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May 2015 WGM Paris, France: May 10 to May 15

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Paris, France, WGM - May 2015 Patient Care WG Meeting Approved agenda:

Paris, France WGM - May 2015. Patient Care WG Meeting Meeting Minutes

  • Sunday, May 10 - International Council Meeting
- No PCWG meeting

Patient Care WGM, Monday, May 11, 2015

Monday Q1

Plenary Session. Pt care attended plenary sessions and did not meet.

Monday Q2

Plenary Sessions. Patient Care attended the plenary meeting and did not have individual meetings.

Patient Care Monday Q3

EHR hosted multiple clinical groups including Patient Care. All groups, including Patient Care provided updates on the work completed, work in progress and areas where member engagement could occur.

The Patient Care slide deck is here: Paris 2015 Mondday Q3 Patient Care

Patient Care Monday Q4


  • Elaine Ayres ( chair)
  • Emma Jones
  • Laura Heermann Langford
  • Jay Lyle
  • Michael Tan (scribe)

Patient Care Administration Slide Deck Monday Q4


  • The minutes from San Antonio were approved. Moved by Laura, second by Michael.

Vote 4 approve, 0 against, 0 abstain.

Agenda review

  • CQI not present, so preparation of Connectathon Geneva will be added to the agenda. Laura will chair and Emma to scribe.
  • Brett wants to discuss some ballot comments on allergies on the joint meeting Wednesday.
  • We need a room for the co-chair lunch. This is instead of the Friday Q0. * Invite Stephen for Concern topic on Thursday.
  • Agenda moved by Laura and second by Emma: 4, 0,0.

WG Health

  • Patient Care has a healthy track record. We got a gold star again.
  • Co-chair elections have been deferred.
  • Elaine Ayres, Russ Leftwich, Laura Heermann Langford, Michael Tan's positions are due for re-election.
  • Extension of Elaine's co-chair position will not be likely , due to change of management at her office.

3 year planning

  • We will close project 1086.
  • What do we do with the DSTU of allergies and intolerances project 1004. We need to give comments before we can put it forware to Normative Edition. Please
  • Project 927 Vital Signs will be closed.
  • Project 881 Allergies DAM is completed and can be closed.
  • Need to check on assesment scales project 664 with William Goossen.
  • Check on project 661 on DCM for medical devices with Anneke Goossen.

New Projects

  • Care Plan EHR-functional model
  • HSI ( Healthcare Systems Integration) Reconciliation. This has been tested in IHE with CDA templates. The intention is to test this with FHIR resources.
  • Stephen Hasley: Maternal Health
    • Has organized active parties in maternal health.
    • Put up a data-set of about 600 data elements.
    • Project would probably look very similar to the CIC effort or the DEEDS project. Stephen would probably look for funding. Is Hasley a HL7 member?
    • This would also need a co-chair to guide the project. Would Russ pick up this project?

Patient Care WGM, Tuesday, May 12, 2015

Patient Care Tuesday Q1


  • Michael Tan
  • Ken Chen
  • Laura Heerman Langford (chair)
  • Michelle Miller
  • Stephen Royce
  • Joshua Mandel
  • Jay Lyle (scribe)
  • Michel Rutten
  • Michael Donnelly
  • Emma Jones
  • Richard Errema
  • David Hay
  • Lloyd McKenzie (lead)
  • Simone Heckmann
  • Richard Kavanagh
  • (one more unsigned)


PC Q1 FHIR There are over 200 items for PC

Target: apply changes by mid-July; target early July to finish review.

  • 6866: Reaction issue. openEHR influence. Why won’t this meet use case requirements? Tabled pending participation of Elaine and Russ.
  • 7121: Procedure status. This could possibly be two resources: one a statement of fact (patient had an appendectomy on this date) and a more detailed resource to track procedure as it occurs. Alternatively, there are simple procedures and complex ones; perhaps address more granular statuses in extension for heavy procedure.

Could procedure be compositional, including steps that may or may not be resources?

How do systems act? Some interfaces focus on one procedure; some query sets.

We agree it needs to be a single resource: you don’t have to worry about which one to use. Cost is that the 80% boundary is fuzzy. Either make a small one and use extensions, or large one that can be profiled down. Implementers agree: one. Use an extension for additional statuses, via list of steps or procedures. FMG will create a common extension for this purpose.

    • PC task: define the detailed procedure extension. Not a July task.

Laura & Jay moved: 3 abstain; 0 against; 12 affirmative

  • 7123: Clem, procedure category vs type. Category is broad. Type is specific.

Codes make level clear, but rationale unclear. Need better definition for category, and change name for type to code, to align with Observation. No, make it “name.”

Add a note recognizing that care should be taken to avoid letting these elements could be semantically out of synch.

Michael moves; Jay seconds. Abstain: 4; Against: 0; Affirmative: 11

  • 7124: site. Approach vs. target site. Clem suggests target is always precoordinated.

Group feels both are needed, but they need disambiguation.

Perhaps this is target, and approach should be an extension?

No; add a coded property to body site to specify which. Optional, for legacy support. Role.

Jay moves; Stephen seconds. Abstain: 4; against: 0; affirmative: 11.

  • Lloyd provided a preview of 7128 (procedure note) & 7185 (impression) future discussion.

Patient Care Tuesday Q2


Michael Tan (Chair), Elaine Ayres (Scribe), Jay Lyle, Emma Jones, Laura Heermann-Langford, Stephen Chu (remote,) Thomas Kuhn, Lori Simon

Minutes: Michael reviewed the current status of the Health Concern project. There are three variations of use cases. 1. Someone may or may not be concerned with something someone else has put on the list. 2. Care team members may disagree about a judgment. 3. A patient disagrees that something is a concern.

In the Care Plan there is a concept of "expressed by" attribute associated with health concern. This should be represented in the health concern model. The health concern in care plan as expressed by role with 1..* cardinatlity. In Health Concern have "Concern Author" but the cardinality is 1..1.

Other roles in health concern - author, custodian and monitor. Care plan has an author and custodian of the care plan. Is the author of the care plan also the author of the health concern?? (modeled this way currently in care plan as it preceded the health concern work).

What if a concern is expressed in different terms (e.g. different words)? Is this a fourth use case? A diagnosis can be "Name 1" and "Name 2" as the issue evolves. Diagram has a replaces function but noted that arrows should support replaced by. Need to be able to support labels for "expressed" by patient, mom, spouse. Need to be able to distinguish between the author of the concern vs. the author of an event (e.g. a different diagnosis).

The concern has one author, but there can be multiple names of the concern that could be authored by one or more individuals (to support the many events within a concern). Therefore, need to associate authors and events.....

1. Actions - attached an author to an event. Create an expressed by concept with the associated term used by the "expressor".

Note similarities to Chief Complaint -- what the patient said, vs. coded chief complaint. An HPI (history of present illness) will add additional information. A narrative associated with a health concern would help with the creation of chief compliant.

The first expression by the patient -- should that be retained or is it a snapshot? Retaining the term will allow for tracking over time. Would you be able to find this term without the "expressed by".

2. Expressed by will be associated with the event level not the concern level. Cardinality will be 1..* This will allow the dare plan to point to the health concern (grey box). This removes the risk of inconsistency.

The notion of a Concern focal event needs to be addressed as well.

MOTION: To ensure many naming events (1..*) are captured, add expressed by to ConcernFocalEvent as a relationship. This is a role property and will be a separate associated box. Will rename the ConcernFocalEvent box as part of this change.

MOVE: Jay/Laura Object - 0, Abstain - 0, Approve - 6

Issue - SDWG -- deprecated "Clinical Status" in C-CDA 2.0. SDWG recommended use of mood codes. Discuss during Thursday Q2.

NOTE: Include the ED group in the near term to review these changes.

Other issues with the model? no other issues noted.

Other topics -- older models, FHIR, review use cases.

Re FHIR -- look at Condition resource and compare to the Health Concern model.

Patient Care - Nutrition Lunch

Present: Elaine Ayres (Chair), Donna Quirk (Scribe), Eric Haas, Rob McClure, Mark Roche, Jeff Brown, Rob Hausam, Suzanne Maddox, Julia Skapik, Vada Perkins, Mary Ann Slack


  • C-CDA R2 Templates

Elaine Ayres reviewed the C-CDA R2 templates and their representation of the Nutrition Care Process. There have been concerns around Healthy Weights due to public health groups using “reported” height and weight. After discussions with Lantana, the HIMSS Interoperability Showcase included a Healthy Weight vignette. In the vignette, data was exchanged between a PCP and community nutritionist using the Lantana Camara Document Editor with the patient entering data via a patient portal. This was a FHIR based C-CDA exchanging narrative and structured data. Terms have been mapped to SNOMED and LOINC. As of Sunday, May 10, 2015, 4 value sets have been published in VSAC to support the C-CDA R2 nutrition templates. The steward of the value sets is AND (Academy of Nutrition and Dietetics).

  • Allergy and Intolerance

Elaine asked for guidance on terminology binding for allergies and intolerances – UNII vs. SNOMED CT – and how to best represent food in CDA templates and other HL7 standards e.g. diet orders and allergies and intolerances.. It is currently a struggle and terminology does not support the HL7 models. It was discussed that there is nothing in CCDA that dictates one vocabulary over another. Need to give better guidance as a first step, i.e. always look at value sets in domain you are working with. If not there then use this. Might want to put the guidance in the C-CDA IG. A definition of substance vs. product was requested. A substance stands alone (i.e. ingredient). A product is a substance that has had something done to it or combination of substances.

  • SPL and GS1

Elaine reviewed parallel projects to obtain all substances on an ingredient list in a structured format. Continue to look for full ingredient list in structured data format. Right now companies have no incentive to give the FDA their list of ingredients on a food label in electronic format. It is possible to create the Nutrition Facts label in a structured format except for the ingredient list which is a text “blob”. Ingredient lists could be structured in the future. What does the FDA expect? There are still logistical issues such as manufacturers change ingredients frequently and regulations dictate how soon they need to inform FDA or CFSAN of the changes. Could create an index of food products like RxNorm if information is available. Still do not know path forward. Attendees from the FDA will follow-up with CFSAN.

Patient Care Tuesday Q3

Patient Care did not meet this quarter.

Patient Care Tuesday Q4


  • Michelle Miller
  • Robert Haussam
  • Elaine Ayres
  • Emma Jones
  • Jay Lyle
  • Pamela Sicluna
  • Donna Quirk
  • Viet Nguyen
  • Laura Heermann Langford (chair)
  • Michael Tan (scribe)
  • Lloyd McKenzie

Minutes: FHIR topics:

  • Which resources does PCWG own? The ones owned by Patient Care are:
    • Condition
    • Procedure
    • Questionnaire
    • Allergy & Intolerance
    • Clinical Impression
    • Referral Request
    • Familymemberhistory
    • Care Plan
    • Goal
    • Flag
    • Communication
    • Communication request
  • Comment 7855: asserter is ambiguous. What is the meaning of asserter. The asserter is person who believes the information is tru and important enough may be important enough to be recorded. The asserter is the individual who is making the condition statement.
  • If the data enterer is different than the asserter, then this person can be entered under provenance instance pointing to the condition.
  • We need to add "related person" under asserter under the resource "condition".
  • Motion move by Viet. Second by Jay.
  • Voting : 1 abstain, 7 in favor, 0 against.
  • Comment 7859 : Rename "asserted date " to "recorded date". The definition should also change. "date the condition statement was documented".
  • Move Viet, second Emma: Vote: 1 abstain, 7 in favor, 0 against.
  • Comment 6132: The conditon/problem/diagnosis does not contain any (codes for) problem.
  • The chapter heading should perhaps be named "condition category codes". The codes are regarded as mutually exclusief according to Lloyd.
  • Another option is to leave problems as "unknown" . The code set is required.
  • The text e.g. should be removed.
  • This issue was difficult to resolve. Lloyd suggests to modify: required into preferred.
  • Vote 1 abstain.0 against 7 approve.

Patient Care WGM, Wednesday, May 13, 2015

Patient Care Wednesday Q1

Present: Elaine Ayers, Emma Jones, Laura Heermann Langford, Michael Padula, Donna Quirk, Kevin Coonan, Julie Murugi,

Minutes: Hosting Child Health Review of progress of the Child Health DAM and Essential Information for Children with Special Healthcare Needs Working on Storyboards. 4 are in development. Working on flushing out the use cases to make it clear where the points of intersection occur, when points of documents are getting populated. Questions on how to get more input and review on the documents. Suggestion made to take the documents/storyboards through a ballot process. Discussion re: level of specificity for the DAM and the Essential Information for Children with Special Healthcare Needs and the importance to be specific and include examples in the documents as appendices so it does not get interpreted in a more detailed way then intended.

Patient Care Wednesday Q2

Patient Care reps attended the Patient Administration WG. Determined to keep same quarter at the next meeting, Also, will add Thursday Q3 to the agenda as a PA/PC meeting hosted by PA.

Patient Care/FHIR Clinician Connectathon Orientation Wednesday Lunch

Present: David Hay, Mark Janczewski, Viet Nguyen, Emma Jones, Rob Hausam, Pat Van Dyke, Laura Heermann Langford, Keith Boone, Rob McClure, Lloyd McKenzie, Grahame Grieve, Ewout Kramer.

Minutes: Viet Nguyen gave an overview of the agenda for the Friday Clinician Connectathon reviewing the goals and outcomes of the activity as well as the use cases to be addressed by break-out groups. A preliminary review of the tool was also completed.

The group decided that this orientation format should be retained for the Atlanta WG meeting.

Patient Care Wednesday Q3

Present: Michael Tan (Chair), Elaine Ayres (scribe), Laura Heermann-Langford, Tim McNeil, Donna Quirk, Emma Jones, Eric Haas, Rob Hausam, Cecil Lynch, Paul Lomayesva, George Cole, Kevin Coonan, Lloyd McKenzie, William Goossen, Ron Shapiro, Lorraine Constable, Magnus Alsaher, Ken Chen, Viet Nguyen.
Minutes: Joint OO/PC

  • GFORGE: 6216 change word "concern" to goal addresses. Short description needs to be changed. Goal question. Goal concern can reference many resources but it is more the reason a goal exists. Change short definition to: Issues addressed by this goal

Move: Eric/Laura Abstain - 1, Object - 0, Approve - 16

  • Procedure request vs. Diagnostic Order -- Boundaries and Relationships. Will take the wording for procedure request and apply to diagnostic order (Eric Haas).
  • GFORGE 6253 Body Site -- move to a data type is proposed vs. a resource. Use case for bodysite -- tracking a lesion, tracking a fetus, a clinical trial with multiple test sites. Reference body site as an extension, as a codeable concept is usually sufficient.

Move: Eric/Rob re recommendation. Abstain - 2, Object - 0, Approve - 15

  • GFORGE 6213 -- withdrawn by voter. Deferred in version 2.1
  • GFORGE 6214 -- food not included as a substance in Care Plan in product - add codeable concept to allow for food. Change the data type the detail.product codeable concept for medication/substance

Move: Eric/Rob Persuasive with Mod. Abstain - 0, Object - 0, Approve - 15

  • GFORGE 6215 Careplan activity detail vs. Careplan activity notes. Rename /careOkab,activity.notes to.progress. Change short display for CarePlan.activity.progress from Comments about the activity to comments about the activity status progress.

Change short display for CarePlan.activity detail.notes from "Extra info on activity occurrence" to "Extra info describing activity to perform"

Change the long definition for CarePlan.activity.progress from notes about the execution of the activity to notes about the adherence status of the activity.

Add the usage note - does not describe the activity to be performed.

Rename CarePlan.notes to CarePlan.note

MOVE: Eric/Rob Abstain - 0, Object - 0, Approve - 17

  • GFORGE 6250 Communication vs. CommunicatioStatement Appears to be like Medication and Medication Statement. Communication is a statement of what has occurred. In communication request -- planned, vs. communication e.g. what was done. CDS may use current communication patterns. This current resource is a record of an event. Comment is withdrawn. Retain same name.
  • GFORGE 6251 Communication.payload definition should accomodate single and multi-part messages. change to "the communicated conet or for multi-part communications, one protion of the communication.

MOVE: Eric/Laura Abstain - 0, Against - 0, Approve - 17

Note that in communication request the same issue exists. Therefore amend the disposition to include communication request as well.

Retain this quarter for combined PC/OO/CDS/FHIR at the next WG meeting.

Patient Care Wednesday Q4

Present: Chair: Elaine Ayres, Scribe: Emma Jones Michael Tan, Viet Nguyen, Gay Dolin, Brett Marguard, Sarah Gaunt, Donna Quirk, George Cole, Rob Hausam, Jenni Syed

Minutes: Review DAF Profile ballot comments

  • Discussion about the date elements in allergyIntolerance. Clarification needed. Brett will reach out to submitter for clarification.
  • Condition resource - severity - change the valueset to mild/moderate/severe
  • List resource - core resource cannot represent "No known …" is present. Resolution: pass the ballot comment back to FMG.
  • smoking status - observation status has a fixed value of final. Discussion: The use of the data based on a business rule should not happen.
  • Block vote on resolved items. Vote results: Moved - Brett, Second: Gay: against 0 - abstain 0- Approved 9

Per Brett - Ballot spreadsheet is not formatted to support import into GForge. Will format sheet and import PCWG Resources comments. The rest of the ballot comments will be handled using spreadsheet only. Elaine request that comments PCWG has voted on should please get added appropriately so not to have to review them again. Agreement from the group.

Allergies and intolerances discussion -

  • Outstanding question of if SDWG will accept proposed changes as an errata
    • Of the changes, the biggest issue is the representation of severity and criticality - preference should be given to this issue.
  • Other changes include -
    • renaming the allergy concern act
      • Have to maintain the LOINC name
    • Allergy adverse event type value sets
      • can change the name of the value set but cannot change the identifier
      • updated the value set concepts
      • extensive discussion about value sets and binding to value set.
      • Discussion of changes to the structure of the observation code and value structure.
      • Still work on the substance piece
      • Would like to work on the difference between severity and criticality first.

Elaine with post list of changes on wiki and notify Brett of its location

SDWG made aware of cardinality of medication reaction in CCDA 1.1 and 2.0 - 0..1. Need to increase to 0..*. Per Gay, this issue was carried forward from CCD. Direction from SDWG to enter this change as erratas against CCDA 1.1 and CCDA 2.0. Emma will enter erratas

Patient Care WGM, Thursday, May 14, 2015

Patient Care Thursday Q1


  • Laura Heermann Langford ( Chair)
  • Kevin Coonan
  • Emma Jones
  • Michael Tan (Scribe)
  • Stephen Chu ( Skype)


  • Request from Kevin to organize a joint meeting with CDS, CQI about continuity of care. They have common interest. Topics are clinical content for decision support, quality measures and continuity of care. Currently the semantics are not similar. Kevin has discuss the need with CQI, but not with CDS. We will bring this up in the co-chair lunch.
  • The OMG calls out an RFP for implementers to deliver a CCS standards with the use of standards from IHE and HL7. If certain standards do not exist yet, you can fill in the gap for that standards. In Kevin's thought's that HL7 should react to OMG to provide implementable specifications for a implementation. As HL7 we have parts of these specifications and the suggestion is to set up a project with combination of other teams to provide these specifications.
  • We discussed the possibility of a project with Stephen through Skype. Key question is if we have enough bandwith to pull this project. Who will manage the project. This project will need a strong project leader to manage the project.

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


  • Elaine Ayres (chair)
  • Jeff Brown
  • Frederic Larcoche
  • Emma Jones
  • Jeffrey Ting
  • George Cole
  • Tessa van Stijn
  • Sarah Gaunt
  • Benjamin Flessner
  • Rob McClure
  • Gay Dolin
  • Mark Shafarman
  • Tim McNeil
  • Keith Boone
  • Jari Porrasmaa
  • Rob Hausam
  • Michael Tan
  • William Goosen
  • Kai Heitmann
  • Simeon Haefliger
  • David Parker
  • Craig Gabron
  • Donna Quirk
  • Jay Lyle (scribe)
  • Kevin Coonan


  • statusObservation

Status observation: Why is this deprecated? Problem/allergy problem status observation are meant for clinical status Deprecated in 2.0 with recommendation not to use because of inconsistency in how it was used and many misinterpretation. Sarah pointed out that status of the problem concern act is different from the clinical status - such as when dealing with remission, etc. They looked at the concepts reflected that could not be represented unless it was mapped. The data type is CNE for the concern act values [which are not clinical values] and can't be changed. Mapping would change the meaning.

Discussion about needing a way to flag something that is not active but need to "flag" so it can trigger an action.

Sarah explained the C-CDA problem concern act status design, using figure 2 in volume 1 of CCDA 2.0. There seems to be uneven adoption of this pattern. Though the problem status observation is deprecated, implementers still have to handle it. Clinically, the value set {completed active aborted suspended} is not sufficient. It was suggested one might map clinical status semantics to RIM state machine codes; this was quickly dismissed as a kluge. If problem status observation is resurrected, there may be conflicts with other C-CDA templates.

Keith pointed out that status may become inaccurate over time; this, however, is true of any record. Rob suggested that the clinical requirement is a Flag indicating concern, possibly with reminder functionality. Keith suggested that if a status observation is needed, it should be redesigned, not resurrected. Mark suggested that the solution needed to support the linking of co-morbidities.

We agreed that we need clinical statuses. Patient Care will confirm the vocabulary and tabulate the semantics of the respective combinations of concern act status and problem status observation values. (This activity may not identify any prohibited combinations, but it will provide unambiguous documentation of the semantics.) PC will then provide a DSTU comment requesting the change.

  • actStatus
Concern (state machine status) Active Inactive Resolved
Completed (must have effectiveTime High)
  • Template Report out

Kai reported that Templates DSTU R1 has resolved 12 comments, and that it has completed the requirements phase. There was some discussion of the relationship to the OID registry. An EST representative suggested that any new requirements be forwarded to EST.

  • Relevant and Pertinent Data project

Keith presented the “Relevant and Pertinent” data project (1183). The audience for this project are developers of EHR systems and health IT systems that are automatically generating documents. The idea is to algorithmatically choose that data to be included in the summary documents. The problem is that summary documents that are being created are huge.

SDWG is sponsoring and CIC and PCWG is cosponsoring. US Realm is interested. Need engagement from care providers for what they think is relevant data to receive in a clinical document.

Need to develop a process to engage with providers and provider groups - ACP, AMA, Oncology providers, HL7 work groups, Public health is interested, HIMSS standards and interoperability, health story, CIC members, etc are interested in participating.

Next step is to get a small group together. Plan is to meet week of memorial day - Project calls will be from SDWG. Initial plan is to define the engagement model. Suggested a spreadsheet to use to provide feedback. Will need an informative document that will address the scope for this and why the project is needed. Need to do the engagement work first. will need the following:

  • Performing outreach
  • Presenting to groups
  • Gathering the feedback
  • Scoping and input - what information do you want to see when receiving the data. Will have a baseline and may have addition to the baseline.

Engagement will be broad. Still waiting for final response from TSC.

Keith requested PC assistance. Kevin, Emma, Ben, and Gay responded affirmatively. The original goal was to ballot in September, but the task of engaging professional societies may push that back to January.

Requirements collisions will be managed with the ballot. Requests for content not in CCDA will be disposed as Not Applicable. The results could be used in any specification, not just CDA, though the request from ONC was about a problem specific to CCDA, and the work will be organized by the MU3 core elements.

  • Heuristics for substances
  • postponed
  • CCDA versioning for 1.1 and 2.0

C-CDA 1.1 is expiring; SD is asking for an exceptional extension of 5 years because the MU rule cannot reference an expire. There is a PSS in development to provide backward compatibility in 2.0 (upgrading 2.0. to 2.1). Covered by PSS for general update to address issues discovered for backward compatability with TSF. Plan is to review thru a wiki process. Have to have something published june/july to have a chance of making into the rule. The process will get discussed on next SDWG call. The project has been discussed in SD but has not been approved. Brett wants added as agenda topic at 4pm. Will be updating the 2.0 PSS.

  • SDWG Questions for templates

Where is templates group at with template repository? - have outline the basics needed for template registry. Requirements are there from a conceptual perspective. Europeans have adopted art deco for practical perspective. Question about using the HL7 OID registry - suggest using that for templates. Suggestion that this need to be brought to EST (Electronic services and tools). Suggestion that OID registry is online - all the root OIDs are registered. Others can register their sub oid. SDWG can catalog all the oids used in sd Igs and register their OIDS.

Patient Care Co-Chair Planning Lunch

Present: Elaine Ayres, Laura Heermann Langford, Michael Tan, Jay Lyle


  • Review of Projects

-Health Concern DAM – will ballot in September. Reviewed ballot schedule. Michael Tan and Jay Lyle will manage ballot materials. Health Concern calls will continue weekly on Thursdays at 4 PM ET. -Care Plan calls will continue on Wednesdays at 5 PM ET every other week beginning on June 3rd. Laura will set up these calls. -Allergy and Intolerance calls will continue on Wednesdays at 5 PM every other week beginning on May 27th. Elaine will set up these calls. -Monthly Patient Care WG calls will continue on Mondays at 5 PM on the first Monday of the month. Elaine will set up these calls. -FHIR calls will continue every Thursday at 5 PM beginning on May 21. Lloyd will not be available for this call, but it will be used to prioritize work leading up to the September FHIR normative ballot. An additional call on Wednesday May 20 will be schedule to work on FHIR issues. Elaine will set up these calls.

  • The draft agenda for the Atlanta meeting was reviewed and agreed upon. Elaine will schedule the rooms using the room reservation system.
  • Michael will complete the post-WG meeting survey.

Patient Care Thursday Q3


  • Lawrence McKnight
  • Kevin Coonan
  • Jay Lyle
  • Michael Tan (scribe)


  • reviewed the most recent DAM model and compared it to the HL7v3 RMIM of Concerns of 2009.
  • The 2009 model depicts "care statements". This should be replaced with "clinical statements".
  • not happy with the naming of "subject 2".
  • Should the Care only be related to the Health Concern? The current practice is that orders are generated from the condition and not a concern. We conclude that Care Plan should have a relationship with the Health Concern Event.
  • This is also consistent with the way it was modeled in 2009.
  • Care providers would pull an order into their notes. ( Condition).
  • More often this would have a relationship to the billing codes.
  • Local name could be different than the name of the condition or problem. His could also have a higher level of abstraction.
  • We also need to review against the Contsys model.

Jay's notes, to be consolidated:

  • The group began by comparing the DAM to the 2009 DMIM for health concern. This model associates the concern with a “Care Statement” (now “Clinical Statement”). This seems similar to our aggregation model.
  • There was discussion of whether the concern should only aggregate naming events (e.g., diagnoses) or also others (supporting evidence, e.g.). If the former, the DAM will be simplified, as the IdentifyingEvent specialization will be absorbed into the Event class.
  • We reviewed the primary requirements for the Health Concern class. These are not take from a requirements repository; they are simply recalled.
  1. Allow a clinician to see how a diagnosis of a problem may have changed over time
  2. Allow a clinician to select salient issues to view in a problem list
  3. Allow a clinician to select salient details to view in a single concern (or provide an armature for other methods--possibly computed--of reducing noise)
  • One argument was that all events associated with a concern are associated automatically, by the system, based on the context of the clinical workflow. E.g., a lab order and result are associated to the motivating diagnosis, so if the diagnosis is a concern, that information is available to view in the concern via the diagnosis.
  • There were three counterarguments. One was simply that there might be facts that the system fails to associate with the diagnosis, for a variety of reasons: it should be possible to manually associate these. This objection was deemed inadequate, as this is a conceptual model. The mode of association or precise path through the object graph is not important, and one might associate the observation with the condition just as easily as with the concern.
  • The second is that, for an ambulatory system, every encounter may re-instantiate the diagnosis object. In this case, it’s unclear how to manage associations, as there are multiple candidates. This issue, too, is deemed a design issue. The diagnosis is a single business object, however many records of state may exist in the EHR.
  • The third is more significant, and it is based on requirement 3, above. If associations are automatic, the clinician has no manual method of reducing the noise. Query-based views might be developed to generate salient sets of observations, but it’s not clear that such queries can be constructed in ways that are categorically clinically reliable.
  • This issue is still open for discussion.
  • We also discussed linking the Plan to the diagnosis rather than the Concern. We did not see any problem with this move, though the link is represented at a higher level, to the Plan package rather than to Plan classes such as orders. As long as we can indicate that the link is actually to an unspecified class within the plan, this is not a problem.
  • Name
  • A diagnosis may contain a very specific name, e.g., acute exacerbation of asthma, whereas the Problem List should present a less granular concept, e.g., asthma. We have modeled a localName property for this purpose. However, we have also allowed for multiple naming events to be current at one time. We have not yet proposed a representation of these intersecting requirements.
  • It was also suggested that we move the association between Concern and List to be between Event and List. This is only workable if the aggregation of the concern is singular (see open issue above). It’s not entirely clear what the purpose of such a change would be.

Patient Care Thursday Q4

Patient Care did not meet.

Patient Care WGM, Friday, May 15, 2015

Patient Care Friday Q1 (PC attended Templates)


  • Jay Lyle (PC attendee)
  • Calvin Beebe
  • Austin Kreisler
  • John Roberts (Templates Scribe)
  • Kai Heitmann
  • Sarah Gaunt
  • others (see the Templates minutes)


Working call time agreed. WGM schedule agreed, including CQI.

For the Quick language project, Richard offered to provide CDS & QCI a proof-of-concept for some syntax options.

Templates DSTU: 12 comments. 2 discussed this week. Need more examples, e.g., coding strength. It was suggested that a specialization should only assert differences. This is permitted, but it also may contain elements in common with the parent. There was also a technical correction on conformance labels. Art Décor: Reference implementation of Templates DSTU. 40 implementer projects currently active. Recent update: support for governance groups, ability to get lists of used artifacts. It’s a repository, but it can also serve as a registry.

Could it be used as a FHIR repository? Currently, it contains any xml constraints, e.g. CDA, V3, SOAP. FHIR has profiles not templates. Not enough overlap.

They have talked with FHIR to synchronize some concepts, e.g., versioning, specialization relationships among profiles. The profile state machine is a subset of the template state machine. Mark and Ewout working on synchronizing governance (for creation & ue) & registry data.

There are also difference among the stakeholders, so it might be difficult to agree on priorities if IHE EU and HL7 are both owners.

It was suggested that, although there are both technical and organizational divergences, the current momentum of FHIR may provide an opportunity to advance templates.

Tooling had looked into an HL7 artifact registry (HingX). This does not seem to have advanced.

There would be three efforts to move forward: technical feasibility, organizational consensus, and advocacy of consideration.

Action item: Calvin to look into potential synergy.

Art Deco is shared; this is happening now in Europe. It manages CDA, extensions.

Changes to CDA in 2.1: ActRelationship types 12 -> ~ 100 (all those in RIM). Adding in many properties from RIM, and updating RIM version, in order to support better clinical mapping to domains.

IHE EU has an open source testing framework (Gazelle); Art Deco has established an MOU to use it.

SD and EST may want to evaluate Gazelle ( Calvin to discover whether there is an organizational constraint.

Art Décor offers validation; Lantana generates schematron; SMART has a tool. Could MDHT be used for validation? This is generally viewed as too hard, as it required implementing java classes for every scenario. There is a US government RFP for validation.

Templates resolved their one FHIR DSTU comment on Wednesday.

Action item: Templates or SD (EST secondary) to propose evaluating Gazelle for CDA validation.

Patient Care/FHIR Friday Clinician Connectathon Q1-Q4


  • Viet Nyugen (Lead)
  • Elaine Ayres (PC Facilitator – Clinical Impression)
  • Laura Heermann-Langford (PC Facilitator – Care Plan)
  • Emma Jones (PC Facilitator – Procedure)
  • Grahame Grieve (FHIR Core Team – Clinical Impression)
  • David Hay (FHIR Core Team – Care Plan and tool)
  • Lloyd McKenzie (FHIR Core Team – Procedure)
  • Cecil Lynch
  • David McCauley
  • Mark Janzewski
  • Pat Van Dyke
  • Rob Hausam
  • Julie Murugi
  • Gay Dolin
  • Kevin Coonan
  • Julia Skapik
  • Josh Mandel


  • Viet reviewed the agenda for the day, the clinical scenarios for each group (clinical impressions, care plan and procedure), and then reviewed the tool.
  • Groups then began their processing of entering as a group data into the tool. Group discussions created multiple comments against each resource. Facilitators are to enter comments into GFORGE to reflect discussions and resource refinements discussed at the connectathon.
  • Review of the Connectathon:
  • Clinicians felt that current format was excellent.
  • Tool can be used for instructional purposes.
  • Comments to PC – how does the resource relate to the process of patient care - the connectathon is a good review process.
  • Participants wondered about the equivalent of the Skype discussion channel for developers. Grahame noted that the developer groups will use a product called Slack in the near future – Slack can channel threads of conversation vs. a running conversation. The group discussed the need to monitor such a comment tool for clinicians. Will continue to evaluate a comment tool that will work for the clinician audience.
  • The group discussed the value of the tool for educating other clinicians about FHIR. The tool will remain available however, the server is updated periodically losing all of the built content. Grahame noted that if clinicians wish to use the tool, please alert him so that he can time updates accordingly.
  • Furore tool will be the official profile build tool. In ClinFhir can build a proposed profile or extension to test resources.