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2016-01-07 Patient Care FHIR Call

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Meeting Information

Patient Care FHIR Resources Conference Call

Location: Conference Call
Phone Number: +1 770-657-9270
Participant Passcode: 943377
Live Meeting:

Date: 2016-01-07
Time: 5-6:30pm ET
Facilitator Michelle M Miller Note taker(s) Michelle M Miller
Attendee Name Affiliation

Elaine Ayres NIH/Department of Clinical Research Informatics
X Stephen Chu
Eric Haas Haas Consulting
X Rob Hausam Hausam Consulting LLC
X Laura Heermann-Langford Intermountain Healthcare
X Emma Jones Allscripts
Russ Leftwich InterSystems
X Jay Lyle Ockham Information Services LLC, VA
Sarah Maulden VA
Jim McClay Univ of Nebraska Medical Center
Russell McDonell Telstra Health
X Lloyd McKenzie Gevity (HL7 Canada)
Larry McKnight Cerner
X Michelle M Miller Cerner
Lisa Nelson Life Over Time Solutions
X Viet Nguyen Systems Made Simple
Craig Parker Intermountain Healthcare
Scott Robertson Kaiser Permanente
Simon Sum Academy of Nutrition and Dietetics
Iona Thraen Dept of Veterans Affairs
X M'Lynda Owens Cognosante
X Nikki Vande Garde Cerner
Quorum Requirements Met: yes


Agenda Topics

  1. Agenda review
  2. Approve previous meeting minutes: 2015-12-17_Patient_Care_FHIR_Call
    • Motion: Lloyd/Stephen Abstain - 3, Negative - 0, Approve - 3
  3. Prior Action Item Follow-up
  4. gForge change request

Supporting Information

DSTU 2.1 Timeline
FHIR Resources owned by Patient Care

  • AllergyIntolerance (1) -- frozen
  • Procedure (1) -- frozen
  • Questionnaire (1)-- potential normative candidate
  • Questionnaire Answer (1)-- potential normative candidate
  • Condition (1) -- possible normative only if it doesn't have substantive changes after working through health concern, negation, and alignment with OpenEHR
  • CarePlan (1) -- probably not enough wide spread implementation to be considered normative, but Lloyd will check with community to see if there are any planned implementations coming up in the next 18 months
  • Goal (1) -- probably not enough wide spread implementation to be considered normative
  • Referral Request (1)-- probably not enough wide spread implementation to be considered normative
  • FamilyMemberHistory (2) genomics / Jonathan Holt – Vanderbilt - interested in contributing to this resource -- possible normative, but may not have wide spread implementation to be considered normative
  • Procedure Request (2)
  • Flag (2)
  • ClinicalImpression (3)
  • Communication (3)
  • CommunicationRequest (3)

Note: Contraindication and Risk Assessment are owned by CDS, not Patient Care
Note: Substantive changes to frozen resources in DSTU2.1 are prohibited unless FMG explicitly approves the substantive change


Prior Action Item Follow-up


WGM - Tues Q4 negation will be discussed
Full agenda is available via Patient Care WGM agenda


Russell logged 9191 to add reasonReference element to Appointment (for linking ClinicalImpression)

Documents / Notes

For all of these examples, there are multiple workflows of how a user could enter this information, such as: freetext note, structured document, communication/inbox message, flag/alert, discrete observations, etc. However, human beings decide which workflow to leverage.

These notes can be created by starting with a blank note, a template for a note (with section headings), or structured data that defaults patient-specific text that is then annotated and summarized.

These are not annotations on the encounter because annotations are not as discoverable as notes. For example, additional codified attributes, such as note type, are not available via annotations. Additional workflow capabilities (read/unread, requiring review/cosignature) are not features of an annotations.

Contents Author Context Point in Time
Physician Inpatient Expectation CMS 2 midnight rule; physician attesting to why the patient needs to remain in the hospital (if no admitting order within 24 hours) Physician Encounter Yes
Office Note or ED Note Chief Complaint, HPI, Review of Systems, Physical Exam, Subjective/Constitutional, Assessment/Impression and Plan (orders), Follow-Up, Billing Notes, Chart data Physician Encounter Yes
H&P Diagnosis/Chief Complaint, Advance Directive, HPI, Past Medical History, Family/Social History, Chart Data (allergies, meds), Review of System, Physical Exam, Assessment and Plan (more comprehensive than the Office Note) Physician Encounter Yes
Consult Note similar to H&P, except only comprehensive within a given specialty Physician Encounter Yes
Inpatient Progress Note SOAP format or freetext format (used when something significant happens after the day's progress note was already written) Physician Encounter Yes
Operative Note Date of Surgery, Surgeon, Assistant, Pre-Op Dx, Post-Op Dx, Operation/procedure codes, Anesthesiologist, Anesthesia used, complications, estimated blood loss, specimens removed, description of surgery/findings (instruments used, etc.) Physician Procedure Yes
Shift (Nursing Progress) Note Major events of the shift, such as:
  • patient ate well, so tube feeding decreased and scheduled insulin given
  • patient general state, meds held, care provided, repositioned patient, fall precautions
  • eye crusty and purulent, doctor paged, waiting for call back
Nurse Encounter Yes
Physician Communication Communication for various reasons, such as:
  • clinical reason - lab result, patient status change (vomit, fever, etc)
  • family reason - family availability if doctor wanted to call family
  • anesthesia or OR cancels surgery, need to notify physician
Anyone Encounter Yes
Pharmacy Intervention Note Pharmacist reviews medications; found patient was on duplicate therapy or found cheaper therapy; actions the pharmacist took or is recommending; billing note about pharmacist time spent; Pharmacist Encounter Yes
Pharmacy Monitoring Note Anticoagulation (monitor labs, intervene if unsafe); Antibiotics Pharmacist Encounter Yes
Rehab Notes (OT, Speech, PT) Chief Complaint, HPI, Physical Therapy Assessment, Treatment, Plan, Goals, Billing Rehab Services Encounter Yes
Nutrition Therapy Note general note, overall dietary note with tube feeding, amount taken orally, how doing with meals, estimated % of caloric intake or protein intake, admit weight to current weight comparison, labs, medications, nutrition diagnosis, RD recommendations, measurable goals RD Encounter Yes
Physician Clarification Request from Medical Records (HIM query) example: Anemia Specificity; Coder will pull things out of chart and say I was confused by these facts....physician(s) reply by comments on the note or addendums on the note Medical Records Encounter Yes

Document Categories

  • Structured Note -- Composition resource provides the meta data and table of contents (like CDA header and definition of hierarchy of sections), and each section will have references to resources (ex. allergies, admit condition, medication); could be just composition and narrative, but intent is that the section content lives in other resources; when reference other resources, typically the reference will be version specific. The snapshot/document is really the bundle overall, which contains the composition, allergy, condition, medication, etc. DocumentReference that points to PDF or FHIR document bundle where narrative points to PDF.
  • Clinical Annotation -- Leaning is to use Observation resource for this. Can query for all observations for a patient or all observations for an encounter. A benefit of using a separate resource is that there could be users who want to note/annotate a resource (like encounter) and they don't have access to update the resource.

Two Options
-- edit the notes element on the resource (blob of text with link to author/date); will create a new version of the resource;
-- annotations maintained separately, so it doesn't impact the base resource (don't get comments when query the base resource) -- new resource (Observation or other)

  • Commentary Note -- Observation resource

gForge Change Requests

Clinical Impression 7424


Adjourned at 6:47 pm Eastern

Meeting Outcomes

  • Lloyd will talk to MnM about the possibility of renaming notes to annotation
Next Meeting/Preliminary Agenda Items
  1. Agenda review
  2. Approve previous meeting minutes
    • Motion: <moved>/<seconded> Abstain - <#>, Negative - <#>, Approve - <#>
  3. gForge change request

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