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January 2014 WGM San Antonio: Jan 19 to Jan 24

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San Antonio WGM - January 2014 Patient Care WG Meeting Approved agenda:

San Antonio WGM - January 2004. Patient Care WG Meeting Meeting Minutes

Patient Care WGM, Monday, Jan 20, 2014

Patient Care Monday Q1


o Stephen Chu (chair)

o Elaine Ayres (scribe)

o Russ Leftwich

o William Goossen

o Michael Tan

o Christina

o Enrique Meneses


• Congratulations achieving the Gold Star in workgroup health . It shows the co-chairs are working as good team. A lot of cleanup work has been done.

• Minutes will be collected by Stephen. There is no fixed template, but meeting objective, agenda , decisions and action items should be present in the minutes.

• Agenda:

o Minutes from Cambridge
o Agenda for the WGM
o 3 year work plan
o Other WG administrative business.

• Vote to approve the minutes from Cambridge:

o Michael moved, Russ seconds the motions.
o Vote: Abstain 2, Against 0, In favor 4.
o Minutes are approved.

• Review of the agenda of San Antonio.

o Changes are registered in the Spreadsheet and placed on the wiki.
o William moved motion to approve the updated agenda, Elaine seconds the motion.
o Vote: Abstain 0, Against 0, In favor 6.
o Agenda for the week are approved.

• Review of the 3 year work plan.

o Plan to publish allergies
o Care plan project is on schedule
o Health Concern project has the intention to bring in a DAM in the May WGM.
o Vital Signs: there is a DSTU from Sept. 2009. Need remodeling of the DMIM. Has it been tested in practice
o Care Coordination: the ballot comments have been dealt with. Next step is a DSTU ballot.
o Pressure Ulcer is now DSTU. Susan wants to publish.
o There is also an old model of Adverse Reaction topic. We need to see if this still a active requirement or whether we should retire this model and harmonize it will allergies.
o Patient Care v2 chapter 11 and chapter 12 revisions. There seems to be no usage of this model in Australia. The project will be closed.
o Michael moved motion to close the V2 project, William seconds the motion.
o Vote: Abstain 0, Against 0, In favor 6.
o Project PC v2 will be closed
o The project of Care Statements has been replaced by clinical statement.
o William moved motion to approve the close the project Care statements, Michael seconds the motion.
o Vote: Abstain 0, Against 0, In favor 6.
o Project Care Statements will be closed.
o The topic of Assessment Scales has reached the DSTU, but has to be transformed to Normative. What does testing encompass? William has the intention to test in Eindhoven and is willing to discuss testing if a time slot could be reserved in the next WGM.
o The status of the medical device project is not known. Action from Elaine to inform on the status of the project.
o Stephen has emailed Healthcare Device group. Email response confirmed that the group has no plan to progress this project. It can be closed and removed from PCWG project insight list
o Project 651 is about the RMIM of Care Plan. This is an informative ballot. Suggest to close the project.
o William moved motion to approve the close the project Care Plan, Elaine seconds the motion.
o Vote: Abstain 0, Against 0, In favor 6.
o Project Care Plan will be closed and harmonized with the current project of Care Plan.
o DCM project had 5 examples. 2 were finished. Number 3 heart rate is now currently ready. But we need a project statement for a new project.
o Care Professional Services. This was originally a Canadian project.
o William moved a motion to close the project Professional Services, Elaine seconds the motion.
o Vote: Abstain 0, Against 0, In favor 6.
o Project Professional Services will be closed.
o Action Item for Elaine: to do the administrative work to close the projects of above.

Patient Care Monday Q2


• Russ Leftwich - chair

• Grant Wood

• Christina Knotts - scribe

• Enrique Menesos

• Thomson Kuhn

• Crystal Kallem

• Eric Larson

• Divya Raghavachari

• Atanc Sen

• Floyd Eisenberg

• Marc Hadley

• Chris Millet

• Patty Craig

• Kendra Hanley

• Kay Fendt

• Michael Tan

• KP Sethi

• Walter Suarez


• Agenda

o Health concern and allergy/intolerances for CQI
o Family History and Care Plan for CQI
o Examples of measures with Care Plan information

• Examples of Measures with Care Plan information

o Measures for falls
o Measures for urinary incontinence
o For hypertension, you must prescribe medication and interventions to show improvements
o Measures would need to be more detailed than "Is there a measure for a condition?"
o Details of the measure contents may vary depending upon the condition (i.e. medication ordered, counseling, etc)
o Children's asthma measure example
• Follow up care arrangements
• Environmental control
• Plan is in place
o Other plans including smoking, unhealthy alcohol use may contain goals that were decided upon between the patient and physician
o Care plan quality measures usually contain these high-level attributes:
• Is the care plan present?
• Has the care plan been given to patient/care giver?
• Has the care plan been transferred to next level of care?
• Has the care plan been acknowledged by patient/caregiver?

o If a plan is updated, is it still defined as the same care plan?

• Care Plan/Plan of Care/Treatment Plan are semantically the same (same data elements)

• Agreement/disagreement is currently included in the care plan

o May be generalized that the recipient understood the care plan or that the recipient has received the care plan

• Care plan is linked to both goals and interventions

• Follow-up: Collaboration between PC Care Plan and CQI to map use cases to care plan DAM - Enrique (use calls proposed below to work through examples)

• MU Stage 2 measure regarding family history : At least 50% of patients have a codified family history on first degree relatives

• Family history may be used to determine whether a patient should/should not be used for a measure depending upon a patient's family history (i.e. frequency of colonoscopy screenings based upon family history of colon cancer)

• Family history may also be used to determine which genetic tests should be ordered for a patient • Follow-up: Coordinate CQI/PC/CG/Child Health joint calls for care plan/family history/measures - Chris Millet

Patient Care Monday Q-Lunch

Joint meeting with Terminology experts on terminology requirements for Allergy/Intolerance project


Elaine Ayres (chair and scribe)

Stephen Chu

Lisa Nelson

Rob Haussam

Russ Leftwich

Jean Duteau

Lee Unangst

Margaret Dittloff

Christina Knotts

Michael Tan

Rob McClurie

Catherine Hoang

Claude Nanjo


  • Note that the two substance hierarchies for food substance and food allergen – the latter should be an allergen represented as chemical substance (if known) that serves as the allergen.
  • Decision – only use the dietary substance hierarchy moving forward, not the food allergen hierarchy.
  • Elaine noted that there are some ~130 dietary substances noted to cause adverse reactions based on the literature. After mapping to SNOMED there are still some missing substances.
  • Decision
Elaine will prepare a USCRS request to add the additional substance to SNOMED.
  • To move forward need to accommodate a model that identifies a food substance and when known, a food allergen substance (chemical) that is a causative agent. In many cases the substance in the food that serves as the allergen may not be known.
  • The group discussed the need for value set of foods that cause adverse reactions.
  • Rob McClure noted in the long term we need to be able to represent the chemical (allergenic substance) and the food, but in the short term we should record both if known.
  • It was noted that the substance egg is used in many contexts – as a food substance, but also in vaccines. Therefore, noting egg as a dietary substance is only one use of the concept “egg”.
  • Catherine Hoang from the VA noted they are developing a VA reference set of foods related to allergies. This work is being done in SNOMED.
  • The issue of UNII codes came up – while they are maintained by the FDA, they are not used to create value sets.
- While UNII’s are used for drug excipients in RxNorm, food UNII’s are not in RxNorm.
- It was noted however that in C-CDA – UNII’s are included as a reference to include foods if needed.
  • Action items:
1. Catherine will send Elaine the current work underway at the VA so efforts are not duplicated in terms of substanes. Catherine is working on a REV set.
2. After comparing Catherine’s work Elaine will determine if any additional substances need to be added to SNOMED and complete a USCRS request.
3. Need to continue to discuss the unresolved issue with UNII codes.

Patient Care Monday Q3


Stephen Chu – Chairing

Michael Tan – Chairing

Elaine Ayres – Scribe

Russ Leftwich

Lee Unangst

Anneka Goossen

Enrique Meneses

Christina Knotts


Need a Plan for this Project and how the project relates to other HL7 Projects, e.g FHIR condition and CDA

Patient Care – Health Concern has two elements:

1. Health Concern Condition
2. Health Concern Tracker

Structure Docs C-CDA has both a Health Concern and Problem Concern

FHIR has a “condition”

There are ISO standards for continuity of care – health issues, health conditions, health concerns and health states (CONSYS).

Health Concern from a Patient Care point of view.

Condition and Tracker

Definition of Health Concern:

Definitions currently on the PCWG wiki:

  • Concern - Definition:
A concern is a matter of interest or importance to someone
  • Health Concern - Definition:
A Health Concern is a health related matter that is of interest or importance to someone, who may be the patient, patient's family or patient's health care provider
  • Russ recommended:
Any clinical concept about which someone has a concern (including the patient). (Wrap in a concern act).

CONSYS -- Health issue or thread that focusses on a concern.

Is a lab value a health concern? Or the concern about cardiovascular health

  • FINAL:
A Health Concern is a health related matter that is of interest or importance or worry to someone, who may be the patient, patient's family or patient's health care provider.
Motion: The definition of a health concern is “A Health Concern is a health related matter that is of interest or importance or worry to someone, who may be the patient, patient's family or patient's health care provider”.
Michael/Annika moved. Opposed – 0, Abstain – 0, In favor - 7
  • Health Concern Tracker:
Started with observation, dispense prescriptions. With multiple components, needed a grouper. Links elements in the EHR that belong to one health concern.
Example – breathing problem vs. breaking a leg. Tie various related elements to each condition.

Concepts – organizer vs. tracer/tracker

Definition of Health Concern Tracker:

  • A Health Concern Tracker enables the grouping and tracking over time of a set of related health concerns (this term created quite a bit of discussion and needs further discussion) , for example signs/symptoms, problems, diagnostic finding, therapy.
  • Note concern is an act that happens at a point in time. Can track a condition as it is ongoing unless resolved.
  • What is the relationship between a concern and a condition? A problem vs. a condition.
Condition is a specialization of a health concern?
Michael will e-mail Susan Matney on history of concepts related to “concern”, “condition” and tracking of these concepts.

Patient Care Monday Q4


Stephen Chu

Laura Heermann Langford

Elaine Ayre

Russ Leftwich


  • Review ballot comments on three types of plan
  • Acknowledge that it will be extremely difficult/impossible to reach consensus on definitions and names for the different types of plan
  • Agree that the Care Plan Logical Model is fully capable of representing care plans of the simplest complicity to highly complex, multidisciplinary, integrated care plans.
  • Discussions and agree on the following proposed changes to the Care Plan DAM contents:
- Removing reference to the three types of plan (Care Plan, Plan of Care, Treatment Plan) from the Care Plan DAM
- Remove the three type of plan from the Care Plan Conceptual and Logical Models
- Remove the "PlanClass" attribute from the Care Plan Logical Model
- The issue of supporting "composition" and/or "association" between different types of plans in the model will need to be addressed
- The storyboards will need to be adjusted to reflect the recommended changes
  • Recommend these proposed changes to wider group at Tuesday Q1 PCWG meeting
  • Lenel and Susan proposed to write a storyboard to be review by the team/group for incorporation in the updated Care Plan DAM

Patient Care Monday Q5: CCS meeting


Stephen Chu (chair + scribe)

Laura Heermann Lanford

Enrique Menese

Gaby Jewell

Steve Fine

Margaret Dittloff

Lee Unangst

Jenny Goodrough

Claude Nanjo

Emory Folly


Overview of background of CCS May 2013 ballot and reconciliation

Many ballot comments point to the need for developing behavioural models describing workflow and activities related to the development, implementation and use of care plan in care management

Activities include:

Care team communication and negotiations, care intervention execution, outcome evaluation,care plan review

How activities related to health events

Care Plans synchronisation, reconciliation/harmonization

A set of behavioural models reviewed

Improvement recommendations made to a number of diagrams

Enrique will make the changes to EA diagrams

To review/finalise on Thursday Q4

Patient Care WGM, Tuesday, Jan 21, 2014

Patient Care Tuesday Q1


Stephen Chu – Chair

Elaine Ayres – Scribe

Laura Hermann-Langford

Lee Unangst

Christina Knotts

Enrique Meneses

Jay Lyle

Russ Leftwich


  • This meeting is continuation of Monday Q4 discussion of the Care Plan based on outstanding ballot comments.
  • DAM articulates a Care Plan (Level 3), and Plan of Care (Level 2) and a Treatment Plan (Level I). Ballot comments (multiple) note that these various levels create confusion.
- Agree that Care Plan DAM document will remove references to the three types of plan. Also remove from the logical and conceptual models.
- Remove planClass (attribute): Plan Class Type and the three types of plans from the detailed model.
- Preserve displayName (attribute) to allow naming of different types of care plan according to stakeholder practice/usage needs
- DAM – inclusion of storyboards – do they have the three levels? Should review the DAM to ensure there is no reference to three levels of care.
- Noted that each type of plan has a common path. If removing the three types of plans how will relationship be represented? Can plans be nested? String names may differentiate but how do you nest or link?
- Note – still need to address compositional issues of linking vs. association in the model.
List of recommendations: 5 recommendations
1. Removing reference to the three types of plan (Care Plan, Plan of Care, Treatment Plan) from the Care Plan DAM
2. Remove the three type of plan from the Care Plan Conceptual and Logical Models
3. Remove the "PlanClass" attribute from the Care Plan Logical Model
4. The issue of supporting "composition" and/or "association" between different types of plans in the model will need to be addressed
5. The storyboards will need to be adjusted to reflect the recommended changes
Refined strategy for care plan DAM: Approve these five recommendations.
Laura/Enrique moved. Opposed – 0, Abstain – 0, Approve – 7
  • Discussion re divergence of plans – use case where care plan is developed for a condition (asthma, rash, weight loss and Coumadin) . With an additional health issue (orthopedic) that requires a change – change based on injury – can’t reach rash, can’t exercise.
- Exercise issue and skin issue – how do you effect change to help meet care plan?
- Is this a divergent plan or a changing care plan – changing at the concern level, at the activity level? Is this an evolving plan or several plans.
- Plans – is there a difference from the patient’s perspective and is there a difference between a plan within one institution vs. between institutions?
- The intervention list and the goals are the elements are changing. Relationship of changes and effecting change – in large part impacted by healthcare reimbursement model (no incentive because there is no billing code to do so).
  • Ballot Reconciliation:
Returned to ballot reconciliation for the Care Plan DAM. Will apply the resolution to all related comments in the ballot.
Block resolution of comments regarding different types of plan:
DECISION Apply decision to all ballot comments that address the three types of care plans.
Move: Laura/Russ Opposed – 0, Abstain – 0, Approve – 7
- No mention of interdisciplinary care plan – recommend that language be added to the DAM. Add to introduction an explanation of different types of care plans and add to glossary.
- ACTION: Laura/Jay moved. Opposed – 0, Abstain – 0, Approve – 7
Editorial Comments:
ACTION: Editorial changes will be made by editor. Laura/Lee moved. Opposed – 0, Abstain – 0, Approve – 7
Next steps – Laura will apply changes to all “care plan type” associated comments and then issue ballot comment spreadsheet to review.

  • Additional Use Case:
Standard use case from Lenel James – February 15, 2014.
  • Post San Antonio WGM Conference calls for Care Plan project:
Standard call – Fortnightly; Wednesdays beginning on February 5.
4:00pm start until week ending 9 March
5:00pm start thereafter
Laura to set up webex sessions
Stephen to schedule HL7 calls

Patient Care Tuesday Q2


o Elaine Ayres (chair)

o Michael Tan ( Scribe)

o John Walsh

o Ellen Torres

o Andrew Norton

o William Goossen

o Christina Knotts

o Sylvia Thun

o Russ Leftwich

o Stephen Chu


• Explanation of the activities of Patient Care such as Care Plan, Allergies, Health Concern

• William searches for the data elements in the old ballot material. It is found in Care structures topic. ( Observation Vital Signs) in the ballot of September 2009.

• Anesthesia is particularly interested in data that is gathered by a machine. A human interface could be present to review the data.

• Why do need these RMIM’s? These are the specializations of the CMETS in the Clinical Statements Choice Box. But because you cannot manage all the variants, we use DCM.

• DCM always contain Evidence, data element, code , UML representation and implementable format such as XML.

• DCM accepted are BMI, heart rate.

• Anesthesia is working with Devices and let that SIG work out the models.

• If the Care Structures need to be updated then 3 possible actions are required:

o Work on the DCM
o Work for a modeling ( HL RMIM) models.
o Work on a implementation guide.

• Currently there are about 25 properly modeled. Anesthesia wants to reuse whatever is available.

• Does Anesthesia have a document with use cases that describe what information is required and registered?

• Anesthesia is working on a DAM. This could be a 4th action item.

• But what does Anesthesia think of the possibilities? They like the structure and the idea, but are struggling with resources and knowledge how to be able to carry it out in a project.

• Elaine would like to have an idea of what the intentions are of Anesthesia. Patient Care co-chairs will do a recap on Friday morning on the impact on workload and appreciate some feedback from Anesthesia.

• We will keep this time slot ( Tuesday Q2 ) for a joint meeting at the next WGM.

• Project Scope statement on Heart Rate.

• A new PSS is required to publish the remaining set of the DCM material of the ballot of 2010.
• Some material were approved in 2010, but other DCM still had comments that had to be resolved. The objective is to publish the DCM, which is PDF and delivered to Don Lloyd.
• The publication is informative material.
• The recommendation is to ask a new project identification.
• Motion to adjust and submit the PSS for the DCM.
• Russ moves the motion, William seconds the motion.
• Vote: 7 approve, 1 abstention, 0 against.
• Motion to publish the DCM.
• William moves the motion, Russ seconds the motion.
• Vote: 7 approve, 1 abstention, 0 against.

Patient Care Tuesday Q3


• Stephen Chu ( Chair)

• Michael Tan (Scribe)

• Roel Barelds

• Jean Duteau

• Howard Strasberg

• Lisa Nelson

• Jay Lyle

• Ken Chen

• Enrique Meneses

• Christina Knotts

• Lorraine Constable

• Margareth Dittloff

• Russ Leftwich

• Elaine Ayres

• Catherine Hoang

• Wendy Huang


• There are 2 “ severity” attributes in the model. One is related to the reaction and the other is the criticality to the condition. The criticality is a clinical judgment usually done by the care provider. Russ has made a matrix with use cases of how the criticality would guide the care provider in his decision support.

• Discussion on the code set of the criticality. Suggestion to allow high, low and unknown or null flavor as the allowed values. Unkown or null flavour can be added. The value set is not set in a domain model and can be decided in the implementation.

• The criticality is already included in the vMR logical model.

• A topic should be raised at the joint meeting with SD to harmonize this model with de Consolidated model version 1.

Action Stephen.

• The subject is raised about “no known allergies”. Vocab is thinking about this matter and will bring in this topic in a joint meeting.

• This use case of a peanut will be added to the DAM to illustrate the case of criticality and severity.

• Also add ( a column for reaction and it’s severity to the matrix to make it clear what the difference is between the historic reaction and the propensity to the allergy.

• It might not be possible to align the models in CDA-r2 to the new acquired model of allergy. There is no guarantee of backward compatibility. The model of criticality is also used in the Netherlands and has proven it’s validity.

• Elaine shows the publication request for the v3 DAM. This can be uploaded to the website. The DAM is informative and does not have to be reballoted.

• It is of importance for ANSI because this will be a reference material for the clinical model.

• There is no relation with Adverse Reaction in the DAM, but according to Lorraine the relationship would be in the logical model.

• Motion:

• Motion from Lorraine to accept the DAM Publication Request
• Seconded by Margaret.
• Vote :
o in favor 15
o Abstain. 0
o Oppose 0

• Post WGM Allergy project conference calls:

• Next conference call be February 12th 2014

Patient Care Tuesday Q4


Michael Tan – Chair

Elaine Ayres – Scribe

Stephen Chu

Chris Filmore

Sadamu Takasaka

Jay Lyle

Jeffrey Tin

Vannak Kann

Lisa Nelson

Howard Strasberg

Margaret Dittloff

Lee Unangst

Lloyd McKenzie

David Rosner

Bill Lord

Enrique Meneses

Cecil Lynch


Hosting FHIR


1. New Projects – FHIR Requests
2. New Project – PC WG Requests
3. Develop New Content

Eight current resources:

1. Adverse Rxn – details of a specific event
2. Alert
3. Allergy and Intolerance – Propensity to rxn – can have O-* adverse rxn’s
4. Condition
5. Care Plan
6. Encounter
7. List
8. Procedure

Also consulted on Family History

Patient Care WG would like to discuss - Health Concern Project and relation to “Condition”

FHIR next steps – Quality review of criteria, request for new criteria. Note that PC WG has not been responsible for their specific resources but looking at maintenance of current resources. We need to develop the internal capability to create and maintain.

Lloyd explained the current construct of resources and extensions. Moving from the80/20 rule to the 99/1 rule if there are health care applications that would use a resources.

Expect 100-150 resources total to meet the 99/1 rule. There are currently 50 resources that can be used with extensions. Publication of the DSTU will have 75 resources. Moving from resources development to profile development to support implementations. (Note - A Resource Profile - a statement of use of one or more FHIR Resources).

Discussion of best practices in light of adding new resources based on needs of the user community. Need to balance good practice vs. complexity. Need to decide if it is a new resource or a resource with an extension. Both resources and extensions are included in a profile. Once the move is made to normative, resources and associated extensions will remain to more clearly define the core resources. FHIR DSTU – another DSTU ballot in January 2015. Will then look at application uptake and specifically the use of resources. Example – care plan uptake – if low uptake, will remain DSTU. Resources like patient and encounter that have to potential to be used and proved sound, will move to normative track.

Will be creating profiles at both the US National and International groups – e.g. NCPDP.

Is there a template for a profile? A profile is a resource that tells you how to capture a data elements associated with a resource – may be optional or mandatory.

Validating against a profile – can use “tags” on a resource. “This resource qualifies for use in XXX profiles”. Also can qualify using and existing profile for validation.

  • - FHIR request for new resources for referral (order the request for care) and care transfer (an event). Also looking to create profiles to support release of C-CDA release 2 for PC WG supported resources – current and new proposed resources. Also looking for help with other profiles.

Referral – what is the set of data that would be needed for a referral. Referral object will not have sections, but needs who is the requestor, who is the patient, what is the service requested, when should the care take place and pointer to additional supporting data (e.g. care plans etc). Can then place this into a “composition” that connects the referral to other resources.

Look at “Care Provision” normative – care referral and care transfer are synonymous. However, systems treat requests and events differently.

  • - FHIT requests for quality enhancements to resource content for the next DSTU – good descriptions, describing how to use content, quality issues, usability issues. For existing resources refining descriptions or defining value sets, FHIR will help with these.

Value sets are FHIR resources – live in the same resources set as other resources. No OIDS in FHIR, but V3 and V2 are available for reference by URI’s. URI’s will pull up value sets.

PC WG resources vs. FHIR resources – FHIR can define the two new resources and validate content with PC WG, as well as quality work and new profiles. However, we need to learn to manage these resources.

A base resource development – 6-8 hours. Learning the tooling – 3-4 hours. The consensus process for descriptions may take longer. Templates may take from 1-7 hours.

Stephen will work with support from FHIR team to develop resources. Would like the new resources and the profiles and updates by beginning of September. Jay will work on the quality aspects of existing resources. Elaine will assist as well with development.

Lisa Nelson will help with C-CDA resources.

What happens if suggestions are not based on implementations? Feedback from implementation community – there are discussion forums at the bottom of each FHIR page. Can subscribe to monitor new postings. Need to subscribe to the resource feeds to monitor to bring questions to WG. Issues should be raised during the PC calls.

There will be a GForge tracker for changes to the FHIR specs. Can categorize by resource and can also categorize by WG. Should track these as well.

Can also post suggested changes to the discussion forum from implementers for suggestions.

Lloyd will discuss how to place content into SVN and how to run a build. Have Skype chat to ask for help.

Next session with FHIR – Friday, January 24 Q2.

Keep same quarters for next WG meeting – Tuesday, Q4 and Friday, Q2.

Patient Care WGM, Wednesday, Jan 22, 2014

Patient Care Wednesday Q1


Russ Leftwich (chair)

Elaine Ayres (Scribe)

Mitra Rocca (CIC)

Dianne Reeves (CIC)

Jim McClay (Emergency Care)

Ken Pool (PHER)

Enrique Meneses


Patient Care hosting CIC, Emergency Care, PHER

  • CIC
- Patient Care requests to review TB DAM for CIC. (Project 371)
- What are pediatric data standards? Will reach out to Child Health WG as an interested party.
- PHER is also and interested party.
- Questions about pediatric data elements –
- Risk statement – student development without any other resources.
- Should align with CDISC standards and terminology developed in conjunction with CDISC.
- Will be a useful model. Register standard data elements in NCI database metadata repository – CADSR.
- CADSR – is a registry and a repository. Need to make this repository known to the larger community.
- There are many meta-data repositories – how do we familiarize users with these?
- What is the meta-data repository for HL7? Risk is creating overlap. Can we have one registry?
- Question to Electronic Services.
- ACTION: Contact Electronic Services to express desire and need for the designation of an HL7 meta-data repository for domain analysis models.
- Move - Ken/Russ Abstain – 0, Against – 0, For – 6
- ACTION: Include Electronic Services with this joint session for next WG meeting to address repository issue.
- Move - Ken/Jim Abstain – 0, Against – 0, For – 6
- Scope element 4 - What are transmission of standard data elements – what will be the methodology.
- Question if this is the IHE profile elements for study recruitment.
- Scope element 5 – complete.

  • CIC involved in EHR Usability. Also working on Schitzophrenia.

  • Emergency Care – Jim McClay
- Published DEEDS data elements – will use for DAM.
- Had to resubmit PSS for this project and plan to ballot in May 2014.
- Includes a general business process flow for an ED and associated data elements. :: - Will map processes to the functional profile.
- Need to define information model. Vendors provided business process models.
- Who “own” DEEDS – was a CDC resource.
- Currently HL7 Emergency Care “owns”.
- Submitted terms to LOINC to ensure it is complete.
- Question use PHINVADS or CADSR as the repository.
- Did a V1 Functional Profile – but did not ballot.
- Handed off to CCHIT.
- Need to do a version 2.
- Can use as an implementation guide.
- Vital Signs – Emergency Care would like the vital signs projects.
- Would expect to see this in our repertoire.
- Need to ensure Devices is involved.
- Vital signs would also be used for public health screening.

  • PHER
- Needs TEP/OASIS – ongoing project. Resources issue.
- Ambulatory Survey – ongoing
- Four publications -- hearing, heart, birth reporting CDA, death reporting CDS – to be published
- Need to know if reporting – why
- IHE profile – ADT streams for births….is there an ADT for death?
- Will need a filter for service, but may exist and can be organized.
- Essential Learning health system standards – governance, standards, (ESTEL) – through CDISC
- Discussed health concern as an active project.
- The concern act – vs. the actual health concern.
- No concern list. Where are these concerns posted and tagged?

Continue with Wednesday Q1 for next WG meeting.

Patient Care Wednesday Q2


Stephen Chu

Elaine Ayres

Laura Heermann Langford

Michael Tan

Enrique Menses


PWWG providing updates to EHRWG on PCWG projects:

- Allergy/Intolerance and Adverse Reaction project
- Care Plan DAM project
- Care Coordination Services Functional Model/Capability project
- Upcoming Health Concern topic

Presentation details as per contents of the powerpoint files.

  • Allergy/Intolerance and Adverse Reaction Project:
Allergy/Intolerance Update powerpoint slides

  • Care Plan, CCS Project and Health Concern topic:
Care Plan, CCS and Health Concern Update powerpoint slides

Refer to EHRWG meeting minutes for further details

Patient Care Wednesday Q3

PCWG hosting Patient Administration and SOA


Laura Heermann Langford (chair + scribe)

Michael Tan (scribe)

Vincent McCauley

Michael Donnelly

Irma Jongeneel

Line A. Saele

Alexander DeLeon

Bryan Postletwaite

Wendy Huang

Enrique Meneses

Elaine Ayers


Patient Administration WG Agenda and Discussions:

  • There has been a DAM about interdependent Registries within PA for several years. But there has been no further endeavor to carry it through. It has gone through ballot. It was in an old tool and the knowledge of this tool has disappeared.
- Now looking for interest in continuing and taking the project to ballot.
- The PSS is number 725. It has been put into the new format and 23 negative comments which has to be addressed.
- Proposal made to look at the DAM to see if there is content in there that is not duplicated in IHE profiels etc that needs additional attention and/or puclicaiton to scope the work.
- Patient admin – will look at the gaps existing in the DAM and the scope of work left to preserve any unique content and let Patient Care and SOA know. Then the workgroups can make informed decisions on which direction to take with the Independent Registry DAM. Brian will report back at the next workgroup meeting. These three teams (Patient Care, Patient Administration and SOA ) to address the finding.
- Each country has an interest to a registry and it would be a pity if this work was lost.
- Perhaps Brian ( PA) would have an interest in this matter because he is active in OMG
- PA has no resources to carry on and asks PCWG is we would want to adopt this project. PA does not have the knowledge to give an answer
  • New FHIR resources being worked on by PAWG–
- Schedules and appointments
- Episode of care (larger then encounter)
- Furthering the Healthcare Services Resource. (which location to find them at, who will be providing services etc.)
  • Joint meeting next working group meeting will be Wednesday Q3.

Care Coordination Services (CCS) Discussions (PCWG - SOA joint project)

  • Need to address which contents (new and previously balloted contents) are to be included in the normative section of the reballoted Document.
- Would like to have the S&I framework to review the contents the week of March 3 or 10.
- Have SOA all hands group review on a Monday meeting March 17 ???
- NIB due February 16th.
  • Need to schedule two joint meetings Tuesday and Wednesday Q3 with SOA at the May meetings.
- Wednesday – 45 minutes: PA project update and next steps. 45 minutes with SOA update on the CCS not completed on Tuesday.

Patient Care Wednesday Q4


Michael Tan – Chair

Elaine Ayres – Scribe

Stephen Chu

Catherine Duteau

Enrique Meneses

Jay Lyle


Discussion of data element repositories and registries.

  • Health Concern discussion re concern vs. condition.
  • Link provided by Russ:
- 3.4 Observation, Condition, Diagnosis, Concern
NOTE: The HL7 Patient Care Technical Committee is developing a formal model for condition tracking.
The examples provided here are greatly simplified so as to illustrate certain aspects of SNOMED CT implementation.

Observations, Conditions, Diagnoses, and Concerns are often confused, but in fact have distinct definitions and patterns.

• "Observation" and "Condition": An HL7 observation is something noted and recorded as an isolated event, whereas an HL7 condition is an ongoing event. Symptoms and findings (also know as signs) are observations. The distinction between "seizure" and "epilepsy" or between "allergic reaction" and "allergy" is that the former is an observation, and the latter is a condition.
• SNOMED CT distinguishes between "Clinical Findings" and "Diseases", where a SNOMED CT disease is a kind of SNOMED CT clinical finding that is necessarily abnormal:
[ 404684003 | Clinical finding ]
 [ 64572001 | Disease ]
• The SNOMED CT finding/disease distinction is orthogonal to the HL7 observation/condition distinction, thus a SNOMED CT finding or disease can be an HL7 observation or condition.
• "Diagnosis": The term "diagnosis" has many clinical and administrative meanings in healthcare
- A diagnosis is the result of a cognitive process whereby signs, symptoms, test results, and other relevant data are evaluated to determine the condition afflicting a patient.
- A diagnosis often directs administrative and clinical workflow, where for instance the assertion of an admission diagnosis establishes care paths, order sets, etc.
- A diagnosis is often something that is billed for in a clinical encounter. In such a scenario, an application typically has a defined context where the billable object gets entered.
• "Concern": A concern is something that a clinician is particularly interested in and wants to track. It has important patient management use cases (e.g. health records often present the problem list or list of concerns as a way of summarizing a patient's medical history).
- Differentiation of Observation, Condition, Diagnosis, and Concern in common patterns:
• "Observation" and "Condition": The distinction between an HL7 Observation and HL7 Condition is made by setting the Act.classCode to "OBS" or "COND", respectively. The distinction between a SNOMED finding and SNOMED disease is based on the location of the concept in the SNOMED CT hierarchy. There is no flag in a clinical statement instance for distinguishing between a SNOMED CT finding vs. disease.
• "Diagnosis":
- Result of a cognitive process: Could potentially be Indicated by post-coordinating a SNOMED CT finding method attribute with a procedure such as "cognitive process".
- Directs administrative and clinical workflow: These use cases typically rely more on the context in which the diagnoses are entered (e.g. where an order set has a field designated for the admission diagnosis). In such a case, the distinction of a (particular kind of) diagnosis is that it occurs within a particular organizer (e.g. a condition within an Admission Diagnosis section is an admission diagnosis from an administrative perspective).
 Something that is billed for: The fact that something was billed for would be expressed in another HL7 message. There is nothing in the pattern for a diagnosis that says whether or not it was or can be billed for.
• "Concern": The HL7 Patient Care Technical Committee is developing a formal model for condition tracking. In that model, a problem (which may be an Observation, a Procedure, or some other type of Act) is wrapped in an Act with a new Act.classCode “CONCERN”. The focus in this guide is on the use of SNOMED CT, whereas the Patient Care condition tracking model is the definitive source for the overall structure of a problem list.
- It should be noted that the administrative representation of a diagnosis and the representation of a concern break the rules from section ‎3.1.1 Observations vs. Organizers, in that these designations are based on context, whereas the designation of something as an Observation vs. Condition is inherent in the clinical statement itself.
  • Group decided to move on from this citation.
  • Current Definition of Health Concern Tracker:
- Note that the following definition is some form of extract from the PCWG "Concern" topic DSTU material
- A Health Concern Tracker contains no semantics beyond that need for tracking excepting the link between related conditions (as identified through ObservationEvent or ObservationRisk assessment conveying Event, Clinical Finding, Disorder assertions, etc.).
- Question:
Is the concern itself the grouper/tracker or is the tracking a separate concept?
- Will continue this discussion Thursday Q4.

Patient Care WGM, Thursday, Jan 23, 2014

Patient Care Thursday Q1


Stephen Chu

Elaine Ayre

Michael Tan

Margaret Dittloff

Others - see OO attendance list


Joint meeting with OO, CDS, Template

OO Hosting

  • Elaine presented update on Allergy/Intolerance and Adverse Reaction project. Details - refer to slide deck in Wednesday Q2 meeting minutes
  • Stephen provided updates on Care Plan, CCS and Health Concern projects. Details - refer to slide deck in Wednesday Q2 meeting minutes
  • Margaret provided update on Medication and Food preferences.
  • Ballot reconciliation:
- Order Services Functional Profile: CDS
- comment disposition (refer to OO meeting notes for details)
  • CDS update:
- CDS plans to develop a logical model consistent with QDMA, C-CDA, FHIR, etc (which may be subsets of QDMA, C-CDA…) to support CDS work.
- It is the intent of CDS to gradually converge the vMR logical model to this new CDS logical model
- CDS will work with FHIR and others to develop this logical model

Patient Care Thursday Q2 (PCWG, SDWG, Template Joint meeting)


Stephen Chu – (Chair)

Elaine Ayres – (Scribe)

Lisa R. Nelson

Rick Geiner

Christina Knotts

Rick Kuchan

Diana Behling

Brett Marquard

George Cole

Willaim Gooseen

Jay Lyle

Benjamin Flessner

Michael Tan

Mark Sharfman

John Roberts

Kai Heitmann


PCWG hosting

  • Agenda:
1. Templates Its ballot (25 Minutes)
2. Structured Docs – request update on Care Plan
3. Patient Care
a. Care Plan
b. CCS
c. Health Concern
d. Allergies and Intolerance

Discussion and Decisions:

  • Templates – Kai Haitmann
- Ballot – V3_TEMPLATESPEC_R1_D1_2014JAN
- Some places already using templates but ballot important next step for template specifications. Over 300 comments, ~ negative.
- Ballot Item ROW #203 – Effective date comments (Persuasive with mod).
Disposition – will handle consistently as “effective date”. Remove all start date references.
Three relevant dates – release date, expired date, and “effective date” (creation date)
Add to glossary – effective time is the creation date.
Votes: Opposed – 0, Abstain – 0, In favor 14.
- Ballot Item ROW #281 –
- Discussion of Templates vs. CDA syntax. Should/shall/may will go away.
- Use Mandatory, Required… instead. Follow cardinality of table in document.
- Conflict of names, verb statement mandatory, Be clear on what is mandatory moving forward.
- Business element name (HITSP C32 – allergy observation with date…).
- In templates, the template element can have point to multiple “business names”. Can re-use templates. Can have optional or mandatory, but such designations make the use of validators more difficult. Need ability to generate an error.
- Need to be able to over-ride error/warning/hint – work on prose/tables to make clear.
- Ability to override – throw an error, a warning, a hint.
- Ballot Item ROW #292 – Template ID’s vs. Business Name.
- Reference from template to template – shall be by ID.
- Can display names as well for usability if desired.
- Disposition: Will add a paragraph that references to templates (and value sets) has to be id only and a template viewer may show also display names or business name of the template for human convenience.
- One field – display will vary.
- Persuasive. – Vote -- Abstain – 1, Negative – 0, In favor – 13.
- Ballot Item ROW #304 - Unconstrained vs. constrained mark-up – style is constrained to italic, bold.
- Look at FHIR style elements.
- Will add the list of allowed tags in fields with that data type and eliminate “unconstrained”.
- Persuasive with mode - Vote -- Abstain – 0, Negative – 0, In favor – 14.
- Static vs. dynamic templates – versioning or new ID’s for each template.
SDWG defines templates as static.
Key will be the relationship of one template to another template – label can describe the version….
May display various versions.

  • Patient Care Update
- Allergies and Intolerance
- R1 C-CDA DSTU comments re criticality vs. R2 ballot comments.
- Also observations on severity – does it refer to the episode of the rxn or the signs and symptoms.
- VA uses severity as the signs and symptoms.
- CDA 1.1 vs. 2 – no difference between the two. RMIM looks good but will need to wait for R2.
- Care Plan/CCS
- Care Plan DAM does not have the behavioral aspect of the implementation.
- It has a focus on the care plan design and structure.
- Designed in conjunction with ONC LCC – detailed Care Plan, Plan of Care and Treatment Plan.
- This relationship generated many ballot comments – found to be confusing and terms seem synonymous.
- Removing these three term designation out of the DAM moving forward.
- An organization can use their desired term.
- Moving into the remainder of ballot reconciliation – revised ballot package in May 2014.
- The CCS (Care Coordination Service Profile) together with SOA.
- The CCS defines a set of functional capabilities – e.g. create a plan (defines collaboration with the care team), the negotiation of a goal and the intervention with the goal.
- The care team may not agree and the negotiation functionality supports the attainment of an agreement/consensus.
- The review of the Care Plan in its entirety is also part of the model. Balloted in May 2013 – but still resolving comments.
- Many comments note lack of a behavioral model.
- Now developing behavioral models to define clearly collaboration, negotiation, review, update.
- Plan is to ballot in May 2014.
- Then need to look back into C-CDA R2 ballot package – vis a vis the Care Plan for Care Plan template. May need a harmonization discussion.
- Recommend to focus on R2 vs. trying to adjust R1.1 via comments/errata.
  • Another topic might be Vital Signs….add to topics for Thursday Q2.
  • Health Concern
- Patient Care in 2007 – had a concern topic. Published a concern clinical model in 2009. Since then how does this relate to condition, problem, diagnosis. How is this used in C-CDA?
- C-CDA – use of Health Concern template. There is also a Problem Concern template. Goal is a DAM for ballot in May 2014.
- New wiki page on Health Concern can be found on Patient Care wiki. Patient care looking at how the health concern relates to many other concepts. There is also the issue of health concern tracker. Have determined the definition of health concern. Still debating the health concern tracker. Today Q4 will continue the discussion.
- Note previous definitions were established and submitted to ISO (2009). Would like to keep DAM V3 agnostic.
- Not only the definitions but also what are you doing with this function. Discussion is still ongoing. Need to harmonize this with C-CDA. C-CDA R2 has the health concern concept but also has the Problem Concern so this will require harmonization.
  • Vital signs RMIM – Emergency Care, Devices, Anesthesia – does Structured Docs WG have any interest?
- Heart rate detailed clinical models will be published.
- Current C-CDA has 12 vital sign elements. Will need to harmonize with DCM work. Does SDWG interested in the preparing a PSS?
  • Next Work Group meeting:
- Retain joint meeting Thursday Q2 – Patient Care, Structured Documents and Patient Care.
- PCWG hosting

Patient Care Thursday Lunch meeting: PCWG and SWDG co-chairs


Stephen Chu (chair, scribe)

Michael Tan

Brett Marquard

Diana Behling

Lisa Nelson


  • There exists disconnects between PCWG artefacts/models and their uses/implementations in C-CDA:
- Allergy/Intolerance
- Adverse Reaction
- Health Concern
- Care plan (least disconnect as the latest C-CDA care plan templates should be based on the Care Plan DAM logical model)
  • Need for better collaboration between PCWG and Structured Document WG on how the PCWG artefacts are translated into C-CDA templates
  • Suggestions:
- PCWG to nominate liaison person to Structured Doc WG (to be discussed and determined at the next PCWG co-chairs meeting/conference calls)
- Lisa Nelson will be Structure Doc WG liaison person to PCWG (Lisa will participate in PCWG conference calls where possible)
- PCWG to learn using Structured Doc template editing tools (trifolia)
- this will require PCWG to nominate/volunteer resource(s)
- Structured Doc WG to notify PCWG on xml examples relevant to PCWG artefacts
- xml examples are produced by CDA template sample taskforce
- Brett will copy PCWG on CDA template sample taskforce communications and available xml samples
- PCWG to provide clinical and clinical informatics review

Patient Care Thursday Q3


(1) Joint meeting with Clinical Statement

Michael Tan in attendance

(2) CDS/ArB meeting

Stephen Chu in attendance


(1) Clinical Statement:

• Status update: CS have passed the normative ballot in September 2013.
• The CS CMETS clone was not included in the normative ballot. This will be corrected in the NE 2014.
• Clinical Statement WG will maintain the CMETS in the HL7v3 RIM

(2) CDS/ArB meeting:

The Health Quality Improvement Domain Analysis Model (QIDAM) seeks to create a conceptual data model that can be used to create data mapping expressions for electronic Clinical Quality Measures (eCQMs) and Clinical Decision Support (CDS) artifacts.

The primary purpose of the QIDAM is to serve as a model of clinical data within data mapping expressions, logical criteria, population criteria, formulae, and other expressions in health quality improvement artifacts. The QIDAM harmonizes the existing eCQM and CDS data models into a single, unified conceptual model. It is designed as an abstract fact model. This model can be mapped onto existing logical models while defining the structure and domain concepts required by eCQMs and CDS artifacts.

There is plan to harmonize QIDAM and vMR logical models into a single model,which is likely to be a hierarchical logical model.

It is also recommended that FHIR profile(s) to be created from this harmonized model.

vMR - QIDAM logical model harmonization proposal and discussion details are available on the slide deck

Patient Care Thursday Q4


Stephen Chu (chair)

Elaine Ayres (scribe)

Enrique Meneses

Michael Tan

David Rowed


  • CCS Topic:
- Enrique presented the behavioral models for the ongoing care plan contribution and sharing environment. The graphic represents the types of care plan contributions, preferences, concerns, goals, risks, interventions, communications, changes, tracking interventions, actions of review, accept, acknowledge and review of outcomes.
- Ask that model adds “identify and review appropriate care team”. May engage, re-engage or dis-engage.
- Enrique will adjust diagram to move the longitudinal encounter to a new tab and add Care Plan Contributions to each.

  • Health Concern:
- Diagram created for health concern relationships.
- This is the original RMIM from May 2009 ballot:
- Are we tracking concerns or conditions?
- With a series of symptoms – cough, itchy nose…may not be concerns.
- Have still not agreed on the relationship of concerns and conditions and how to track and group over time.
- Calls Thursdays at 4 on a weekly basis.

Patient Care WGM, Friday, Jan 24, 2014

Patient Care Friday Q0: PCWG Co-Chairs meeting


Stephen Chu

Elaine Ayres

Michael Tan

Jean Duteau

Jay Lyle


  • Welcome to PCWG new co-chairs: Jean Duteau and Jay Lyle
  • New deadline on May ballot submission: 3 March 2015. Care Plan and CCS project team and co-chairs need to be aware of new deadline
  • Review DESD voting responsibilities assignments: Jay and Jean; changes to assignments for Stephen and Laura
  • Future – discuss monitoring other groups outside of DESD (e.g. SDWG, Templates)
  • CMET Maintenance – in ballot material – PC has two – will monitor but no current action.
May need an allergy, care plan CMET when those models are published
  • Stephen provided updates on lunch meeting with SDWG - see Thursday lunch quarter meeting notes
  • Assessment Scales and DCM projects: progression to publication.
- Jean Duteau has agreed to shepherd these

Patient Care Friday Q1

Template hosting PCWG PCWG representatives attending


Stephen Chu (scribe)

Michael Tan



  • HL7 partner with the HingX project which is a registry (of metadata)
- it is a useful resource for user to discover what health resources are available, e.g. template artefacts and where to find them (points to a template repository)
- There was a pilot that investigated how the HingX registry would interface with templates repositories
- But momentum on HingX has ebbed recently
- Recommendation to revitalise this initiative
- HingX has API – need to identify and evaluate relevant metadata and APIs for interface into Décor
- Suggestion to identify the required metadata and APIs and bring them back to Template group for validation
- OHT is operating a HingX server and is available for agencies to use services of the server


  • Template ITS DSTU ballot – continued ballot reconciliation
- Received about 300 comments, approximately half are negatives
- Should be able to resolve all negatives
- Ballot passed
- Can go to publication
- Motion: revisit the question of normative publication in January 2015 WGM
- all voted affirmative, motion carried
  • Template ITS pilot/prove of concept project. This project can now be closed.
- The proof of concept project was able to show 2 things from trifolia workbench:
- Using XSLT
- Able to extract the xml data from trifolia (proprietary format from Lantana)
- Able to convert the xml data into décor format
- Also have IHE templates converted into décor format
- It is possible to convert template in MIF format (e.g. NHS templates) into décor format
  • Template WG 3 year work plan discussed and approved:
- refer to Template WGM minutes for details

Patient Care Friday Q2


o Stephen Chu (Chair)

o Michael Tan (Scribe)

o Ewout Kramer

o Sue Thompson

o David Rowed

o Ken McCaslin

o Joshua Mandel

o Ed de Moel

o Robert Worden


• Continuation of the discussion of last Tuesday. At that time there thoughts from Lloyd that there are two separate resources ( Referral, Transfer). Ewout explains, that the WG will decide whether there will be 2 separate resources.

• Governance. There are worries about the governance on the maintenance of the resources. Especially PCWG is handicapped by shortage of people to be able to keep up with pace from FHIR.

• PCWG decides which resources are to be made in FHIR. The FIHR management group (FMG) will survey the procedures.

• According to David Rowed: Care Provision in V3 was meant to create systems for the future, but systems did not follow. Care Provision was not possible in V2. Hopefully this will pick up in FHIR.

• An easy way is to look what systems already have built. What is more difficult are the new features that are new to the market.

• Stephen is searching for guidelines from the FMG how to decide what has to go into the core and what should be modeled in extensions and profiles.

o Stephen expressed that it will be useful for the FMG to agree with stakeholders a set of determination criteria, e.g:
- what are currently in implementation
- what are considered clinically important as determined by practice guidelines and clinical safety requirements

• The FMG will issues an email notice of expanding the FMG membership to add 2 more members.

o Stephen indicated that it will be useful for PCWG to consider nominating a representative to expanded the FMG membership.
o PCWG will discuss this in a PCWG co-chair conference call to be held in February.
o Action Stephen.

• Regarding FHIR modelling of Referral and Transfer of Care resources: there are two important issues in the modelling:

o The static model (contents supporting referral and transfer of care)
o The behavior (dynamic states representing workflow matters such as request, promise, reject, request for more information, etc)

• Motion to take the Care transfer model of Patient Care Provision model and the review of materials from HL7v2 chapter 11 and 12 as starting point for developing one common FHIR resource for transfer as well as referral . Second by Robert Worden.

• Votes :
o Abstain : 2
o Against : 0
o In favor: 5
• Motion carried.

• Ewout explains the FHIR documentation and tools.

Patient Care Friday Q3

There is no PCWG meeting this quarter

Patient Care Friday Q4

There is no PCWG meeting this quarter