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September 2013 WGM Cambridge

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Cambridge WGM - September 2013 Patient Care WG Meeting Approved agenda:

Cambridge WGM - Sept 23 to Sept 27, 2013 Patient Care WG Meeting Meeting Minutes

Patient Care Monday September 23, 2013

Patient Care Monday Q1

HL7 Plenary Session

PCWG - no meeting

Patient Care Monday Q2

HL7 Plenary Session

PCWG - no meeting

Patient Care Monday Q3


Chair: Stephen Chu; NEHTA;

Scribe: Michael Tan; Nictiz;

Iona Thraen; VAMC;

Christina Knotts; FDB;

Gordon Raup; Datuit;

Elaine Ayres; NIH;

Meva Choi; ONC;

Evelyn Gallego; ONC;

William Goossen; Results4Care;

Susan Matney; 3M;


• The agenda is reviewed and approved. Stephen will post approved agenda on Patient Care wiki and notify PCWG finalised agenda through email to the PCWG mail list.

• Kevin Coonan will not attend this WGM and will not be able to lead discussions on the Health Concern topic. However, the group decide that the Health Concern topic should still be discussed because of the dependence of other projects and the need of various stakeholders for this topic.

• A couple of key contributors to PCWG projects are not able to physically attend the Cambridge WGM. Stephen has asked the HL7 to provide a mini polycomm device, but the request was rejected.

• Wednesday Q1 joint meeting might need a larger room.

• Stephen explains the intention of the joint meeting with EHR. This is to discuss the functional models for allergies, Care Plan, Care Structures.

• Tuesday Q3 will chaired by Elaine and scribed by Iona.

• Wednesday Q1 will chaired by Elaine and scribed by Iona.

• The Thursday Q1 will be a joint meeting of OO, PCWG and CDS; and will be hosted by OO. This meeting was formerly held on Mondays Q4 but had to be shifted due to unavailability of CDS members. The Care Plan project meeting has to be shifted to Thursday Q4.

• The room for Thursday Q2 is too small to host PCWG, “Structured Documents” and "Template" groups. Stephen will request a bigger room. A note will be posted on the meeting information board. (NOTE - arrangement has been made. The joint meeting will be at the SDWG regular meeting room - Molly Pitcher)

• Gordon Raup offers to present Care plan manager on Thursday Q4.

• The agenda is approved and versioned as version 7. Vote 11, against 0 and 0 abstention.

• PCWG has a co-chair position open for election. Stephen urged members to vote for a new co-chair. Voting closes on Wednesday.

• PCWG discussed, voted and approved the following:

Mission and Charter

Will work on finalising 3-year work plan at first co-chair conference call: Monday 7 October 2013 (Elaine to organise and send out conference call details to all co-chairs)

Patient Care Monday Q4


Stephen Chu - Chair

Elaine Ayres – Scribe

Evelyn Gallego

Mera Choi

Jim McClay

Laura Hermann Langford

Michael Tan

Iona Throen

Clayton Curtis

Christina Knotts

Russ Leftwich

Gordon Raup

Kevin Coonan (by phone)



1. Review existing DSTU health concern

2. Ensure we have common definition for health concern

3. Discuss correlate projects through PC WG

  • Review of current Health Concern model:

Brief review of history of 2009 Health Concern DSTU: project started possibly as early as 2004/2005. DSTU status in 2009. Model now expired

Can re-ballot current DSTU twice, or retract.

Has topic and RMIM’s but no storyboards; possibly no Project Scope Statement.

Model important to many projects – question presumption that this project is complete?

Question of whether existing Care Concern model is still suitable for supporting changing needs and new requirements.

Do we need a Domain Analysis Model?

Discussions on what is "Health Concern"? There are several perspectives of Health Concern.
IT/HL7 v3 perspective: Used as a tracker for tracking patient health concerns.
Patient perspective: used to express issues ranging from "annoying" to "worrying that requires attention, management or interventions"
Health provider perspective: a generic label for linking related and evolving health issues over time, e.g. chief complaint,symptoms, problems/problem list (including allergy/intolerance), preliminary diagnosis to actual diagnosis to resolved and a part of the past medical history.

Question on differentiating problem list vs. allergy list also raised.

A peanut allergy – should be on the problem list and the allergy list. An allergy to feathers should just be on the allergy list.

What is the concept that links all of these things together? May have complaints, but may not have a diagnosis.

Health concern – HITSP- any issue that you have a concern about. A problem is a concern. But a concern might not be a problem.

Transition from paper based system – to EMR.

Providers may have different problem lists for the same patient. Each provider may have specific rules for a problem list, but the collection of these is useful.

There may be many users of this information – providers and patients.

To cope with the limitless number of concepts – risks, dx, past medical history, genomics, exposures. All these need to go into a bucket “about your health”. Applying business rules to filter off to various uses for these data – e.g. cardiology

Does every health concern need a care plan? Or is the plan to monitor?

What about concerns that exist that are not in the bucket?

C-CDA – health concerns can exist anywhere? Can be tied across the various templates.

Health concerns are included in MU3.

Custodian, target, author are tied to each health concern.

How is proposal different than original DSTU? More details, different types of conditions. How do you manage a condition over time? What is the confluence of concerns that may lead to a diagnosis?

Project goals – health concern per se and how it relates to care plan and care record.

Must define a health concern clearly as a start.

Motion: Develop a Project Scope Statement that defines the health concern concept, the uses and context of use and the relevant components to support the use. The context of use must consider existing work as well as other related efforts.

Michael/Iona – Abstain – 0, No – 0, Yes – 12

Kevin - want to model and provide narrative description.

Need a PSS – and other groups – DSS, Pharmacy, SDWG, Emergency Care, SOA, Child Health, EHR, FHIR, PHER

Brought up existing PSS for Health Concern. Michael will work with Kevin on this project.

S & I Framework Health Concern – Use case for care plan with definitions e.g. components of the care plan. Also had functional requirements in C-CDA. Have mappings for health concerns. In ballot reconciliation now (over 1000 comments). Check S & I website.

Consys – continuity of care in EU. Check Open EHR.

  • FHIR tomorrow Q4 – re Care Plan resource – Gordy Raup.

Care plan for FHIT – list of conditions, list of goals and list of activities with no relationship between these three lists. Propose links between there – d.g. activities and goals, and conditions and goals. But to link these each needs to be a separate resource and not within care plan.

The issue of 80/20 would preclude new resources. However, these lists are not useful if not linked.

PC WG – feels that additional resources would be needed to properly use these resources.

Patient Care Tuesday September 24, 2013

Patient Care Tuesday Q1


Chair – Russ Leftwich/Laura Heerman Langford

Scribe – Elaine Ayres

Attendees –

Catherine Hoang

Susan Matney

Iona Threan

Margaret Dittloff

Gordon Raup

Jay Lyle

Christina Knotts

Floyd Eisenberg

Lenel James


Comments received – group will review non-ballot comments.

Ballot Statistics:

16 Negative majors

16 Negative minors

Remaining: affirmative with suggestions, comments, and typos

1. Issue of including payors – Lenel James asking for representation of payors. Note that payors actively involved in care management and care planning to ensure cost-effective, evidence based quality outcomes. Suggest adding a use case for the payor actor.

a. VOTE – Iona/Margaret Abstain – 0, No- 0, Yes - 9

2. Issue of outcomes (Floyd Eidsenberg) – in DAM but not obvious. Stated as an observations. Would like to use as decision support and current model does not appear to support this.

a. Block VOTE for Floyd’s comments – Susan/Margaret Abstain - 0 No - 0 Yes – 10

b. Susan – follow-up to see if outcome is included in HL7 terminology

Patient Care Tuesday Q2

This Quarter of meeting was planned as a joint meeting with Anaesthetic Group to discuss "Vital Signs" R-MIM and DCMs / Care Structures update and ballot preparation

No one from Anaesthetic turned up to this meeting.

Meeting was cancelled as a result



This is a standing arrangement of PCWG and Anaesthetic group to discuss matters of mutual interest/concern.

Stephen confirmed this meeting arrangement with Anaesthetic group co-chair after the Atlanta meeting prior to room booking.

PCWG has a very tight meeting schedule and could have used this quarter for ballot reconciliation.

To discuss the non attendance of Anaesthetic members and review the standing arrangement at the Friday Q0 PCWG co-chair meeting.

Stephen has emailed Anaesthetic group co-chairs to seek clarification and confirmation whether the groups still wants to have a joint meeting with PCWG at the next WGM.

Patient Care Tuesday Q-Lunch

Joint Meeting with CQI to discuss Quality Measure requirements for Care Plan


Stephen Chu (NEHTA) Chair

Iona Threan- Scribe

Ben West (EPIC)

Christina Knotts (FDB)

Gordon Raup (Intuit)

Iona Thraen (VAMC)

Floyd Eisenberg I (Parsimony LCC)

Patty Craig (The Joint Commission)

Crystal Kalleu (Lantana Consulting)

Walter Suarez (Kaiser Permanente)

Russ Leftwich (Tn eHealth)

Laura Heermann Langford (IHC)

Chris Millit (NQF)

Vaspann Patel (NCQA)

Kimberly Smuk (AMA)

Jyothi Mallampalli (Mathematica)

Evelyn Gallego (ONC S&I)

Peter Goldschmidt (UDG)

Rustin Ary Kennedy (eCare Informatics)

Anne Smith (NCQA)


  • Stephen Chu opened meeting and provided background to the Care Plan project
Patient care plan started in 2011. Care Plan is considered by many stakeholders as critical component of coordinating care
The care plan project team started with reviewing expired Care Plan DSTU model and contributions from many international stakeholders including Australia, Canada, Europe, etc. The team decided that the best approach was to revisit the requirements as the international models showed a range of variations.
The project recommended with tasks to develop a set of story boards and use cases
Looked at requirements which included master care plan and detailed plan which later harmonized to ONC plan of care and care plan

A care plan can be static but Chu’s vision is that it is dynamic, longitudinal and support real time care coordination through complex workflow management engines to support coordinated care effectively across continuum and providers

The team developed 6 or 7 story board and use cases, all are incorporated into the Care Plan DAM (Domain Analysis Model) which is balloted in the September 2013 ballot cycle
The team worked closely with ONC and structured document group (SDWG). SDWG produced a set of templates for plan of care and care plan concepts which were included in the September 2013 DSTU ballot of C-CDA update
The Care Plan DAM includes a set of key care plan components which include Health Concerns, health goals, interventions, activities, intrinsic and extrinsic risks, and how patient preferences and barriers which act as modifiers to health goals and interventions/activities.
The Care Plan DAM received about 80 comments on balloting of mixed ballot comment types (negative major, minor; affirmative questions, suggestions, etc). Reconciliation has been started and continue after WGM.
Will update DAM document and put out for next balloting with aim at Jan or May 2014
Working with SOA group on care coordination and collaboration services (CCS) definition with first round of balloting completed in May 2013, Ballot generated about 80 comments and reconciliation ongoing with aim for second ballot in Jan 2014.

  • CQI views/comments on quality measures for Care Plan:
Provide a venue for all providers to input into the quality measures of care coordination and collaboration. What is it that will be in the document and make sure that the quality organizations needs will be met.
Issues of psych quality measures, need to know that hospital has sent on to the next level. Do we have a structure of a care plan that has been sent back and forth. And the plan must include goals, interventions, and outcomes.

PCWG comment: care plan structure is fully capable of supporting goals, interventions and outcomes in Psychiatric care.

In QRDA there is already a care planning – what are the components and are they present and:
Is there an actually a template for a care plan?
PCWG comment: C-CDA contains a set of templates. There are also entryRelationship templates that connect goals, interventions, activities

  • Discussion:
Care Plan development is still at the DAM level.
The DAM includes a logical model upon which SDWG has developed a set of Care Plan template
The logical model also supports the design of treatment plan, plan of care and care plan as specified in LCC functional requirements for Care Plan
It will be useful for CQI to understanding the care plan structure in order to develop relevant quality measures. Care Plan project team can't determine whether additional care plan component(s) may be required to meet quality measures requirements until the measure criteria are adequately defined.
Also working with FIHR to develop care plan resource. There is still a needed step to create profile (including extensions) for specific purposes/use cases. Continuous collaboration between FHIR and care plan project team will be required.
There is question on whether guidelines or measures for decision support will need to be developed and modeled.

Going forward does the VMR have capacity to include care plan and DAM. One of the challenges, what is domain specific and what is not domain specific to quality.

PCWG comment: The care plan has the capacity to provide information/data to decision support engine but it is not a decision support tool. How health goals and preferences or barrier impact on interventions may benefit from the use of decision support engine. Likewise, decision engines may also help in assessment the interventions appropriate to policy, guideline, etc.
Care coordination project would provide linkage between care plan and decision support, possibly through a set of metadata (which will need to be defined)
Alignment of quality measures, CDS and transitions of care, and care plan. Common data needs to be defined for multiple uses (decisions support, care, quality, etc.). The issue of process is being addressed by process/dynamic models development which has been started prior to Cambridge WGM.
Care plan provides structure for organizing data. CSS is process for how data is to be used in care plan development, initiation, care team negotiations and collaborations.
The next phase of care plan DAM development can consider how to address quality measures. But CQI needs to define the quality measures adequately for PCWG. Need to be tested: are the hooks present to accommodate both quality measures and Decision support. What are the hooks. Want to make sure the model connects to the new models.
Has a gap analysis been done through the pathway? To identify what is missing. Will need further work and collaborations.
Also need to look at what we are trying to achieve and reported through CMS. Care plan is being proposed for Meaningful Use and connect with ONC LCC and HL7.

  • Care plan perspectives:
Besides the care plan structural components, what quality metrics are you looking for with regard to health concerns, activity or intervention and outcome in care plan. Quality measure criteria that need to be incorporated into care plan efforts will need to be clearly defined by CQI. What exists to date? Are there more in addition to what are mentioned here? Answers to these will help determine whether we have the right attributes? How do the two groups work together?
CQI: Hard to say because in varying states and depends on contractors. If in conversation maybe we should be looking at what is
Need to dedicate some time to have conversation regarding on what measures are currently under development as well as MU 3 measures. Needs to go through varying channels to determine relevance of multiple measures.
The issue needs to get to HHS to inform contractors who are in development. Is there a logical model that could be addressed in time? Isn't the work with the CCDA the answer for MU 3?
There is a level between use cases where there is an infrastructure that defines the patterns. There are particular measures that related to the goal or to interventions in order to define the attributes.
Care team roster gap to have codified member unique ID. The care team roster in care plan DAM in its current state will not adequately this issue.
What Patient Care Plan is looking for from CQI for example health goal a set of criteria, (e. Start date, end date, measureable, etc.).
Each care plan varies depending on health issue being addressed and clinical practice, etc
As each measure type is defined what is needed in the care plan will be different. For example pediatric asthma, home management, controllers,

Psych measures, information to be sent on to next level of care, discharge meds, dosage, indications, for use, includes next level of care recommendations.

Working with nursing looking at whether there is a health concern, intervention, goals. QMR can handle attributes from Care plan

NCQA working on measures on MU stage 3.

The structure is there but the specifics are the challenge

  • Actions:
Need to articulate the goals of the collaboration
Needs to develop use cases
Recommend a joint meeting at next face to face
Invite other group at next model discussion
Address at structure and template level
Patty to email list of existing quality measure and storyboards to Stephen
Regular PCWG Care Plan projet call alternate Wednesday 5 pm EST
Set up call to walk through use cases

Patient Care Tuesday Q3


Christina Knotts (FDB)

Grahame Grieve (Health) intersections

Elaine Ayres (NIH)

Stephen Chu (NEHTA)

Meva Choi (ONC)

Russ Leftwich (TN e-health)

Jean Duteau (DDI)

Margeret Dittloff (CBORD)

Catherine Hoang (Dep. of Veteran Affairs)

Lorraine Constable (Constable consulting)

Michael Tan (Nictiz)


  • Topic of Q3 is discussion of the ballot comments on the Clinical Models of allergies and intolerances.

The results of the discussion and the dispositions are registered in the ballot comment spreadsheet:

• The allergy test value should be “ANY”. Persuasive.
• Stephen wants an extra status on observation and on condition. This is available. Not persuasive.
• A walkthrough is required for manifestation and observation. Not persuasive, but will add extra explanation.
Motion moved by Elaine to approve the disposition: Second by Margeret: Result of voting: 6 in favor, 1 abstain, 0 against.

• The requirement for prescriber preferences were not considered persuasive. The WG suggest to misuse “criticality” for this purpose. Netherlands should implement the model as DSTU. If an extra requirement is necessary then this could be considered for future use.
• The Observation event 6 is constrained to subject reaction. Stephen ‘s consideration is almost the same reasoning as behind the meaning of criticality as Michael’s previous comment. The disposition is to expand the definition.
The motion was moved to approve the disposition: 7 in favor, 1 against en 0 abstain.

Patient Care Tuesday Q4


Michael Tan – Chair

Elaine Ayres – Scribe

Gordon Raup

Christina Knotts

Iona Threan

Graham Grieve

Catherine Hoang

Gaby Jewel

Lindsey Hoggle

Margaret Dittloff

Rik Smithies

Laura Heermann Langford


  • Ballot reconciliation: FHIR
1. Resource clarification for Family History – consistent with what a family GP might include. Genetics group asking for additional related or different resources. However, no suggested resources provided. Ballot item will not be resolved until FHIR confers with Genomics but PC feels that “Family History” is the documentation of a patient provided concept of family disease states.
2. Care Plan resource – has goal, activity and participant.
a. We need links between activities and goals as well as conditions and goals.
b. On the activity – need a link to what represents the intervention. In activity not action taken vs. just action. Rename action taken to action resulting.
i. Recommend that action be change to “action resulting” that serves as the reference to the other resource(s). Additional issue of timing issues – timing of the activity vs. the timing of the execution of the activity. E.g. in two weeks time begin taking aspirin twice a day. Details can be a link to any other resource. Any details of two resources must not disagree with each other.
ii. Care plan activity box – then link to a simple activity and links to medication and procedure resources.
 : VOTE – Graham/Gordy No – 0 , Abstain – 0 , Yes - 10
c. Can you use extensions to link goals, activities and conditions?
d. Appears that there is the case for linkages. The following options were proposed:
i. Option 1 - Care plan begins with a list of conditions.
1. Each condition has a list of goals
2. Each goal has activities.
ii. Option 2 - Have ability to link without hierarchy. Keep one resource.
1. A goal may result in a concern.
2. Will provide linkages.
3. Multiple conditions may point to one goal.
4. See FHIR ballot re resolution.
iii. Move Option 2 - Graham/Gordy No – 0 , Abstain – 0 , Yes - 10
e. Option 3 – have separate resources for conditions, goals and activities
3. Generic Care Plan resources – patient resource
a. Specific resource vs. template for the condition itself for care plan. Now the patient is optional.
b. What are the other conditions that must describe template qualifiers?
c. Move – Keep the patient as part of the resource (not optional). Could add a care plan template resource to extend capabilities if needed. Graham/Iona - No – 0 , Abstain – 0 , Yes – 10
4. Procedure Resource - Type of procedure is optional and who it was performed on. But if patient says I had an operation but no known procedure. Could use a generic code. But currently if you use the resource you must enter a code.
a. Make this 1.1 but add a note to use text if the eact nature of the procedure can’t be coded.
Vote – Graham/Gaby No – 0 , Abstain – 0 , Yes - 9

Patient Care Wednesday September 25, 2013

Patient Care Wednesday Q1

Present: Stephen Chu (PC) NEHTA - Chair

Iona Thraen (PC) VAMC - Scribe

Michael Tan (PC) NICTIZ

Anita Walden (CIC) Duke Translational Institute

James McClay (Emergency WG - EWG) University of Nebraska Med Center

Elaine Ayres (PC) NIH

Mitra Rocca (CIC) FDA

William Goosen (PC) Results 4 Care

Rus Leftwich (PC) TN eHealth

Craig Purdon (Standards Australia)

Christine Knotts (PC) (FDB)

Laura Heermann Langford (PC and EWG) (IHC)

Community Based Clinical Care – no show

Public Health Emergency Response – no show


Presentations of different groups

  • Clinical Interoperability Council (CIC):
Anita Walden (co-chair), Mitra Rocca (co-chair)
4 projects balloted
1) EMS – did not pass
2) Trauma CDA – passed (informative)
3) Major Depressive – passed (informative)
4) Schizophrenia – passed (informative)
New project
CIC – EHR – CQI – EHR usability Work group working with expert with Duke University, literature review, access data base, 14 aspects of usability,
Phase II – invite clinicians, researchers, CIOs what are aspects of usability criteria they seek in hospitals and clinics
Goal to enhance functionality of EHR and then have functionality profile of usability.– American College of Physicians EHR WEB resource conducted surveys of several hundred MD about use of EHR with useability questions. Describes issues of usability
Sept 11 meeting with Univ of Texas Center of Sharp C (grant) software to test EHR on aspects of usability
Next steps
1) MD/Schizophrenia working on content and working on reconciliation. Reached out to professional society to get feedback on DAM and will hand to CDISC (International)
2) Don’t have way to incorporate into EHR – spoke with Clem McDonald for NLM for research
3) Possible phenotype project over next 6 months
4) Trying to engage students into HL7 process – we allow students to participate in calls

What is the relationship between Patient Care to CIC?
Detailed Clinical Model is example
Emergency Medical Services Domain Analysis Model
Look to Patient Care to see what exists in HL7 that we can incorporate – Link
If there is a DAM can it be used in CIC effort.
CIC works with clinicians to develop content, then work with PC for messaging standards.

  • Update from PC
Current projects in progress: Care Plan DAM - informative ballot Sept 2013; Allergy/Intolerance clinical models - DSTU first ballot Sept 2013; Care Coordination Services in collaboration with SOA - informative ballot May 2013, aiming for second ballot January 2014
Issue on co-sponsorship – goal is actively seeking content or technical expertise into project
Otherwise should list as interested party
for co-sponsored projects: would like to see a more formal relationship including asking for expert contributions
Problem of bandwidth within Patient Care limits its capacity to function as co-sponsor
Don’t want to be only co-sponsor in name only
Trauma registry CDA – PCWG does not have bandwidth to be co-sponsor. It popped up on PCWG radar
Need to establish more formal and closer tie – maybe through co-chairs, or project lead and regular follow-ups through emails and/or conference calls

CIC agrees with more formal – sought out input but did not get responses.

Talked several times engaging PC but did not get response

What should CIC do to reach out to facilitate more formal relationship?
Any projects needing PC involvement at certain check points let PC know, ie when DAM reaches certain check-point can we get patient care involved in one conference call. Contact Elaine Ayers for making arrangements.
CIC will send PC an email for joint meeting in next few weeks – arrange around clinicians time.

Might have to push to Friday meetings or Thursday pm

Russ is working membership categories. Most of clinicians are not HL7 members. Intent of health professional category by bringing them on board gently. Give them some status with HL7

  • Emergency WG representative comments:
Timing of reaching out and response and speed at which the process proceeds – difficulty in responding, why is Emergency Medicine as co-sponsor, why have the members not been engaged. The EWG negatively balloted and are not feeling responded to. Work group members feel their opinions are not getting heard. No funding for domain expertise – expertise is voluntarily and difficult to engage. Perception of specialty society is that CIC is supposed to be reaching out to professional input and the contract runs too fast for voluntary input. For example Schizophrenia – we have been involved in process for 2 years.
Emergency providers have not been involved – but trauma registry is not consistent with EHR data elements
Other projects – one of the clinical review committee have identified clinical expertise – feed in small doses, not participating in every conference fall, small group agreement, then disperse to professional society for feedback. We do have projects in which groups have participated every 2 weeks.
Need better coordination formally, across HL7 by expertise.
EWG asking for relief from co-sponsorship – not enough bandwidth in HL7 without funding.
Groups with contract funding get through the system quickly for voluntary input.
Proposal: Set of Recommendations to HL7 board (endorsed by PC) (vote – Russ/Stephen – 1 abstain (AW) 9 affirmative
- Develop mechanism to negotiate with professional societies to fund domain experts to meet timelines
- Create opportunities for CV academic domain (clinical informatics) expertise for participation
- Include expertise in HL7 (information technology)
- Adopt timelines for voluntary participation
- Only nominate work group as co-sponsorship if there is enough band width to actually participate.
- If not enough bandwidth then list as interested party
- Require project scope to include HL7 facilitators (clinical informatics board certified)
- Ask HL7 board to convene task force to develop guidance in access and communicating with professional societies
- Ask HL7 board to develop guidance for methods of obtaining funding for HL7 collaboration
- Ask HL7 board to develop project traceability harmonization mechanisms across projects
Vote to support by PC and then send to DESD
Timing and funding of expertise is issue
Discussion: how to work with professional societies, need for process to oversee and develop guidance, many societies have engaged management companies that know nothing about clinical or HIT expertise. Most of larger societies have informatics committee or staff person who is informaticist.

  • Emergency Work Group - James McClay (co-chair)
Balloted Emergency DAM – not harmonized – lack of bandwidth to harmonize
Putting in publication request for consideration.
PC update D-MIM and R-MIMs

  • Joint meetings for January
Joint meetings are identifying disconnects but not how to fix
Standing agenda items
- Project updates
- Common interests
Propose agenda
Send outline agenda to all groups

Agreed to continue WED Q1 Joint Meeting

Patient Care Wednesday Q2


PCWG representatives to EHRWG

Stephen Chu

Elaine Ayres


PWWG providing updates to EHRWG on PCWG projects:

- Allergy/Intolerance DAM Out of Cycle Ballot; Allergy/Intolerance Clinical Models DSTU Ballot (September 2013)
- Care Plan DAM Informative Ballot (Sept 2013)
- Care Coordination Services Functional Model/Capability Informative Ballot (May 2013)
- Upcoming Health Concern topic

Presentation details as per contents of the powerpoint files.

allergy/Intolerance Project:

Care Plan and CCS Project:

Refer to EHRWG meeting minutes for further details

Patient Care Wednesday Q3


Stephen Chu (NEHTA) - Chair

Michael Tan (Nictiz) - Scribe

Iona Thraen (VAMC)

Elaine Ayres (NIH)

Susan Matney (3M)

Russ Leftwich (TN e-health)

Laura Heermann Langford (IMHC)

Margeret Dittloff (CBORD)


  • Care Coordination Service (CCS) functional model/capabilities discussion:
This session was originally designated as a joint PCWG/SOA meeting to discuss matters related to the Care Coordination Service (CCS) functional model/capabilities which is a joint project of PCWG and SOA. The joint meeting was agreed to since January meeting at Phoenix.
There appeared to be a confusion in the SOA WGM agenda. No SOA representative turned up to the meeting. Stephen went to the SOA meeting in an attempt to find SOA members after about 10 minutes of waiting. Vince McCauley was the only person in the SOA room.
He came to the PCWG meeting room, indicating that he could try to find other SOA representatives to attend the joint meeting.
As Enrique (the key contributor from SOA on the CCS project) was off-site connecting only via a mobile device, and the difficulty in connecting Enrique to the meeting via skype call over a mobile device, Stephen indicated that it would be too difficult to coordinate the meeting with off-site participation and try to track down any SOA members at the same time.
It was decided that PCWG would use this session to discuss Care Plan topic and organise joint PCWG-SOA meeting to discuss CCS matters for the next WGM at San Antonio.

  • PCWG Discussions:

The remaining of this session was used to discuss PCWG related topics

• The CCS ballot comment resolution process is still ongoing. Plan is to get CCS ready for January 2014 ballot
• Care Plan project - ballot reconciliation will continue after Cambridge WGM. Conference calls to be organised
• Health Concern topic: Significant debates on what "Health Concern" was, from HL7 v3 and clinical perspectives. Stephen provided a brief description of the differences between the two perspective and how they could be aligned.
• Health Concern from HL7 v3 perspective consists of two concepts: Health concern "tracker" and health concern observation
• Health Concern from clinical perspective: assertion (by provider or patient/family) about conditions/issues that require attention. This aligns with health concern observation from HL7 v3 perspective
• The WG will review and modify the PSS of Health Concern. The first step is to decide whether we should produce a DAM. This is considered important because there is a lot of ambiguity in the meaning and interpretation of concern.
• The DAM should provide explanation for the different viewpoints. I.e. the patient viewpoint or the care providers concern. The project scope was adjusted to meet the need. Besides the DAM it will also provide the basis for producing a clinical model and templates.
• The project need section content was left intact.
• Stephen suggests to replace the need to produce CMETS with templates. CDA uses templates, but Michael disagrees, because CMETS are still in use.
• The PSS needs to be finalized in another quarter.

Patient Care Wednesday Q4


Stephen Chu (NEHTA) - Chair

Michael Tan (Nictiz) - Scribe

Christina Knotts (FDB)

Elaine Ayres (NIH)

Russ Leftwich (TN) e-health

Jean Duteau (DDI)

Margeret Dittloff (CBORD)


  • Elaine provided a brief update on Allergy/Intolerance project update.

• Loose ends discussed.

o The preferences ( patient preference, diet preference, end of life preference) will go through OO and will be balloted in January. Jean Duteau explains that the team is thinking about a framework to define a preference.

• Continuation of the ballot review of allergies:

o The other comments Michael placed referred to other artifacts with the same complaint, that prescribing guidelines could not be registered. The motion is to duplicate the initial disposition into this comment.
o Vote results: 4 in favor, 1 against, 0 abstain.
o The walkthrough is not clear on the usage of “value” in combination with the use of material kind. Guidance is necessary to explain to the implementers how these attributes should be used.
o The code contains the type of allergy such as “intolerance”.
o The difference between allergies and intolerances will be explained.
o Stephen wants an entry point directly to the allergy observation instead of the concern-event. This is not considered as persuasive.
o Uncertainty code is missing in the observation-event and in the adverse event.
o The attribute “text” is missing observation-event in the adverse event. The text is meant to give more detail about .
o The motion is put forward to accept all previous dispositions.
o Vote results:
 6 in favour, 0 against, 0 abstain.
o The comment about effective time is considered “not persuasive”, but the explanation will be adjusted to explain the usage of effective time.
o The comment on missing walkthrough is not considered persuasive, but the walkthrough will be modified.
o The motion is put forward to accept the dispositions.
o Vote results:
 6 in favour, 0 against, 0 abstain.

Patient Care Thursday September 26, 2013

Congratulations to Laura Heermann Langford for being elected as a new PCWG co-chair

Patient Care Thursday Q1

Joint meeting: OO, PCWG and CDS

OO hosting


Stephen Chu

Elaine Ayres

(Template co-chairs also present)


  • Template update - by template co-chairs:
Want to coordinate with VMR and not to have multiple flavours of templates
Explore versioning paradigm (template ID similar to vocabulary)
Actual design needs status/date
Using v3 basic model used in CDA for template structure
Schema is a set of constraints on existing model, as in CDA
XML is the ITS
Working on the reusable/shareable templates
Registry functions to share templates, tracking of templates and use, etc
VMR and Template groups to work together to identify what attributes to be capture for templates
Challenge with using the same data model: need to align
Metadata is most important to synchronise
VMR is to leverage a template development methodology defined by template group
VRM templates includes a set of business/clinical processing rules. How these rules are to be represented as template metadata will need to be explored
Also question on how the VMR template contents are to be represented as CDA templates

  • VMR logical modelling started in 2008
Initial approach was to simplify representation of CDA
New requirements added later
The VMR logical model contains a “clinical statement” component (which can be used for care plan components representation)
Discussions on VMR representation of Allergy:
PCWG inputs:
Should consider supporting: allergy, intolerance and allergy/intolerance (where clinical differentiation of the specific type is not possible)
should separate allergy/intolerance as condition and reporting of adverse reaction resulting from exposure to allergen or substance of intolerance
Should differentiate "criticality" (applied to reaction as a whole) and "severity" (applied to signs and symptoms of reactions)
PCWG and CDS to work together on how Care Plan data and metadata as "hooks" to VRM and decision support engines

  • Order service update
3 services specification: functional model development
Order services; unified communication; and escalation
Project scope statement approved in Atlanta WGM
Order service functional model – first draft close to ready including an EA model largely based on Lab order
Need to decide whether contents are sufficient to go on informative ballot in January 2014

Refer to OO meeting notes for more details

Patient Care Thursday Q2


Total attendees – 32

1. Stephen Chu – Chairing

2. Elaine Ayres – Scribe

3. Margaret Dittloff

4. Benjamin Flessner

5. Janet Campbell

6. David Sundaram-Stukel

7. John Roberts

8. Mark Shafarman

9. Lisa Nelson

10. Austin Kreisler

11. Kai Heitmann

12. William Gooseen

13. Christof Fessner

14. Vinayak Kulkarni

15. Iona Threan

16. Wendy Huang

17. Clem McDonald

18. Michael Tan

19. Brett Marquard

20. Gay Dolin

21. Bob Dolin

22. Larry Garber

23. Tessa van Stijn

24. Russ Leftwich

25. Laura Heermann Langford

26. Stephen Royce

27. Catherine Hoang

28. Jennifer Sisto

29. George Cole

30. Gordon Raup

31. Mark Roche

32. George Konmid


  • Announcements - CDA R3 – will meet with FHIR Q3
  • Templates Update - Kai Heitmann presenting:
Amalgamated three documents into one January 2014 ballot document. This is the combination of Template ITS and an update on the Templates R1. The PSS for the Templates DSTU R2 has been distributed as a draft. This summarizes what the document will accomplish. Looking for co-sponsorship with SDWG and PC. Looking for other co-sponsors or interested parties as well.
Patient Care is willing to support for Allergies and Intolerances and Health Concern projects.
What does co-sponsorship involve?
Current care message DMIM depend on proper templating to become normative.
William Goossen will volunteer as a resource from Patient Care.
SDWG and Patient Care will support the PSS for Templates DSTU.
Question on template versioning in C-CDA leading to negative ballot comments on C-CDA update.
Bob Dolin suggests several phone conferences and a list-serv discussion to sort this out to address ballot comments.
The planned Templates DSTU will have details on how to accomplish versioning.
Kai will address the ballot comments with SDWG on a conference call.

  • Allergy/Intolerance Update - Stephen Chu and Elaine Ayres Presenting
Domain Analysis Models – completed but on the ballot to move to publication.
Noted issues with preferences and project occurring through OO for medications and food, and the availability of a FHIR resources for allergies and intolerances.
Allergy/Intolerance Clinical Models – ballot
Terminology – consistent with C-CDA
Differentiating between allergy vs. intolerance. From a clinical point of view will not necessarily differentiate.
The allergy/intolerance list is used to ensure patient safety. The VA calls this the “adverse reaction tracking system”. Select a reactant and whether it was observed or historical.
AAR – allergy and adverse response used at Utah. Clinicians look for the term allergy.
Coding will help distinguish between an allergy vs. and intolerance.
List of potential reactions – ineffective – do not give again. Ended up in preference work.
Encouraged to use clinical models as DSTU.
The issue of criticality vs. severity –
continue to clarify the issue of criticality as applied to the allergic condition.
Severity applies to the reaction.
Recommend that flags based on science be included along with the use of criticality/severity. Criticality is a professional judgment.
Next steps – testing, terminology, ensure consistency with C-CDA.
Next phone call will be on Wednesday October 9 at 5 PM. Will move to 4 PM once the US moves to Standard Time.

  • Care Plan Update - Laura Heermann Langford
Care plan DAM in ballot reconciliation. The Care Plan DAM will be re-balloted as informative.

  • C-CDA Update and Ballot Reconciliation
Ballot Item 198 – Goal Observation Template. Currently conforms to the Planned Observation template. Question is if the Goal Observation needs to conform to the Planned Observation? For example do you really need a “targetsitecode” to reflect a change in patient’s weight? Note – you do not need a target site code, but it is there if you wish to use it. After further discussion decided that the recommendation is persuasive and that the conformance restraint will be removed between the two templates.
VOTE: Abstain – 2, Oppose – 0, Approve - 25
Ballot Item 245 – Chapter 3.65 Planned Coverage Template (new template). The health insurance type value set (new) is different than the source of payment typology value set (used in QRDA and other older templates). Should these be the same? Need to check the policy activity template and the planned payment template.
There are state-specific value sets and there will be changes that are made with ACA. There may not be a master set. Iona Threan will research value sets. If the value sets are being clarified – need a source to indicate “self-pay”. This item needs further research and will not be included in the block vote for today.
Ballot Item 444 - Planned Encounter (Chapter 3, Section 3.66). Issue of inclusion of a CPT code? Current value set is in SNOMED. May not know the CPT code in advance of the encounter. Discussion of the consistency with the Encounter Template. Requires further discussion and analysis.

  • Same session planned for Thursday Q2 in San Antonio.

Patient Care Thursday Q3

PCWG - no meeting (Clinical Statement Meeting)

PCWG delegates (co-chairs) to Clinical Statement


Stephen Chu

Michael Tan


  • CS Ballot
Second attempt at normative ballot
Last ballot (May 2013) – missing mood code requiring harmonization
Harmonization went through
CS reballoted
Received only one negative comment, resolved
CS passed ballot and will progress to publication

  • CMET issue:
Last several meeting, CS has been changed due to harmonization activities with pharmacy models
Previously published CS CMET now not aligned with CS model
Synchronisation of CEMT to updated CS model needs to be done
Synchronisation/refreshing can be considered as technical correction.
Suggestion: CMET to be processed as technical correction and proceed to publication. If MnM objects, then proceed to ballot

  • Review of CS Group Documents:
Approved after minor modification
Mission & Charter document review
Approved after minor modification

  • CS Future directions –
Continue to have joint OO and Patient care meetings (CS/OO/PCWG)
Thursday Q3: to be used as joint CS, PCWG, Template joint meeting to discuss CS template development
WGM meeting session(s) for monitoring progress, harmonization, etc
Conference calls as required for pre-harmonization, short term requests
FHIR does not have its own model ( rather to the RIM) – therefore FHIR does not depend on CS

  • Discussion on Australian request/proposal to add two values (diagnostic services section) to v2.x Table 0074:
US (meaningful use) also has similar requirement
Discussed and accepted to put into a queue for balloting in v2.9 (or earlier version if possible, e.g. 2.8.1) – v2.9 ballot cycle likely to be 2 years; if v2.8.2 to accommodate US regulatory requirements, likely to be soon after April 2013
Australia free to decide early adoption at own risk

Refer to CS meeting notes/minutes for further details.

Patient Care Thursday Q4

Clinical Statement: matters related to CS concluded in Q3

Q4 CS time slot is used to address OO matters

PCWG co-chairs back to PCWG meeting for this session: Care Plan project meeting


Stephen Chu (NEHTA) - Chair

Michael Tan (Nictiz) - Scribe

Gordon Raup (Datuit)

William Goossen (Results4Care)

Russ Leftwich (TN e-health)

Laura Heermann (IMHC)


  • Stephen provided an update on a brief conversation with Dr Larry Garber during cookie break on continuing collaboration with ONC:
• PCWG Care Plan project team will continue to work on Care Plan DAM and CCS. Progress will be communicated to ONC/LCC via document exchange and email.
• Monthly check-point conference calls between PCWG and ONC/LSS to be organised for harmonization discussions
• ONC pilot project on CDA implementation of Care Plan exchanges to commence
• Question: Is LCC conference call going to convene again shortly? This is not known.
  • Care Plan software demo:
• Gordon shows how the software of Datuit works. The software went live in July and is now trying out in pilots. It is the patient’s care plan in which various care providers work in an interactive manner. This is not same concept as FHIR in which a static Care plan is crafted from a template of care plans.
• This care plan is more about access to the treatments and not so much about the management of the care plan.

PCWG Discussions:

• Laura presents the information model of Care plan (contained in the DAM) . There are layers in the hierarchy in the Care plan modeling, ranging from the care plan to treatment plan and instructions.
• According to William the naming of the hierarchy is not in line with the names given in O&O and Clinical Decisions support.
• Many comments in the ballot are about the ambiguity of name giving. (i.e. Care Plan, Plan of Care and Treatment plan).
• According to Gordon the objects that are missing in the current DAM is the master protocol and the other is the fragment.
• This used to be present in the old DMIM of Care Plan from 2009 - care plan structure in "DEF" mood.
• The care plan model shown in the current DAM is intended to be a standardised structure for different types of plans: Care plan, plan of care and treatment plan.
• The example of the C-CDA that Laura shows is used for exchanging a Care Plan instance. The contents of which reflect a snap shot of the dynamic Care Plan. The actual Care Plan is a dynamic plan of which William argues should not refrain to a document only.
• The old RMIM contained a recursive relationship to be able to express the dynamic relationship.
• It was agreed that it will be very useful to have a visual representation of the different types of plan and how they relate to each other. This will clarify most of the confusions stakeholders are currently expressing. Stephen agreed to develop a first draft representation for comments.

Patient Care Friday September 27, 2013

Patient Care Friday Q-0

PCWG co-chairs


Stephen Chu

Elaine Ayres

Laura Heermann Langford

Michael Tan

Russ Leftwich


Discussed and agreed to have dedicated regular conference calls for other workgroups to discuss with PCWG matters of interest to PCWG and other workgroups. Need to find call time convenient to Australia, Europe and US (Eastern). US Eastern 4pm or 5pm Eastern daylight saving; or 8am US Eastern, 9am US Eastern daylight saving will be suitable

Discussed workgroup health. Need to resolve outstanding project - Project 988: Medical Record, consent. This is not likely a PCWG project, need to identify which WG owns the project and remove from PCWG project list.

To clean up 3-year work plan document and send to HL7 to rectify issue.

Monthly co-chair calls: first monday 5pm US daylight saving and 4:00pm US Eastern (next meeting 7 October)

Health concern calls: Thursday afternoon US Eastern. Michael to liaise with Kevin and set up calls

Patient Care Friday Q1

PCWG representatives/co-chairs attended Template group meeting


Stephen Chu

Elaine Ayres


Template co-chair updates on meeting with other HL7 workgrous:

  • Template meeting with FHIR and Structured Document to discuss work items going forward to work on FHIR resources and C-CDA templates:
    • On going discussions that CDA R3 may not be happening. CDA to capitalise on FHIR resources. All C-CDA templates will likely to be transferrable/interoperable with FHIR resources
  • Discussions with CDS:
    • CDS to adopt metadata framework/structure used by Template group and to adopt Templates ITS
  • PCWG input:
    • PCWG seeks input from Template groups on how to create templates for outputs (R-MIMs) from projects such as Allergy/Intolerance. Template group co-chair to email PCWG co-chairs with links to template development resources as starting point informative materials

Template ITS:

The ITS aims at facilitating the use of CDA templates in CDA-IGs

The focus is on ability to transform templates between different tools (e.g. trifolia and MDHT)

Underlying persistent format is DÉCOR

Currently there are several hundred CDA templates. Goals is to use MDHT to import templates data (produced from a proprietary tool – trifolia to produce XML exports and into DÉCOR

Templates DSTU:

A Template DSTU document has been produced and refined by contributors

Scope of DSTU includes: versioning, relationships, how to deal with instances, ITS describing xml format for exchange of templates Currently working on finalising the document

PCWG needs to review and comment on the document. Latest version of the Template DSTU has been obtained from Template group co-chairs.

PCWG will need to organise review and comments submission to Template.


DECOR is an interface for – scenarios, rules (template), IDs (OIDs), terminology, datasets, issues; and repository for templates

More information about DECOR can be obtained from the following resources:

Fact sheet:

Powerpoint slides as PDF file:

The link to the EU CCDA starting project is:

The EU CCDA just started

Refer to Template WGM meeting minutes for further details

Patient Care Firday Q2

FHIR Ballot Reconciliation: PCWG resources


Stephen Chu (chair)

Grahame Grieve

Elaine Ayres

Russ Leftwich

Laura Heerman Langford

Gordon Gaup

Brian Partlethwaite

Lee Unangst

Zoran Milosevic


Ballot comment disposition:

details and voting: refer to FHIR ballot disposition spread sheet