1. Make the title of this page the name of your IG Proposal (the appropriate label is already attached to the page).
2. Fill out fields below
3. Publish page at bottom right
4. Get the IG sponsor work group to approve the content and update the Committee Approval Date
5. Send an email to fmgcontact@hl7.org to trigger a review of the content on one of the FHIR Management Group's regular calls.


Committee Approval Date:

This is the date the sponsor for the IG approved the text of this IG proposal (objective is to ensure they agree with the realm, code descriptions, etc).

Patient Care Work Group approved August 5, 2020

Publishing Lead:

If there are problems with an IG or questions about readiness, this is who HL7 staff and/or the FMG will follow up with.

Gay Dolin

Contributing or Reviewing Work Groups:

Who needs to review the IG prior to ballot or final publication

Primary Sponsor: Patient Care

Co-Sponsor: Clinical decision Support (CDS)

Co-Sponsor: Learning Health System

FHIR Development Project Insight ID:

'Pending' is ok, so long as the PSS has been submitted to HQ

1618

Scope of coverage:

What are the scope boundaries of this resources?  Specifically, how is it distinct from other IGs in the core space?  Who is it targeted at?  Note that what we want is the overall scope of what it will eventually be, not necessarily what's covered by the current project.  The objective is to ensure that we "right-size" IG scopes so that the publications we have 5+ years from now will have clear boundaries and will fit well together.  (Please don't just copy the scope section from your PSS.)

The scope boundaries of this implementation guide areThe primary goal of the MCC IG is to support the querying for patient-centered care planning and care coordination data elements ( Health and Social concerns, Goals, Interventions and Health Status/Outcomes) from all the clinical and home/community based settings where a person receives care.Ultimately, this project will enable  leveraging SMART on FHIR apps to dynamically aggregate and relate all the elements of care planning and care coordination relevant to an individual. The implementation guide is focused on 4 common chronic conditions: 1) chronic kidney disease (CKD), 2) type 2 diabetes mellitus (T2DM), 3) cardiovascular diseases (specifically, hypertension, ischemic heart disease and heart failure), and 4) pain.  It defines the representation of the chronic condition clinical data elements through minimal additional constraints on US Core profiles. The IG will be tested repeatedly to define the structures, transactions and directions for using the FHIR Care Plan resource as a FHIR resource that can support patient focused care planning and management in the real world. 

How is it different from other IGs in it's core spaceThere are currently no comprehensive HL7 FHIR Care Plan Implementation Guides based on the FHIR Care Plan profile. Work in this pace currently includes: 1) a C-CDA on FHIR Document-based Care Plan (Pharmacy) implementation guide, and  2) the US Core Care Plan profile, and 3) a balloted, but not yet published, FHIR IG (Da Vinci Payer Data Exchange (PDex)) that is payer focused and points to the US Core Care Plan Profile, but does not constrain it. 4) the eLTSS FHIR Care Plan IG is  focused only on long term care services and support and patients in nursing homes and home care and is not designed to follow patients throughout all care settings.

Who is it targeted ativerse clinical, home & community-based care settings, and research settings.

What is the stretch goal ("What will it eventually be - not necessarily whats covered in the current project")The current project is envisioned as a proof-of-concept and first step toward an IG that will ultimately support widespread implementation of a truly comprehensive shared care plan that would follow a person longitudinally from conception to death and include key data elements for all major diseases and conditions.

Content location:

What is the URL for the Github repository where the IG source is maintained?  Note that this must generally be under https://github.com/HL7/

We were not given an HL7 GitHub repository location yet. It is my understanding that FHIR IG Proposal had to be done first.

The IG is currently being built in Trifolia: https://trifolia-fhir.lantanagroup.com/lantana_hapi_r4/MCC-IG/home

Proposed IG realm and code:

Realm should generally be 'us' or 'uv'.  The 'code' is what will appear as the URL of the IG.  It needs to be relatively short, unique within the HL7 space and as intuitive as possible for implementers looking at it.  It must also be all lower-case.

Realm: US 

Code: us/mcc

Package ID: hl7.fhir.us.mcc

Maintenance Plan:

Who will be maintaining this content in the long term (5-10 years down the road - after the initial development project is finished).

Content will be maintained under HL7 PCWG sponsorship, updated at least as often as required to keep the IG from expiring

The National Institute of Health's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Agency for Healthcare Research and Quality (AHRQ) will drive, coordinate and advocate for the long term maintenance of this project.

Short Description:

DO NOT COPY FROM PSS.  This is a short (2-3 sentence) description of the IG content expressed in present tense that describes what the IG does and who it's for.  It will be displayed in the initial search results for the IG and will allow future implementers to evaluate whether the implementation guide has potential relevance when scanning through a list of possible IGs that met their search criteria.  This should not talk about the project or work group at all.

Provides representation of clinical and social data elements in the FHIR Care Plan format. Focuses on 4 common chronic conditions: 1) chronic kidney disease (CKD), 2) type 2 diabetes mellitus (T2DM), 3) cardiovascular diseases (specifically, hypertension, ischemic heart disease and heart failure), and 4) pain.

Long Description:

DO NOT COPY FROM PSS.  This is a longer (2-3 paragraph) description of the IG content expressed in present tense that describes what the IG does and who it's for.  It will be displayed as the detailed registry entry for a given implementation guide in the IG registry.  It should provide information about the scope of the IG, what systems it covers and what type of interoperability it enables.  This should also not talk about the project or work group.  It should be written from the perspective of the project being long complete and someone is just evaluating the artifacts.

The implementation guide provides representation of clinical and social data elements in the FHIR format and defines where these elements should be represented within the FHIR Care Plan Resource. It describes the necessary operations and transactions needed to generate, aggregate and exchange care plans. The primary audience for this specification is EHR independent application developers and EHR developers of Care Plan modules and IT departments at implementation sites. A secondary target audience are consumers of structured Care Plan data such as researchers and payers. It provides the rules and methods to achieve this aggregated view within a Care Plan structure pulling data from all systems where patients receive care, including patient provided data. Interoperability is often hamstrung by policy, technical, business and cultural challenges among EHRs to write back or pull data into their EHRs which is needed to provide a holistic picture of patients.

Involved parties:

What external agencies (if any) are involved in the creation of the IG? 

This work is supported by The National Institute of Health's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Agency for Healthcare Research and Quality (AHRQ)  and the Assistant Secretary for Planning and Evaluation’s (ASPE) Patient-Centered Outcomes Research (PCOR) Trust Fund.

Expected implementations:

What implementers have already committed to the IG or are otherwise expected.  The focus of HL7 is getting widespread implementation of specifications, not just balloting them, so the FMG wants to know what implementer reach-out has occurred and what degree of implementer commitment exists.  Also, specifications must generally meet FMM 2 maturity criteria (at least 3 independent test implementations successfully demonstrating interoperability across most of the IG scope) prior to going to ballot

This is the list of potential sites as of July 2020:

Content sources:

Where are/will the requirements for the IG being taken from?  What external specifications are being consulted?

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) expert panels have converged on a core set of  data elements of importance to an initial set of common chronic diseases. Specification of interest external to HL7 is the IHE Dynamic Care Plan Profile

Example Scenarios:

Provide a short description of 2-3 interoperability exchanges that will be enabled by this IG
  1. Generate comprehensive eCare Plan in clinical setting
  2. Expose (share) eCare Plan to clinical care team and patient/caregiver
  3. Receive and incorporate eCare Plan data updates (e.g. completed interventions)
  4. Attribute Care Team Members
  5. Consent to share eCare Plan information for research (e.g. S4S)
  6. Consent to share eCare Plan sensitive information with specific team members

       7. Expose (share) eCare Plan to community-based (non-clinical provider)

IG Relationships:

Does your IG depend on any other IGs?  If so which ones?  Are you expecting other IGs to depend on your IG?  If so, which ones?

The MCC IG depends on the US Core Implementation Guide

The MCC IG will be using profiles from the BSeR: Bidirectional Services_eReferral IG

The MCC IG may use profiles from the developing Gravity SDoH after its ballot and publication

Timelines:

When do you expect to bring the proposed IG to ballot for the first time?
We anticipate balloting in September of 2022

FMG Notes

Leave this area blank.  The FMG will fill in any changes they would like to see or questions they have during their review here.