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January 2017 WGM San Antonio, Jan 14 to Jan 20

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San Antonio, WGM - Jan 2017 Patient Care WG Meeting Draft/Approved agenda:


Day Time   Room Event Host Joining Chair Scribe
January 15
AM Q1 ?
Q2 ?
PM Q3 ?
Q4 ? FHIR co-chair updates
Day Time   Room Event Host Joining Chair Scribe
January 16
AM Q1 Frio Patient Care WG Administration Meeting Review agenda for the week, Update the PCWG documents - DM, M&C, SWOT, 3 year plan - Must do the DMPand the 3 year plan - consider moving the SWOT and M&C to the same timeline. Michael Jay
Q2 Rio Grand East Mega joint session EHR Laura
PM Q3 Nueces FHIR Change requests - Care Plan, Care Team, Goal
  • GF#11342 - Add CareTeam.relatedTeam or other composition relationship - 2016-09 core #500
  • GF#11344 - Allow CarePlan.activity.detail.performer to be CareTeam - 2016-09 core #502
  • GF#10624 - QA 4a: Consider whether Goal.priority (CodeableConcept) should be bound to an external code system such as SNOMED
  • GF#10613 - QA 4e: Clean up valueset-goal-status
FHIR Michelle Michael
Q4 Rio Grande Center Joint Session with FHIR & OO on FHIR workflow FHIR Emma
Q4 Frio Continue Q3 discussion on CarePlan, Goal, and CareTeam trackers
  • GF#10613 - QA 4e: Clean up valueset-goal-status
  • GF#11116 - Better define the careplan.activity.outcome field. - 2016-09 core #270
  • GF#10615 - QA 4: Clean up valueset-goal-status-reason
Day Time   Room Event Host Joining Chair Scribe
January 17
AM Q1 Rio Grande Center FHIR/PCWG - CIMI - Skin Care model meeting. Stefan Hufnagle project CLIM CIMI and FHIR - I, ECWG Laura Emma
Q2 Rio Grande Center FHIR requests including updating condition scope to include concern events FHIR-I Michelle Michael
PM lunch ?
Q3 Rio Grande Center FHIR CarePlan, Goal, and CareTeam value sets as part of ONC Care Coordination
  • GF#10725 - QA 4: CareTeam CodeableConcepts need a binding to a value set
  • GF#11334 - Constrain participant role value set - 2016-09 core #492
  • GF#10620 - QA 7a: CarePlan.activity.outcome needs a binding to a value set
  • GF#10623 - QA: Goal CodeableConcept elements are missing a binding to a value set
Michelle Lisa
Q4 Rio Grande Center Negation + other topics; OO, FHIR-I, Vocab, Clin Genomics, CIMI, SD, ED Jay Emma
Day Time   Room Event Host Joining Chair Scribe
January 18
AM Q1 Regency East #1 PCWG-FHIR trackers for clinical resources - Procedure and applying workflow patterns (for procedures)
  • GF#12595 - Condition needs a search parameter for Condition.evidence.detail
  • GF#11162 - Suggest include reference to remedial treatment(s) - 2016-09 core #316
  • GF#10626 - QA: Procedure.usedCode needs a binding to a value set
  • GF#10627 - QA 4a: Consider binding Procedure.focalDevice.action (CodeableConcept) to codes from an external coding system - vocab
  • GF#10293 - Apply FHIR workflow standardization changes to Patient Care Resources
Michelle Emma
Q2 Directors Episode of Care; Care Team PA will host PA Michelle/Michael
PM lunch Blanco
Clinician-On-FHIR Preperation meeting
Q3 Rio Grande Center PC/RCRIM/CIC Joint meeting - Topic: Adverse Event (RCRIM) CIC, RCRIM, PC Elaine
Q3 Nueces FHIR/PCWG Joint meeting (PCWG Hosting FHIR reps)
  • GF#12608 - CarePlan - Add ReferenceGroup to the list of supported references
  • GF#11119 – Differentiate ProcedureRequest and DiagnosticRequest and align their elements (Danielle Friend) - related Zulip Chat
  • GF#11026 – Relationship between Condition and Observation (Jay Lyle)
Q4 Rio Grande Center Allergy/Intolerance topic meeting

Medication value set subproject

Food substance value set subproject
Day Time   Room Event Host Joining Chair Scribe
January 19
AM Q1 Rio Grande Center Care Plan -invite FHIR, Structured Docs, Pharmacy

HL7 C-CDA 2.1 Care Plan Document Template - Lisa Nelson HL7 Care Plan Domain Analysis Model/FHIR Harmonization - Laura Heermann/EMma Jones HL7 Care Coordination Services (CCS) functional model - LH/EJ HL7 CDA R2 Personal Advanced Care Plan Document - Lisa Nelson HL7 FHIR Care Plan Resource - LH/EJ IHE PCC Dynamic Care Planning Profile- EJ IHE QRPH Early Hearing Detection and Intervention (EHDI) Plan of Care- Lisa Nelson HL7 Clinical Oncology Treatment Plan and Summary - Jeff Brown NCPDP/HL7 Pharmacist Care Plan - Shelly Spiro Care team members definition update (Laura/Emma) Child special needs Care Plan/Care Team Implementations

Check the minutes ....
SD, Pharmacy, LHS, CH, FHIR-I Laura Emma
Q2 Regency East #3 Joint meeting with SDWG and Template Topic: Care plan, Allergy Intolerance (criticality), Clinical status SD, Templates Russ Elaine
PM lunch Blanco
Co-Chair Admin Meeting
Q3 Pecos Assessment scales - ballot reconciliation; SDC update; Michael Michael
Q3 Live Oak FHIR Ballot Reconciliation - Reviewing workflow patterns for conditions
  • GF#10293 - Apply FHIR workflow standardization changes to Patient Care Resources
  • GF#10635 - QA 5a: Resource references exist in both directions for Condition and ClinicalImpression
  • GF#11209 - Feedback on ClinicalImpression - 2016-09 core #363
  • GF#10387 - CommunicationRequest needs ability to describe the location that the communication is about (John Moehrke)


  • Continue talking about ProcedureRequest/DiagnosticRequest
FHIR Michelle Michelle
Q4 Live Oak Dynamic Care Planning and Dynamic Care Team Management FHIR Profile and other interoperability related projects Primary work: FHIR ballot reconciliation FHIR, HSI Emma Michelle
Day Time   Room Event Host Joining Chair Scribe
January 20
AM Q1 ClinFHIR  
Q2   ClinFHIR        
PM Q3   ClinFHIR        
Q4   No meeting        

San Antionio WGM - January 2017. Patient Care WG Meeting Meeting Minutes

Sunday, January 15

International Council Meeting
- No PCWG meeting

Patient Care WGM, Monday, January 16, 2017

Monday Q1

Chair: Michael Tan
Scribe: Jay Lyle

Attendees Michael Tan, Jay Lyle, Russ Leftwich, Rob Hausam, Amit Popat, Michelle Miller, David Pyke, Emma Jones, Laura Heerman, Elaine Ayres, William Goossen


  • Need to look at urgent FHIR work & prioritize; ensure we can cover what's needed
    • Get through ballot reconciliation by Feb 5
      • Ballot: 27 GForge items + 9 trackers. Average 30 minutes.
      • Prioritize by resource? List as shown seems reasonable.
      • Can we transfer Questionnaire & Response to FHIR-I?
      • Maturity includes things other than ballot resolution.
      • It may be appropriate to leave some at a lower maturity level. Plan items look unlikely to get to 3.
        • If FHIR-I doesn't take Questionnaire, move it above Plan resources in priority.
    • Motion: Approve transfer of stewardship for Questionnaire & Response from PC to FHIR-I
      • withdrawn
    • Motion: Ask FHIR-I to assume responsibility of Questionnaire/QuestionnaireResponse to get it through STU3 (e.g. reconciling outstanding tracker issues, applying changes, and addressing any QA messages and checklist items) (Gforge 12512)
      • Moved by Laura; Russ seconds
      • Vote: 11, 0, 0
    • 224 warnings
    • 125 elements need examples
        • A volunteer task force coordinated to provide examples for most of these
      • 29 related to value sets. Rob to see what he can do.
    • Deferred trackers: done
    • Applying resolved trackers. Michelle & Rob.
    • FMM spreadsheet.
    • Info. 46 RIM mappings; John Hatem to assist. Some example issues; see team above.
    • Workflow mappings - Michelle
    • QA volunteers: Emma, Russ, Jay, Rob. Michelle to give the go.
  • GForge reconciliation in meetings
    • To be time-boxed
  • Agenda for the week
    • MQ3 primarily Goal items
    • Tue Q4: possibly time for additional GForges
    • WQ3: Adverse Event; also plan definition, OO/PC trackers. Trying to get a second room; otherwise, just Adverse Event.
      • RCRIM scheduled with CIC this slot; perhaps that room is available.
      • Russ to coordinate with CIC.
    • WQ4: Elaine to chair; Jay to scribe
    • Need a home for Criticality discussion. Th Q2 Allergy
    • THQ2: Russ to chair; Elaine to scribe
    • THQ3 split into 2: assessment scales in one meeting; FHIR ballot
    • THQ4 agenda thin: use for FHIR ballot reconciliation
  • ClinFHIR
    • Process is now pretty mature
    • Need to look at having groups interact
    • Options
      • Take it on the road. Chile. AMIA
      • Support connecting to other points. Just servers, or do we need organizational barriers?
  • Co-chairs: Review Product Matrix. List on web site may be out of date.
    • Elaine to find later version if available; Michael to coordinate with staff. Revisit on Thursday.
    • Ditto decision making process: next call.

Monday Q2




Monday Q3

FHIR Change requests - Care Plan, Care Team, Goal
Chair: Michelle Miller
Scribe: Michael Tan


  • Michelle Miller
  • Emma Jones
  • Tracey Coleman
  • Dave Carlson
  • Viet Nguyen
  • Russ Leftwich
  • Rob McClure
  • Laura Heermann Langford
  • Michael Tan

GF#11342 - Add CareTeam.relatedTeam or other composition relationship - 2016-09 core #500

  • Care teams can have nested sub care teams. Can you relate a team to another team.
  • What does “newer” mean in newer team.
  • Do we need a a value set such as : replaces, consists of,
  • Point that the relationship is partly overlapping the role.
  • This resources should not be used to track the teams.
  • Future consideration will be adding a new element to convey the RACI elements for lead vs consult, but that is deferred from this G-forge.
  • Vote : 8- 0 -0

GF#11344 - Allow CarePlan.activity.detail.performer to be CareTeam - 2016-09 core #502

  • Is an activity performed by the whole team or a specific person?
  • Changing the definition of the care team. The Care team is not an actor, but the individual members of an individual organization are.
  • Vote : 8 -0- 0

GF#10624 - QA 4a: Consider whether Goal.priority (CodeableConcept) should be bound to an external code system such as SNOMED. This value set is probably not available in SNOMED ( high priority, medium priority, low priority) . Should the value be a FHIR or an v3 code set? Rob has confidence in a FHIR code set. This is the new thinking. Where code sets can be found easily.

  • The recommended value set would be:
    • High priority
    • Medium Priority
    • Low priority.
  • Vote 8 -0-0

GF#10613 - QA 4e: Clean up valueset-goal-status

  • The value set on goal status have different types of meaning. Some our outcome, some are status.
  • Is the outcome reported through the goal? It is not reported thru the activity outcome reported in a new care plan.
  • Example of use case of COPD.
    • Goal: stop Smoking cessation
    • Goal outcome result: former smoker.
    • Goal status: met
  • This value set looks very much like the value set of goal achievement. Is this a similar value set?
  • Suggestion to simplify the value set to : met/ not met/ in progress.

Monday Q4

Cont FHIR Change requests - Care Plan, Care Team, Goal

Chair: Michelle Miller
Scribe: Emma Jones


  • Michelle Miller - Cerner
  • Emma Jones - Allscripts
  • Tracey Coleman - Allscripts
  • Dave Carlson - VA
  • Viet Nguyen - Leidos
  • Russ Leftwich - InterSystems
  • Laura Heermann Langford - Intermountain Health Care
  • Margaret Dittoft - Academy of Nutrition and Dietician


The following gForge items were discussed

  • GF#10613 - QA 4e: Clean up valueset-goal-status
    • Item brought to a resolution: Updated valueset-goal-status to have hierarchy; fixed status defintions; fixed type
  • GF#11116 - Better define the careplan.activity.outcome field. - 2016-09 core #270
    • Item brought to resolution: Definitions cleaned up
  • GF#10615 - QA 4: Clean up valueset-goal-status-reason
    • Item brought to resolution: Changed the statusReason from CodeableConcept to be a string instead
  • GF#12622 - QA: CarePlan.relatedPlan.plan Name of child (plan) overlaps with name of parent (relatedPlan)
    • Item brought to resolution:Rename CarePlan.relatedPlan.plan to CarePlan.related.plan

Minutes of joint session on FHIR Workflow
Hosted by FMG

  • STU 3 has patterns of how workflows are used in practice.
  • Logical models can be mapped to represent a status. Should we have patterns for other categories of resources such as catalog entry, entity role?
  • There was some inconsistencies detected between de different resources. Should this be resolved? No one stood up.
  • There is a lot of good things about V3 where it was clear what the workflow pattern was.
  • The status can be found on the task, updated by the owner of the task.
  • Can you send out multiple task requests and until a service provider accepts that task, then the other tasks will be withdrawn. No one interested to pursue this topic.
  • How do you manage a task if you are going beyond the wall’s of the organization. How do you manage between different systems? Answer given that this can be fulfilled.

Monday Q6: Placeholder for extra meeting if necessary

TSC, DESD Present:

Minutes: See minutes from DESD

Patient Care WGM, Tuesday, January 17, 2017

Tuesday Q1

Chair: Laura Heerman
Scribe:Emma Jones


  • Dave Pyke - Ready Computing
  • Jay Lyle - JP Sys
  • Michael Tan - Nictiz
  • Amit Popat - Epic
  • Stan Huff - Intermountain
  • Guillaune Rossignal - Almerys
  • Fahmi Bassetta - Almerys
  • Serafina Versaggi - Dept of VA
  • Catherine Hoang - Dept of VA
  • Dan Morford - Book Zurman Inc (VA)
  • Claude Nanjo - Cognitive Medical Systems
  • Emma Jones - Allscripts
  • Michael U/D Del - UMCG
  • William Goosen - Results 4 Care
  • Tessa Van Stijn - NICTZ
  • Neelima Chennama-raja - CBCC
  • Karen Nocera - CBORD
  • Craig Parker - Intermountain
  • Mark Kramer - Mitre
  • Ress Leftwich - InterSystems
  • Patrick Langford - Intermountain HealthCare
  • Kind Allen - Penrod
  • Yukinori Konishi - HL7 Japan
  • Masaaki Hirai - HL7 Japan
  • Laura Heerman - Intermountain
  • Steve Hufnagel - FHA Contractor
  • Galen Mulrooney - VA
  • Joey Coyl
  • Susan Matney - Intermountain HealthCare


Presented Clinical Example: CIMI-FHIM-CQF-USCore Integration

  • Worked with patient care to add the concepts of clinical topic
  • Under "ACT" have harmonized the signature, Order, procedure
  • Signature provided some complexity
  • Evaluation is a LOINC SNOMED Q&A pair
  • Statements uses assertion structure. Need to be able to distinguish between the two.
  • Need help from patient care in harmonizing the models

Reviewed Model Driven Architecture Vision to seamlessly support developers and implementers

  • See ballot documents for slides
  • CIMI responsible for repository, structure definition and governance
  • FHIR responsible for their run-time value sets, reusable components, governance

+Noted family history is an assertion and not an evaluation.

    • Stan original diagram has it as an observtioatn.
    • This point illustrates the problem. Granted it can be one thing but structurally it can be something else.
  • From a patient care WG perspective, we need more flag waving from CIMI on what PC need to do.

Next Topic Skin Wound

  • Purpose is to test CIMI with content. Using the CIMI-FHIM-CQI-USCore integration
  • Goal was to take the DAM and put it into CIMI because it's a defined set of stuff. Limited to physical exam skin assessment and the braden instrument. Also wanted to test the data.
  • Ended with some of this content into CIMI. Did not get to represent the CIMI skin model

1. Working on assess what's in the ballot vs what's in the LOIN assessment panel 2. Thought it might be useful to demonstrate a quality measure in this domain - can we come up with a quality measure that can pop out of the modeling - e.g. Zika assessment Assertion and evaluation and the - in some cases might be either, if either need to support both which need to be made transformable.

  • Did a LOINC to CIMI property comparison.
    • Need to understand context between LOINC and SNOMED - LOINC does not have assertions.
    • Suggested if there is a wound in LOINC, the wound type should be asserted
    • CIMI has an assertion class e.g. bodysite in loin is a qustion. CIMI does not have that - it has an assertion.
    • Can't structure the clinical information the way the panel is structured. Have to have an assertion of the wound.
  • Took a fork in the road that diverges from making this an evaluation
    • 2 approaches - 1. defined a general representation of a wound. 2. took a specialization of the the wound and added these as attributions of the assertion.
    • The assertion that has the wound property baked into the class is another approach.
    • Per Mike Cramer - have a project to type the properties and go directly to FHIR profiles. Wound has some properties of condition, observation. It’s a wound assessment - don't care "what" it is. It's a wound. Will have the structure data.
    • Not just trying to model Skin and wound. We're trying to get LOINC and SNOMED fit together. This is the sausage making of getting these things to fit together.
    • LOINC panel doesn't have assertion.
    • Will have the same problem with questionnaire.
    • More discussion about assertion, evaluation, clusters
  • How to put in the workflow - if the wound is tunnelling need to say something about it
  • Claude Nanjo - OpenAir demo their modeling which binds each attribute to related terminology
    • Every part of their model points to LOINC. Combined a reference model with the archetype to get the whole semantics of the modelling.
    • Have produced various clinical models
    • Worked on tooling to be able to capture the clinical areas rapidly. Have to have the standards that allow this to happen. Want to publish FHIR profiles
    • Captured things that were in the DAM.
    • Can write CDS rules and Quality measures on top of this.
    • What about SNOMED concepts? Can do that as well.
    • Susan agrees their tooling can be helpful. Need to talk about complementing each other efforts so that things don't get out of synch.
    • Need to have context - where it fits in the EHR, where does it originate?
    • Susan and Mark will connect
  • Plan for Madrid - Ballot information, Tuesday Q1 will be on the agenda and patient care will host.
  • CIMI Meet weekly on Fridays 10am EST

Tuesday Q2

Chair: Michelle Miller
Scribe: Michael Tan


  • Michael Tan
  • Jay Lyle
  • Michelle Miller
  • Emma Jones
  • Guillaume Rossignol
  • Fahri Besetta
  • Martin Hurrell
  • Russ Leftwich
  • Jukimori Konishi
  • Massake Hirai
  • Dave Carlson
  • Tessa van Stijn
  • David Tao
  • Lisa Nelson
  • Josh Mendell
  • Amit Popat


  • GF#10090 - Condition Introduction
    • Objective of this meeting is to deal with the FHIR resource of condition. We are not changing the model, but defining the scope of what is a condition. The original specification is quite limited and the discussion is whether we should relax the restrictions. This has the risk that certain information could be also registered as other FHIR resources such as family history, allergy or procedure.
    • A health concern is an issue of which a person ( could be care provider) is concerned about.
    • A problem list consists of conditions. ( and diagnosis?)
    • Is unemployment also a valid entry as a condition? This depends on the context where it is used. In a mental healthcare setting this could be a valid problem for a depressed patient treated by a psychiatrist.
    • A condition does not necessarily have to be a problem, such as a pregnancy. The wording has been simplified.
    • The definition has been revised paragraph by paragraph. Motion to approve the revised definition:
    • Vote 18 P -0 N-0 A
  • Next issue about Condition Onset and Condition Abatement.
  • One issue ( no Gforge number yet) is about a circular definition of the word condition. This has been modified to clinical condition.
    • Vote 17 P-0 N- 1 A.
  • GForge nr.10635 Issue of circular reference of condition and clinical impression. Is it always pointing to the same condition? This issue was not resolved during this quarter.

Tuesday Q3

Chair: Michelle Miller
Scribe: Michael Tan


  • Michael Tan
  • Tracey Coleman
  • Emma Jones
  • Serafina Versaggi
  • Karen Nocera
  • Farzanah Numa
  • Ken Salyaads
  • Russel Oh
  • Kent Bui
  • William Goossen
  • Dave Carlson
  • Margeret Ditloff
  • Viet Nguyen
  • Michelle Miller


Main topic is FHIR issues about the Care Team

  • GF#10725 - QA 4: CareTeam CodeableConcepts need a binding to a value set
    • Other comparable resources have a code for a status
    • Active/ on hold / inactive / Entered in error.
    • The suggestion to add “held” as a status has been withdrawn.
    • Misunderstanding about a relationship between a patient and a care team. The assignments from a care plan can be cancelled, but the care team still exists.
    • Motion to add a code list:
    • Viet/ Margeret:
    • Vote : 9 P- 0 N- 4 A
  • CareteamCategory:
    • Encounter focussed team ( one single encounter)
    • Episode of care focused team
    • Longitudinal team
    • Research team
    • The issue is to distinguish the differences between these various codes. The is a hierarchy between these codes, which is not always obvious.
    • Motion to move this table:
    • Viet/ Dave
    • Vote: 7 P– 0 N - 6 A
  • GF#11334 - Constrain participant role value set - 2016-09 core #492
    • Currently this a large list of about 900 values of which some do not make sense for a role. However the binding is a not compulsory. The value set is an example and an implementer can constrain values or choose an alternative code system. The comment is not regarded as persuasive.
    • Motion moved
    • Viet / Michael
    • Vote : 7 P – 0 N – 6 A

Tuesday Q4

Chair: Jay Lyle
Scribe:Emma Jones

Attendees Gert Voelewijn - NTIZM; Heather Green - LG Information; Galen Mulrooney - VA: Patrick Langford - Intermountain HealthCare; Greg Gustafson - Penrad; Ron Shiparo - Qvera; Farzanah Nahid - NHS Digital; Steve Hufnagel - FHA Contractor; Karen Nocera - CBORD; Kirk Allen - Penrad; Chris Melo - Philips; Daniel Varlson - HL7 germany; William Goosen - Results 4 Care; Bectil Reppen - HL7 Norway; Oyvind Aassue -; Michael Van der der -; Serafina Versaggi - Dept of VA; Gay Dolin - IMO; Tracey Coleman - Allscripts; Michelle Miller - Cerner; Jay Lyle; Michael Tan - Nictiz; Richard Esmond - Penrad; Carmela Goudera - IMO; Lloyd McKenzie - Gevity; Elaine Ayres - NIH


  • Primary topic - Review the negation project output and see its usefulness. Conversion from CCDA to FHIR in terms of 'no allergy to'
    • Need to be able to get from one format to the other. Agreement that this is needed.
    • Jay's Spreadsheet was sent out.
      • Uses the concept model. Yellow highlights because un-clear
      • Example page has queries present. Last page are ways to help solution designer.
  • What is the deliverable? Cross family deliverable - cross paradigm informative. Guidance document? Policy document - circulate amongst all the work groups and get comment back.
  • Topics discussed:
    • No allergy to … how to handle when converting from C-CDA to FHIR
    • Transformation: how can a negated concept be transformed from one formalism to another
    • Need to have a formulation of what the clinician means. What are you negating? Only the part that is seen can be negated so assumptions should not be that other **bones have fracture. Need Consistent approach.
    • See this gForge for discussion

GF#11351 - whether AllergyIntoleranceCategory should be SNOMED

Patient Care WGM, Wednesday, January 18, 2017

Wednesday Q1

Chair: Michelle Miller
Scribe: Emma Jones


  • Michael Tan - Nictiz
  • Jay Lyle
  • Emma Jones - Allscripts
  • Lloyd McKenzie - Gevity
  • Michelle Miller - Cerner
  • Oliver Krauss - Univ of Upper Austria
  • Danielle Friend - Epic
  • Viet Nguyen - Leidos
  • Eric Haas


  • GF#10293 - workflow patterns applied to Condition and Procedure
  • GF#12592 - Procedure.not performed should be a status value
  • GF#12595 - Condition needs a search parameter for Condition.evidence.detail
  • GF11162 - Suggest include reference to remedial treatment(s)

Wednesday Q2

Hosted by: Patient Admin (Brian P.)
Scribe: Michelle Miller for PC



  • Michelle reviewed CareTeam
  • PA food for thought: Should CareTeam.participant.role be 0..*?
  • Add "and/or" to "Planned participants in the coordination and/or delivery of care for a patient or group"


  • Michelle highlighted changes to Condition introduction changes with respect to concerning events.


  • PractitionerRole getting pulled out from Practitioner
  • No longer able to search Practitioner by Organization
  • Reviewed all places where the Practitioner is references to assess whether to:
    • Add Org next to Practitioner
    • Change Practitioner references to be either Practitioner/PractitionerOrg
    • <reference value="Practitioner/45#role=3">
  • Action Item: Because Practitioner can reference multiple Organizations, Brian will notify other work groups that reference Practitioner to consider whether their resource(s) need to add Organization to specify that context.
  • Action Item: Michelle to log tracker item for CareTeam
  • Motion Approved: PA will create a standard extension on the Practitioner references likely called PractitionerOrganization - which Ref (Organization).

Wednesday Q3

Chair: Michelle Miller
Scribe: Emma Jones


  • Hans Buitendyl - Cerner
  • Kensaku Kawamot - Univ of Utah
  • Peter Lamb - NCCN
  • Mary Visceglia - NCCN
  • Marten Smits - Furore
  • Gert Uvelewijn - NICTIZ
  • Catherine Lasome - ION Informatics
  • Danielle Friend - Epic
  • Reshma Patel - ESAC
  • Chris Markle - ESAC
  • Francois Macary - Phast
  • Howard Strasbers - CDJ
  • Thomson Kuhn - Acpoline
  • Michael Tan - Nictiz
  • Anne Smith - NCQA
  • Patty Craig - The Joint Commission
  • Dave Carlson - VA
  • Kathy Pickering - Cerner
  • Guilherme Del Fiol - Univ of Utah/VA


  • GF#12608 - Add ReferenceGroup to the list of supported references
  • GF#11119 - Differentiate ProcedureRequest and DiagnosticRequest

Wednesday Q4

Chair: Elaine Ayres
Scribe: Michael Tan


  • Peter Jordan
  • Jay Lyle
  • David Parker
  • Marten Smits
  • Karen Nocera
  • Ivan Niezgook
  • Tessa van Stijn
  • Sheryl Taylor
  • H. Soleriu (Mayo)
  • Russ Leftwich
  • Lloyd McKenzie


Two Topics

  • Substance value sets.
    • David/ Jay/ Elayne and Cerner have done analysis
    • Collection of 65 million data records. Mostly based on US data.
      • Foods,
      • Environment
      • Medication
    • Jay has discussed the topic on allergy value set conference call. The goal is to find some common ground .
    • Michael points out that there is a joint ISO project of IDMP, that is currently active under supervision of FDA and EMA.
    • In IDMP they have thought about the structures on which you might want to register allergies and intolerances. We should not reinvent the wheel for this purpose.
    • It is also important to consider the maintenance of the value sets. SNOMED is not capable of maintaining the substances tables of medication. It would be more logic to involve the organizations that allow medication in a country such as the FDA and EMA, because these organizations register all substances and create codes for these substances. This will probably in GSRS,
  • Representation of Adverse reactions.
    • Change proposal to make adverse event as a stand alone resource.
    • What was the reason to merge adverse reaction with the allergy intolerance?
    • Russ is in favour to make a separate resource for adverse event. You don’t know beforehand if the adverse event is an allergy or intolerance. It could turn out to be a drug-drug interaction. The adverse event would be a physiologic event.
    • There is some discussion of why the substance is mentioned in the allergy as well in the reaction. The allergy puts the substance in the attribute code.
    • Lloyd feels strongly against the idea of making adverse events a separate resource. You can capture the adverse event in a condition. Michael does not agree. An adverse event is an event at a certain moment in time. Lloyd points out that conditions also captures events.

Patient Care WGM, Thursday, January 19, 2017

Thursday Q1

Chair: Laura Heerman
Scribe:Emma Jones


  • Emma Jones - Allscripts
  • Dan Morford - Book Zueman (VA)
  • Dave Carlson - VA
  • Margaret Dittloff - Academy of Nutrition and Dietitics
  • Annette Vernon - FDA
  • Jeff Danford - Allscripts
  • George Cole - Allscripts
  • Thompson Kuhn - ACP
  • Lloyd McKenzie - Gevity
  • Ron Shapiro - Qvera
  • Nick Radov - Optum
  • Chris Melo - Philips
  • Ken Salyards - SAMHSA
  • Russ Leftwich - InterSystems
  • Laura Heerman - Intermountain
  • Sue Thompson - NCPDP
  • Shelly Spiro - PHIT Collaborative
  • Zabrina Gonzoga - Lantana
  • Michael Padula - Children's Hosp Philadelphia
  • Scott Robertson - Kaiser Permanente
  • Gay Dolin - IMO
  • Mark Shefarmda - S.Consulting INC
  • Michelle Miller -Cerner


  • Madrid - Continue this quarter until San Diego
  • Upcoming value based care implementationathon. Will be announced as an HL7 event. Useful to the payer community. Lenel james is organizing. To happen in April.
  • DAM - need to map to FHIR - see notes thru out. Using the same storyboard.
  • FHIR Care Plan resource care plans
  • ONC Care team project - Learning Health Systems (LHS) is proposing taking over this project by submitting a care team DAM. To enable a LHS there is a more robust model of what a care team is. Every one in the system know about the patient but who is the care team for the patient. It's everyone that touches the patient. To make operable need to define the members of the care team and their relationship to each other. Is this the whole care team process and the methodology behind care team This will be a necessary piece to compare models and improve the models. Time is not set but will take it over from the ONC care team.
  • IHE Dynamic Care Team Management Profile (DCTM) - New profile this year
  • IHE Dynamic Care Planning (DCP)- Plans to test at IHE Connecthaton next week but one of the testing partners pulled out so may not get tested.
  • FHIR Care Plan and Updates -
    • FHIR Connecthathon - Bob Anyman Care Plan updates. Resources loaded in Allscripts application (TW). Active clinical involvement in defining the storyboard and demonstrating the workflows. Subscription resource used to send notification when Care Plan was updated. Need to automate some of the notifications to decide when to update the members of the team. Looking ahead to interact with other tracks such as plan definition track - want to be able to include definition decision rules to determine interventions to be added or recommended to the care team. In the plan definition those kinds of things can be defined. CarePlan resource referred back to the plan definition and make it dynamic. Using the fhir resource to have coordination with the planDefinition. Also scheduling - tie into a scheduling service. Looking at application to provide a patient facing view of the care plan dynamic where appts are added for blood draws.
    • Children with special needs can use this kind of use case driven testing in the future. This time diabetes was used as the use case.
  • Time to look at changes to DAM and how the FHIR resources maps to the model. Clin-on-FHIR maintain the care plan.
  • There is a desired for example care plans. So if anyone have some care plans please share them.
  • Add a storyboards section to your wiki page. Label them as a use case under category on the HL7 wiki to be able to query them in one place. Ask everybody that have use cases if they add a category on their wiki page will look at the category page. Suggestion made to look at the 21st Century Care Act has a large section on care plans. Also see here for more care plan requirements[1]
  • Personal Advance care plan - CCDA and also part of the CCDA on FHIR. Connecthaton tracks information are on the wiki with the presentations.
  • New York Care Plan project - Lisa nelson - working with the NY team on their pilot and working to help clarify the value sets needed for Care Plan types and Care Team types and members. Will be rethinking how the Friday night call will go forward, but if people are interested they should let PCWG know and we can connect them into the work. The goal is to keep a broad group to stay in agreement while exploring a variety of points of view.
  • CCS - OMG has had an RFI on the CCS for the past year. Active work happening. This summer will be some updates on this work. Will have some STU. Allscripts participated in the early part of the RFI.
  • EHDI - The Health Story Project will be showcasing the EHDI work in an upcoming HSP Roundtable presentation on Feb 6th. They are writing a white paper in IHE as a use case in the 360X work to explore how to do closed loop care planning.
  • Oncology - Not present
  • SDWG - George Cole: C-CDA implementhanathon with half dozen vendors - off SDWG wiki [2]-will see the different C-CDA documents that were submitted. Some of the decisions are posted. Decision that for Care Plan document, four sections are better to use but there are other reasons why other sections may show up.
    • Dave: Sample Data - need common set of practitioner names and patient names, a consolidated common set.
  • Pharmacy - Zabrina - PSS changes - create Care Plan using CCDA 2.1; requirements from NCPDP; Lantana is the modeling facilitator. Implementers have increased to 6.

ONC high impact pilot - receive the care plan and validate that the care plan meets the spec. Implementation will start in 2 weeks. By August will submit a draft IG ballot

    • Informed PCWG about decision to put the prescription information to put the intervention section instead of putting it in an additional medication section
    • Pilot will have 6 places will use the draft of the standard that has not gone to ballot. Communicare NC will start to receive them from system vendor by end of march. Ballot documents due in Aug. Will later absorb the ballot changes
    • Pharmacist Care Plan Project Documents
  • Children with Special Needs - Working with what exists with the longitudinal care plan. Creating a document to share what children with special health needs. If not doing an IG, how can they help implementers model things that are unique to this population?
    • There are 5 story boards - see their wiki
    • Scope - trying to focus on plans of care - everything from preferences to contraindications
    • Need feedback on how to model want is needed - use of companion guides? Templates? Need to figure out what the deliverable will be for this. CCDA care plan can be used but very broad - should there be a broader version of it? If left broad, should they do a DAM that is used for pediatrics?
    • Suggestion that something that is implementable will get more uptake. Such as a C-CDA IG. Maybe a more constrained option. Is a constrained care plan really needed or should there be examples thru example task force? Suggestion to provide a sample file. Running into the same issue with pharmacy because can't change the description in the IG so putting the guidance in the sample files. Suggestion that if no changes for C-CDA Care plan use the ballot folder for the sample files

This is needed because urgent care for these patients need some sort of awareness notice; they often have equipment; contingent plan for providers that are not the usual care provider.

    • EHR WG proposal around school nursing can also re-use this.
    • CP DAM - what's missing in the DAM that need to be updated for this population? Need to look at the current DAM for gaps and the second thing to do is to do the gap analysis with CDA and FHIR and call out the important things as an informative document or as a white paper.
    • There is a paper templete called a portable health record that is designed for children with special needs. This also applies to adults with special needed.

Thursday Q2

Joint with SDWG and Template WG


  • Jay Lyle – Chair
  • Elaine Ayres – Scribe
  • Kai Heitmann
  • Mark Sharfarman
  • Emma Jones
  • Michael Tan
  • Ivan Niezgook
  • Karen Nocera
  • William Goossen
  • Ken Salyards
  • Sean Muir

1. Medications – suggested by W. Goossen – use IDMP. Implemented in US. Vocabulary for data elements. Is the IDMP a data model? It is part of the model, ID’s a substance. Links to SPL and the Common Product Model. May not be entirely relevant for clinical purposes. Also includes biologics and devices. Can this be used in C-CDA for the substance heuristic? PC has a project to look at frequencies of medications and foods. To what is data mapped? IDMP has the model, GSRS has the actual UNII coded ingredients and drugs. Use the string “penicillin” and see how standard terminologies support this work. In an ideal world all strings would come from one system. The list may be published with various maps to realm-specific terminologies. GSRS is mapped for various substances. William will provide a reference to this information.

2. Relevant and Pertinent not covered

3. Clinical Status Current status of clinical status – in C-CDA 2.0 problem status was deprecated. This does not mean it can’t be used. Should be undeprecated. What is the relationship between the problem status and the act status – it was confusing. Decision was made only to use the act status. Errata – but needs a value set creation which is needed from patient care. The slides have the suggested value set. Proposed Value set: (as reviewed and approved by PC)

  • At risk
  • Active
    • Relapse
    • Recurrent
  • Inactive
    • Remission
    • Controlled
    • Resolved

FHIR as three values in AI for clinical status.

There are erratas last updated in December 2015. The IG has guidance on deprecations but nothing in the companion guide.

Fix could be in 2.1 and backwards compatible with 2.0. No plans to reballot. New Volume 3 – Problem status could be a new template for optional use without changing the release number of 2.1. Could also undeprecate with same template ID, change binding and add new value set. Does the value set have to go to Vocab for harmonization? Process not yet clear on this.

Deprecated codes are in SNOMED as qualifier codes but are different that the suggested list.

Are codes proposed in SNOMED? In different qualifier hierarchies.

The value set with “At risk” is not clear with Active and Inactive. From a behavioural health perspective – may have a controlled condition that is active. There is an expectation that only one code would be used, not the ability to use many.

The use of the value set should not be driven by C-CDA and FHIR. Should be able to choose more than one code if needed for expression by the clinician.

Kai suggests the use of a new template with consonance of value sets in C-CDA and FHIR.

ACTION Item – figure out what is needed clinically, then use the Volume 3 update. Timing onVolume 3 – was a ballot with occupational data health and UDI. The occupational data health will be published in April, UDI was not usable. There is a new Volume 3 process underway. Get two weeks for analysis, two weeks for ballot and two weeks for implementation (Brett Marquard) so out of cycle process. Other new templates are already in the new companion guide that will be published.

MOTION: Send back to PC to reevaluate clinical requirements, determine cardinality, determine alignment with risk, and assess ways to support harmonized solutions. Once this is solved, propose a new problem status template to C-CDA

Moved: Emma/William Abstain: 1, Neg -0, Approve - 12

Will be discussed during the Co-Chair call.

4. Criticality – need for harmonization? a. Definitions and codes are different in C-CDA and FHIR AI b. V3 codes are not always used in FHIR c. FHIR strings are often more language based than code based. d. FHIR does have same codes, uses different OIDS e. Action item – Look at difference and determine needs for harmonization. f. Put on next allergy call to discuss variants. Does this need to go to vocab? Rob will prepare.

5. Care Plan – no topics

6. Templates – STU for templates exchange format that ended in November 2016 has been extended. No further STU comments since last year. All comments are resolved and will be dispositioned. Will revise STU and go normative.

7. Keep same day and time for Madrid.

Thursday Lunch: Co-Chairs Meeting



Thursday Q3

Chair: Michael Tan
Scribe: Michael Tan


William Goossen


William Goossen


  • Topic of the session was resolving ballot issues from the ballot in September of Assessment Scales.
  • The comments were updated in the ballot spreadsheet.
  • There is not enough quorum and therefore an e-vote will be set out.
  • The Assessment scales have to be reballoted. We did not have enough affirmative votes in September.
  • A big problem is, that we do not have a publishing facilitator. Michael has approached Andy Stechishin but Andy is currently not present.

Thursday Q3

Chair: Michelle Miller
Scribe: Emma Jones


  • Michelle Miller - Cerner
  • Lloyd McKenzie - Gevity
  • Dave Carlson - VA
  • David Tao - ICSA Labs
  • Ron Shapiro - Qvera
  • Danielle Friend - Epic
  • Jenny Brush - ESAC
  • Oliver Krauss - Univ of Upper Austria
  • Jeff Danford - Allscripts
  • Emma Jones - Allscripts
  • Tracey Coleman - Allscripts
  • Marten - Furore
  • Elaine - NIH


  • GF#10293 - Workflow patterns applied to CarePlan
  • GF#12647 - Add CareTeam.participant.practitionerOrganization
  • GF#10627 - Keep CodeableConcept, relax binding strength to Preferred, and change to use SNOMED codes
  • GF#10626 - Use the existing value set that Device uses, valueset-device-kind.html, with an example binding strength
  • GF#10620 - See gForge item for changes

Thursday Q4

Chair: Emma Jones (first half) / Michelle Miller (second half)
Scribe: Michelle Miller (first half) / Emma Jones (second half)


  • Michelle Miller - Cerner
  • John Rhoads - Philip Health care and Healthcare Devices WG
  • Jenny Brush - ESAC
  • Jeff Danford - Allscripts
  • Emma Jones - Allscripts
  • Tracey Angeles - Conduent
  • Marten Smits- Furore
  • Michael Tan - Nictiz

SDC update

Existing IHE FHIR based profiles can be found here -
IHE Dynamic Care Planning:

Dynamic Care Planning (profile developed last year): IHE Profile is here -
IHE PCC FHIR based Profiles being developed this profile year:

  • Dynamic Care Team Management
  • Point of Care Medical Device Tracking (current profile development): Profile Proposal
  • Remote Patient Monitoring (RPM) Update
    • Add an additional transaction to RPM, where the data payload is a FHIR bundle instead of a V2 PCD-01 message, and to add FHIR resources as modules in the Content Creator instead of the PHMR.
  • Patient Centric Data Element Location Services (QED on FHIR)
    • Introduce location discovery and fine grained access to health data to coexist and complement coarse grained (document as a coherent set of fined grained data elements) access.

FHIR Trackers:

  • GF#12647 - Add CareTeam.participant.practitionerOrganization
  • GF#10626 - QA: Procedure.usedCode needs a binding to a value set
  • GF#10627 - QA 4a: Consider binding Procedure.focalDevice.action (CodeableConcept) to codes from an external coding system
  • GF#10620 - QA 7a: CarePlan.activity.outcome needs a binding to a value set
  • GF#12661 - QA: Add binding

Patient Care WGM, Friday, January 20, 2017


Friday Q1




Friday Q2




Friday Q3




Friday Q4