions and goals and outcomes.\nThis project has built and houses its value sets in the National Library of Medicine's (NLM) Value Set Authority Center (VSAC). The value sets are not directly bound within the foundation profiles, but value set library pages are provided with links to the value sets in VSAC and descriptions of where within the profile each value set may be used. Because the value sets are housed in VSAC, it is necessary for implementation sites to obtain a free (for the US) UMLS license. In addition, HL7 FHIR Policies requiring everything to be open source in all realms, may present some implementation validation issues when interfacing with a value set housed in VSAC. This IG will provide guidance for this issue.</p>\n<h3>History of the Care Plan and Electronic Care Plans</h3>\n<p>The concept of a care plan began as a teaching tool for nursing students to research and document the medical conditions their patients had and identify the associated nursing care and family support needed. This was documented in a structured paper format that fostered the nursing process. The nursing process is the identification of health concerns and related goals, and the interventions needed to meet those goals and then evaluating the meeting of those goals – the outcomes. Over the years, the care plan evolved from a student teaching tool to something required for most patients in some format by various regulating or certifying bodies, and further, from a nursing care based plan, to an interdisciplinary patient focused tool.</p>\n<p>Most major vendors have electronic Care Plan modules, but the degree to which the modules are implemented and actively used is unknown. Few, if any, are exchange standards ready or mapped to exchange standards. The first HL7 standard representing Care Plan was the C-CDA Care Plan document designed to represent an instance of an EHR Care Plan similar to the Continuity of Care (CCD) CDA. Many of the learnings and designs for the FHIR Care Plan Resource and this IG were derived from the C-CDA Care Plan. There is also an IHE <a href=\"https://wiki.ihe.net/index.php/Dynamic_Care_Planning_(DCP)\">Dynamic Care Planning (DCP)</a> that provides the structures and transactions for care planning, creating, updating and sharing Care Plans that meet the needs of many, such as providers, patients and payers..  The Office of the National Coordinator (ONC) has put into regulation requirements around goals and health concerns which can currently be met by free text. The Dynamic Care Planning (DCP) Profile provides leveraged FHIR Resources to provide the structures and transactions for care planning and sharing Care Plans that meet the needs of many, such as providers, patients and payers. The DCP profile leverages the FHIR Care Plan resource, but does not specify, describe or define the use of it for representing specific conditions or multiple conditions. We are unaware of any real world implementations of it at this time.</p>\n<p>We believe that this IG will be the first fully defined HL7 FHIR IG leveraging the FHIR Care Plan resources as its backbone structure for representing a dynamic care plan and testing its ability to bring together aggregated patient care plan data including patient outcomes.</p>\n<h3>Project Overview</h3>\n<p>More than 25 percent of Americans have MCC, accounting for more than 65 percent of U.S. healthcare spending. These individuals have complex health needs handled by diverse providers, across multiple settings of care. As a result, their care is often fragmented, poorly coordinated, and inefficient. Therefore, data aggregation is particularly important and challenging for people with MCC. These challenges will increasingly strain the U.S. health system, with the aging of the U.S. population. Projections suggest numbers of adults aged 65 and older will more than double and numbers of those aged 85 and older will triple by 2050.</p>\n<p>Care plans are a prominent part of multifaceted, care coordination interventions that reduce mortality and hospitalizations and improve disease management and satisfaction. In addition, proactive care planning promotes person-centeredness, improves outcomes, and reduces the cost of care. By design, care plans take a patient-centered approach, both by making comprehensive health data available across providers and settings and through the incorporation of data elements that have not traditionally been included in health IT systems (e.g., social determinants of health SDOH, patient health and life goals, patient preferences). While Care Plans have been developed, they remain paper-based in many U.S. healthcare settings and are not standardized and interoperable across care settings when electronic. While care plans focused on a single disease or condition are unlikely to be tenable for patients with MCC or their providers, existing care plans infrequently address individuals with MCC. The development of care plans based on structured data has been proposed as a method for enabling electronic systems to pull together and share data elements automatically and dynamically. Such aggregated data would not only provide actionable information to identify and achieve health and wellness goals for individuals with MCC, but also would reduce missingness and improve quality of point-of-care data for use in pragmatic research.</p>\n<p>The Fast Healthcare Interoperability Resources (FHIR) specification is an open-source standard for exchanging healthcare information electronically based on emerging industry approaches. The FHIR workflow specification includes a CarePlan request resource that may facilitate transfer of data for an e-care plan across healthcare settings. SMART (https://smarthealthit.org/) and SMART on FHIR standards include open specifications to integrate applications with health IT systems and may enable the development of an e-care plan application that can integrate with a variety of electronic health record (EHR) systems.</p>\n<p>Initiated by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the multiple chronic conditions (MCC) electronic care (eCare) Plan Project aims to develop, test, and pilot an interoperable eCare plan that will facilitate aggregation and sharing of critical patient-centered data across home, community, clinic, and research-based settings for persons with MCC, including chronic kidney disease (CKD), type 2 diabetes mellitus (T2D), cardiovascular disease (CVD), pain with opioid use disorder (OUD), and long COVID.</p>\n<p>The HL7-based activities of the MCC eCare Plan Project include:</p>\n<ul>\n<li>Identified use cases to support the documentation and exchange of MCC eCare plan data within EHRs and related systems.</li>\n<li>Identified, developed, and prioritized the necessary MCC data elements and clinical terminology standards and FHIR® mappings that will enable the standardized transfer of data across health settings.</li>\n<li>Develop, test, and ballot an HL7® Fast Health Interoperability Resources (FHIR®) Implementation Guide based on the defined use cases and MCC data elements.</li>\n</ul>\n<p>Non-HL7 related activities of the MCC eCare Plan project will be facilitated through the <a href=\"https://ecareplan.ahrq.gov/collaborate\">AHRQ eCare Plan Project Confluence</a>:</p>\n<ul>\n<li>The project includes the develoment and testing of an open-source clinician and patient facing SMART-on-FHIR eCare plan application for managing persons with MCC.</li>\n</ul>\n<h4>Project Timelines</h4>\n<ul>\n<li>January 2024: A For comment ballot to gather community input prior to the formal STU Ballot</li>\n<li>September 2024: Formal STU Ballot</li>\n<li>May 2025 Formal HL7 Publication</li>\n</ul>\n<h3>Guidance</h3>\n<p>The guidance section provides general implementation guidance and best practices. It describes the relation to and reuse of the US Core Implementation Guide profiles and reuse of its conformance requirements and expectations for the servers and client applications. Vocabulary use and value set binding heuristics are described.</p>\n<h4>Relationship to US Core</h4>\n<p>This Implementation Guide reuses US Core profiles either through direct use or by constraining select profiles for representation within a FHIR Care Plan profile. Where US Core does not have a profile or function that is needed for the use cases or data elements, the IG constrains or directly reuses other resources, or profiles defined in other FHIR IGs.\nThis guide will reuse the US Core Care Plan. However, the required US Core CarePlan.text and the required Care.Plan.category:AssessPlan may be limiting factors for this context of use: aggregation of multiple chronic condition care plans and the ability to query for structured data within a structured Care Plan. As such, we recommend adding additional Care Plan categories if deemed more informational to reflect multiple chronic condition care coordination and plans and to hard code “Multiple Chronic Condition Care Coordination Plan” at CarePlan.text</p>\n<h5>General US Core IG Conformance</h5>\n<p>This guide will adhere to or build on US conformance requirements, most of its <a href=\"https://www.hl7.org/fhir/us/core/general-guidance.html\">General Guidance</a>, and its <a href=\"https://www.hl7.org/fhir/us/core/capstatements.html\">Capability Statements</a> where applicable.</p>\n<h5>Provenance</h5>\n<p>This IG recommends implementers adhere to guidelines and definitions provided in US Core’s <a href=\"https://www.hl7.org/fhir/us/core/basic-provenance.html\">Basic Provenance Guidance</a>.</p>\n<h5>Must Support</h5>\n<p>This IG will adhere to the US Core <a href=\"https://www.hl7.org/fhir/us/core/general-guidance.html#must-support\">Must Support</a> concept and rules.</p>\n<h3>Acknowledgements</h3>\n<p>This Implementation Guide was made possible through the visionary leadership of the <a href=\"https://www.niddk.nih.gov/\">National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) </a>and the <a href=\"https://www.ahrq.gov/\">Agency for Healthcare Research and Quality (AHRQ) </a>with funding from the <a href=\"https://aspe.hhs.gov/collaborations-committees-advisory-groups/os-pcortf/explore-portfolio\">Office of the Assistant Secretary for Planning and Evaluation (ASPE)</a>. The joint NIDDK-AHRQ project team can be found <a href=\"https://cmext.ahrq.gov/confluence/display/EC/Project+Team\">here</a>. We would also like to thank the many clinicians, patients, caregivers, researchers, advocates, and subject matter experts who served on our <a href=\"https://cmext.ahrq.gov/confluence/display/EC/Technical+Expert+Panels\">Technical Expert Panels</a> and <a href=\"https://cmext.ahrq.gov/confluence/display/EC/Contract+Monitoring+Board\">Contract Monitoring Board </a> for their time, insight, and support.</p>\n<p>This Implementation Guide was created under the supervision and review of the <a href=\"https://www.hl7.org/Special/committees/patientcare/index.cfm\">HL7 Patient Care Work Group</a>. This is the HL7 project page for the <a href=\"https://confluence.hl7.org/display/PC/Multiple+Chronic+Conditions+%28MCC%29+eCare+Plan\">Multiple Chronic Conditions e-Care Project.</a></p>\n<p><strong>Implementation Guide Contributors:</strong>\n&lt;table border=&quot;1&quot; cellspacing=&quot;0&quot; style=&quot;width:100.0%&quot;&gt;\n&lt;tbody&gt;\n&lt;tr&gt;\n&lt;td style=&quot;background-color:#d9e2f3; width:89.75pt&quot;&gt;\n&lt;p&gt;&lt;strong&gt;Contributor&lt;/strong&gt;&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;background-color:#d9e2f3; width:148.5pt&quot;&gt;\n&lt;p&gt;&lt;strong&gt;Organization&lt;/strong&gt;&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;background-color:#d9e2f3; width:229.5pt&quot;&gt;\n&lt;p&gt;&lt;strong&gt;Role&lt;/strong&gt;&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;background-color:#d9e2f3; width:211.5pt&quot;&gt;\n&lt;p&gt;&lt;strong&gt;email&lt;/strong&gt;&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Jenna Norton&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;NIH/NIDDK&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Project Champion&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;jenna.norton@nih.gov&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Kevin Abbott&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;NIH/NIDDK&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Project Champion&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;kevin.abbott@nih.gov&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Arlene Bierman&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;AHRQ&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Project Champion&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;arlene.bierman@ahrq.hhs.gov&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Evelyn Gallego&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;EMI Advisors&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Project Champion&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;evelyn.gallego@emiadvisors.net&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Gay Dolin&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;Namaste Informatics&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;IG Design Lead&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;gdolin@namasteinformatics.com&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Bret Heale&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;Humanized Health Consulting&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;IG Developer&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;bheale@humanizedhealthconsulting.com&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Himali Saitwal&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;EMI Advisors&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Terminologist&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;himali.saitwal@emiadvisors.net&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Sara Armson&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;RTI/ONC&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Terminologist&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;sara.armson@hhs.gov&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Karen Bertodatti&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;EMI Advisors&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Project Manager&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;karen.bertodatti@emiadvisors.net&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Savanah Mueller&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;EMI Advisors&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Analyst&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;savanah.mueller@emiadvisors.net&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Emma Jones&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;Allscripts Veradigm&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Domain Expert&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;emma.jones@allscripts.com&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Dave Carlson&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;Clinical Cloud Solutions&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Solutions Architect, Test Implementations&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;dcarlson@clinicalcloud.solutions&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;tr&gt;\n&lt;td style=&quot;vertical-align:top; width:89.75pt&quot;&gt;\n&lt;p&gt;Sean Muir&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:148.5pt&quot;&gt;\n&lt;p&gt;JKM Software&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:229.5pt&quot;&gt;\n&lt;p&gt;Developer, Test Implementations&lt;/p&gt;\n&lt;/td&gt;\n&lt;td style=&quot;vertical-align:top; width:211.5pt&quot;&gt;\n&lt;p&gt;sean.muir@jkmsoftware.com&lt;/p&gt;\n&lt;/td&gt;\n&lt;/tr&gt;\n&lt;/tbody&gt;\n&lt;/table&gt;</p>\n</div></div>"
  },
  "url": "http://hl7.org/fhir/us/mcc/ImplementationGuide/hl7.fhir.us.mcc",
  "version": "1.0.0-ballot",
  "name": "MCCeCarePlan",
  "title": "MCC eCare Plan Implementation Guide",
  "status": "draft",
  "experimental": false,
  "date": "2022-11-18",
  "publisher": "HL7 International - Patient Care WG",
  "contact": [
    {
      "name": "HL7 International - Patient Care",
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/patientcare"
        }
      ]
    }
  ],
  "description": "### Introduction\nThis HL7&reg; Multiple Chronic Condition (MCC) Care Plan Implementation Guide (IG) defines FHIR R4 profiles, structures, extensions, transactions and value sets needed to represent, query for, and exchange Care Plan information. It defines how to represent coded content used to support the care planning activities focusing on the needs of patients with multiple chronic conditions. This initial version focuses on Chronic Kidney Disease Type 2 diabetes mellitus, common cardiovascular disease (hypertension, ischemic heart disease and heart failure), chronic pain and Long Covid.The profiles defined within this IG were based on data elements of importance identified by the National Institute of Health's (NIH) National Institute of Diabetes and Digestive and Kidney Disease technical expert panels.\n\nA Care Plan is a consensus-driven dynamic plan that represents a patient’s and Care Team Members’ prioritized concerns, goals, planned and actual interventions and the resultant care outcomes. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers, and providers), to guide the patient’s care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions. A Care Plan may represent one or more Care Plans and serves to reconcile and resolve conflicts between the various plans developed for a specific patient by different providers. It supports the following use cases:\n \n1.         Query for patient data across providers and compile into a consolidated care plan representation.\n2.         Encourage capture of and communication of a patient's health concerns and related goals, interventions, and outcomes.\n3.         Gather and aggregate patient data for uses beyond the point of care (e.g. public health, population health, quality measurement, risk adjustment, quality improvement, and research.)\n\nThis FHIR IG addresses the needs of multiple audiences. It provides technical artifacts that assist programmers when implementing standards-based FHIR application program interfaces (APIs) for specific purposes. It provides instructive material that explains how FHIR is used to accomplish specific use cases. It also provides general information that helps business analysts and technology decision-makers understand the use cases and benefits associated with achieving specific data exchange capabilities. A FHIR IG is as much a business planning tool as it is an educational resource and a technical specification.\n\n### How to Read this Guide and Cautions\nThis Guide is divided into several pages which are listed in the navigation bar at the top each page. The contents of each page are listed in a yellow \"Contents\" box at the top right of each page.\n\n### Value Set Library\n\nRather than creating nearly 1000 profiles covering important concepts for chronic care coordination for use within the MCC FHIR Care Plan profile, we have created 21 foundation profiles which conform to US Core Profiles (where available) adding constraints or extensions pertinent to their representation within a dynamic FHIR care plan and then creating libraries of value sets pertinent to the base profiles for representing chronic conditions, and their related interventions and goals and outcomes. \nThis project has built and houses its value sets in the National Library of Medicine's (NLM) Value Set Authority Center (VSAC). The value sets are not directly bound within the foundation profiles, but value set library pages are provided with links to the value sets in VSAC and descriptions of where within the profile each value set may be used. Because the value sets are housed in VSAC, it is necessary for implementation sites to obtain a free (for the US) UMLS license. In addition, HL7 FHIR Policies requiring everything to be open source in all realms, may present some implementation validation issues when interfacing with a value set housed in VSAC. This IG will provide guidance for this issue.\n\n### History of the Care Plan and Electronic Care Plans\n\nThe concept of a care plan began as a teaching tool for nursing students to research and document the medical conditions their patients had and identify the associated nursing care and family support needed. This was documented in a structured paper format that fostered the nursing process. The nursing process is the identification of health concerns and related goals, and the interventions needed to meet those goals and then evaluating the meeting of those goals – the outcomes. Over the years, the care plan evolved from a student teaching tool to something required for most patients in some format by various regulating or certifying bodies, and further, from a nursing care based plan, to an interdisciplinary patient focused tool.\n\nMost major vendors have electronic Care Plan modules, but the degree to which the modules are implemented and actively used is unknown. Few, if any, are exchange standards ready or mapped to exchange standards. The first HL7 standard representing Care Plan was the C-CDA Care Plan document designed to represent an instance of an EHR Care Plan similar to the Continuity of Care (CCD) CDA. Many of the learnings and designs for the FHIR Care Plan Resource and this IG were derived from the C-CDA Care Plan. There is also an IHE [Dynamic Care Planning (DCP)](https://wiki.ihe.net/index.php/Dynamic_Care_Planning_(DCP)) that provides the structures and transactions for care planning, creating, updating and sharing Care Plans that meet the needs of many, such as providers, patients and payers..  The Office of the National Coordinator (ONC) has put into regulation requirements around goals and health concerns which can currently be met by free text. The Dynamic Care Planning (DCP) Profile provides leveraged FHIR Resources to provide the structures and transactions for care planning and sharing Care Plans that meet the needs of many, such as providers, patients and payers. The DCP profile leverages the FHIR Care Plan resource, but does not specify, describe or define the use of it for representing specific conditions or multiple conditions. We are unaware of any real world implementations of it at this time.\n\nWe believe that this IG will be the first fully defined HL7 FHIR IG leveraging the FHIR Care Plan resources as its backbone structure for representing a dynamic care plan and testing its ability to bring together aggregated patient care plan data including patient outcomes.\n\n### Project Overview\n\nMore than 25 percent of Americans have MCC, accounting for more than 65 percent of U.S. healthcare spending. These individuals have complex health needs handled by diverse providers, across multiple settings of care. As a result, their care is often fragmented, poorly coordinated, and inefficient. Therefore, data aggregation is particularly important and challenging for people with MCC. These challenges will increasingly strain the U.S. health system, with the aging of the U.S. population. Projections suggest numbers of adults aged 65 and older will more than double and numbers of those aged 85 and older will triple by 2050.\n \nCare plans are a prominent part of multifaceted, care coordination interventions that reduce mortality and hospitalizations and improve disease management and satisfaction. In addition, proactive care planning promotes person-centeredness, improves outcomes, and reduces the cost of care. By design, care plans take a patient-centered approach, both by making comprehensive health data available across providers and settings and through the incorporation of data elements that have not traditionally been included in health IT systems (e.g., social determinants of health SDOH, patient health and life goals, patient preferences). While Care Plans have been developed, they remain paper-based in many U.S. healthcare settings and are not standardized and interoperable across care settings when electronic. While care plans focused on a single disease or condition are unlikely to be tenable for patients with MCC or their providers, existing care plans infrequently address individuals with MCC. The development of care plans based on structured data has been proposed as a method for enabling electronic systems to pull together and share data elements automatically and dynamically. Such aggregated data would not only provide actionable information to identify and achieve health and wellness goals for individuals with MCC, but also would reduce missingness and improve quality of point-of-care data for use in pragmatic research.\n \nThe Fast Healthcare Interoperability Resources (FHIR) specification is an open-source standard for exchanging healthcare information electronically based on emerging industry approaches. The FHIR workflow specification includes a CarePlan request resource that may facilitate transfer of data for an e-care plan across healthcare settings. SMART (https://smarthealthit.org/) and SMART on FHIR standards include open specifications to integrate applications with health IT systems and may enable the development of an e-care plan application that can integrate with a variety of electronic health record (EHR) systems.\n\nInitiated by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the multiple chronic conditions (MCC) electronic care (eCare) Plan Project aims to develop, test, and pilot an interoperable eCare plan that will facilitate aggregation and sharing of critical patient-centered data across home, community, clinic, and research-based settings for persons with MCC, including chronic kidney disease (CKD), type 2 diabetes mellitus (T2D), cardiovascular disease (CVD), pain with opioid use disorder (OUD), and long COVID. \n\nThe HL7-based activities of the MCC eCare Plan Project include:\n \n - Identified use cases to support the documentation and exchange of MCC eCare plan data within EHRs and related systems.\n - Identified, developed, and prioritized the necessary MCC data elements and clinical terminology standards and FHIR® mappings that will enable the standardized transfer of data across health settings.\n - Develop, test, and ballot an HL7® Fast Health Interoperability Resources (FHIR®) Implementation Guide based on the defined use cases and MCC data elements.\n \nNon-HL7 related activities of the MCC eCare Plan project will be facilitated through the [AHRQ eCare Plan Project Confluence](https://ecareplan.ahrq.gov/collaborate):\n - The project includes the develoment and testing of an open-source clinician and patient facing SMART-on-FHIR eCare plan application for managing persons with MCC.\n\n####  Project Timelines\n - January 2024: A For comment ballot to gather community input prior to the formal STU Ballot\n - September 2024: Formal STU Ballot\n - May 2025 Formal HL7 Publication\n\n\n### Guidance\nThe guidance section provides general implementation guidance and best practices. It describes the relation to and reuse of the US Core Implementation Guide profiles and reuse of its conformance requirements and expectations for the servers and client applications. Vocabulary use and value set binding heuristics are described.\n\n####  Relationship to US Core\n\nThis Implementation Guide reuses US Core profiles either through direct use or by constraining select profiles for representation within a FHIR Care Plan profile. Where US Core does not have a profile or function that is needed for the use cases or data elements, the IG constrains or directly reuses other resources, or profiles defined in other FHIR IGs. \nThis guide will reuse the US Core Care Plan. However, the required US Core CarePlan.text and the required Care.Plan.category:AssessPlan may be limiting factors for this context of use: aggregation of multiple chronic condition care plans and the ability to query for structured data within a structured Care Plan. As such, we recommend adding additional Care Plan categories if deemed more informational to reflect multiple chronic condition care coordination and plans and to hard code “Multiple Chronic Condition Care Coordination Plan” at CarePlan.text\n\n\n#####  General US Core IG Conformance\n\nThis guide will adhere to or build on US conformance requirements, most of its [General Guidance](https://www.hl7.org/fhir/us/core/general-guidance.html), and its [Capability Statements](https://www.hl7.org/fhir/us/core/capstatements.html) where applicable. \n\n#####  Provenance\n\nThis IG recommends implementers adhere to guidelines and definitions provided in US Core’s [Basic Provenance Guidance](https://www.hl7.org/fhir/us/core/basic-provenance.html). \n\n#####  Must Support\n\nThis IG will adhere to the US Core [Must Support](https://www.hl7.org/fhir/us/core/general-guidance.html#must-support) concept and rules.\n\n### Acknowledgements\nThis Implementation Guide was made possible through the visionary leadership of the [National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) ](https://www.niddk.nih.gov/)and the [Agency for Healthcare Research and Quality (AHRQ) ](https://www.ahrq.gov/)with funding from the [Office of the Assistant Secretary for Planning and Evaluation (ASPE)](https://aspe.hhs.gov/collaborations-committees-advisory-groups/os-pcortf/explore-portfolio). The joint NIDDK-AHRQ project team can be found [here](https://cmext.ahrq.gov/confluence/display/EC/Project+Team). We would also like to thank the many clinicians, patients, caregivers, researchers, advocates, and subject matter experts who served on our [Technical Expert Panels](https://cmext.ahrq.gov/confluence/display/EC/Technical+Expert+Panels) and [Contract Monitoring Board ](https://cmext.ahrq.gov/confluence/display/EC/Contract+Monitoring+Board) for their time, insight, and support. \n\nThis Implementation Guide was created under the supervision and review of the [HL7 Patient Care Work Group](https://www.hl7.org/Special/committees/patientcare/index.cfm). This is the HL7 project page for the [Multiple Chronic Conditions e-Care Project.](https://confluence.hl7.org/display/PC/Multiple+Chronic+Conditions+%28MCC%29+eCare+Plan)\n\n**Implementation Guide Contributors:**\n<table border=\"1\" cellspacing=\"0\" style=\"width:100.0%\">\n        <tbody>\n            <tr>\n                <td style=\"background-color:#d9e2f3; width:89.75pt\">\n                    <p><strong>Contributor</strong></p>\n                </td>\n                <td style=\"background-color:#d9e2f3; width:148.5pt\">\n                    <p><strong>Organization</strong></p>\n                </td>\n                <td style=\"background-color:#d9e2f3; width:229.5pt\">\n                    <p><strong>Role</strong></p>\n                </td>\n                <td style=\"background-color:#d9e2f3; width:211.5pt\">\n                    <p><strong>email</strong></p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Jenna Norton</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>NIH/NIDDK</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Project Champion</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>jenna.norton@nih.gov</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Kevin Abbott</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>NIH/NIDDK</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Project Champion</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>kevin.abbott@nih.gov</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Arlene Bierman</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>AHRQ</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Project Champion</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>arlene.bierman@ahrq.hhs.gov</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Evelyn Gallego</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>EMI Advisors</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Project Champion</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>evelyn.gallego@emiadvisors.net</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Gay Dolin</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>Namaste Informatics</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>IG Design Lead</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>gdolin@namasteinformatics.com</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Bret Heale</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>Humanized Health Consulting</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>IG Developer</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>bheale@humanizedhealthconsulting.com</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Himali Saitwal</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>EMI Advisors</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Terminologist</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>himali.saitwal@emiadvisors.net</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Sara Armson</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>RTI/ONC</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Terminologist</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>sara.armson@hhs.gov</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Karen Bertodatti</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>EMI Advisors</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Project Manager</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>karen.bertodatti@emiadvisors.net</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Savanah Mueller</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>EMI Advisors</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Analyst</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>savanah.mueller@emiadvisors.net</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Emma Jones</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>Allscripts Veradigm</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Domain Expert</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>emma.jones@allscripts.com</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Dave Carlson</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>Clinical Cloud Solutions</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Solutions Architect, Test Implementations</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>dcarlson@clinicalcloud.solutions</p>\n                </td>\n            </tr>\n            <tr>\n                <td style=\"vertical-align:top; width:89.75pt\">\n                    <p>Sean Muir</p>\n                </td>\n                <td style=\"vertical-align:top; width:148.5pt\">\n                    <p>JKM Software</p>\n                </td>\n                <td style=\"vertical-align:top; width:229.5pt\">\n                    <p>Developer, Test Implementations</p>\n                </td>\n                <td style=\"vertical-align:top; width:211.5pt\">\n                    <p>sean.muir@jkmsoftware.com</p>\n                </td>\n            </tr>\n        </tbody>\n    </table>",
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            "valueString": "path-expansion-params"
          },
          {
            "url": "value",
            "valueString": "resources/parameters/expansion-parameters-mcc.xml"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "copyrightyear"
          },
          {
            "url": "value",
            "valueString": "2020+"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "releaselabel"
          },
          {
            "url": "value",
            "valueString": "Comment only"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "autoload-resources"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "path-liquid"
          },
          {
            "url": "value",
            "valueString": "template/liquid"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "path-liquid"
          },
          {
            "url": "value",
            "valueString": "input/liquid"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "path-qa"
          },
          {
            "url": "value",
            "valueString": "temp/qa"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "path-temp"
          },
          {
            "url": "value",
            "valueString": "temp/pages"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "path-output"
          },
          {
            "url": "value",
            "valueString": "output"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "path-suppressed-warnings"
          },
          {
            "url": "value",
            "valueString": "input/ignoreWarnings.txt"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "path-history"
          },
          {
            "url": "value",
            "valueString": "http://hl7.org/fhir/us/mcc/history.html"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "template-html"
          },
          {
            "url": "value",
            "valueString": "template-page.html"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "template-md"
          },
          {
            "url": "value",
            "valueString": "template-page-md.html"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "apply-contact"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "apply-context"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "apply-copyright"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "apply-jurisdiction"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "apply-license"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "apply-publisher"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "apply-version"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "active-tables"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "fmm-definition"
          },
          {
            "url": "value",
            "valueString": "http://hl7.org/fhir/versions.html#maturity"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "propagate-status"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "excludelogbinaryformat"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      },
      {
        "extension": [
          {
            "url": "code",
            "valueString": "tabbed-snapshots"
          },
          {
            "url": "value",
            "valueString": "true"
          }
        ],
        "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-parameter"
      }
    ],
    "grouping": [
      {
        "id": "new-group1",
        "name": "Multiple Chronic Condition (MCC) FHIR Care Plan",
        "description": "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."
      },
      {
        "id": "new-group19",
        "name": "MCC CaregiverConsiderationsObservation"
      },
      {
        "id": "new-group20",
        "name": "MCC CaregiverOnCareTeam"
      },
      {
        "id": "new-group16",
        "name": "MCC CareTeam"
      },
      {
        "id": "new-group2",
        "name": "MCC Chronic Disease Conditions"
      },
      {
        "id": "new-group15",
        "name": "MCC Clinical Impression"
      },
      {
        "id": "new-group21",
        "name": "MCC Clinical Test Observation"
      },
      {
        "id": "new-group7",
        "name": "MCC Diagnostic Report and Note"
      },
      {
        "id": "new-group8",
        "name": "MCC Document Reference"
      },
      {
        "id": "new-group11",
        "name": "MCC Family Member History"
      },
      {
        "id": "new-group6",
        "name": "MCC Goal"
      },
      {
        "id": "new-group13",
        "name": "MCC Immunization"
      },
      {
        "id": "new-group3",
        "name": "MCC Laboratory Result"
      },
      {
        "id": "new-group4",
        "name": "MCC Medication Request"
      },
      {
        "id": "new-group14",
        "name": "MCC Nutrition Order"
      },
      {
        "id": "new-group12",
        "name": "MCC Observation SDOH Assessment"
      },
      {
        "id": "new-group18",
        "name": "MCC PatientCaregiverConditionStatus"
      },
      {
        "id": "new-group5",
        "name": "MCC Procedure"
      },
      {
        "id": "new-group17",
        "name": "MCC QuestionnaireResponse"
      },
      {
        "id": "new-group10",
        "name": "MCC Service Request"
      },
      {
        "id": "new-group22",
        "name": "MCC Simple Observation"
      },
      {
        "id": "new-group9",
        "name": "MCC Symptom Observation"
      },
      {
        "id": "new-group23",
        "name": "MCC Imaging Observation"
      }
    ],
    "resource": [
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCMedicationRequest",
          "display": "Multiple Chronic Condition Care Plan Medication Request"
        },
        "name": "Multiple Chronic Condition Care Plan Medication Request",
        "description": "This profile constrains [US Core Medication Request ](http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group4"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCLaboratoryResultObservation",
          "display": "Multiple Chronic Condition Care Plan Laboratory Result Observation"
        },
        "name": "Multiple Chronic Condition Care Plan Laboratory Result Observation",
        "description": "This profile constrains [US Core Laboratory Result Observation Profile](http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group3"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCGoal",
          "display": "Multiple Chronic Condition Care Plan Goal"
        },
        "name": "Multiple Chronic Condition Care Plan Goal",
        "description": "This profile constrains [US Core Goal](http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group6"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCDiagnosticReportAndNote",
          "display": "Multiple Chronic Condition Care Plan Diagnostic Report and Note"
        },
        "name": "Multiple Chronic Condition Care Plan Diagnostic Report and Note",
        "description": "This profile constrains [US Core Diagnostic Report and Note](http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group7"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCChronicDisease",
          "display": "Multiple Chronic Condition Care Plan Chronic Disease Conditions"
        },
        "name": "Multiple Chronic Condition Care Plan Chronic Disease Conditions",
        "description": "This profile constrains [US Core Condition Problems and Health Concerns Profile](http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns) 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..",
        "exampleBoolean": false,
        "groupingId": "new-group2"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/DocRefPACP",
          "display": "DocRefPACP"
        },
        "name": "Document Reference to Patient's Personal Advance Care Plan (Advance Directive)",
        "description": "This profile constrains US Core DocumentReference to reference, query for and retrieve Personal Advance Care Plans that exist for a patient.",
        "exampleBoolean": false,
        "groupingId": "new-group8"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCFamilyHistory",
          "display": "Multiple Chronic Condition Care Plan Family History"
        },
        "name": "Multiple Chronic Condition Care Plan Family History",
        "description": "This profile constrains the FHIR Family Member History Resource for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group11"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCProcedure",
          "display": "Multiple Chronic Condition Care Plan Procedure"
        },
        "name": "Multiple Chronic Condition Care Plan Procedure",
        "description": "This profile constrains [US Core Procedure ](http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group5"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/mccCarePlan",
          "display": "MCCCarePLan"
        },
        "name": "Multiple Chronic Care Condition Care Plan",
        "description": "This profile constrains the FHIR Care Plan Resource to represent the requirements of a care plan for patients with multiple chronic conditions.",
        "exampleBoolean": false,
        "groupingId": "new-group1"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "CarePlan"
          }
        ],
        "reference": {
          "reference": "CarePlan/MCCCarePlan",
          "display": "Care Plan"
        },
        "name": "Multiple Chronic Condition Care Plan Example",
        "description": "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)",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Procedure"
          }
        ],
        "reference": {
          "reference": "Procedure/Dialysis",
          "display": "Procedure"
        },
        "name": "MCC Procedure Example - Dialysis",
        "description": "MCC Procedure Example - Dialysis",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCProcedure"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "DiagnosticReport"
          }
        ],
        "reference": {
          "reference": "DiagnosticReport/BoneSurvey",
          "display": "Diagnostic Report"
        },
        "name": "MCC Diagnostic Report and Note Example",
        "description": "MCC Diagnostic Report and Note Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCDiagnosticReportAndNote"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "FamilyMemberHistory"
          }
        ],
        "reference": {
          "reference": "FamilyMemberHistory/father",
          "display": "FamilyMemberHistory"
        },
        "name": "MCC Family Member History Example - Father",
        "description": "MCC Family Member History Example - Father",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCFamilyHistory"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "DocumentReference"
          }
        ],
        "reference": {
          "reference": "DocumentReference/PACP",
          "display": "Document Reference"
        },
        "name": "MCC Document Reference to Advance Directives Example",
        "description": "MCC Document Reference to Advance Directives Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/DocRefPACP"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Condition"
          }
        ],
        "reference": {
          "reference": "Condition/ConditionCKD",
          "display": "Condition"
        },
        "name": "MCC Chronic Condition - CKD Example",
        "description": "MCC Chronic Condition - CKD Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCChronicDisease"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Goal"
          }
        ],
        "reference": {
          "reference": "Goal/WGT-loss",
          "display": "Goal"
        },
        "name": "MCC Goal Example - Weight Loss",
        "description": "MCC Goal Example - Weight Loss",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Practitioner"
          }
        ],
        "reference": {
          "reference": "Practitioner/practitionerMCC-1",
          "display": "MCC Practitioner - Nephrologist"
        },
        "name": "MCC Practitioner - Nephrologist",
        "description": "US Core Conformant Practitioner Example For MCC - Nephrologist",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Practitioner"
          }
        ],
        "reference": {
          "reference": "Practitioner/practitionerMCC-2",
          "display": "MCC Practitioner - Nurse Practitioner"
        },
        "name": "MCC Practitioner - Nurse Practitioner",
        "description": "US Core Conformant Practitioner Example For MCC - Nurse Practitioner",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Practitioner"
          }
        ],
        "reference": {
          "reference": "Practitioner/practitionerMCC-3",
          "display": "MCC Practitioner - Primary Care Provider"
        },
        "name": "MCC Practitioner - Primary Care Provider",
        "description": "US Core Conformant Practitioner Example For MCC - Primary Care",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "PractitionerRole"
          }
        ],
        "reference": {
          "reference": "PractitionerRole/PractitionerRoleMCC1",
          "display": "MCC Practitioner - Nephrologist Provider Role"
        },
        "name": "MCC Practitioner - Nephrologist Provider Role",
        "description": "US Core Conformant Practitioner Role Example For MCC - Nephrologist",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "PractitionerRole"
          }
        ],
        "reference": {
          "reference": "PractitionerRole/PractitionerRoleMCC2",
          "display": "MCC Practitioner - Nurse Practitioner Role"
        },
        "name": "MCC Practitioner - Nurse Practitioner Role",
        "description": "US Core conformant Practitioner Role example for MCC",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "PractitionerRole"
          }
        ],
        "reference": {
          "reference": "PractitionerRole/PractitionerRoleMCC3",
          "display": "MCC Practitioner - Primary Care Provider Role"
        },
        "name": "MCC Practitioner - Primary Care Provider Role",
        "description": "US Core Conformant Practitioner Role Example For MCC - Primary Care",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Observation"
          }
        ],
        "reference": {
          "reference": "Observation/bunMCC"
        },
        "name": "MCC Lab Observation - BUN",
        "description": "BUN Lab Observation",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCLaboratoryResultObservation"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Patient"
          }
        ],
        "reference": {
          "reference": "Patient/cc-pat-pnoelle",
          "display": "MCC Patient"
        },
        "name": "MCC Patient",
        "description": "US Core Conformant Patient Example for MCC",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "CareTeam"
          }
        ],
        "reference": {
          "reference": "CareTeam/MCCCareTeamexample",
          "display": "US-Core MCC example CareTeam"
        },
        "name": "Multiple Chronic Condition Care Plan Care Team",
        "description": "MCC Example of US Core Care Team",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-careteam"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Goal"
          }
        ],
        "reference": {
          "reference": "Goal/HPT-WNL"
        },
        "name": "MCC Goal Example - Normal Hypertension",
        "description": "MCC Hypertension Goal Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Observation"
          }
        ],
        "reference": {
          "reference": "Observation/MCCweight"
        },
        "name": "US-Core MCC Weight Example",
        "description": "Weight Observation Example",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-body-weight"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "MedicationRequest"
          }
        ],
        "reference": {
          "reference": "MedicationRequest/MCCMedExample"
        },
        "name": "MCC Medication Request Example",
        "description": "MCC Medication Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCMedicationRequest"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCSymptomObservation",
          "display": "MCCSymptomObservation"
        },
        "name": "Multiple Chronic Condition Care Plan Symptom Observation",
        "description": "This profile constrains [FHIR R4.0.1 Observation](http://hl7.org/fhir/R4/observation.html) creating a symptom profile for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group9"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Observation"
          }
        ],
        "reference": {
          "reference": "Observation/Symptom1"
        },
        "name": "MCC Symptom Observation Example - Taste Sense Altered",
        "description": "MCC Symptom Observation Example - Taste Sense Altered",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCSymptomObservation"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCServiceRequest",
          "display": "MCCServiceRequest"
        },
        "name": "Multiple Chronic Condition Care Plan Service Request",
        "description": "This profile constrains [US Core Service Requst](http://hl7.org/fhir/us/core/StructureDefinition/us-core-servicerequest) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group10"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "ServiceRequest"
          }
        ],
        "reference": {
          "reference": "ServiceRequest/foodpantry-referral"
        },
        "name": "Multiple Chronic Condition Service Request - Food Pantry",
        "description": "Multiple Chronic Condition Service Request Food Pantry Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCServiceRequest"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCObservationSDOHAssessment",
          "display": "MCCObservationSDOHAssessment"
        },
        "name": "Multiple Chronic Condition Care Plan Observation SDOH Assessment",
        "description": "This profile constrains [US Core Observation SDOH Assessment Profile](http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group12"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Observation"
          }
        ],
        "reference": {
          "reference": "Observation/AHC-HRSN-item-example-68517-2"
        },
        "name": "MCC Observation SDOH Assessment",
        "description": "MCC Observation SDOH Assessment Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCObservationSDOHAssessment"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCImmunization",
          "display": "MCCImmunization"
        },
        "name": "Multiple Chronic Condition Care Plan Immunization",
        "description": "This profile constrains [US Core Immunization Profile](http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group13"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Immunization"
          }
        ],
        "reference": {
          "reference": "Immunization/immunizarion-1"
        },
        "name": "Multiple Chronic Condition Care Plan Immunization Example",
        "description": "Multiple Chronic Condition Care Plan Immunization Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCImmunization"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCNutritionOrder",
          "display": "MCCNutritionOrder"
        },
        "name": "Multiple Chronic Condition Care Plan Nutrition Order",
        "description": "This profile constrains [NutritionOrder](http://hl7.org/fhir/StructureDefinition/NutritionOrder) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group14"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "NutritionOrder"
          }
        ],
        "reference": {
          "reference": "NutritionOrder/fiberrestricteddiet"
        },
        "name": "Multiple Chronic Condition Care Plan Nutrition Order Example",
        "description": "Multiple Chronic Condition Care Plan Nutrition Order Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCNutritionOrder"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCClinicalImpression",
          "display": "MCCClinicalImpression"
        },
        "name": "Multiple Chronic Condition Care Plan Clinical Impression",
        "description": "This profile constrains [ClinicalImpression](http://hl7.org/fhir/StructureDefinition/ClinicalImpression) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group15"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "ClinicalImpression"
          }
        ],
        "reference": {
          "reference": "ClinicalImpression/clinical-impression-example"
        },
        "name": "Multiple Chronic Condition Care Plan Clinical Impression Example",
        "description": "Multiple Chronic Condition Care Plan Clinical Impression Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCClinicalImpression"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCQuestionnaireResponse",
          "display": "MCCQuestionnaireResponse"
        },
        "name": "Multiple Chronic Condition Care Plan Questionnaire Response",
        "description": "This profile constrains [US Core QuestionnaireResponse Profile](http://hl7.org/fhir/us/core/StructureDefinition/us-core-questionnaireresponse) for use in the MCC FHIR Care Plan or other FHIR Care Plans.",
        "exampleBoolean": false,
        "groupingId": "new-group17"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCCareTeam",
          "display": "MCCCareTeam"
        },
        "name": "MCCCareTeam",
        "description": "This profile constrains [US Core Care team](http://hl7.org/fhir/us/core/StructureDefinition/us-core-careteam) 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.",
        "exampleBoolean": false,
        "groupingId": "new-group16"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "CareTeam"
          }
        ],
        "reference": {
          "reference": "CareTeam/careteam-of-noelle",
          "display": "Care Team of Noelle Example"
        },
        "name": "MCC Care Team Example",
        "description": "MCC Care Team Example",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-careteam"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "RelatedPerson"
          }
        ],
        "reference": {
          "reference": "RelatedPerson/caregiver-of-noelle"
        },
        "name": "Caregiver Example",
        "description": "Caregiver Example",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "QuestionnaireResponse"
          }
        ],
        "reference": {
          "reference": "QuestionnaireResponse/hunger-vital-sign-example"
        },
        "name": "MCC QuestionnaireResponse Example",
        "description": "MCC QuestionnaireResponse Example",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-questionnaireresponse"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCPatientCaregiverConditionStatus",
          "display": "MCCPatientCaregiverConditionStatus"
        },
        "name": "Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation",
        "description": "This profile constrains  [FHIR R4.0.1 Observation](http://hl7.org/fhir/R4/observation.html) 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.",
        "exampleBoolean": false,
        "groupingId": "new-group18"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCCaregiverConsiderationsObservation",
          "display": "MCCCaregiverConsiderationsObservation"
        },
        "name": "Multiple Chronic Condition Care Plan Caregiver Considerations Observation",
        "description": "This profile constrains [FHIR R4.0.1 Observation](http://hl7.org/fhir/R4/observation.html) 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.",
        "exampleBoolean": false,
        "groupingId": "new-group19"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Observation"
          }
        ],
        "reference": {
          "reference": "Observation/caregiver-consideration-obs-example"
        },
        "name": "MCC Observation of Caregiver considerations example",
        "description": "MCC Observation of Caregiver considerations example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCCaregiverConsiderationsObservation"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Observation"
          }
        ],
        "reference": {
          "reference": "Observation/caregiver-feelings-condition-status"
        },
        "name": "Multiple Chronic Condition Care Plan example of Observation of Caregiver feelings towards status of a patient's condition",
        "description": "Multiple Chronic Condition Care Plan example of  Observation of Caregiver feelings towards status of a patient's condition",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCPatientCaregiverConditionStatus"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCCaregiverOnCareTeam",
          "display": "Multiple Chronic Condition Care Plan Caregiver on Care Team"
        },
        "name": "Multiple Chronic Condition Care Plan Caregiver on Care Team",
        "description": "This profile constrains [US Core Care team](http://hl7.org/fhir/us/core/StructureDefinition/us-core-careteam) for use in the MCC FHIR Care Plan or other FHIR Care Plans when there is a requirement for the focus to be on one caregiver as a team participant. The purpose is to establish that the RelatedPerson is a caregiver for the indicated patient and can be reference from the [MCC Caregiver Considerations Observation](StructureDefinition-MCCCaregiverConsiderationsObservation.html) profile.",
        "exampleBoolean": false,
        "groupingId": "new-group20"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "CareTeam"
          }
        ],
        "reference": {
          "reference": "CareTeam/caregiveronteam-of-noelle",
          "display": "CaregiverOnCareTeam of Noelle Example"
        },
        "name": "Multiple Chronic Condition Care Plan example of MCC CaregiverOnCareTeam",
        "description": "MCC CaregiverOnCareTeam of Noelle Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCCaregiverOnCareTeam"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCClinicalTestObservation",
          "display": "Multiple Chronic Condition Care Plan Clinical Test Observation"
        },
        "name": "Multiple Chronic Condition Care Plan Clinical Test Observation",
        "description": "This profile constrains [US Core Clinical Test Observation Profile](http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-clinical-test) 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 Test profile.",
        "exampleBoolean": false,
        "groupingId": "new-group21"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Observation"
          }
        ],
        "reference": {
          "reference": "Observation/pulse-intensity-palpation"
        },
        "name": "MCC Clinical Test Observation example",
        "description": "Multiple Chronic Condition Care Plan example of Clinical Test Observation",
        "exampleCanonical": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-clinical-test"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "CapabilityStatement"
          }
        ],
        "reference": {
          "reference": "CapabilityStatement/mcc-server",
          "display": "MCC Server CapabilityStatement"
        },
        "name": "MCC Server CapabilityStatement",
        "description": "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/STU5.0.1/CapabilityStatement-us-core-server.html](http://hl7.org/fhir/us/core/STU5.0.1/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](http://hl7.org/fhir/us/mcc/ImplementationGuide/hl7.fhir.us.mcc), as well as other conformance artifacts of the MCC eCare Plan Implementation Guide.",
        "exampleBoolean": false
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCSimpleObservation",
          "display": "Multiple Chronic Condition Care Plan Simple Observation"
        },
        "name": "Multiple Chronic Condition Care Plan Simple Observation",
        "description": "This profile constrains [FHIR R4.0.1 Observation](http://hl7.org/fhir/R4/observation.html) 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.",
        "exampleBoolean": false,
        "groupingId": "new-group22"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Observation"
          }
        ],
        "reference": {
          "reference": "Observation/simple-observation-example"
        },
        "name": "Multiple Chronic Condition Care Plan Simple Observation Example",
        "description": "Multiple Chronic Condition Care Plan Simple Observation Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCSimpleObservation"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "StructureDefinition:resource"
          }
        ],
        "reference": {
          "reference": "StructureDefinition/MCCImagingObservation",
          "display": "MCCImagingObservation"
        },
        "name": "Multiple Chronic Condition Care Plan Clinical Imaging Observation",
        "description": "This profile constrains [US Core Imaging Observation Profile](http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-imaging) 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.",
        "exampleBoolean": false,
        "groupingId": "new-group23"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Observation"
          }
        ],
        "reference": {
          "reference": "Observation/mcc-imaging-observation-example"
        },
        "name": "Multiple Chronic Condition Care Plan Imagining Observation Example",
        "description": "Multiple Chronic Condition Care Plan Imagining Observation Example",
        "exampleCanonical": "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCImagingObservation"
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "CapabilityStatement"
          }
        ],
        "reference": {
          "reference": "CapabilityStatement/mcc-client",
          "display": "MCC Client CapabilityStatement"
        },
        "name": "MCC Client CapabilityStatement",
        "description": "This Section describes the expected capabilities of the MCC Client actor. See [http://hl7.org/fhir/us/core/STU5.0.1/CapabilityStatement-us-core-client.html](http://hl7.org/fhir/us/core/STU5.0.1/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](http://hl7.org/fhir/us/mcc/ImplementationGuide/hl7.fhir.us.mcc), as well as other conformance artifacts of the MCC eCare Plan Implementation Guide",
        "exampleBoolean": false
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/tools/StructureDefinition/resource-information",
            "valueString": "Parameters"
          }
        ],
        "reference": {
          "reference": "Parameters/expansion-parameters-mcc"
        },
        "name": "Expansion Parameters SNOMED US Version",
        "description": "Parameter file",
        "exampleBoolean": true
      }
    ],
    "page": {
      "extension": [
        {
          "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
          "valueUrl": "index.html"
        }
      ],
      "nameUrl": "index.html",
      "title": "Home Page",
      "generation": "markdown",
      "page": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "mcc_use_cases.html"
            }
          ],
          "nameUrl": "mcc_use_cases.html",
          "title": "MCC Use Cases",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "structure_and_design_considerations.html"
            }
          ],
          "nameUrl": "structure_and_design_considerations.html",
          "title": "Structure and Design Considerations",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "profiles_or_resources_directly_reused_in_this_guide.html"
            }
          ],
          "nameUrl": "profiles_or_resources_directly_reused_in_this_guide.html",
          "title": "Profiles or Resources Directly Reused in this Guide",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "security.html"
            }
          ],
          "nameUrl": "security.html",
          "title": "Security",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "questionnaire_response.html"
            }
          ],
          "nameUrl": "questionnaire_response.html",
          "title": "Questionnaire Response",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "mcc_care_plan_sdoh_guidance.html"
            }
          ],
          "nameUrl": "mcc_care_plan_sdoh_guidance.html",
          "title": "MCC Care Plan SDOH Guidance",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "note_on__include_and__revInclude.html"
            }
          ],
          "nameUrl": "note_on__include_and__revInclude.html",
          "title": "Note on _include and _revinclude",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "us_core_general_requirements.html"
            }
          ],
          "nameUrl": "us_core_general_requirements.html",
          "title": "US Core General Requirements",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "mcc_must-support.html"
            }
          ],
          "nameUrl": "mcc_must-support.html",
          "title": "MCC Must-support",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "capability_statements.html"
            }
          ],
          "nameUrl": "capability_statements.html",
          "title": "Capability Statements",
          "generation": "markdown"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "mcc_value_set_libraries_and_usage.html"
            }
          ],
          "nameUrl": "mcc_value_set_libraries_and_usage.html",
          "title": "MCC Value Set Libraries and Usage",
          "generation": "markdown",
          "page": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_chronic_condition_value_sets.html"
                }
              ],
              "nameUrl": "mcc_chronic_condition_value_sets.html",
              "title": "MCC Chronic Condition Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_clinical_test_value_sets.html"
                }
              ],
              "nameUrl": "mcc_clinical_test_value_sets.html",
              "title": "MCC Clinical Test Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_goal_value_sets.html"
                }
              ],
              "nameUrl": "mcc_goal_value_sets.html",
              "title": "MCC Goal Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_laboratory_result_value_sets.html"
                }
              ],
              "nameUrl": "mcc_laboratory_result_value_sets.html",
              "title": "MCC Laboratory Result Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_medication_request_value_sets.html"
                }
              ],
              "nameUrl": "mcc_medication_request_value_sets.html",
              "title": "MCC Medication Request Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_observation_imaging_value_sets.html"
                }
              ],
              "nameUrl": "mcc_observation_imaging_value_sets.html",
              "title": "MCC Observation Imaging Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_observation_sdoh_assessment_value_sets.html"
                }
              ],
              "nameUrl": "mcc_observation_sdoh_assessment_value_sets.html",
              "title": "MCC Observation SDOH Assessment Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_procedure_and_service_request_value_sets.html"
                }
              ],
              "nameUrl": "mcc_procedure_and_service_request_value_sets.html",
              "title": "MCC Procedure and Service Request Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_questionnaire_response_value_sets.html"
                }
              ],
              "nameUrl": "mcc_questionnaire_response_value_sets.html",
              "title": "MCC Questionnaire Response Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_simple_observation_value_sets.html"
                }
              ],
              "nameUrl": "mcc_simple_observation_value_sets.html",
              "title": "MCC Simple Observation Value Sets",
              "generation": "markdown"
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
                  "valueUrl": "mcc_symptom_value_sets.html"
                }
              ],
              "nameUrl": "mcc_symptom_value_sets.html",
              "title": "MCC Symptom Value Sets",
              "generation": "markdown"
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/tools/StructureDefinition/ig-page-name",
              "valueUrl": "downloads.html"
            }
          ],
          "nameUrl": "downloads.html",
          "title": "Downloads",
          "generation": "markdown"
        }
      ]
    },
    "parameter": [
      {
        "code": "path-resource",
        "value": "input/capabilities"
      },
      {
        "code": "path-resource",
        "value": "input/examples"
      },
      {
        "code": "path-resource",
        "value": "input/extensions"
      },
      {
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        "value": "input/models"
      },
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        "value": "input/operations"
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        "value": "input/profiles"
      },
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        "value": "input/resources"
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        "value": "input/testing"
      },
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      },
      {
        "code": "path-resource",
        "value": "fsh-generated/resources"
      },
      {
        "code": "path-pages",
        "value": "template/config"
      },
      {
        "code": "path-pages",
        "value": "input/images"
      },
      {
        "code": "path-tx-cache",
        "value": "input-cache/txcache"
      }
    ]
  }
}

name : MCCeCarePlan

{

}