2017-11-30 Patient Care FHIR Call
|Patient Care FHIR Resources Conference Call
Location: Conference Call
Time: 5-6:30pm ET
|Facilitator||Michelle M Miller||Note taker(s)||Michelle M Miller|
|X||Elaine Ayres||NIH/Department of Clinical Research Informatics|
|X||Stephen Chu||The Australian Digital Health Agency (ADHA)|
|Evelyn Gallego||EMI Advisors LLC|
|X||Eric Haas||Health eData Inc|
|X||Rob Hausam||Hausam Consulting LLC|
|X||Laura Heermann-Langford||Intermountain Healthcare|
|X||Tony Little||Optum 360|
|Jay Lyle||Ockham Information Services LLC, VA|
|Russell McDonell||Telstra Health|
|Lloyd McKenzie||Gevity (HL7 Canada)|
|X||Michelle M Miller||Cerner|
|Lisa Nelson||Life Over Time Solutions|
|Viet Nguyen||Lockheed Martin, Systems Made Simple|
|Mike Padula||The Children's Hospital of Philadelphia|
|Craig Parker||Intermountain Healthcare|
|Simon Sum||Academy of Nutrition and Dietetics|
|Iona Thraen||Dept of Veterans Affairs|
|Serafina Versaggi||Dept of Veterans Affairs|
|Quorum Requirements Met: yes|
- Agenda review
- Approve previous meeting minutes 2017-11-09_Patient_Care_FHIR_Call
- Motion: Stephen/Rob
- Clinical Note
- Prior Action Item Follow-up
- gForge change request
- FHIR_Conformance_QA_Criteria - remember to check updated workflow patterns, too
- FHIR QA Conformance Tracker
- Tracker Issues - https://docs.google.com/a/lmckenzie.com/uc?id=0B285oCHDUr09Mzh3b09rMFhEV1E
- Resolve QA Warnings to have resource FMM > 0
- Resolve QA Information messages to achieve FMM = 3
Structured data entry might differ from the resulting note structure
We need to define what unstructured means (e.g. are there sections in the note?)
- EHRs have historical notes as well that may not be as structured as they are today
- Subject, encounter, author, date, chief complaint, note type, status and the content of the note is text (structured content may be used as input into the note, but note, itself, is persisted as text)
- Is the note always associated with an encounter? Yes (from Epic)
- What does Epic call it? Unified Clinical Notes (treat ambulatory and transcription notes similarly)
- Clinical Notes are separate from billing notes.
- Typically procedure notes are considered clinical notes.
- Can attach comments to one or multiple results.
- Inpatient does tie notes to an encounter or episode of care.
- Ambulatory systems can write a consultation or referral letter.
Comments or annotations are not discoverable on their own. Comments or annotations are discovered as part of a medication, procedure, observation.
Notes can be discovered on their own and the note generally summarizes structured data.
Post-visit note -- meds to take, notes generated to give to patients, so no ICD-10 codes - needs to be patient friendly, not the full med list - just what changed/discussed
Some of this can vary by organization, such that some orgs will treat HIM query as clinical notes and some don't
- Eric and Rob agree NO observation because the note is more like an impression
- In the past, one argument against "a Composition defines the structure, it does not actually contain the content" but Brett said that the content of each section *can be* included in the Composition section
- Eric will add to an existing tracker a comment about the contradictory statements. Scope of Composition is "While a Composition defines the structure, it does not actually contain the content" but later on Composition.section.text says "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative."
- CCDA can include some clinical notes as a section (note section; entry is note activity)
- Outpatient Progress Note includes what has been prescribed, next visit, etc. Inpatient Progress Notes may differ slightly
- Is Composition too heavy? Does it warrant a new resource if it is "composition-lite"?
- Composition isn't named intuitively
- Not many vendors have implemented Composition (e.g. Cerner, Epic, Allscripts is starting to implement Composition) -- we'd really like more visibility to how Composition is being used (e.g. case report bundle together information to send to a public health org)
- If we use Composition, it would blur the boundaries of what is more like an after-visit summary (or bundling) rather than a specific clinical note
- Review prior strawman 
- PC attend SD - 10-12 Eastern on Thursdays (Dec 14)
- Collaboration between SD and PC on new guidance on using Composition for Clinical Notes
Prior Action Item Follow-up
- QA 4a. Condition.category is CodeableConcept with FHIR-defined value set - related to past GF#11091 -- Rob H. provided an update -- this is still an open question with next step to talk to Grahame and Ted.
- revisit GF#13026 Condition.clinicalStatus -- Rob will consult with SNOMED and Stephen's PPT is attached to the tracker
High Priority Resources (AlleryIntolerance, Condition, Procedure)
- FHIR Admin FHIR_Ballot_Prep
- QA guidelines have changed: FHIR_Conformance_QA_Criteria
- No PC resources are currently targeted for normative, but we can still evaluate
- AllergyIntolerance - questions about reaction/AdverseEvent - is this just writing down boundaries?
- Condition - questions about health concern/linking - need Connectathon planned around concern management, need use cases (from domain analysis) and scenarios to test and recruit implementers to participate
- Procedure - questions about splitting Procedure (performed) vs ProcedureStatement (history/ patient stated) - need to draft resources as a starting point and sync with Russ on whether we need a more generic patient activity statement resource
- Procedure statement is a good idea. Need to broaden the concepts to other activities. Idea is to have activity statement and then profile it specific to procedure. A patient statement about their exercise or nutritional intake or their ADLs, these are different
- Who are the actors that would use this - patient statement and carer statement but can be an activity statement that a provider can use as secondary information. Scope includes provider use as well.
- PMH - where it should be possible do distinguish surgical or diagnostic procedure from when the patient reported the procedure. Post surgery, the surgeon will make an interventional procedure report. This is different. FHIR has a procedure report. OO part would be the diagnostic report (report of findings) and the report that is interventional - these are two different reports. How does FHIR separate the two. And how does FHIR handle the real world where these are combined? Ultrasound guided biopsy would be a diagnostic report with findings (description of the procedure and description of findings).
- There is an extension that adds the types of terms that you would see on the procedure.
- Might be a more general solution but it's not settled.
- Standard operative report has a description of the procedure and a section that deals with findings.
gForge Change Requests (Backlog)
- GF#14064 Review Request pattern alignment for CommunicationRequest and CarePlan
- GF#13936 CommunicationRequest - intent value set (Ravi Kuchi)
- GF#13979 QA 4a: Communication.topic needs binding to a value set (Michelle Miller)
- GF#13903 CarePlan should allow tracking of past activities (i.e. past interventions) (Rick Geimer)
- GF#13302 Vocabulary issues with AdverseEvent
- GF#13698 AdverseEvent.suspectedEntity.instance should allow CodeableConcept
- GF#11021 Increase cardinality of substance and make certainty relation to substance, not reaction - 2016-09 core #40
- GF#13892 Need guidance on overlap of AdverseEvent.event.text and AdverseEvent.description (Lloyd McKenzie)
- GF#13893 Correction to AdverseEvent.subject definition (Lloyd McKenzie)
- GF#13894 AdverseEvent.eventParticipant needs work (Lloyd McKenzie)
- GF#12509 CareTeam participant (Michelle Miller)
- GF#12673 How to handle HCT/TP
- GF#12993 Please Create a NonMedicationAdministration object or an Administration object
- GF#13047 Add DosageInstructions to Procedure
- GF#12676 Guidance request for GP SOAP in FHIR (Alexander Henket) -
- GF#12633 Split Procedure into Procedure and ProcedureStatement (Lloyd McKenzie)
- Zulip chat asking for implementer feedback: https://chat.fhir.org/#narrow/stream/implementers/topic/Procedure.20vs.20ProcedureStatement
- Dave commented that there is relevance for ProcedureStatement in context of CarePlan activities (Activity Statements where the activity is a procedure)
- GF#10028 Careplan: Provide ability to specify patient and/or provider preferences (Emma Jones)
- meet need with a profile for preference on the observation resource. Requirements are a preference category (nutrition, medication, care), the preference priority (high/medium/delayed from C-CDA) and with elements of expressor and recorder.
- This profile would not be developed for this release cycle
- GF#13140 logical definition of care-plan-category value set may require realignment with SCT changes (Matthew Cordell)
- pending SNOMED proposal: https://confluence.ihtsdotools.org/display/cmag/Care+plans
- Rob said he would follow up on the status of the SNOMED proposal
- GF#10635 QA 5a: Resource references exist in both directions for Condition and ClinicalImpression (Michelle Miller)
- ClinicalImpression is not mature enough to resolve this issue. Ask MnM for an exemption on the QA checklist (re: Condition having a circular reference with ClinicalImpression)
- Add note: "A known issue exists with circular references between Condition and ClinicalImpression, which is due to the low maturity level of ClinicalImpression. The Patient Care work group intends to address this issue when ClinicalImpression is considered substantially complete and ready for implementation"
- GF#11173 CarePlan needs support for reviews - 2016-09 core #327 (Stephen Chu)
- Tracking of reviews and plans for reviews is something that applies to many resources, not just CarePlan (e.g. protocols, standing orders, long term care admissions, etc.). This is something probably best handled by "Task" but will require a fair bit of analysis and discussion with other work groups to agree on approach. Defer to R4. Consider transfer to OO who owns Task
Adjourned at 6:30pm Eastern
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