May 2013 WGM Atlanta

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May 2013 Atlanta WGM - Patient Care Meeting Minutes

Patient Care Monday May 06 2013

Patient Care Monday Q1


Stephen Chu (Chair)

Elaine Ayres (Scribe)

Russ Leftwich

Christina Knotts

Kevin Coonan

Margaret Dittloff

1. Reviewed Agenda and assignment of duties

2. Formalized approach for new co-chairs – voting on Michael Tan, Russ Leftwich, Elaine Ayres

3. Publication of 320.2 – project – need update from William Goossen

4. Ballot reconciliation – CCS Clinical Care Statement and Allergy and Intolerances planned for this WG

5. Project Leadership

a. Health Concern – Kevin Coonan to lead
b. Allergy and Intolerance – Stephen Chu and Elaine Ayres to lead
c. CCS – John Farmer and Kevin Coonan to lead
d. Care Plan DAM – Laura Hermann Langford and Stephen Chu to lead

6. Draft minutes from Phoenix WG –

approval – Move – Russ/Elaine move.
Abstain – 0, Object – 0, Approve – 4

7. New PSS – Patient Preferences (Kevin noted he has a model).

Patient Care Monday Q2


Stephen Chu (Chair)

Enrique Meneses

Jon Farmer, Thrasys, USA, (

Laura Heermann Lanford

Russ Leftwich

Gordon Raup, (

Christine Knotts First Databank, USA, (

Ballot reconciliation on first informative ballot on Care Coordination Services Functional Model (CCS-FM).

Majority comments came from ONC/S&I group

CCS Roadmap:

To complete ballot reconciliation during and after May 2013 WGM

Progress to DSTU ballot in September 2013

CCS services profile technical specification development to follow - by OMG (Object Management Group) in collaboration with HL7

First ballot reconciliation session focused mainly on major negative comments

see consolidated ballot comment spreadsheet for details

Second ballot reconciliations session - Tuesday Q1

Expect to continue ballot reconciliation via conference calls after Atlanta WGM

Patient Care Monday Q3


Stephen Chu )Chair)

Laura Heermann Lanford (Scribe)

Kevin Coonan

Thom Kuhn

Michael Tan

Gaye Dolin

Zabrina Gonzaga

Russ Leftwich

Call in: Enrique Meneses Gordon Raup

Care Plan DAM Ballot delayed to Sept Ballot Cycle

o Continue refinements to the DAM components.

- Will include incorporating comments received on the SOA CCS ballot as well.

o Review of the Care Plan Structural Model.

- The “Plan” structure is designed generic enough to support Care Plan, Plan of Care and Treatment Plan.
- The model illustrates the use of inheritance of shared features from an abstract plan class.
- The computable information models – the labels may be helpful for discussion on the screen, but in the meaning or structure may still be the same class. The structure needs to be useable but it may only be seen in examples of the instantiated model, not the model itself.
- Concern has been expressed in the SOA CCS ballot reconciliation discussion that the terms and their use may be ambiguous and confusing. Plan is to provide a glossary, dictionary- including synonyms.
- Review of the model structure Overview – who, why what, when and where.
- Discussion to what needs to happen with actions/vs planned actions. Need to continue looking at that area to obtain clarity.
- Discussion on risks for health concern and the relationship with health concern.

o Care Coordination Service

- Review of accomplishments and progress of ballot to date. See slide deck from presentation for details. (review of purpose of CCS, plans for DSTU in Sept., objectives of CCS, business rules and capabilities of the service.

o Review of Coordination with S&I Framework

- Review of the Care Plan Workflow (conceptual model). Largely in line with the HL7 model. Not all data elements referred to in the CCS model are not all represented in this conceptual model – but they are not in conflict.
- We have not gone in to the dynamic sense of the model yet – have been dealing more with the static model. Once are are happy with the stability of the structural model then we need to look at the behavioral model. It is the behavioral model that will be most influential to the CCS.
- Review of the March 27 call with S&I team and the items identified as collaboration points.
- To Do: Need to schedule shared calls with S&I and HL7 team. Will target 5 pm ET.


- Concerns that the FHIR technical team does not understand the clinical aspects of care plan.
- Their aim is “if it is not currently supported by implementers then we are not interested”.
- This does not seem to be an helpful approach for standards development. We understand the for uptake the standard has to be implementable – but if it isn’t clinically useful what is the point?
- Many concerns expressed about the 80/20 approach FHIR is taking, the lack of maturity and agreement of “Care Plan” that it is difficult to see even 80% agreement amongst systems, and even those are likely not “correct”.
- Not sure how to get the FHIR team more engaged with the PCWG on the complex piece of care plan to

o Structured Documents Project Scope Statement- Consolidated CDA DSTU 2013 Update

- To be discussed this week:
Q4 Tuesday
Q1 and Q2 Thursday
- Context
- Broad scope statement to cover 3 aspect
- One part is being sponsored by MASS HIE (becon grant), another by Partners – to fix the ambiguity in consolidated, then there is the care plan CDA document type through CDC and ASPE

o Scope

This project will make various updates to Consolidated CDA, limited to:

• Updating the existing C-CDA Consult Note and creating Referral Note and Transfer Summary document types, incorporating existing templates and new data elements identified by ONC S&I LCC community providers as priority for the delivery of care when transitioning a patient from one provider and/or setting to another.

• Creating a Care Plan document type, using existing C-CDA templates plus new templates identified by ONC S&I LCC community providers aligned with HL7 Patient Care WG’s Care Plan DAM.

• Incorporating C-CDA errata that have been identified and approved by HL7.

• Updating Meaningful Use Stage 2 templates (i.e. those C-CDA templates that map to Meaningful Use Stage 2 data elements) based on comments received through the C-CDA DSTU page.

o Note: PCWG is working on the model for the care plan in development. (the one on the ballot site now, will likely not be the one included on the next ballot (per Kevin – he is creating another model)

o Enrique has agreed to do a modified model for CDA

o Not sure we will need a stable model – there will always be changes due to the complexity of the model.

o For Bullet 1 – would like to see the relationship between consult note and referral note and care plan called out.

o Active use of the DSTU page for errata publishing. These are often very straight typos – this bullet will pull these in and fix the issues.

o Fourth bullet is a clean up as well.

o Currently targeting Monday S&I Call for these meetings. Hope to accommodate all of the scope topics in this call – but yet needs to be discussed. Times of calls need to be coordinated to closely

Patient Care Monday Q4


Stephen Chu (Chair)

Michael Tan (Scribe)

Elaine Ayres (documenting ballot comments resolutions)

Russ Leftwich (

Laura Heermann Langford (

Christina Knotts (

Carolyn Silzle (

Jean Duteau (

Lorraine Constable (

Patricia Greim (

Allergy/Intolerance and Adverse Reaction DAM second informative ballot Comments reconciliation

• Block vote on the typos issues that will be corrected by Elaine: 7 in favor and 1 abstain.

• The Negative major is from Jean Duteau. The term Manifestation was misunderstood. Jean was meaning “occurrence” while Stephen and other clinicians understood as manifestation of signs and/or symptoms similar to OpenEHR term. This was discussed in the conference call. The text and model in the DAM will be updated to ensure consistency with FHIR resources on Allergy/Intolerance and adverse reactions. Vote on the disposition: 8 in favor, 0 abstain.

• The comment from Terrie Reed is not considered persuasive. The use case story is not meant to be exhaustive. The model does capture the possibility of inclusion of test results. Vote on the disposition: 8 in favor, 0 abstain.

• The next comment from Terrie is not regarded as persuasive. The submitter does not seem to require any action. No allergy test is 100% sensitive or specific. It depends on the judgment of the clinician and the clinician should be allowed to include the allergy to the list. Vote on the disposition: 8 in favor, 0 abstain.

• The next two Neg-Mi comment from the FDA are not regarded as persuasive. The view is that regardless of the definitions the care provider might want to decide for himself on the status. The purpose of the DAM is intended to convey the clinicians belief that a risk for an adverse sensitivity exists. It might not be possible nor it might be undesirable to expose the patient to challenge test for the purpose of confirmation. The reference is meant for allergy specialists but the DAM is meant for general clinical use. Vote on the disposition: 9 in favor, 0 abstain.

• The next Neg-Mi comment about “unconfirmed” from the FDA is persuasive with mod. The term unconfirmed is replaced with “suspected” in the glossary. Vote on the disposition: 9 in favor, 1 abstain.

• The comment from FDA about latex is not seen persuasive. The term latex is commonly used in healthcare.

• The removal of the link on page 31 will carried out. The link does not seem to be in every version of the PDF. Vote on both dispositions: 10 in favor, 0 abstain.

• The suggestion to consider requirements for Public Health reporting is considered, but no action is required. Actually we thought we had addressed the use case. Vote on the disposition: 10 in favor, 0 abstain.

• The negative votes from the previous ballots were withdrawn except for the FDA. Elaine will contact ballot comment submitter to review and withdraw negatives where appropriate


All ballot comments dealt with.

Ballot reconciliation completed.

Jean and Lorraine will update the model and send document to Elaine to update the texts to reflect all agreed/approved ballot dispositions

Ballot disposition spreadsheet will be uploaded to HL7 ballot desktop by co-chair; and email request to ballot submitters to review resolutions and withdraw negatives where appropriate.

PC Monday Q5

Both project leads (Stephen and Laura) have to attend co-chairs meeting in Q5.

Care Plan Q5 meeting cancelled.

Patient Care Tuesday May 07 2013

Patient Care Tuesday Q1


Kevin Coonan (Chair)

Stephen Chu (Scribe)

Laura Heermann Langford (

Enrique Meneses

Susan Matney (

Wendy Huang (

Dick Donker (

Alex Deleon (

Russ Leftwitch (

Margaret Dittloff (

Topic 1:

Encounter Vocabulary

Harmonization/HL7 vocabulary change Proposal: to add one concept to ActEncounterCode under ActCode code system to indicate a type of patient encounter that indicates it precedes a subsequent encounter

Rationale: to support the identification of patients who are scheduled to visit a on a future date. This allows clinical results (e.g.: Lab, Diagnostic Imaging, etc.) be attached to the "PRE" encounter type to remain attached to the encounter (and follow the patient) when the account is changed from the PRE status tone of the other encounter types – ambulatory, short stay, inpatient (acute or non-acute, if known), etc.

Discussions on rationale for the proposal ensued. PA representatives in participation.

Motion: to endorse proposal to add one HL7 code (PRE) to ActEncounterCode to support the business requirements of correctly identifying patients visit before subsequent encounters of ambulatory, inpatient, etc

Moved: Wendy; Seconded Margaret

Votes: abstain: 1; against: 0; 7 in favour

Motion carried.

Topic 2:

Care Coordination Services Functional Model (CCS-FM) Informative Ballot

Comments Resolution

Ballot comments 61, 62, 63, 64, 65, 66

After a considerable amount of discussion on the ballot comments on these two item, it was moved (by Russ) that follow-up with the submitter to seek further inputs would be required (seconded by Laura).

Votes: abstain: 0; object: 0; in favour: 7. Motion carried.

Ballot comment 67

Disposition result: ballot comment considered non persuasive. Reason: there are multiple types of psychometric measurement scales. The balloted document contained examples only.

Move: Laura; second: Russ
Votes: abstain: 1; Object: 0; in favour: 6. Motion carried.

Ballot comment 69

Ballot comment on this item was considered persuasive.

Motion: system should have context information (e.g. health concern, health risk) as pre-condition. This information should also be inputs to determine NewProposedAction. Remove [optional] from text.

Move: Stephen; Second: Laura. Motion carried.

Outcome: Enrique to schedule conference calls (Tuesday 5:00pm US Eastern). Comment submitter to be contacted to participate in ballot comments resolution. First conference call to start after Atlanta WGM.

Patient Care Tuesday Q2

Joint with Anesthesia: Vital signs representation

(Anaesthesia not represented)


Kevin Coonan (Chair)

Elaine Ayres (Scribe)

Susan Matney

Jim McClay

Laura Heermann Langford

Carolyn Silzle

Michael Tan

Review of Project Statement:

Vital Signs and Anthropometric Measures- DSTU for Detailed Clinical Models.

Kevin has a new project scope statement for vital signs and anthropometric measures. Designation of project participants determined – Project Facilitator – Kevin Coonan, Modeling facilitator – Kevin Coonan, Vocabulary – Susan Matney, Domain Expert – Laura Heerman Langford, others TBD.

Implementers – TBD

Project purpose – create templates and CMETS for vital signs and anthropometrics.

Clarify short and long-term monitoring -

Add head circumference to scope. Will use length (vs. height). Note – limited to ED, Anesthesia types of measures. Add level of consciousness.

Ask to make a more discrete list – the actual most used measurements. Remove to future list – CVP, Pulmonary artery catheter value for CO, PCWP, PAS, PAD, mixed venous oxygen saturation, continuous ECG monitoring.

Current elements – heart rate and pulse rate, including fetal heart rate, systemic arterial blood pressure, heart rhythm, temperature of patient, respiratory rate, oxygen saturation as measured by pulse oximetry, person length (height), person weight, Occipital Frontal Circumference (OFC). (Consistent with Structured Documents CDA).

Need to consider LOINC value sets – potential set HITSP CDA value set.

Most difficult concept is the clinical context of the measures.

What are existing vital signs models – Open EHR, CIMI, DEEDS, IHC CEMs.

Outcomes – implementation guides and CMETS.

Timeline for the PSS was developed. Goal is to ballot May 2014.

Will have routine calls with other groups – looking at 5 PM eastern on Mondays or Thursdays.

Will complete PSS and send to ED, Anesthesia and Devices.

Patient Care Tuesday Q3


Elaine Ayres (Chair)

Michael Tan (Scribe)

Russ Leftwich

Margaret Dittloff

Lorraine Constable

Kevin Coonan

Christina Knotts

Daniel Henzi

Gaby Jewell

Topic 1:

Project scope statement discussions:

• PSS Patient Preferences:

- This is the next step after the DAM after the successful of ballot of Diet and Nutrition. The participation of Pharmacy in co-sponsoring this project is questioned. The requirement is to broaden the preferences for drug therapies as well. In the Diet and Nutrition patients can state their preferences for food. This is almost similar with drug therapies. But the group is reluctant to broaden the scope. This has not been described in the use cases of the DAM. (I.e. positive preferences.) Up till now the use cases have only dealt with “dislikes”. The team does not feel comfortable in moving the topic to a more generic level.
- The suggestion is to put down a separate project scope statement under supervision of patient care.

• PSS: Ballot material for Allergies and intolerances.

- The project scope statement is filled out. A second implementation candidate ( besides the Netherlands) is still vacant. (Cerner is only interested in mapping).
- On the binding with value sets we must bear in mind, that the ballot material should be modeled for the Universal realm and not specifically only for a particular country.
- Environmental allergies ( such as poison ivy) are not described in the DAM and therefore out of scope. Latex is in scope. Questions about biologicals. They are actually not medication, but they are ordered.
- The goal is to go for DSTU. The ballot is planned for September 2013.
- CDA r2 has known issues for not being able to cater the previous allergy model. Kevin questions whether it is not possible to bring out a patch on the clinical statement or either go to CDA r3. This topic should be addressed with Structured Documents. Action item: Kevin Coonan
- Kevin would like to produce the ballot material for the US realm and add SNOMED as the vocabulary binding, but Elaine and Michael do not agree. The ballot should be prepared for the Universal realm and then the US can derive a specific US realm product with constraints for the US.
- Vote : Michael moves the PSS for a vote. Second from Russ. 6 in favor of the PSS. 2 abstain

Topic 2:

Health Concern topic discussion

- Ran out of time. To be scheduled to another time.

Patient Care Tuesday Q4


Kevin Coonan (Chair)

Elaine Ayres (Scribe)

Daniel Henzi

Russell Leftwich

Lloyd McKenzie – FHIR representative

Gaby Jewell

Jean Duteau

FHIR Discussions

Lloyd McKenzie – Review of FHIR spec. ballot reconciliation – allergies and intolerance, care plan, family history.

1. Adverse reaction – substance or reaction for inclusion (not the list). The record of an adverse reaction must have one symptom and one substance.

2. Exposure type – codeable concept – using original text. Have drug administration, Immunization. Jean to replace with a better code set.

3. In FHIR – a medication is not a substance. Immunizations are in the medication class.

4. Adverse reaction – adverse sensitivities ….about reported or anticipated adverse sensitivities to substances. Will go back to requester for further clarification.

5. Care plan status – planned, active or ended. Is there a need to add more codes? Add a completed code is proposed and ended can imply termination. Act status will not be used as too abstract. Add a resource link to superseding care plan. Kevin suggests for planned use draft (new), active, held (suspended), ended and completed.

6. Family History – Relation discussion – related person will be changed to a string for name, relationship concept – 1.1 and codeable concept, deceased will be changed from date/age to age or age range at death. For onset use Age|Range.

7. Severity should be a codeable concept.

8. Problem – codes need further specification.

9. Asserter – accepted newly defined definition for asserter.

10. Problem – reference to a problem resource or a string.

11. Procedure – merge description into problem resource.

12. Procedure – performer needs to be mandatory.

13. Change definition of procedure to changing physical, mental or other condition.

Have five remaining items. Will need to schedule for an upcoming call to resolve remaining issues with Lloyd McKenzie.

Patient Care Wednesday May 08 2013

Patient Care Wednesday Q1


Kevin Coonan (Chair)

Elaine Ayres (Scribe)

Elysa Jones

Jay Lyla

Clay Mann

Brian McCourt

JD Baker

Russ Leftwich

Mitra Rocca

Rob Savage

Erin Holt

Anita Walden

Maryam Younes

Meredith Nahm

Susan Matney

Lavanian Dorairaj

Laura Heerman Langford

Jim McClay

Dianne Reeves



Meeting minutes:

1. Elysa Jones – PHER Project - (OASIS) Presentation of EDXL Tracking of Emergency Patients – TEP Patient Care WG is a co-sponsor

New XML extension mechanism which will enable better message exchange under EDXL.
Document will be available for a 60 day review.
Tracking emergency patients – V2 and V3 with two PSS. Specifications between TEP and V2 and V3 messages.
Disaster triage and evacuation of hospitals included so therefore bi-directional.
Based on NEMSIS 2.2.1 and tested in Tennessee (NEMSIS mapped to SNOMED).
This is an implementation guide with storyboards to display different types of emergency scenarios.
The document does define transport – message header with message transport types.
Have a section on extensions for augmentation of data transfer capabilities.
Tracking of emergency patients vs. clients (separate). A client is for example a refugee.
Terminology – TEP defines in data dictionary but discussed terminology standards.
Action: Suggested SNOMED-CT as a standard.
Vehicle – need to know location and potential arrival time at ED.
Mapping to other standards would be helpful.
Review of PSS – Patient Care would be a co-sponsor. Interested parties – EC, PA, EHR and CIC.
Need a terminology SME. This will be informative project.
Is this a document or a message? This is a specification, so more mapping, not a document. Maps TEP to V2 or V3.
Motion: Include CDA in the V3 PSS. Jay/Susan moved. Discussion – 50% mapped to NEMSIS. Also includes patient/client tracking information. CDA are good for patient care hand-offs. Managing resources is not CDA. Can provide a transform to systems that can use a CDA. Can a receiver ignore what they don’t want. Need more of an analysis of the need for a CDA.
Amended motion: The analysis for the inclusion of a CDA should be included in the PSS V3.
Jay/Rob Votes: 0 negative, 4 Abstensions, 15 approved.

2. Jay Lyle – CIC Trauma Registry System PSS – DSTU US Realm

Scope statement now sent to PSC – question clinical validity of the spec. Need more clinical vetting. Goal – to develop a CDA implementation guide based on the Trauma DAM to support submissions to ACS National Trauma Data Bank (NTDB).
CIC and SD sponsoring. US realm project. Seeking Patient Care concurrence.
Will there be data extracted and transferred from ED systems? This would come from the hospital to the registry. Local trauma registries – multiple vendors. This will give these systems a standard format. Are the vendors represented? There are five vendors that have been involved and willing to participate in DSTU.
This project needs to be constrained to one way message from ED to registry.
Unintended consequences with meaningful use? Will all ED’s be required to submit.
Why a CDA – just use a V2 message. This is not needed for a generally consumable standard – just through specific vendors dealing with a central registry. Reports sent to trauma quality improvement program.
Using current models or are new models. EMS spec – normative this fall. Harmonization is through existing templates. Request – modeling done with other work groups.
Joint meeting in September – PHER/CIC/Emergency to focus on ballot reconciliation.
EHR data elements – needs joint with CIC and EHR with Patient Care.
Note that CIC DAM’s not moving forward to implementable standards. Need to refine these hand-offs. DAM’s have UML class diagrams – need something that can be used by clinicians. Needs to address through MnM.

3. CIC Activity Update – Anita Walden

a. Cardiology Ballot reconciliation – Cardiac Imaging DAM. Supported by a number of professional societies. Have over 500 data elements. Have 600 ballot comments and are in ballot reconciliation. R3 – imaging to meet needs of FDA and professional societies. To facilitate standards for stakeholders. There is a related CDISC standards, a registry need. NEXT STEP – core set of data elements to CDSIC. Any work with structured documents for imaging report? IHE has a cardiac imaging content report profile.
b. Trauma Domain Analysis Model – was approved. Will be published.
c. New projects – EHR usability and CIC will participate. DAM’s for schizophrenia. MAX Tool – works for any UML models. Need help for export of UML’s from DAM’s. Abdoul Malique managing this project. EHR has a tool for functional profiles. Several other tools – Lantana Trifolio and Detailed Clinical Models (DCM).

4. Kevin Coonan –

a. Quality of clinical content specifications is a concern of Patient Care.
b. Single model of a patient centric concept-oriented lifetime health record
i. Episodic (encounter based)
ii. Health Concerns
iii. Care Plans
c. Patient Care wants to be more engaged in this process – as a resource for other groups dealing with clinical content specfications.
d. Two immediate activities –
i. CDS orders and plans of care – re vMR ballots.
ii. Structured docs – plan of care.
iii. S & I – CDS and Health e-Decisions. (PC working with LCC).
iv. IHE – cross-document workflow. (NOTE CCS project).

5. Retain Wednesday Q1 as joint PHER/CIC for September 2013 WG meeting.

Patient Care Wednesday Q2

Presentations by PCWG delegate to EHRWG


Stephen Chu

Kevin Coonan

Elaine Ayres

Russ Leftwich

Laura Heermann Langford

Presentation to EHRWG by Stephen and Elaine

Allergy/Intolerance and Adverse Reaction (see slide deck for details)

slide deck:

Care Plan project (see slide deck for details)

slide deck:

Patient Care Wednesday Q3

PCWG-SOA Joint meeting on Care Coordination Services Functional Model (PCWG Hosting)


Stephen Chu (Chair)

Elaine Ayres

Kevin Coonan

Enrique Meneses (via conference call and webex)

Bo Dagnall

Ken Rubin

Iyrna Roy

Strafano Loni

Jon Farmer (via conference call and webex)

Vince McCauley


The project for Care Coordinated Services Functional Model is working with the S&I framework Longitudinal Care Coordination (LCC). Also working on care plan model through IHE in addition to activities through HL7.

May 2013 Ballot - attracted approximately around 80 comments. Many comments from the S&I Framework representatives

Working through ballot comments reconciliation during Atlanta WGM. Will continue on conference calls after Atlanta meeting.

Some of the issues noted on the ballot pertain to the Care Plan DAM, not the CCS. These comments will be addressed by revisions to the Care Plan DAM.

Question if there are significant issues raised about the functional model. First pass analysis does not appear to identify "show-stopper" type of issues. Reviewed the ballot site content done to provide those present at this meeting with a sense of the type of comments.

Question – how does CCS relate to the continuity of care record? This was a question from the S&I Framework.

What are next steps on this project? If ballot reconciliation successful address all comments and issues, will progress to DSTU ballot in September

SOA has supported the CCS work – SOA has weekly calls that spotlight projects on a rotating basis. SOA wants Patient Care to manage the project – SOA will interact with Enrique and will depend on Enrique to update the SOA work group.

Strategic planning – how does the CCS harmonize with other projects (SOA question).

Will complete ballot reconciliation and will then refine the ballot document as per comments. PC will plan on resubmitting this ballot in September 2013 for the DSTU phase. Will then move on to the OMG technical specification development. Enrique asked about the scope of the PSS.

OMG process to develop an RFP takes two meeting cycles. OMG meets quarterly. The next OMG meeting in June, followed by a meeting in September concurrent with HL7.

Recommend that prior to complete ballot reconciliation is entirely complete in September – give OMG a document to begin work and specify standards based on HL7 work as of a certain date. Note that the September ballot will close the week prior to HL7/OMG. If supposition is that the ballot will pass – OMG can move ahead.

For September meeting – have joint SOA and PC and do ballot reconciliation.

Will retain Wednesday Q3 as the joint SOA and PC meeting, with PC hosting to discuss relevant issues.

Remainder of ballot reconciliation will be done via conference calls over the next several months. Note that S & I timeframes are brisk.

The model is working well with other countries – issues with plans of care. The terminology on different types of plan (care plan, plan of care, treatment plan) is confusing. This will need to be addressed by glossary, definitions and synonyms. However, all business requirements can be aligned with the model.

Patient Care Wednesday Q4

Allergy/Intolerance and Adverse Reaction meeting


Stephen Chu (Chair)

Michael Tan (Scribe)

Elaine Ayres

Russ Leftwich

Margaret Ditloff

Christina Knotts

Rob Hausam

Tom de Jong

Jay Lyla


• Update on the status Allergy and Intolerances for other WG ( who are on the sideline)

May 19th New PSS defined for Modeling Allergies for DSTU.
July 7th NIB due
July 14th Initial content for allergies
July 28th final content.
DAM for allergies has been balloted twice and has passed.
Netherlands will be implementer of the DSTU Clinical model.
There has been some discussion whether an implementation guide is part of the project scope. The implementation guides will be set up after the first ballot round.
For Netherlands the binding will be with Dutch value sets such as the G-standard. Kevin would like a generic binding within SNOMED-CT, but Robert has never heard of that. The binding with terminologies will be within the concept domain.

• Update on the PSS of Diet orders. The PC WG will continue with the work which is described currently in the DAM. The medication preferences has to described in use cases as well. The ownership of the project lies now within PC. But if Pharmacy would like to pick up the drug preferences then PC would not object. Tom suggests to give the lead to O&O because they have a neutral position and have experienced co-chairs.

• Conference call for Care Plan is scheduled for the 15th May.

• The conference call for the allergy project is every Wednesday starting on the 22nd of May at 5 pm EST.

• The Pharmacy WG will be co-sponsor of the allergies project. Pharmacy will discuss the PSS for allergies on their conference call on the May 13th.

• The topic of health concern will be discussed on Thursday May 9th Q1. Stephen will look for a room.

• Co-chairs of PC will convene on Friday morning May 10th during breakfast.

Allergy/Intolerance and Adverse Reaction Project update slide deck:

Patient Care Thursday May 09 2013

Patient Care Thursday Q1

Two tracks of meeting happened during Thursday Q1

Track 1: Joint PCWG-OO-CDS meeting (OO Hosting)

Track 2: Health Concern discussions

Track 1: Patient Care Delegates to OO-PCWG-CDS joint meeting


Stephen Chu

Elaine Ayres

Margaret Dittloff


Updates from CDA-SOA:

Service Interface Specification project update: contract from VA for 12 months to produce a set of services interface specs – ballot May 2014
Services functional model for delivering alerts, recommendations and other notification using email, sms, voip and other comm channels
Provide for routing and or escalation – tracking target to deliver the alert messages
Service functional mode for ordering pharmacy, lab, radiology, consult and nutritional services

Support applications and service-to-service interactions required, e.g. by CDS

Service functional model for subscribing to clinical events of interest and receiving notice when new data is available
Support two common forms of filtering: topic-based and content-based
Project scope statement discussed and approved at this joint meeting
OO as primary sponsor and CDS as co-sponsor
PCWG co-chair recommended leads/co-leads of this project to liaise with Care Coordination Services Function Model project team co-leads to ensure collaboration and harmonization where appropriate.
Recommendation to PCWG - keep close watch on this project and provide inputs/comments where appropriate

Update on Allergy/Intolerance and related projects from PCWG:

Allergy/Intolerance and Adverse Reaction DAM progressed through second informative ballot in the May 2013 ballot cycle. Ballot reconciliation of comments is essentially completed. Will progress to DSTU ballot next phase.
Allergy/Intolerance project scope statement to develop DSTU artefacts: voted and approved by OO and CDS as co-sponsors. Will go to Pharmacy for approval via conference call on Monday after the WGM
Food and medication preference project – discussed at OO-PCWG-CDS joint meeting. OO agrees to take on primary sponsor role as preference information is key to ordering processes in general. Patient Care, Pharmacy and CDS as co-sponsors. Project scope statement will also go to Pharmacy for co-sponsoring endorsement
Latest update - Both allergy/intolerance and preference PSS has been discussed at pharmacy meeting in Atlanta. A couple of questions on Allergy/Intolerance DSTU artefacts and implementers have been raised by Pharmacy which will be addressed during next week. Pharmacy will initiate e-vote process to complete the assessment. Goal is to have the PSS ready for submission before 17 May.

Updates on Care Plan:

as per update to EHRWG

Updates from CDS:

VMR – v2 implementation guide: currently in ballot reconciliation process

Track 2: Health Concern - PCWG meeting


Michael Tan (chair and scribe) Kevin Coonan Tom de Jong Laura Heermann Jim McClay Patricia Greim


Patient Care Thursday Q2

Joint PCWG-Structured Doc-Template meeting


Stephen Chu – Chair Elaine Ayres – Scribe Michael Tan Kevin Coonan Russell Leftwich Robert Dieterle Viet Nguyen Kai Heitman Brett Marquard David SundarinStukel Benjamin Flessner Lisa Nelson Vinauak Kulkami Iryna Roy Gaye Dolin Bob Dolin Kunal Agarwal Larry Garber Tessa vanStijn Laura Herrmann Margaret Dittloff Mark Shafarman Amnon Shabo Brian Scheller Harray Solomon John Roberts Zoran Micosevl Anil Luthra Sarah Gaunt Kanavar Setthi Sabrina Gonzago George Kenorria Mark Roche Robert Wood Diana Behling Anne Smith Rusty Henry

Agenda: Templates Update (Templates) Allergy Project (PC) Care Plan Topic (PC) CDA-IG (SDWG)


Templates update: – Kai Heitman

Goal – DSTU ballot R2 planned for discussion in September WG meeting and then ballot in January 2014.
Template versioning – note dimensions of versions as well as inter-template relationships.
Need to define relationship to other artifacts.
Testing against the tooling – update on ART-DÉCOR. Have introduced a template repository – refers to other projects such as C-CDA, IHE, epSOS.
Template is a constraint to a current model – this scope is to describe templates constructs. This is not a new model. Must be able to share templates between organizations as well as governance groups.
Template update slide deck:

Updates on Care Plan:

Care Plan DAM/Care Coordination Service Update – Laura Heermann Langford, Gaye Dolin, Bob Dolin
Care Plan DAM – will be balloted in September 2013, the CCS was balloted in May 2013.
Project Scope Statement for Consolidated CDA DSTU 2013 Update – looking for PC co-sponsorship.
SDWG – will vote Thursday, May 16, 2013
Other interested parties – ONC S & I LCC WG, IMPACT Project, NYeC, Healthix, CCITI, DHHS ASPE, CDC, CMS, IHE

Updates on C-CDA Project on Care Plan:

Larry Garber update – re C-CDA Project.

Policy for Stage 2 and Stage 3 MU.
Criteria for transitions of care.
IMPACT project in Massachusetts is funded by ONC.
Update to consult note, new templates for referral and transfer of care summary and plans of care.
Will be balloted in September 2013.

Discussions on C-CDA: Care Plan project:

Builds on previous work on the structure of the care plan. The vision of care coordination is the driver in the US and also internationally.
Rename C-CDA will become C-CDA: Templates for Clinical Notes.
Make sure that the concept that care plan and referral concept is not lost – need to ensure a closed loop referral.
Should address the patient participation in this process.
Ensure the scope addresses the care plan notes and referral summaries.
How will you identify team members – especially those in and outside of an organization? Also need the relationships within the care team. This is in scope.
Health concerns, goals, status, care team members and status are the key pillars of the project.
Will coordinate with Templates, IHE and digital signatures.
Identify new section and document level templates essential to this process.
Documents will be housed on S&I wiki pages.

Clarify scope additions – patient generated document, genomic testing results, digital signature approach.

Discussion of US Realm specificity. Issue of value sets vs. concept domains bound to realm-specific terminology. Need to look at how to best take the CDA and make universal.
Current IG has value sets based on a particular realm.
Recommend a gap analysis from US realm to international realm to move towards an umbrella C-CDA. The European Union is interested in such a gap analysis. Keith Boone through IHE PCC is looking at requirements for a universal C-CDA.
As co-sponsor – what are expectations of Patient Care? Recommend one working sub-working group. Currently part of Monday S&I WG LCC call (11 AM ET). Question if another weekly call is necessary. Will do a Doodle Poll. PC would like to review prior to balloting.
ACTION – Patient Care to co-sponsor this PSS Russ/Laura moved. Abstain – 0, Oppose – 0, Approve – 13.

Update on Allergy/Intolerance project:

Patient Care – Allergy and Intolerance Project Update – Elaine Ayres and Stephen Chu
Use of templates, terminology work questioned.
DAM now complete – moving to clinical models DSTU with implementation guide for documentation.
Use of implementation guide – have US realm IG value sets already. How can we work with SDWG to create universal templates?
Will this work influence the existing C-CDA templates? Agreed that this project will result in the need to make changes to the current C-CDA templates. Key concepts in the DAM include the concept of a condition and the difference between the signs and symptoms and criticality.
Concept domain for allergies – yes, I have an allergy or no, I don’t will be described in the next phase of this project.

Discussions on: Patient Generated Documents

Is a PGD only for provider to provider? No – is designed to convey clinical documents. Is there need for “legal authentication”?
Should there be a provider C-CDA and a patient C-CDA. MU states must be able to use a CDA document. Patient generated documents ot currently in MU. What does in C-CDA mean? Balloting individual IG’s will probably not continue. Can use same templates may use different balloting mechanisms.
A repository of templates may be a better approach. Inclusion in C-CDA does not mean inclusion in MU. However, it is better if the templates are tied together.

Patient Care Thursday Q3

Clinical Statement: Host - CS

PCWG delegates to CS


Stephen Chu

Kevin Coonan

Michael Tan


Clinical statement completed normative ballot in May 2013 ballot cycle

Topic 1: Clinical Statement Normative Ballot - comments reconciliation

One negative comment requires structural vocabulary harmonization - Supply mood code set missing a couple of essential mood codes

Considered as significant change

Requires resubmission for ballot in September

Passed motion to accept ballot reconciliation and move forward to request withdraw, and prepare for September ballot

Topic 2: Tooling liaison update

Tooling requirement from Clinical Statement: Clinical Statement team requires to perform model harmonization with models produced by other groups that have impact on structural and semantic aspects of Clinical statement model. This is current a manual process which is very labour intensive process and error prone.

Requirement: automated model<->model transform checker/validator

such tool is very difficult to produce

But may be possible with producing OWL based representation to RIM of two models, then compared the OWL outputs of both models to determine differences

An OWL tool has built in tool to do OWL representation comparison. More works will need to be done. This is a working process tooling project.

Information on tooling liaison:

Patient Care Thursday Q4

Clinical Statement: Host - OO


Stephen Chu

Kevin Coonan

Michael Tan


This quarter is dedicated to discussion on a v2.8 issue

See Clinical Statement Atlanta meeting minutes for details

Patient Care Friday May 10 2013

Friday Q1 and Q2

Child Health

Present - PCWG delegates to Child Health meeting:

Stephen Chu

Russ Leftwich

Elaine Ayres


Child Health EHR Functional Profile Release 1
Co-sponsor C-CDA 2013 update
Portable health record template
EPSDT Milestone template
Paediatric nutrition and diet
Anthropometrics Template
Developmental survey electronic Q&R


Topic 1:

Child Health EHR Functional Profile:

Child Health Group plans to initiate a project to reaffirm HL7 child health EHR functional profile release 1
A PSS scope statement was reviewed and approved
There does appear to be any problem with the contents of EHR Functional Profile on child health. But the contents do not appear to be as granular as they should be
The group identify the need to take up a new project to review and develop new functional requirements for inclusion beyond reaffirmation of the Release 1 work

Topic 2:

Portable Health Record:

This is intended to create a form on child for parents to carry for emergency
Meds, problems, allergies, providers
Special instructions/directives (on treatment/special procedures, e.g. vascular access), esp for special need kids
AAP has template on website
Merge with ‘summer camp health form
CDA abstract of PHR (personal health record) or EHR
Considered to be highly useful and should be support

Topic 3

EPSDT Milestone Template (similar to Australia’s Child eHealth Record)

Plan to create CDA template
Contents: longitudinal record for individual
Exchangeable with PHR
Registry of documents
Align with Bright Futures program (for monitor development of children across the board)
Diet and nutrition section
Key issues for continuity of care information requirements:
Height/length, weight history/head circumference
Percentiles based on growth charts
Z scores for <5th and > 95th percentiles
Diet/feeding history: oral intake, supplemental intake
Food allergies
Dental history
Developmental or medical issues impacting nutritional status
Motor skills/physical activity
Cross walk of the information requirement against EHR functional profile. There are alignment with the following:
DC1.4.1 – food allergies
DC – non medication orders
DC 1.8.4 – clinical measurements (Ht/Wt)
No provision for nutrition templates
Anthropometrics Template:
Section template as described for nutrition

Topic 4 Developmental Survey:

Adapt balloted electronic survey and responses
Enable software services that could return template survey responses to EHR

End of PCWG May 2013 Meeting Minutes