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September 2014 WGM Chicago: Sept 14 to Sept 19

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Chicago WGM - September 2014 Patient Care WG Meeting Approved agenda:




Phoenix WGM - May 2014. Patient Care WG Meeting Meeting Minutes


Patient Care WGM, Monday, September 15, 2014


Monday Q1 - Plenary Session

No PCWG meeting



Monday Q2 - Plenary Session

No PCWG meeting



Patient Care Monday Q-Lunch - Allergy/Intolerance Terminology Meeting

Present:

Elaine Ayres (Chair)

Donna Quirk (Scribe)

Russ Leftwich

Stephen Chu

Margaret Dittloff

Jay Lyle

Jim Case

Rob Hausam

Rob McClure

Evelyn Gellago

Jane Miller (IHTSDO)

Julia Skapik

Naseer Ahmed

Mark Roche

Lee Unangst

Crystal Stalling

Sarita Keni


Minutes:

  • Allergy and Intolerance Food Substances – Elaine Ayers reviewed the Allergy & intolerance RMIM model.
  • Update on SNOMED-CT Submissions -Elaine reviewed mapping work for allergies. Chose to use SNO-MED CT for terminology.

Issue – where do you put these terms? Multiple places? New terms are in US extension. How to get to International extension? Jim Case will reviews extensions and moves to international.

  • Discuss use of UNII vs. other systems
- Issues discussed.
We don’t know how to enter a UNII code. Don’t know how to participate. Rob McClure – UNII codes created in context of substance creation – request code when substance created. FDA responsibility now with USP. May be different rules. Need to get clarity about this. UNII codes obtained for drug ingredients. Very unclear area. Food label is proprietary – nutrition facts, ingredients etc belong to the company so don’t have access. Labels aren’t electronic for reuse. “Others” ingredients on label – don’t know what it is. Hard to link to bar code and nutrition facts. Leaning toward SNOMED due to international extension and hierarchy. Russ Leftwich raised a practical consideration – most food reactions occur outside of home
  • Diet Orders – Margaret Dittloff gave an update. Supplement part of model is problematic. Recently put into SNOMED classes of supplement products. Now we need the specific product names for practitioners. Next step – how do we get info from the manufacturer to get to product and ingredient levels.
- Issues - Negation – DSTU comments for negation Putting negation in model – not in terminology. Is there negation in FHIR? Need to ask
  • RxFOOD and Structured Product Labels – Elaine and Margaret reviewed new project to answer questions about supplement, enteral product and baby formula product formulations and ingredients using SPL. Can get info into First data bank etc. but need an active ingredient to get to RxNorm. Can we use existing processes? Need UNII codes for SPL – so again – need to know the inner operation of UNII.
- Need to know the role of GS1. Need to get GS1 to table.
  • Preferences - The Preferences model is an outgrowth of allergy work. Question raised about canned, cooked, raw. Jim Case shared the terms are a class with no children. In preference model represented as an observation and supply. Per Elaine – needs more work
  • C-CDA – Elaine reviewed C-CDA R2 nutrition templates. A nutrition status observation must have an assessment. The nutrition status observation serves as the “nutrition diagnosis”.
  • Status of SNOMED-CT and LOINC Terms - Significant terminology work completed and on-going in LOINC and SNOMED. Will put in value set authority when ready.
  • FHIR resources for nutrition - Want to do assessments – will be working on this during this week
  • Elaine asked: Do we continue to have nutrition meeting? Yes!! Discussed how to advance agenda items and what is the priority? How do we advance ingredient level detail info – what is the path forward? Mark Roche can help with GS1. How do manufacturers get involved? It was recommended to position terms then go to GS1.


  • Slide deck presented at meeting:
- Food Substance Allergy/Intolerance Terminology project discussions powerpoint slides (pdf format) - Monday - Lunch Quarter



Patient Monday Q3

Present:

Stephen Chu (chair)

Michael Tan (scribe)

Emma Jones

Enrique Meneses

Annie Alexander

Christina Knotts

Russ Leftwich



Minutes:

• Approval of Phoenix WGM:

o Any questions and no further discussion
o Russ move to approve the minutes, Michael second
o Vote: 6 in favor, 0 abstain, 0 disapprove.

• Meeting Agenda for Chicago is reviewed:

o Actions still required for the FHIR lunch meeting.
o Wednesday Q1:
- The Child Health has started a project about a high level summary for children.
- The second project is EPSDT screening. The states are responsible for carrying out.(Medicaid).
Emma has information about IHE and hearing screening and will send it to the PCWG list.

• Stephen needs input for the PCWG information for joint meetings.

For example the Health concern ballot statistics. action MTan

• In the FHIR meeting we need to consider whether clinical asssessment is a new resource.

o To be discuss at joint meeting with OO - Wednesday Q3

• Also need to determine whether Procedure order needs to be a new FHIR resource.

Issue - need to determine what "education" resource is:
- It seems logic to consider education is a procedures of instruction type
- but education is more than just instruction
- there are 4 components in education (assessment/evaluation, materials/contents, order/plan, delivery/instruction).
- Informed consent is a specific type of instruction

• Thursday Q2 joint with SD. Topics for discussions include:

o Allergy/Intolerance and adverse reaction harmonization
o Care Plan harmonization
o Discussion on two templates (Allergy Status and Problem Status observatios) by SDWG
- Stephen is unclear why SD has deprecated these templates.
- The replacement: using Act.Status value + effectiveTime are considered inadequate to express the rich clinical semantics for clinical status of conditions

• Friday Q1 Michael will attend the templates session and report back .

• The other co-chairs will be occupied with the clinical connectathon.

• Anne asked what the templates contains.

o Stephen and Michael explained that: these are architectural specifications how to set up templates, version control and maintenance.
o The template group does not define any specific template for example a care plan.
o Clinical or administrative templates are developed and published by HL7 domain groups such as PCWG, SDWG
o Realms specific organisations such as the ONC may also produce and publish templates
o Templates are then published in template repositories designed conforming to the Template ITS published by Template WG

• The agenda is reviewed and approved at the meeting.

o Russ move to approve the minutes, Michael second
o Vote: 6 in favor, 0 abstain, 0 disapprove.


Patient Care Monday Q4

Present :

Stephen Chu – Chair

Laura Heermann Langford – Chair

Elaine Ayres – Scribe

Michael Tan

Margaret Dittloff

Lenel James

Christina Knotts

Annie Alexander

Russ Leftwich

Enrique Menses

Emma Jones

Crystal Stollings



Minutes:

• Reviewed the current status of the Care Plan Projects.

o Second informative ballot in May 2014
o Post Phoenix ballot reconciliation completed in mid August
o NOTE: next phase - need to evaluate status of the old Care Paln RMIM – is this a stagnant DSTU? Or align with current Care Plan DAM.

• Determine next project phase for Care Plan project.

o Questions:
- With a C-CDA Care Plan – what is the relationship of a V3 RMIM to other work.
- Would RMIM be to provide backwards compatability?
- Do we do further RMIM work or use C-CDA/FHIR models?
An RMIM can be used for messaging exchanges in V3.
CDA care plan document is not designed to support work flow requirement.

• The logical model in the DAM is informative enough for FHIR.

o But to do analysis and harmonization with the Care Plan FHIR resource
o FHIR care plan resource can be mapped to V2, V3 and openEHR.

• What are the harmonization activities with C-CDA R2?

o Note that the Care Plan DAM was done in parallel with the C-CDA care plan templates funded by ONC.
o Question: Do you do the harmonization with C-CDA care plan templates first or work on the RMIM.

• SDWG working on payor issues – work will occur this fall.

o A small list of other changes to the Care Plan can be accommodated (will have support). Note – this is C-CDA R2.

• Decision – harmonize the Care Plan with the C-CDA but will need a SDWG resource.

o Discuss with SDWG on Thursday Q2 and request a liaison individual for this harmonization work.
o ACTION – need a resource from SDWG for the C-CDA harmonization work. PSS for RMIM will follow.

• CCS – DSTU ballot. Ballot reconciliation complete.

o SOA group will drive the technical specification and RFP to complete the work for OMG.
o Patient Care needs to know how to support this work.
o Will need a quarter with SOA on the next F2F agenda.

• RMIM ballot?? Do we need a PSS now?

o If ballot not in January would not need to do now.
o Would recommend that we work on story boards now while we are together.
o If ballot in May perhaps have a PSS done now will help move forward.
o Aim for September ballot cycle 2015.

• Conference call schedule:

o Alternating Wednesdays with Care Plan and Allergies and Intolerances.
o Allergy calls will begin on October 1, 2014
o Care Plan calls will begin on October 8, 2014

• Review of story boards from Care Plan DAM for the Payor Use Case to meet SDWG request.

o Three overarching issues to resolve –
1. Address validity and accuracy of clinical contents
2. Should not focus on execution of the care plan at the expense of care plan contents
3. The exchange is aspirational vs. based in reality
o Discussions:
- Health plans cannot access the HIE data? Noted typical vs. actual.
- Exchange of documents by DIRECT, but at the moment this is too ambitious.
- Providers today do not package up a care plan document and send elsewhere.
- Right now more like a discharge plan/orders.
- What care plan would be sent – nursing? Other?? To make this happen, this will need to be part of the payment system requirements.
- Rather than a set of orders – the story board includes more historical information.
- Home Health agencies do create care plans – transfer summary and care plan (Form 485 – the Plan of Care for treatment). But a care plan is not final until you have seen the patient to confirm. This is the basis of the care plan template in C-CDA R2. The essential data elements for the care plan are the same.
- Question on Why does SDWG want a CM/DM specific storyboard?
- what is required is identification of what extra data are required from the care/disease management perspective in addition to existing storyboards on acute care, chronic condition care, home care, etc
- Discussions: systems that are creating care plans. In an in-patient system – pulling the data into a CCD. How does this get to the payor, or other facility? Fax or via a portal or a client/proprietary application. Now the economic incentives to be in the middle of the transactions helps decrease costs.
- In current care plan DAM – there are payor scenarios. Need to take a look at the actual content as well as one-way vs. two way exchange.
- Where is the patient’s care plan? The PC WG DAM was about the consolidation of these various care plans.
o Next steps – Lenel James will recraft the use case based on comments e.g. clinical best practices and focus on data required for inclusion. Then return to Patient Care for review.


  • Slide deck presented at meeting:
- Care Plan and CCS updates to PCWG - Care Plan session: Monday Q4



Patient Care Monday Q5: Placeholder for extra meeting if necessary

  • No PCWG meeting
  • Patient Care co-chairs to Co-Chairs and DESD meetings



Patient Care WGM, Tuesday, September 16, 2014


Patient Care Tuesday Q1

Joint with FHIR regarding Structured Data Capture (SDC) group from ONC

Present:

Stephen Chu – Chair

Elaine Ayres – Scribe

Roel Barelds

Michael Tan

Dave Carolson

Oyrinda Aassre

Gordon Raup

Crystal Staallings

Keely Straus

Bill Mojurski

Scott Deerwester

Jason Mathews

Gaby Jewell

Annie Alexander

David Hay

Farrah Darbouze

Evelyn Gallego

Vijay Shah

Hector Cintron

Atenue Sen

Emma Jones

Graham Grieve

Ed Larson

Lee Unanst

Mark Roche

Enrique Menses

Russ Leftwich

Larry McKnight

Kevin Coonan



Minutes:

  • Ballot reconciliation regarding patient care related comments.
- Received over 200 comments. Lloyd has developed dispositions for the comments.
  • Dispositions:
1. Why send patient data when ultimately want the full form. Pre-population of the form vs. auto population of the form. But why do you send patient details to a form repository? There were some use cases where pre-population of data are allowed – public health use cases for example. Disposition accepted.
2. Profile defines data elements – allowing extensions may limit the interoperability. If you are compliant to the profile would remain interoperabile. This ballots the resource and the profile. Disposition accepted.
3. Missing mappings – accepted as persuasive.
4. Mapping class component missing in resources – why not use the reference specification. Using an external resource – need to know who the publisher is. (not resolved)
5. Element extension has additional constraints – vs. other elements. Element extensions define additional extensions that can be reference in other profiles. These are extensions for meta-data elements. Recommend rename the extensions – vs. element extensions to something less generic. Persuasive with mod.
6. Make attribute required questionnaire.required, questionnaire repeat changed to 1…1 -- Persuasive
7. Questionnaire with answers not referencing the subject? Feel that not all forms will need a subject – e.g. anonymous surveys, groups, devices. Who is the subject? If dealing with questionnaires from other sources – how is this handled? Profile is 0..1, resource is 1..1. The profile can add the restraint vs. the resource. Will need additional discussion off-line.
- Ballot reconciliation for Stephen’s comments will be voted on by OO.


  • Patient Care – questionnaire and questionnaire answers – there may be more edits to these resources. The work will be done through S & I calls. After this ballot cycle will go through the DSTU FHIR ballot.
  • Care Plan – runs across PC, FHIR, SDWG and S & I. What is S & I plan for the Care Plan templates. PC will be embarking on C-CDA harmonization and a potential revamp of the Care Plan RMIM. S & I – will transition to HL7. S & I will not host any calls. September 29th – will close out project.
  • For policy work – working with provider organizations. A new work group through the Accountable Care WG – will evaluate and inform ONC with respect with care planning. CMS plays a significant role with payment. A NPRM – paying providers use of care planning. Industry feedback on use of care planning based on MU2 re C-CDA R1.1. Many associations pushing back on this requirement. ONC did an environmental scan regarding exchange of care plans (standard and non-standard).
  • CQI – and PCWG about quality measures related to care plan content. What role does ONC play in terms of quality measures? A lot of work with CMS and their common data element library. Focused on patient assessment.. Looking at new care coordination quality measures. “Measure gaps project” – one project is care coordination.
  • CMS – CDE library – MDS/OASIS/CARE TOOL -- data element harmonization. Patient assessment tools – hoping they can use the SDC data elements to standardize. From a community perspective – under Medicaid – ONC will have long term care services and support. This project will look at community assessments. In assessments – tools like pressure ulcer or cognitive tools and there is clinical judgment related to examination.
  • CMS wants to harmonize and create governance around assessments and tools. The data element includes the permissible set of values. Home assessments – ability to walk X feet – can ask in a hospital, vs. in home. For home health – these are the values that are permissible. Constraints – the name itself, the value itself. Using ISO 111179 describes these. Definitions are drawn from LOINC, SNOMED and RxNORM.
  • Question context vs. stand-alone. Embedding meaning in the form makes use difficult.
  • A data group can be used to provide context constraint as per ISO 11179. Need to explore the relationship between common data elements. But this must be maintained. For example – vital signs – need a domain owner for groupings. In the implementation guide – there is now support for relationships between data elements.
  • Post coordination of questions and their answers are needed for interpretation and re-use. Mark Roche will meet with ISO re relationships between common data elements. There may be some useful information in the CIMI models. Stripping the form context eliminates data context.
  • The functional care plan requirements through ONC – will that spec need to be updated? The ONC Care Transformation office – have a care plan acceleration project. This would be the avenue for this request.
  • Domain owners for content – who will these be? Every content will be put into registries or registries. These will be put into NLM – pulling data elements in from various other registries. The domain owner – will they participate in the registration authority. Or can ask another registry to maintain your data element(s). How will these CDE’s be harmonized and have a common definition? The CDE repository will be like VSAC for value sets. The curation and harmonization of these CDE’s has yet to be determined.



Patient Care Tuesday Q2

Present:

Michael Tan (Chair)

Elaine Ayres (Scribe)

Enrique Menses

Jay Lyle

Annie Alexander

Katherine Duteau

Emma Jones



Minutes:

  • Health Concern DAM ballot reconciliation
- details:
- See Health Concern DAM amalgamated ballot spreadsheet



Tuesday Q-Lunch - Pre-Clinical Connectathon Meeting

Present:

Stephen Chu (chair, scribe)

Elaine Ayres

Russ Leftwich

Lloyd McKenzie

David Hay

Viet Nugyuen



Minutes:

  • Objective of session:
- finalised clinical scripts for Friday clinical connectathorn
- Preview of connectathon user interface


  • Clinical scripts: acute care, chronic condition, allergy/intolerance and adverse reactions
- No changes required; David Hay indicated that the scripts are quite complex
- PCWG clinical team expressed that the clinical scripts were based on real patient scenarios
  • User interface:
- Not expected to be production/industry strength quality
- expected to be adequate in supporting data entry and retrieval based on clinical scripts
- more works required for data retrieval function
  • Evaluation criteria:
- Elaine will prepare an evaluation form for use on the day



Patient Care Tuesday Q3

Joint meeting with CQI

PCWG Hosting

Present:

Stephen Chu (Chair, Scribe)

Russ Leftwich

Stan Rankins

Patty Craig

Floyd Eisenberg

Enrique Meneses

Lawarence McKnight

Annie Alexander

Jason Mathews

Anne Smith

Vaspaan Patel

Eric Larson

Thomson Kuhn

Kauuarpreet Sethic

Martin Rosner

Tessa Vanstijn

Chris Millet

Mark Kramer

Rosemary Kennedy

Julia Skapik



Minutes:

  • Floyd presented a slide on care plan outlining requirements for a patient care plan (see slide deck). Discussions progressed as the slides were presented.
  • Stephen commented that immediate gaps analysis indicated that the PCWG Care Plan logical model contained all structural components that meet the requirements outlined in the slide deck.
  • Floyd indicated that there was need to express in patient care plan the entity role (e.g. patient family, carer, provider, etc), not necessarily person name - of those responsible for delivery of care activities/interventions; and also to express the capability scope (not the person or role) responsible for care plan activities.
  • The PCWG care plan logical model already includes roles (based on HL7 roles) classes for assigning care plan activities responsibilities, but will need to consider the inclusion of scope of capabilities.
  • Significant discussions were also on longitudinal patient centric care plan versus individual provider care plans. It was agreed that the patient centric care plan would be the overarching care plan and care coordination tool.
  • There was also discussions on the need to separate care plan processes from care plan contents.
- care plan processes are addressed by the Care Coordination Services functional model and profiles
- Care plan contents are contained in the Care Plan DAM model
  • CQI was requested to consider what detail data elements, e.g. goal date, intervention date, etc that would be required for care quality checks.
  • Both PCWG and CQI agreed to keep joint meeting - Tuesday Q3 - at the January 2015 WGM with PCWG hosting.


  • Slide deck presented at meeting:
- Joint PCWG-CQI Meeting - Care Plan presentation from CQI: Tuesday Q3



Patient Care Tuesday Q4

PCWG hosting FHIR

Present:

Stephen Chu (chair)

Michael Tan (scribe)

Lloyd McKenzie

Jay Lyle

Jason Matthew

Donna Quint

Wendy Blumenthal

Denise Warzel

David Pike

Enrique Meneses

Annie Alexander

Margeret Ditloff

Russ Leftwich

Elaine Ayres

Emma Jones



Minutes:

  • FHIR resources timeline:
- Current timeline for next DSTU proposal should be end of next month.
- FMG will review and report back before end of Octobre.
- 4th December draft content for new profiles or resources.
- 30th March 2015 deadline for gold content (meeting all quality criteria)
  • Care Plan resource discussion:
• Certain FHIR resources are not being used, such as Care Plan, because they are too complex. What could we do to make it more useful? An interoperable Care Plan is also rather new, while observations and such are rather common.
• An suggestion is to make proposals in Care Plan more accesible. A Care Plan would then constitute of proposals and actual care plan. This would be a kind of status of the Care Plan.
• Care Plan is the core with 3 things hanging from this resource. Goal, participant and activity.
• Readers do not understand the meaning of data elements activity and simple. But simple is an adjective and not a noun. If the name needs to be adjusted a change request should be submitted. ( link at the bottom of page).
• Suggestion to change Activity.detail to be Activity.reference, the class simple to become detail and simple.detail to become detail.note. Elaine moved, Russ second the proposal.
• Vote: 0 proposed , 3 abstain, 13 in favor. Motion accepted.
• An activity is not so complex as an procedure order.
• There is also a requirement for time in the Goal class.
• There is a requirement for tagging goals from NCI. A change request should be submitted by NCI.
• PCWG would like the resource to be part of the next clinical connectathon.


  • Referral Resource:
• Question is whether there is a requirement for order response.
• There might be a requirement for the equivalent of Care Provision event.
• We will wait first for the experience in the field


  • Procedure Order:
• There is still work to be done for procedure orders.
• There are order resources which look rather similar like prescription order, diet order etc. Lloyd expects that in the end there will be a handfull of order types.
• Elaine would like the bigger picture or strategic plan for the structure of FHIR. There are now so many types of orders. Lloyd thinks that the various types of orders is a problem for O&O and not patient care.
• The PCWG should look into issues like assesments in comparison with observations.
• Education is now under procedure. This is not natural for vendors. An example is giving patient education. Suggestion that putting education as a seperate resource would broaden the various kinds of education under the umbrella of this resource.
• With education it is important not only to know that the education has been given, but also that the education has been understood. This could mean that we could consider to make education a seperate resource. This will discussed further in a seperate quarter.



Patient Care WGM, Wednesday, September 17, 2014


Patient Care Wednesday Q1

PCWG hosting Child Health

Present:

Michael Padua – Co-Chair – Child Health

Russ Leftwich – Co-Chair – Patient Care

Elaine Ayres – Scribe

Enrique Meneses

Stephen Chu

Emma Jones

Donna Quirk

Denise Warzel

Russell Ott

Nancy Orvis

Pele Yu


Minutes:

  • Essential elements required for special healthcare needs children for transitions of care.
- Design a clinical reference for children that requires complex medical care when entering new environments.
- Based on examples –
o Emergency Information Form for Children with Special Needs (AAP?ACEP)
o Portable Health Record for Children, Youth or Adutls with Genetic Condiiton (Hawaii)
- CMS Form 485 – Home Health Certification Plan of Care (informed the Care Plan in C-CDA)
- C-CDA R2
o Addresses devices, contingency plan and directive and preferences.
o Which concepts are already in C-CDA R2 and what needs to be added?
- Bi-weekly meetings – Mondays 3-4 PM – begin on September 22.
- Data elements gap analysis:
o Cognitive and functional status assessments.
o Is there a way to structure a baseline – and variations.
o Review of current forms and form elements.
- Discussed use of current C-CDA templates – e.g. CCD, Care Plan
- Discussed potential tools that might be used for those without EHR environments.
- How do you model – preferences, e.g. procedures to be avoided
1. Model as a contraindication?
2. Model as a negation
3. HITSP – value set for not-given
4. Procedural contraindications


o Nutrition – enterals, supplements
- An order might the best way to display the information.
- Food – not so prescriptive.
o Continuous feedings are often an issue.
- Representing medication schedules in CDA – PRN medications.
- Orders – one for bolus, one order for continuous.
o Diagnosis – with time
- Looking to meld the various forms into one master form.
- Functional limitations and activities permitted are check boxes. Are there other elements needed and what other data elements are needed?
o In CDA – there are functional status value sets linked to SNOMED codes.
- Do we need a preferences section – to capture a variety of patient wishes. Do we need a flag for special needs?
- The CDA implementation – no specific style sheets so that highlighting preferences will be available.
  • What is the relationship of C-CDA and FHIR resources – can create a profile for how to use these resources.
- The profile is like an implementation guide. The questionnaire resource helps with organizing the questions.
  • How to represent medical devices – there is a device section in CDA.
- These data elements may have preferences and/or contraindications. Note that C-CDA R2 has UID element.
  • How might you represent an alert?
- How do represent when to intubate? Can you have administrative alerts and clinical alerts.
- Note current section on allergies, adverse reactions and alerts –
- How do you represent critical concepts vs. nice to know.
- Is there way to categorize clinical alerts – could you filter by strength of preference?
- Can we use existing structured lists for critical concepts?
- In models – can’t use severe or mild – because these are observations of something that has happened.
- These warning boxes are the worst that could happen….
  • Action items:
1. Bi-weekly calls
2. Enrique will give a modeling for dummies presentation and CDA and the stylesheet that represents it.
3. Will speak with Structured Docs re outstanding issues
4. Dietitians will present R2 nutrition templates
5. Retain Wednesday Q1 time slot for next WG meeting.



Patient Care Wednesday Q2

PCWG co-chairs updating EHRWG

Present:

Stephen Chu

Elaine Ayres

Laura Heermann Langford

Russ Leftwich

Jay Lyle

(full attendance - see EHRWG meeting minutes)


Minutes:


  • See EHRWG meeting minutes


  • PCWG update topics:
- Care Plan DAM
- Care Coordination Services functional model/profile
- Health Concern DAM
- PCWG in FHIR


  • PCWG update slide deck:
- PCWG updates to EHRWG - Chicago WGM Wednesday Q2
- PCWG updates: Allergy/Intolerance - Chicago WGM Wednesday Q2



Patient Care Wednesday Q3

New FHIR clinical resources discussion (Clinical Assessment, Procedure Request)
Hosted FHIR and OO representatives

Present:

• Elaine Ayres (co-chair)

• Stephen Chu (co-chair)

• Michael Tan (scribe)

• Nasser Ahmed

• Laura Heermann Langford

• Evely Gallego

• Kevin Coonan

• Jay Lyle

• Emma Jones

• Rob Hausam

• Lynn Perrine

• Farrah Darbourne

• Denise Warzel

• Donna Quirk

• Eric Haas

• Crystal Stollings

• Kelly Strausbaugh

• Jim McClay

• Enrigque Meneses

• Margeret Ditloff

• Lloyd McKenzie

• Rik Smithies

• Russ Leftwich

• Rob McCurrie


Minutes:

  • Clinical Assessment:
• Clinical assessment is more than only an observation and the assessment tool. It is more and it leads to a prognostic statement.
• Where do you store the data for the assessment? Some input is intended for billing.
• Russ indicated that "goals" should be included. Rob does not completely agree.
• The name risk assessment can rather be replaced with outcome assessment.
• Kevin thinks that condition is a type of observation and that this part of hierarchy. Condition is part of the family, but there is no hierarchy.
• If systems cannot disambiguated then we should not have two separate resources.
• Enrique suggests to set up a mindmap to create clarity in the definitions.
• Elaine suggest to stick to existing resources as much as possible.
• Patient Care suggests to write a profile that includes observation, condition and risk assessment.
• Decision: to profile existing resources (Observation, Condition, Risk Assessment) to create Clinical Assessment.
- PCWG to own resource with inputs from OO
  • Procedure Order:
• Do we need a separate FHIR resource to order a procedure or can use general order?
• Stephen thinks that a general order should be able to refer to a procedure.
• Kevin asks how do you explain why you want the order. This is not in the order itself, but the order is not alone. It could be in the hierarchical higher level.
• Decision: a new Procedure Resource to be created. OO to own the resource with inputs from PCWG


  • Meeting slide deck:
- FHIR new resources discussions - Chicago WGM Wednesday Q3


Patient Care Wednesday Q4

Present:

Elaine Ayres (co-chair, scribe)

Stephen Chu (co-chair, scribe)

Jay Lyle

Brian Scheller

Lisa Nelson

Roel Barelds

Rob Hausam

Diana Behling

Christina Knotts

Donna Quirk

Emma Jones

Katherine Deteau

Jean Deteau

David Parker

Annie Alexander

Amy Wang

Rick Germer

Russ Leftwich

Rob McClure

Kevin Coonan

Russell Oft



Minutes:

  • See meeting discussions in slide deck and change requirement document.
  • Meeting slide deck:
- Allergy/Intolerance project discussions - Chicago WGM Wednesday Q4
  • Allergy/Intolerance - C-CDA harmonization discussions & decision:
- Allergy/Intolerance - C-CDA harmonization - Chicago WGM Wednesday Q4



Patient Care WGM, Thursday, September 18, 2014


Patient Care Thursday Q1

  • PCWG co-chair (Stephen Chu) reporting to OO
  • PCWG meeting: Electronic Services re Data Elements Registry Project - Invite CIC, Emergency, S&I , NLM

Present:

• Elaine Ayres, chair

• Jay Lyle, scribe

• Russ Leftwich

• Evelyn Gallego

• Dianne Reeves

• Mark Roche

• Naseer Ahmed

• Michael van der Zel

• Greg Staudenmaier

• Crystal Stollings

• Kelly Strausbaugh

• Kevin Coonan

• Denise Warzel

• Michael Tan

• Wendy Blumenthal

• Daniel Vreeman

• Thomson Kuhn

• Hector Cintron

• Annie Alexander

• Enrique Meneses

• Stephen Chu

• Emma Jones

• Vijay Shah

• Farrah Darbouze


Minutes:

  • Agenda:
- Common Data Element Repositories, with SDC project team


  • In Phoenix, we noticed different programs using different approaches to creating data element repositories (specifically, CADSR & SDC). HL7 may have a role in providing a repository, possibly via electronic services.
  • SDC began in Jan 2013 with a goal of defining data element syntax (not the elements themselves). These elements are not designed for primary care, but for secondary uses (safety, research, etc.), though some of them may leverage elements that exist in EHRs already. This effort will help to bridge the gap between clinical medicine & research.
  • The project began by surveying existing standards, and chose to base the SDC metamodel on the ISO 11179 data element metadata standard. This standard is already used by many existing repositories and should facilitate harmonization. This alignment is not a replication of all elements identified in 11179, but a selection of an appropriate subset.
- The project has two phases. In the first phase, an SDC specification was developed under the rubric of IHE. The second phase is to develop a similar specification under HL7, specifically based on the FHIR resource. That specification is under a draft for comment ballot; the team anticipates another comment ballot in January followed by DSTU in May 2015. It includes both a data element resource (which can be compositional, when those relationships are integral to the semantics of the element) and a questionnaire resource (that supports the arrangement of elements in explicit context that might be used in other contexts).
  • ONC is agnostic as to what actual repository or repositories are used to store the elements so defined.
  • The project has coordinated with ONC’s FHIM.
- [? Harmonized with cadsr. Ask Dianne?]
  • The project surveyed several repositories, including USHIK, PHIN VADS, CADSR, HL7, and assessed which parts of 11179 are used. About 80 properties were identified, and most reuse the ISO names.
  • Models will specify semantic identifiers for classes, properties, and “elements,” composed of class + property.
- These semantic identifiers will be unique to the element, though authoring and search tools need to support the ability to find an element using synonymous or related concepts.
  • Next steps include subsetting the code systems currently identified for model semantics to simplify the element authoring process, and prioritizing the attribute list to support more effective browsing.
  • How element registries will communicate or coordinate centralized or federated is to be determined.
- SDC has no position on repository governance. FHIR may offer a collection of elements, but implementers should use what they need.
  • MU will establish a “common data set” that US EHRs will have to be able to produce (including gender etc.), and these elements will be documented using the SDC specification. (This is not an SDC effort.)
  • PC would like to use these SDC elements for DAMs. NCI has supported requests to load elements to CASDR, and continues to do so. Opportunities continue to evolve (NLM, CaDSR, AHRQ, possibly HL7).
  • Tooling to load repositories would be good.
  • While SDC is a US realm project, it is anticipated that the form (if not the content of the elements) should be similar across realms.
  • It is desirable to publish in as many forms as possible to support the widest community of adopters.
  • Next WGM:
- PC will not host this specific topic next WGM. We recommend SDC stay in touch with EHR and BRIDG.


  • PCWG reports to OO at Joint OO-CDS-PCWG meeting (OO hosting)
- Stephen reported on the following PCWG project status:
o Allergy/Intolerance and adverse reaction
o Care Plan DAM 2nd informative ballot
o Health Concern DAM 1st informative ballot
- Stephen also reported on the following new FHIR resources/profile to be initiated:
o Clinical Assessment - will be a new profile of the following FHIR resources (owned by PCWG):
- Observation
- Condition
- Risk assessment (name change proposal in process to better reflect prognostic assessment
o Procedure Request - a new resource (or reuse of other existing resources) - owned by OO
o Patient Education - to be discussed at post-Chicago conference calls




Patient Care Thursday Q2

Joint with Structured Document and Template: PCWG hosting

Present:

Stephen Chu – Chair

Elaine Ayres - Scribe

Diana Behling

Brian Scheller

Tim McNeil

Brad Arndt

Jay Lyle

Martin Harthorn

David Hay

Lisa nelson

Isabelle Gibaud

Michael Tan

Martin Rosner

Mark Shafarman

Christina Knotts

George Cole

Rick Geimer

Brian Reinhold

Peter Gilbert

Eric Rose

Laura Heermann Langford

Brett Marquard

Gaby Jewell

Atanu Sen

Matthew Rahn

Kevin Coonan

Steve Fine

Enrique Meneses

Annie Alexander

Ed Larson

John Feikema

Kai Heitmann

Emma Jones

Amy Wang



Minutes:

  • PC Harmonization Requirements:
1. Allergy and Intolerance – working with Lisa Nelson on harmonization.
a. Template definitions vs. V3 model
b. Five high level items related to reaction observation
i. Severity template used in two places – replaced with criticality.
c. Using Trifolia to fold decisions into new templates to bring back to SDWG with new entries.
d. Additional entry relationships – when designing templates how do you line up with existing models.
e. Terminology still requires some work – adding to dynamic value sets as potential errata.
f. Other changes – e.g. these documents will no longer be valid – will have to evaluate if re-ballot will be necessary esp. re certification.
Example replacing severity with criticality. Deprecating something that is a SHOULD constraint will be problematic.
g. Will probably re-ballot over the next year – could add major changes to this process.
h. Re SDWG agenda – assertion pattern, criticality value set.
i. Re downstream changes – dependencies re QRDA – speak with CQI.
2. Care Plan Harmonization
a. Finished second informative document – completing ballot. Publish in November.
b. Will review the existing care plan RMIM to align with the new logical model
c. Will also do a gap analysis with the Care Plan DAM and the C-CDA care plan section. Will need harmonization and need a SDWG liaison for this activity.
Scope was for the LTC coordination. Did not consider workflow. Must be attentive to not break the use cases used.
Do not anticipate that the C-CDA will fully represent the V3 model – but do want to make sure that key data elements are available for exchange.
Will keep in mind backwards compatibility.
The payor community has raised a number of issues. Care management and disease management have come up with the payor group.
d. Thursday calls – second hour (11-12 eastern). – SDWG will appoint a liaison.
3. Health Concern
a. Currently balloted DAM – in ballot reconciliation.
b. Will have a second ballot round
c. Health concern – with multiple entry types
i. 32 different possible entry types.
d. Will need to evaluate this in terms of the care plan.
  • Deprecated Templates - PCWG presenting clinical requirements to justify "reactivation" request
a. allergy status and problem status
b. Request to undeprecate these templates.
c. In C-CDA 1.1 –
i. Allergy-Intolerance Observation used by Allergy Problem Act
1. Contains Entries: depracted allergy status observation.
2. In Table 126 allergy status observation – point to a history table – active, inactive, resolved (SNOMED codes)
3. There is lack of clarity between inactive and resolve.
ii. Problem status
1. Status code – completed
2. Effective time – high/low
3. Using “statusCode + effective time” to communicate “status” is inadequate
4. The status may be active, inactive (semantically different from resolved) , resolved, refuted
5. There are many other clinical status conditions: remission states including in remission, partial remissions, full/complete remission, …. And relapse states e.g. relapse, relapse after partial remission, relapse after full remission.
6. Request inclusion of problem status template and allergy status observation template
a. In R2 completed, active, aborted and suspended (these are machine status terms)
7. Deprecated to inconsistencies in templates to begin with.
8. Act status is the status of the observation, not the clinical status.
iii. Status of the overall concern
1. Status of the concern in the database, vs. the clinical status.
2. Re R2 – post ballot – these comments were made. Question disposition.
3. At the concern level – on the active tracking list or not. Toggling of the status code governs inclusion on the list. Vs. the clinician level observations. What is the status of these problem observations from a clinical viewpoint.
4. Words from the state model have a very different clinical meeting.
iv. Next step – look through ballot comments to see what the comments were. C-CDA R2 will be published in the next month. Bring up as a release R2 DSTU comment (vs. errata). Lisa will work
- Deprecated C-CDA Templates - Allergy Status Observation and Problem Status Observation presentation:
- Allergy and Problems Status C-CDA templates presentation - Chicago WGM Thursday Q2


  • Structured Documents – no agenda items


  • Templates
1. Balloting now complete as of January 2014. Comments (300) resolved (12 negative ballots resolved) and will be published as a DSTU.
2. Progress on FHIR related projects – using FHIR profiles to express concepts that cannot be included in the Templates DSTU.
3. Looking for one single sources of constraint language.
4. PSS submitted -- populate HINGX with templates metadata. Would like seamless inclusion templates into HINGX. HL7 Electronic Tooling (ETs) will be working on this project from a technical perspective.
5. Meeting Friday Q1 to discuss current project
6. US Realm Task Force – Data Access Framework for FHIR objects. Have asked for Templates to join this project. Transfer CDA templates into FHIR objects and back.
7. Can express C-CDA R1.1 can be expressed in Templates DSTU. What is plan for C-CDA R2 to begin this work? What would be next step? Is this part of the templates DSTU?


  • Next WGM:
- All groups agreed that R2 should go through the same process.



Patient Care Thursday Q3

  • PCWG co-chair (Stephen Chu) to Clinical Statement meeting
  • PCWG meeting: Health Concern ballot reconciliation

Present:

Elaine Ayres

Michael Tan

Jay Lyle

Annie Alexander

Emma Jones


Minutes:

  • Health Concern ballot reconciliation
- Negative comments are discussed and disposition decision made
- see amalgamated ballot spreadsheet for details


  • Clinical Statement meeting notes:
- Clinical Statement (CS) business:
o CS decision making process (DMP) change proposal discussions. Proposed changes are passed with modifications.
o CS in maintenance, no further business until new contents required
o details of DMP changes - see DMP document and CS meeting minutes
- OO discussions: HL7 v.2x ballot reconciliation and change requests: discussed and approved
o see OO meeting notes for details



Patient Care Thursday Q4

Health concern DAM - ballot reconciliation

Present:

Elaine Ayre

Stephen Chu (Chair, Scribe)

Michael Tan (documenting ballot reconciliation dispositions and voting result)

Emma Jones

Kevin Coonan



Minutes:

  • Health Concern DAM ballot reconciliation
- Negative comments discussed and disposition decision made
- See amalgamated ballot comment spreadsheet
  • Ballot Issue 27 (on amalgamated spreadsheet):
- this issue is about Care Plan - Health Concern cardinality
- the ballot comment is that the cardinality should be 0..* instead of 0..1
- the issue was discussed and a disposition decision arrived at Thursday Q3 ballot reconciliation session
- Kevin Coonan attended the meeting at Q4 and made a motion to reopen the issue for discussion and revoting
- the motion was defeated (Abstain: 1, Oppose: 2; in favour: 1)
  • Health Concern conference call:
- to commence Thursday 2 October 2014; US Eastern 4:00 pm
- Michael Tan to organise call schedule and webex



Patient Care WGM, Friday, September 19, 2014


Patient Care Friday Q0: PCWG Co-Chairs meeting

Present:

Elaine Ayre Stephen Chu Laura Heermann Langford Russ Leftwich Jay Lyle Michael Tan


Minutes:

  • PCWG co-chairs numbers: discussion and decision to be deferred to post Chicago WGM PCWG conference call - Monday 6 October.
  • Projects update: on current and new projects
  • Next meeting/conference call: Monday 6 October



Patient Care Friday Q1


(1) FHIR clinical connectathorn

- Invitees to participate

(2) Template WG meeting

- PCWG representative(s) to attend
Michael Tan
Jay Lyle


Present (Clinical Connectathon):

Russ LEftwich

Mark Janczewski

Stephen Chu

Laura Heermann Langford

Elaine Ayres

Julia Skapik

Emma Jones

Pat Van Dyke

Rob Hausam

Jim McClay

Chuck Jaffee

Chandil Kumar

Gay Dolin

Peter Bernhusdt

Grahame Grieve

Kevin Coonan

Viet Nguyen

David Hay

Andrew Kanter


Minutes:

  • Participants short introduction
  • Introduction (Russ Leftwich; David Hay)
- Processes and tooling (data entry)
- one clinical scripts per participant; two scripts if possible
  • Data entry through FHIR user interface
- generated lots of discussions during data entry processes using clinical scripts



Patient Care Friday Q2


FHIR clinical connectathorn

- Invitees to participate


Present (Clinical Connectathon):

Russ LEftwich

Mark Janczewski

Kevin Coonan

Stephen Chu

Laura Heermann Langford

Elaine Ayres

Julia Skapik

Emma Jones

Pat Van Dyke

Rob Hausam

Jim McClay

Gay Dolin

Peter Bernhusdt

Grahame Grieve

Kevin Coonan

Viet Nguyen

David Hay

Andrew Kanter


Minutes:

  • Data entry via FHIR user interface continued
  • 30 min of group discussions prior to lunch
  • Notes (from Elaine Ayres):
- Helpful for Connectathon
1. Need to be able to describe the encounter information itself – setting, place, room
2. Need a place in the UI to gather comments during the process – not to post process information from written notes.
3. Coding/1 fields – need to have a purpose.
4. Include list resource for next connectathon
- Needed Profiles
1. Relating data – so for example relate sign/symptom, diag, labs, meds etc together
2. Profile for vital signs -- need a consolidated vital signs template (see C-CDA vital signs template). Need to support qualifiers – like fully clothed.
- Comments on various resources
1. Observation – status not needed as 1..1 on a height/weight, why a reliability.
2. ccObservation – issued – date field is not clear
3. ccObservation – body site – example of terminology binding needed
4. ccObservation – Target – not clear on use
5. Condition – should allow for more than date/time.
Needs a text string field or estimated date or “1-2 months ago..”
Especially needed for quality measures.
Or do you need profiles for each use case.
6. Care Plan – period of time – needs start but may not have end.
7. Care Plan – what is the role of role/member
8. Care Plan – why do you have both amount and quantity
9. Care Plan – Activity
10. Medication Prescription – Identifier is an odd name –
11. Family History – need overall vs. based on a particular individual.
Need to be able to express absence of family history of….
12. AllergyIntolerance – empty list with positive assertion of no known allergies or intolerances
13. Past medical history – use condition
14. Need ability to capture active medications and compliance (including taking, not taking, or erratic, inconsistent) –
need to capture reconciliation as well. What about PRN – how often.
Need notation – reconciled list – with date/time stamp.
- Comments
1. Clear pattern of temporality of events – dates and times
a. Need historical events – but to what degree to you allow for loose statements
2. Use the QUICK model for future Connectathons – In January – there will be a QUICK on FHIR model
3. Lab vs. Panel – combine LOINC codes
4. Look at IMPACT study re data elements for exchange
5. Assessments – tools for assessment, other structured assessment
6. Provisional diagnosis – cite as provisional condition
- Recommend looking on profiles.
Will have all resources and all resources will have terminology look-ups.
- Does this format work for FHIR? Yes
Clinicians feel that this was helpful as well.



Patient Care Friday Q3


FHIR clinical connectathorn

- Invitees to participate


Present (Clinical Connectathon):

Russ LEftwich

Mark Janczewski

Stephen Chu

Laura Heermann Langford

Elaine Ayres

Julia Skapik

Emma Jones

Pat Van Dyke

Rob Hausam

Jim McClay

Gay Dolin

Peter Bernhusdt

Grahame Grieve

Viet Nguyen

David Hay


Minutes:

  • Post participants data entry analysis
- walk-through chronic condition clinical script
- discussions on what FHIR resources need to support
- how these requirements should be supported
  • Next WGM (January 2015 - San Antonio):
- Tuesday lunch meeting
- Friday: Q1 to Q3 - connectathon exercise
  • Notes (from Grahame Grieve):
o Discovered issues from the connectathon:
- Do you have to pre-coordinate the medication form?
- MedicationStatement - reason given
- MedicationPrescription - codeable concept on asNeeded - why?
(overlap on conditions)
- medication List status = reconciled?
- Overlap in Condition.status and Condition.certainty
- Vital Signs interpretations - can we get better codes?
- Identifying standard lists
- Condition.onset: date/time, Age, or string
- Nurse doing dipstix - assumed time?
- Vital signs qualifiers (fully clothed, sitting)
- Urine Dipstix - is this a diagnostic report, or not?
- Family History
- is this condition the cause of death?
- Genetic relationships - part of the base family history?
- summary of family history?
- how do you do a medication conformance claim?
- need profiles for vital signs and social history
- can nutrition order do "reduce salt intake". Does compliance feature for this?
- Diagnostic Order schedule
- take this medication 3 hours before surgery
- scheduling blood collection - part of order or not?
- summary observations?



Patient Care Friday Q4


Present:



Minutes:

Clinical Connectathon concluded at Q3

No Q4 meeting