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January 2015 WGM San Antonio: Jan 18 to Jan 23

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San Antonio WGM - January 2015 Patient Care WG Meeting Approved agenda:

San Antonio WGM - January 2015. Patient Care WG Meeting Meeting Minutes

  • Sunday, January 17 - International Council Meeting
- No PCWG meeting

Patient Care WGM, Monday, January 19, 2015

Patient Care Monday Q1

Present:Present: Attendees: Elaine Ayres (Chair), Michael Tan, Ashu Ravichander, Brady Keeter, Matthew Graham, Emma Jones, Russ Leftwich, Kevin Coonan, Ken Chen, Jay Lyle, Larry McKnight, William Goossen.

Minutes: Minutes: 1. Approve meeting agenda Note all minutes must be pasted into the wiki – will check on status on Friday morning Agenda approved – MOVE – Russ/William Abstain – 0, Negative – 0, Approve - 11

2. Approve minutes of the September WG meeting – Chicago Russ/Jay Abstain – 0, Neg – 0 Approve - 11

3. Review status of WG documents for compliance

a. Mission and Charter - Michael b. Decision making practices - Updated c. SWOT - Michael

4. Status of Co-Chair positions a. Three openings in May – Michael, Elaine, Russ b. Discuss possible candidates

5. Co-Chair administrative meeting – Friday at 8 AM

6. Review of projects and status – three year plan a. Care Plan – V3, FHIR b. Care Plan SOA – next phase of Care Coordinated Services – question dependencies on V3 and FHIR. OMG working on an RFP. c. Health Concern – finish work on the DAM and FHIR. d. Allergy and Intolerance – V3, C-CDA, FHIR. e. PSS William/Russ Abstain – 0, Negative – 0, Approve - 11 f. FHIR Resources g. Anesthesia – Anesthesia working on but no significant updates. Not meeting this WG. h. Other projects – IHE PCC – proposal evaluated and accepted. Will create volume I of profile (end of Feb). There is an HL7/IHE work group being formed. PC will be a co-sponsor. i. New project proposals – j. Allergy and Intolerance terminology implementation guide

K. IHE IMIA/HIMSS/ICN Showcase – Geneva Switzerland 2016 meeting

  • Use HL7 standards and IHE profiles.
  • PSS approval as co-sponsor – MOVE - Russ/Emma Abstain – 1, Negatives – 0, Approval – 10

7. Clinician Connectathon

Patient Care Monday Q2

Attendees: Chair – Michael Tan Scribe – Elaine Ayres Jay Lyle Larry McKnight Margaret Dittloff David Pyke Ken Chen Kevin Coonan

Minutes:**Health Concern Ballot Reconciliation** Ballot reconciliation – Health Concern DAM – informative ballot, R2

27 comments total • 2 Negative Major comments • 11 Negative Minor comments

Larry has sent out a new drawing. The health concern is what tracks the health care concern components. Links in the care plan and adds a health concern list object. Each problem is a concern and each concern has an event. Note that different clinicians may view a concern differently – e.g. an allergy from a clinician vs. an allergist need to be accommodated. Can have a goal – proposed or met?

Does a tracker function need to be included or is this more a list of health concerns? A FHIR resource has condition – the attributes include an event.

There is an inconsistency with current DAM – Larry has suggested changes. Discussed changes in format – move additional introductory prose before the model.

Previously – was condition, and updated to concern. There is inconsistency across all HL7 models. Can stick to these names if they remain consistent.

Is a FHIR resource needed for health concern, vs. using existing resources with some extensions? Need to make a definitive determination.

Add a glossary to the DAM. How does this relate to model names and definitions. Pull in model as a text based document.

Ballot reconciliation – began with negative majors. Two items.

Jay/Ken moved Abstain – 0, Neg – 0, Approve – 6 for both negative majors. Ballot reconciliation moved to negative minors. Who owns a health concern? Is this a terminology issue? Who is responsible? The concern has an author – but who is the custodian? Who do you send an update to?

Need to be clear on the author, the custodian (system or organization) and who can allow modifications. Are these in scope? Have the identifier, but not addressed but other issues.

Patient Care Monday Lunch

Nutrition Terminology Lunch

Present: Elaine Ayres – Chair Scott Brown Pavla Frazier Christina Knotts Jim Case Russ Leftwich Cathy Welch Margaret Dittloff Jay Lyle Galen Mulrooney Darrell Woelk Rob McClure Lisa Nelson Julia Skapik Koichiro Matsumoto Jane Millar

Minutes: Agenda Review/Questions:

Presentation slides: Nutrition Terminology 2015 1 19

VA foods (Jaye Lyle) – Needing to identify exact compounds but rather difference between canned tomatoes (referring to food “composition”, i.e., what are the additives) and fresh.

Medications can have composition but not foods (per Jim Case). No concept in SNOMED – to create composition for foods – and this is not going to change; Russ – commented that this is low priority, few reproducible cases as additives Rob McClure – the way to handle this as a database – to figure out; bad to link it in a terminology. So we won’t attempt this in a terminology – instead point to a proprietary database to access that level of information. If we can identify the specific reactant – it could go in independently but not in the composition sense, (but as a pre-coordinated concept). C-CDA R2 work.

The C-CDA model allows us to document the Nutrition Care Process. Question: what are the terminology bindings?

The direction the Academy is taking is to mimic terminologies that RD's use in their scope of practice. Many of these terms are in SNOMED and we are in the process of submitting many terms to LOINC.

Nutrition Status Observation & Nutrition Recommendations US Edition SNOMED CT

Note on the IHTSDO2015 work plan – work being proposed last year and not done but were related to diets; have not pushed forward. Are these terms migrating past the US? Jim Case said this is not on the 2015 work plan. The concern is that they do not want to do this work piecemeal. Jay said he is putting a group together. Jim Case said that we have not forwarded it to international until we have it all and we need to understand what these mean, e.g., nutrition status observation.

Lisa Nelson and Jim said that they do not know what nutrition status observation means (Lisa and Jim). To them, it looked like the NutrtitionStatusObservation led to the NutritionAssessment. Elaine explained that every NutritionStatusObservation shall have a NutritionAssessment.

Elaine - To move forward, should we do a white paper? (This information is already in the CCDA). Jim Case said there is not obstacle to getting the terms into the US Extension, except understanding the meaning of the concepts. Getting them promoted to International level –depends on resources.

Jane (IHSTDO), what is the purpose of this CCDA what is the implementation use case, and is it used internationally? Answer: this is a series of templates to support the NCP. Yes, the NCP is standardized internationally. Jane: is this using the terms they produced (eNCPt)? Elaine - we have said they cannot use internal terms any more. This is getting the terms in SNOMED and LOINC. The focus is on terms that support the NCP with a goal of integrating the information into the EMR.

Rob – If the concepts that are being created are US Ext. and balloted internationally, - then how to IHTSDO users know that this concept is coming from a US Extension? C-CDA – is US Realm only ballot IHTSDO needs to hear from member countries to prioritize the work.

Example: VA is working on SMART forms pulling from these concepts (has IDNT in VistA). So we’ve been talking about creating value sets. Jane (IHTSDO) – Was going to report on what we were going to do last year and when they see it fitting in. Need to get the countries asking for this directly from IHTSDO If you want terms to be moved into the international realm. Not about development but more about are you going to implement. Submit to try to get on the project list for 2016. If you are going to implement it, we could prioritize it for 2016.

Margaret said the Dietitians of Australia are interested. Jim Case: If this is done, it would cause a lot of churn, because it would require retiring several hundred terms and this could be an impact. So they need to be reassured that this is a true benefit. Bottom line: get Australia and Europe to lobby for these terms.

      • Lobby – NEHTA to push for this.\\

Rob - Ongoing issue of putting this in ballot – invisible concepts – US Edition of SNOMED (have to reference the code system used). This is a Version. Needs to be clear in the ballot where do you go get these codes. Status of SNOMED – has this improved the clinicians; Academy will reconsider these terms for future eNCPT

Margaret. The terminology bindings only exist for the US. She gave the example of how since the terms are not licensed outside the US. For example, our FHIR xml would not render on the FHIR server in Australia. This is the practical outcome. Status of mapping NCPT to SNOMED Now RD's will go to SNOMED or LOINC instead of the local coding. LOINC mapping is underway. CCDA R2. OIDS are in there for CCDA R2. Rob McClure asked a question about the terms which were rejected (as seen on the slide). Did this information go back to the clinicians who were using the terms? Rob McClure said that in his opinion if the words were needed to meet practice needs the Academy should discuss how to respond. Jim Case said there was extensive discussion on the terms which were rejected. The reasons were that either the terms were duplicates, or too obscure. Nutritional Recommendations. We are showing value sets from CCDA R2, but they have not made their way to VSAC. Nutrition Status Observation or Nutritional Status Observation (nutrition or nutritional) Be consistent about use of nutrition vs nutritional Take the hyphen out of SNOMED CT

Jim Case suggests not using grouper terms like "feeding regime" even if it expands the value set significantly". These terms are each examples of……? Suggestion: remove the top 5 items since they are header terms".

Rob McClure suggested that we need an intentional (query based) concept. Query based – intentional definition of the value set – those top five - that concept and all its descendants; not this concept but all its descendants’ e.g. Modeling of this could include a relationship type of thing – (print names) swallowing difficulty – caused by or result in Jim Case, can we get a more precise picture of what this definition for Nutritional Status means? Describes the overall nutritional status of the patient including findings Difficult for a clinician to pick what they want and differentiate better (c-CDA value sets need work). Elaine said we want to change the value sets which are already in CCDA. Margaret Dittloff reviewed the Nutrition Order Terminology work

Nutrition Order Resource proposal in FHIR We are looking to use our work here. Margaret presented the Resource. It's very similar to V3 in that we can separate the texture modification and food types (ground meat, etc.)

Encounter-hospital Diet In some of the editing it got bound to our food preference modifier. Jim Case said that these are all dietary regimes and they should all be pulled out of the regime hierarchy. (Every diet is a dietary regime: map this to dietary regime). Rob McClure: there should be a cardinality of 0 to many. Gs1: they have same – without pork and without beef Cardinality = 0..Many Fluid Consistency in FHIR

Discussion of “Dietary Regime” vs “Substance” - Get advice from - The fluid is a substance (qualifier is the honey-thick) - Focus of the concept is fluid - Complex problem – needs further discussion o Finding it in the sea of SNOMED – o Consistency in the qualifier – if I have an attribute that describes this. (the attribute would (for example “dietary consistency qualifier”, have values like honey thick" , "nectar thick", etc. Jane mentioned that other disciplines would use this such as nurses and speech therapists. We mentioned we got these terms from the dysphagia terminology. (If we do this, then they would retire some other terms). This is our first start at putting enterals, formulas, etc. into the SNOMED product hierarchy.

Patient Care Monday Q3


Present: Russ Leftwich (Chair), Ken Rubin (presenting), Emma Jones (scribe), Martin Rosner, Dave Pyke, Michael Tan, Christina Knotts, Laura Heerman-Langford, Kevin Coonan, Enrique Meneses (on phone)

What is OMG (Object Management Group)? - Standards body that does not write standards. They adopt standards. The Task force puts together the RFP, people respond to it with a candidate standard which become the standard. Goal is to get competing submitters to work together on a standard that is implementable. Process includes an initial submission and a revise submission. Typically during revise submission stage, the competing submissions agree to work together. The goal of the submitters are to commit to a specification as well as implementation. They have 18 months to complete the specification submission.

The OMG process begins with an OMG RFP. The CCS FM RFP will be issued at OMG March 2015 meeting in Reston VA.

CCS FM RFP Review Introduction - provides the context of the SFM and the dates for the RFP. Note that the most recently published version of the artifact. Section 1-5 - copyrights info, info about OMG, etc Section 6 - CCS FM specific information. This section is sub-divided into four areas. 1. Mandatory requirements that have to be addressed in the specification submission 2. Optional requirements that submitters may elect to address. This provides opportunity to address nice-to-haves. Goal is to provide an opportunity to not set the interoperability too high (hindering adoption) or too low (stifling interoperability). 3. Issue for discussion - e.g. FHIR - addresses requirements that submitters need to consider but don't want to be bound to implementing 4. Evaluation criteria - Preference will be given to submissions based on (e.g.) CP DAM. This is a way to inform the voting pool on what is important for the RFP.

Noted CCS FM gaps/updates (need from PCWG): [need to have updates to CCS FM done by Feb 18, 2015] 1. Need to clarify care plan fulfillments - things that have been done. Need to be clearly defined in the functional model. Laura/Kevin will forward email to Enrique to make note to update the CCS FM. 2. Need to re-visit Profile Grouping - may need more flushing out to provide additional functionalities. 3. CCS FM speaks well to care plan management more than it does to care coordinating. Need more clarification and better explanations of care coordination.

PCWG Next Steps: Patient Care need to schedule calls to address these issues - Enrique will send availability for Tues and Wed (for the next few weeks until feb 18).

OMG Timeline RFP completion - need to be ready for approval by OMG March 2015 Submitters Letter of Intent due Dec 2015 Submitters initial submission due March 2016 Submitters revised submission due Sept 2016 Expect adoption Late 2016 - by this point, implementers should be in EA. Submitters call for the votes.

Patient Care Monday Q4

Present: Laura Heerman Langford, Russ Leftwich, Lisa Nelson, Kevin Coonan, Thom Kuhn, Emma Jones, Michael Tan, Brian Scheller, Lawrence McKnight, Darrell Woelk, Ashu Ravichander, Christina Knotts, David Pyke, Matthew Graham, Becky Angeles

Minutes: Chair: Laura Heerman Langford Scribe: Russ Leftwich

Lenel James/Lisa Nelson Care Plan Storyboard 8 presentation

   encounters: annual exam, ED visit for asthma, CM/DM, PCP f/u
   analysis of alignment with C-CDA R2 Care Plan 19 issues to address prioritized by importance from A to D
   as potential solution to evolution of care plan Lisa Nelson demonstrates 8 document template stages that represent evolution
   C-CDA Care Plan document template has 4 sections - Goals, Concerns, Assessments/Outcomes, Interventions - but sections complex
   multiple different care plans can be distinguished separately within one Care Plan document; human readable information distinguished and
       people's involvement/acceptance of plan, timing of the plan
   issues raised during discussion: ability to represent different views, longitudinal views, patient friendly language, conflicting goals and concerns,   
      prioritization of goals, machine readable data that is not represented as human readable text
   the presenters intend to seek implementers for draft versions of templates that address the issues identified, but do not have a current plan to 
       provide feedback to the C-CDA R2 DSTU
   A copy of this presentation will be uploaded to the wiki. 

Discussion of next steps for Care Plan ensued and the incomplete nature of the FHIR Care Plan resource.

Review of FHIR resources that belong to patient care, includes Care Plan, and submission of change orders through G-forge to accomplish changes in PCWG designated resources, as well as reconciliation of Care Plan ballot comments.

Russell Leftwich

Patient Care WGM, Tuesday, January 20, 2015

Patient Care Tuesday Q1

Present: Russ Leftwich (Chair), Laura Heerman-Langford (Chair), Emma Jones (scribe/presenting), Lloyd McKenzie (FHIR Rep), George Cole, Thom Kuhn, Ray Murakami, Gayathri Jayawardena, J. Hyun Song, Yukonori Konishi, Sadamie Takaseki, Masaaki Hirai, Jeffrey Ting, Matt Jensks, Brad Arndt, Michael Donnelly, David Parker, Russell Ott, Erik Pupo, Brady Keeter, Michael Tan, Brian Scheller, Ken Chen, Kevin Coonan, Chris Brancato, Peter Pork, Chris Melo, David Pike

Minutes: IHE PCC RECON Profile Overview of IHE RECON profile provided - Will be a work item out of the new IHE/HL7 work group with PCWG involvement

  • Past work with CDA artifacts
  • Current work to use FHIR Resources

Goal of the profile is to communicate that a list has been reconciled, who did the reconciliation, when the reconciliation occurred and the source from which the reconciled items were obtained. Need FHIR group to provide insight into which FHIR artifact to use for this.

Per Lloyd, recommend use of Resource Provenance with focus on the list that is being reconciled or the resource that is being reconciled. For example, Provenance can be applied to a medication list or to care plan if care plan will include the care team. Resource Provenance can be further constrained via profile for specifics that are needed.

RECON Discussion

  • What happens during the reconciliation process? In theory, two lists are compared and the result is a third list that becomes the "active" list. Some systems may retained records of the previous two lists in case there is need to access again.
  • In the case of reconciling care providers - FHIR does not yet have a out-of-box list of providers (this may need to be added). In the case of reconciling care team members, this may need to be done by applying Resource Provenance to Care Plan (where Care team members are defined). By doing this, can apply provenance to goals, interventions, etc - other components of care plan.
  • Immunization - Can also use Resource Provenance to reconcile immunization recommendations with immunization history.
  • Reconciling a group may be a big stretch

Overview of IHE profile process and timeline provided. IHE RECON profile calls are every other Tuesday at 11:00 EST. Call information is available at

Updated RECON profile is available at

Recommendation to use Resource Provenance - will need to profile this resource to be able to specify what is needed for reconciliation.

Care Plan Change Requests (facilitated by Lloyd)

tracker item 5456 - PC need to review with OO

Gforge tracker item 5401 - Care plan always a document? Need to be able to exchange care plan without it being a document. There are multiple resources for care plan - need to stick with a single resource and have multiple profiles. Design is to aim for a single resource. There will be numerous profiles. Need to look at real world situations and create profiles from that. Comment rejected.

Gforge tracker item 5332 - Care Plan Activity does not link to the participant it's associated with. Need to provide ability for the activity to have a participant and reflect the role of this participant. Discussion about tying goals/activity to participants. Resolution provided.

Patient Care Tuesday Q2

Present: Michael Tan – Chair Elaine Ayres – Scribe Russ Leftwich Larry McKnight Jay Lyle David Pyke Thomson Kuhn Ken Chen Kevin Coonan

Minutes: *Health Concern Ballot Reconciliation* Statement how to related current terms to legacy terms. The comparison of naming conventions in C-CDA and Contsys.

Reviewed Larry McKnights revised diagram 5.

HealthConcernList replaces health concern tracker. Health concern event is related to the health concern. Concern owner includes provider, patient family and group.

Larry related to 2008 ballot. Includes reference to older terms.

Who is an owner? This is the person who voices the concern. That determines the status of the concern, not the status of the observation per se. When is a problem done, vs. a health concern. The custodian of the health concern will need to set policies and procedures for health concern.

The group continued with ballot reconciliation of negative minors. Figure 5 in document and proposed diagram will require additional discussion and modeling. Proposed diagram is not a UML diagram, so we will need to develop a strawman.

1. Jay will draft a new model and then send to Larry to review. 2. Will keep care plan as a side entity but can point to it with a change in arrow structure. 3. Remove health concern tracker box, provider box, and concern identifier (author and custodian instead). 4. Change clinical status to status 5. Link author to concern not concern name 6. Author and custodian will be attached to the concern – events are linked but the concern itself is related to the author.

Note that the “list” will have pointers. The lists may not be the same between providers.

Issues related to the understanding of work flow – may inform the DAM.

List of to do items for changes: 1. prefer legacy terms; terms from Larry’s diagram 2. make identifier ‘ConcernAuthor’ 3. create “ConcernCustodian” -- check on whether that’s right 4. concern status not clinical status 5. Author to concern not name 6. add list. PCP, nurse, specialist. Pointers, owner, sequence.

  • Concern owner diff from list owner

7. Remove tracker, identifier 8. Problem list, allergy list as specializations 9. Add concern owner - person, organization; see V3. Allow delegation, transfer. 10. Relationships: see 2008 ballot 11. OK to keep plan as ‘out of scope’ 12. Imported concern

  • You can decide to bring it in and make it yours
  • You can decide to bring it in and keep original owner
  • Either way you need origin data for reconciliation
  • Events copied; concern merges

13. Include dynamic model for reconciliation

Motion – Larry/David for changes to diagram #5 as discussed. Against – 0, Abstain – 0, Approve – 8 Motion – Larry/Elaine typos to be fixed by document editor. Against – 0 , Abstain – 0, Approve - 8

One more quarter – Thursday Q4 for health concern discussion.

Ongoing phone call for PC Health Concern calls – Thursdays at 4 PM starting January 29 on a weekly basis.

Patient Care Tuesday Q3

Present:Russ Leftwich, Elaine Ayers, Floyd Eisenberg, Laura Heermann Langford, Emma Jones, Rob McClure, Cathy Welsh, Shelly Spiro, Margaret Ditloff, Laurence McKnight, Brady Keeter, Darrell Woelh, Michael Tan, Katherine Duteau, Juliet Pruloni, Martin Rosner, Colin Wright, Patty Craig, Gay Dolin, Dave Parker, Evelyn Gallego, Julia Skopik, Kendra Hanley


Gaye Dolin Presenting

Review of work done previously. (Anatomy of Allergy Intolerance Templates.)
Review of Allergy Types: value set of SNOMED-CT codes (value set including Medication drug class, clinical drug ingredient, unique ingredient identifier, substance other than clinical drug.
Review Proposed plan coming out of Materials Summit --- validate and expose intensional definition of these value sets, propose resolution to ONC/CMS folks, get value sets added to VSAC, get clarifications/guidance add to R2 companion guide including value set URLs (find out the current status of the R2 companion guide).
  • Discussion re: how do we represent substances, why do we need to represent substances?
  • rethinking - do we really need to represent every substance? Or just a subset that are known reactants?
  • Discussion point: there needs to be some sort of larger picture on how things fit in (such as vaccines are medications)
  • Discussion point: We need a way to maintain a list of agreed allergens - but a valid place to hold the information. USP? to evaluate and map to a drug classification?
  • Discussion - what do we do know? We have CDA 1.1 where it cannot be expressed well, then we have the improved version that won't be seen for a little while - what can we do in the interim? Code set to use in system for now? Idea - look at the workflow proceeses that cannot be incorporated into the standard. Don't get into the weeds (storage etc) as they can be solved before really needed. Wondering if we can use value set defined in R2 in R1 while we wait for field to catch up. If so then, need complete/finalize the value sets.
  • 11/24/2014 Next Steps:
    • suggest-- Rob, Jim and Brett will work together with Olivier to determin time lines to accomplish making available drug class value sets with linked lists of RxNorm codes.
    • When LOE and time lines are estimated, this group will reconvene to - 1) discuss the remaining issues, 2) Plan for communication to the community.
    • Create robust DSTU comments on both C-CDA R1.1 and R2, HL7, DSTU comment pages
    • Propose resolution to ONC/CMS folks
    • Get value sets added to VSAC
    • Discuss "sub-value ("min") set of "(99orsomenumber)" codes"
    • Get clarifications/guidance added to R2 companion guide including Value set URLs find out the current status of the R2 companion guide).
  • Today Next Steps:
    • We need a list of the substances that cause reactions and somebody needs to maintain that list.
    • We will replicate this conversation at Thurs Q2 Structured Documents for further discussion.

PCWG/CQI - will keep this quarter as a joint meeting going forward.

Patient Care Tuesday Q4

Present: Russ Leftwich ( Chair), Elaine Ayres, Lloyd Mc Kenzie, Evely Gallego, Laura Heermann Langford, Michael Martin, Il Kon Kim, Do Youn Lee, Joon Hyun Song, Jae Woo Sin, Joanna Johnson, Shelly Spiro, Becky Angeles, Farrah Darbouze, Danielle Friend, Dave Carlson, Kevin Harbauer, Brady Keeter, Margereth Dittloff, Cathy Welsh, Michael Tan (Scribe), Kevin Coonan,


  • Evelyn Gallego gives an introduction on the reconciliation of the ballot comments on the FHIR project of the Questionnaire resource, which is used for data capture. Lloyd leads us through the comments:
    • A non persuasive disposition is placed that common questions can be defined using data Element resource. Vote: 19 in favor, 0 against, 1 abstain.
    • Examples of questionnaires are not clear, some people think that the questionnaire can only be used for medication and immunization. The examples are extended. Questionnaire is a data capturing tool. It would not be advisable to capture medication list with a questionnaire. The questionnaire can reference to another FHIR resource. You can use questionnaire for all kinds of queries, but you can't do very much with the answers. Disposition is to add another example. For example and "patient intake form" or "insurance claim form". Motion moved by Elaine, second by Margeret: Vote 17 in favor,2 against, 0 abstain.
    • The next comment is about naming in the example. This will be changed: Motion moved by Elaine, Second by Margeret: Vote 20 in favor, 0 against, 0 abstain.
    • Remark questionnaireAnswerSource; The definition now says: the person who answered the questions about the subject. Only used when this is not the subject himself. The commenter recommends to discard the patient. Mind that the subject of the questionnaire need not be the patient himself. Suggestion to modify "source" definition and remove the second sentence. Motion moved by Emma, second by Margeret: Vote 20 in favor, 0 against, 0 abstain.
  • The second ballot section is about the Care Plan resource. The FHIR Care Plan maps to CCDA r1:
    • Should there also be an outcome section in the Care plan? Emma does use outcome sections in their Care Plan ( attached to goal). The definition of the word "outcome" is not unique. It is used with different meanings. Suggest to keep it out of the 80% until the requirement is more apparant.
    • Priorities ( high medium low) and indication are functionally required with goals. It is also important to know the originator of the goal. Priority will added to Goal. Source will be added as a standard extension: Motion moved by Elaine, second Laura: Vote 20 in favor, 0 against, 1 abstain.
    • One comment suggests to add codified barriers to a Care Plan. The suggestion was to put the barriers in the Alert resource, but the commenter thinks this is not robust enough. Lloyd wants to define an extension that allows capture of support relationship allowing Care Plan to link to other resource. This could link to Alert. Motion moved by Elaine, second Evelyn: Vote 22 in favor, 0 against, 0 abstain.
    • Barriers will be added as an alias to Alert: Motion moved by Lloyd, second Cathy: Vote 22 in favor, 0 against, 0 abstain.

Patient Care WGM, Wednesday, January 21, 2015

Patient Care Wednesday Q1

Present: Russ Leftwich (chairing), Elaine Ayres (scribe), Wendy Huang, Larry McKnight, James Topping, Margaret Dittloff, Scott Brown, Diane Reeves, William Gooseen, Ken Chen, Michale Tan, Michael van der Zel, Emma Jones, Anita Walden, Mike Padua, Mitra Rocca.

Minutes: Joint meeting with PC/Child Health and CIC

1. *MD Epinet project -- a user group would be valuable. Use of unique device identifier for epi pens. HL7 input would be useful for this registry project - complement rather than duplicate work work towards interoperability.

MD Epinet originally set up by FDA but now a membership organization.

ACTION -- Anita and Russ will speak with Chuck Jaffe.

2. *Michael van der Zel - presentation on the MAX tool. (Model Automated eXchange). Slides:

MAX is a Models XML format this is compatible with a spreadsheet based on a simple XML structure. In EXCEL developer tab there is XML expansion pack that can be used.

A UML Schema diagram was shown. There are object types and relationship types. The functionality allows for import/update, export, validate (Schematron), transform and edit parts of models using spreadsheets.

Can be used between different systems, e.g. Enterprise Architect and Rational Rose. Can start with a model or a spreadsheet. Demo of a BMI with weight and length in EA. The export takes the XML (showed XML file). Then imported into EXCEL. Note that 80% of EA file is supported in EXCEL - the additional 20% requires a separate file.

The model was expanded in EXCEL and then imported back into EA.

Current uses - EHR-S FM R2 validation and publication, DCM validation, publication and transformation, UMCG EHR-S Architecture and Reporting, Archimate in EA and MIF as UML. CIC has used these for their domain analysis models.

Child Health interested for this for developmental screening data elements. PSS now completed. Only high level data elements in the Functional Profile at present (from 2008). Want to align with requirements from CDC and American Academy of Pediatrics. Will start with EHR FM-2 as starter set of concepts.

Michael showed a use of of taking data elements from EHR-S FM 2 to extract key data elements.

Are there RIM elements and value sets available? Michael showed an example of FHIR resources. Can include the value sets in FHIR to the EA model (logical model).

This tool can also help with HL7 publishing files. Can also be used to manage all of the various files into one large model. MAX will be completed with a PSS to complete the tutorials and other HL7 materials. However, the tool is ready.

Can a EHR Functional Profile back to EHR-FM? Depends on spreadsheet - but there are cell formats that need to be removed and each column needs to be turned into an object.

3. *Update on Child Health projects - Mike Padua a. *Children with complex special needs form -- looked at similar templates for content.

  • Creating storyboards for presenting to an ER, School/Camp, referral to a new sub-specialty providers, or transitioning between providers.
  • Includes contingent care plans, nutritional care plans, device needs, communication for non-verbal patients, contraindicated procedures.
  • Enrique is helping with modeling work.
  • Meet on Mondays at 5 PM EST beginning on February 2.
  • Need assistance with storyboards.

b. *Developmental Screening Derived Profile (EHR based). (see above re Functional Profile)

  • Note AHRQ use of the original Functional Profile.
  • There is a need for these data elements for meaningful use.
  • The EHR visibility project helping to highlight profiles developed. Involves improvement of usability. Pediatric specific contact would be helpful. Group meets routinely Tuesday Q2.

4. *Common data elements updates for registries and reporting. Mike asked about existing resources for common data elements - portal -- will provide a view into common data element sets. NIH will be harmonizing these data. AHRQ also has standard data sets as well. The National Children's Study - also in the NIH portal for common data elements. NLM is the value set authority for MU data elements. The portal will pick up these data sets. Propose a session talking about secondary use of EHR data.

4. *Standing WG meeting time with Child Health - Wednesday Q1.

Patient Care Wednesday Q2

Patient Care at the multiple work-group update hosted by the EHR WG. Laura Heermann Langford and Elaine Ayres presented updates on Care Plan, Care Coordination Services (CCS), Allergies and Intolerances, Health Concern and the Patient Care FHIR resources. The group agreed that an overview session of the various clinical projects would be beneficial at the Paris WG meeting, but the suggestion was made that the overview should be done earlier in the week -- potentially Monday Q3.

PC Update Slides

Patient Care Wednesday Q3

Present: Elaine Ayres (Chair), Jay Lyle (scribe), Russ Leftwich, Margaret Dittloff, Cathy Welsh, Ray Murakami, Danielle Friend, Ashu Ravichander, Michael Donnelly, Emma Jones, Joshua Mandel, Brian Scheller, Jos Baptist, Michael Tan, Dave Carlson, Yunwei Wang, Brad Arndt, Tom Hyun Song, Laura Heerman-langford, Rob Hausom, Ken Chen, Riki Merrick, Clem McDonald, Chris Melo, Do YunLee, Larry McKnight, Kevin Coonan



  • New clinical assessment resource
  • Eric Haas: GForge item 3839
  • GForge item 5456
  • Disambiguating observation & condition
  • Disambiguating order & request

A Clinical assessment resource is proposed

Clem raised two issues. One is that the term is polyvalent, indicating the intended SOAP assessment, but also denoting various finer-grained assessment instruments. In fact, some of the adduced examples are instruments: this is incorrect. This is not Apgar. It is agreed (but not voted on) to call it “impression.”

The second issue is that the structure seems unduly detailed. Making a clinician break out a note in this sort of structure and maintain relationships within it adds excessively to the workload. Even if the design only supports but does not require this level of articulation, it could be picked up in a regulation.

A SOAP assessment commonly repeats observations from elsewhere; it does not include no de novo observations. An Impression asset could be profiled as a composition of other resources already defined. CDA may provide a benchmark for how to structure this asset and the level of detail to provide. It was suggested that the V3 DAM addressed these requirements, but the recorder finds no DAM or V3 model for assessment or impression.

Action items:

  • Rename this resource “impression”
  • Compare it to C-CDA specification
  • Compare it to visit note

This may not wind up being a resource, but some people felt it would be useful; we’ll draft it.

GForge 3839 (&3372)

Motion - link to the encounter where the order is created. Any results would be linked to that encounter. Cardinality 0..1.

MOVE: Rob/Margaret Abstain - 1, Against - 0, Approve -- 24

I.e., any diagnostic report that is created could contain a reference to the encounter in which the order was created.

GForge 3379

Same issue as above, with observation.

MOTION: Change observation.encounter to an encounter during which the observation is made, with a cardinality of 0..1. 1/21/15 - PC/OO/FHIR Motion: Josh/Rob Abstain - 0, Negative - 0, Approve -- 25

I.e., accept the change currently drafted to associate the observation resource, optionally, with the encounter at which the observation was made

GForge 5456 Riki

Will add a boundaries and relationships section to the condition resource that clearly distinguishes between observation and condition. 1/21/15 PC/OO/FHIR MOVE: Rob/Clem Abstain - 0 , Negative - 0 Approve - 24

I.e., add a “boundaries and relationships” section to the Condition resource, as is provided for the Observation resource.

Patient Care Wednesday Q4

Present: Elaine Ayres (Chair), Jay Lyle (scribe), Russ Leftwich, Margaret Dittloff, Cathy Welsh, Ray Murakami, Ken Chen, Jos Baptist, Christina Knotts, Emma Jones, Rob Hausom, Kevin Coonan, Michael Tan, Rob McClure, Dave Pyke



  • Allergy models
  • CCDA harmonization R1 & 2
  • FHIR resources
  • OpenEHR harmonization
  • [other topic]

We have allergy models in V3--DAM and V3 in DSTU

We need test implementations for the V3 DSTU

  • Netherlands: Art Décor may test
  • The question was raised of whether CDA or FHIR tests could qualify as V3 DSTU trials. Some present felt the answer was clearly not; others held that it might be possible. The question was left open.

We wish to move the concept definitions into SKMT.

CCDA R1.1 harmonization:

  • Add criticality
  • Allergy intolerance type (need value set)
  • Proposed terms: SCT, LOINC, FHIR

It was generally agreed that time would best be spent focusing on R2.

The HTA reported that the process is still being defined, and that some questions could not yet be answered.

The HTA will confirm that a request is aimed at the appropriate system (including extensions), provide guidance on the request, and make requests, if international. Probably. HTA plans to address these questions on Friday.

It was suggested that HL7 might have its own SCT extension, which would obviate the sorts of delays the allergy project is facing (IHTSDO won’t consider major changes while an internal assessment of the domain is under way). The HTA representative will bring the question up at HTA again.

The project requests a non-allergy intolerance concept. Also asking QRDA to include parent concept of “allergy or intolerance to substance”.

Requesting Criticality of allergy or intolerance

Should the question be LOINC? Open question; we’ll follow HTA guidance.

Severity. We like 3 of 6 in SCT & currently in C-CDA. Not an HTA question; an SD question.

LOINC request list. Includes question of whether to ask for AI severity or just severity.


FMG has merged Allergy/intolerance with reaction, based partly on OpenEHR input. PC disagrees with the merge.

It should be possible to record reactions that are not indicative of individual propensities, and not have those reactions appear in an allergy list.

A reaction may involve a complex encounter, but that’s an encounter composition. This is a historical summary record that a reaction occurred.

Motion: Split these back up; replace “event” embedded class with an existing resource if possible (e.g., observation, extended), a new one if not

Russ moves, Jay seconds; 1 abst, 0 opposed, 13 for

Motion expand type code value set (Kevin). Not seconded.

Agenda item for substance coding will be addressed at SD tomorrow.

Vocabulary facilitator was asked when Vocabulary will complete review of the outstanding PSS to define best practices for terminology development. Vocab feels that IHTSDO needs to be encouraged to participate actively, and IHTSDO will require one or more members to advocate for this before it will appear on the IHTSDO work plan.

Patient Care WGM, Thursday, January 22, 2015

Patient Care Thursday Q1

Patient Care representatives attended the Orders and Observations WG meeting along with CDS and Templates. A Patient Care Project update was provided. The group discussed the difference between order and request as per GFORGE tracker item 5283.

Patient Care Thursday Q2 =

Joint meeting with PC/Structured Documents and Templates

Attendees: Russ Leftwich (Chair), Elaine Ayres (scribe), Austin Kreisler, Laura Heermann Langford, Gaby Jewell, Steve Fine, Vinayak Kullami, Rob Hausam, Benjamin Flessner, Brett Marquard, Mathias Aschoff, Ganathri Janawareoena, Lawrence McKnight, William Goossen, Russell Ott, Chris Brancato, Kevin Coonan, Emman Jones, Rob McClure, Ray Murakami, Jeff Brown, Tessa Van Stijn, Cathy Welsh, Gay Dolin, Mark Shararman, Kai Heitmann, Lisa Nelson, George Cole, Brian Scheller, Michael Tan, Keith Boone, Angellique Cortez, Colin Wright.

Agenda: Templates C-CDA to Templates 2.0 and versioning Structured Documents DAF ballot Allergy and Intolerance Harmonization Care plan harmonization – health concern C-CDA Care plan templates C-CDA and FHIR Clinical Status vs. Act Status

1. Templates – Kai Heitmann Conversion from C-CDA 2.0 to Templates ITS Conf statements have changed – added CONF:81 vs. Conf. Release one only had numbers with no prefix. The validation tools on-line work without an issue. But the implementation guide is not consistent either. Need to go back to the committees to resolve. Templates DSTU in use in Europe – the templates ID needs to remain consistent.

Also versioning of templates 1.1 vs. 2.0 – for templates that are unchanged the existing ID was used. No extension was assigned – only if it was changed.

Is there one C-CDA with all 1.1 and 2.0 templates – validators conform to 1.1 or 2.0. IG is a collection of templates in a particular version state. The version identifiers on the templates describe this version. If applied to a registry – are the changes a new version or do you need two versions? The issue is with the unchanged templates in 2.0. 2.0 is adopting specs from 1.1. The errata on 1.1 may not be carried through to 2.0. These would be technical corrections in the publication.

There are value sets in the package – are these versioned? If the definition of the value set changed these would be versioned. These should follow VSD rules. (this needs to become policy). The current version of Value Set Definition is on the Vocab wiki.

2. Structured Documents – DAF ballot (Brett Marquard) Data Access Framework for accessing data for meaningful use. Some require discussion with Patient care. Will send list to PC Co-Chairs and then we will farm out the comments to meetings.

3. Allergy and Intolerance comments – put in 1.1 and 2.0. Note that is a duplication of 1.1 and 2.0. Need to keep up with other derivative products. Substances summit -- review of templates

Severity observation needs to be changed to criticality.

Current value sets – allergy type:

No generic enough code, and dander and environmental allergy are not correct.

Substance-Reactant for Intolerance value set – these are grouping value sets. NDFRT, clinical drug ingredient, Unique Ingredient Identifier and substance other than clinical drug.

The heuristic has a priority order…NDFRT, then RXNOMR, then UNII then SNOMED CT.

All value sets have intensional definitions that are not housed anywhere and therefore not available to implementers.

Discussed with PC and what are the most common of the multitude of codes that might be available from multiple sources. Also hard to implement heuristics.

Value to having intensional definition – needs to be very clear on use of a value set. But there is no standard for exposing the intensional definition. The intensional definitions should be in VSAC. Do you use the definition rather than the value set.

For NDFRT – an intensional definition might work, but for RxNORM and others will this work.

The VSAC needs to represent these within the next couple of weeks.

Need and extensional value set of terms that can be used. Creat robust DSTU comments on both C-cDA r.1.1 and R2 , HL7 comment pages Propose resolution to ONC/CMS

Can still use big set as the background, but small set can be used as the min set. All should be able to exchange identifiers as a minimum.

This would be a binding element that can referenced in the artifacts. Keep max of all, with a min that is well defined.

Min and max with interoperability - using a min for example with race and ethnicity vs. CMS sets. In an interoperability viewpoint, will not validate. Have to use codes that roll up to min classes. If you choose max, need to point back to min. However, min will always be in max.

Having the value sets in the same place might be an issue.

The work needs to be reviewed and managed by an authoritative body. There are four value sets – need stewards. The IDMP is to focus on these value sets for drugs.

How will HL7 support this work? Do we need a project for allergy value sets? Need a PSS including PC, Structure docs and Vocab. Current 1.1 value sets – are now old. Validators now need to be updated. Gay, Bob and Brett – need to be sure that validators can be updated on new content. Can the errata for 1.1 point to 2.0. Will get the immediate content out. What is the role of HL7 HTA.

MOTION – Patient Care Allergy and Intolerance Project Chairs organize this project through HL7 and deals with process issues within HL7. Laura/Keith Abstain – 0, Negative – 0, Approve – 28.

Patient Care Thursday Q3

No meeting. Patient care representatives attended the Clinical Statement/OO meeting.

Patient Care Thursday Q4

Health Concern Ballot Reconciliation

Attendees: Michael Tan (Chair), Elaine Ayres (Scribe), Kevin Coonan, Larry McKnight, William Goossen, Ray Murakami, Russ Leftwich

Minutes: Ballot reconciliation Component – the concept is not clear until later in the document.

MOTION: Explain in a note what a component/event is (whatever term is chosen) (as applies fo Figure 4). Against – 1, Abstain – 0, Approve – 6.

Revamp of Figure 5 – the updated figure does not include goal. Just need to make sure that terms are in alignment with the rest of the document.

MOTION: Approve the updated diagram as presented. Addition of other items can be addressed on a future call. Larry/Russ Against – 0, Abstain – 0, Approve - 7

Concern relationship kind provides terms to support concern relationships. Likewise event relationship is supported by event relationship kind (needs terms).

8.1 Figure 3 Actor diagram – discussion of relationship of concern viewer to Concern Identifier. MOTION: Change diagram of actors – remove relationship arrows for the top two roles to avoid in appropriate constraint and remove the bottom three roles. Add custodian role. Therefore there will be six roles – concern author, concern custodian, concern monitor (instead of concern person), health concern list owner, and health concern list modifier, patient. As suggested: 1. Concern author: the individual who identified a Health Issue as needing monitoring as a Health Concern. 2. Concern custodian: the entity (typically organization) who is responsible for the maintenance and governance of the Health Concern 3. Concern updater/modifier: an authorized individual who is able to add new information or change existing information to a Health Concern as authorized by the Custodian 4. Concern monitor: an authorized entity (individual, organization, device, software) who is able to access information within a Health Concern, but not change it. In addition, it is implied, if not explicit, that updates/changes of a certain nature are communicated to a Concern monitor. 5. Patient: the subject, or mother of fetus, who is the subject of the Health Concern. Their ability to access or change or even comment on aspects of a Health Concern are governed by the Custodian, statute, government or organizational policy which is beyond the scope of this analysis. 6. Health Concern List owner: an entity (individual, device, software) which has a dynamic list of one or more Health Concern related Health Issues, which may be represented as point in time snap-shots or as a subscription which automatically populates with each use/view.

Move – Jay/Kevin Abstain – 0, Against – 0, Approve – 7

The diagram still needs a check against the V3 properties list, check on relationship semantics from the 2008 model. Status – is it a concern status or a clinical status?

8.4.8 Attributes list “inPatientWithKnown” -- leave open until next conference call.

Patient Care WGM, Friday, January 23, 2015

Patient Care Friday Q0: PCWG Co-Chairs meeting

Cancelled. Next regular PC Co-Chairs call will be held on Monday, February 2nd at 5 PM ET.

Patient Care Friday Q1

(1) Template WG meeting

- PCWG representative(s) to attend
  • Discussion how to link templates or constraints in templates in FHIR. There should be possibilities in the profile, but this has not really been thought about.
  • There is a possibility to link a template to a functional model.
  • Update of the ART-DECOR tool. Kai Heitmann gives a quick presentation of the new features on ART-DECOR.
  • Now working on the terminology server.
  • There is a profile editor now for FHIR, should this be integrated with ART-DECOR or should they build a new editor?

(2) Agenda: open

- FHIR Clinician Connectathon



Patient Care Friday Q2

Agenda: open

FHIR Clinician Connectathon



Patient Care Friday Q3

Agenda: open

FHIR Clinician Connectathon



Patient Care Friday Q4

Agenda: open

FHIR Clinician Connectathon