View source for January 2017 Clinician-on-FHIR Planning Notes

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==Tracks to be addressed==

* Allergy/Intolerance and Adverse Reaction
* Family Member History - Clinical Genomics
* Emergency care, covering:
: - Condition
: - Procedure
: - Allergy/Intolerance
: - Referral Request
: - Clinical documentation:
: -- Past Medical History
* Medication
* Diagnostic Request, Report and Observation
* Care Plan, covering:
: - Instruction
: - Care Team

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Goal = create at least one (or more if possible) meaningful example(s) (actual JSON resource instance) for each FHIR resource otherwise the limitation of the FHIR resource is identified.

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==Planning Notes for Each Track==

Seven tracks have been identified for the January 2017 Clinician-on-FHIR event.


===Care Plan===

* For discussion on: 01 November 2016 conference call<br>

''Track lead/co-leads'':<br>
: - Laura
: - Emma

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''Scope'':<br>
: - To include: Instruction, Care Team

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''Goals/Objectives''<br>
:- What is the best way to do instruction?
* Communication does not seem to meet the needs of what is needed (demonstrate why. meta data? what is missing). 
* Careplan.activity.... does not seem to mee the needs (demonstrate why, what is missing?)
* Use the list resource and list them as text (why does this work or why not?)

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''Lessons from previous Clinician-on-FHIR''<br>


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''Use cases / Scenarios''<br>
:- define what is meant by instruction
* Discharge instruction (Take this med, get this follow up, follow this activity or diet)
* First set (MU)
:-a. Diet: Diabetic low salt diet
:-b. Medications: Take prescribed medications as advised.
:-c. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility for Immunosuppression treatment.
:-d. For Fever of > 101.5 F, or onset of chest pain/breathlessness contact Emergency.
* Second Set (MU)
:-a. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility.
:-b. In case of fever, take Tylenol as advised in plan of treatment.

* Vaccine Instruction
* Care activity instruction 
* Fellow provider instruction - 
: - Examples:
:: -- Shoulder arthroscopic repair
::: Post op: patient sees Physical Therapist (PT) before each follow-up session with the surgeon
::: PT may receive instructions from the surgeon to:
:::: - assess and record shoulder joint mobility/ROM, pain level
:::: - PT exercises with the following restrictions, e.g. for week 2 post-op follow-up
::::: ~ PROM FL < 150 degree
::::: ~ Scaption to < 150 degree
::::: ~ ER neutral to 30 degree
::::: ~ IR in 55 degree
:: -- (Instruction to pharmacy)
* Post procedure protocol/instructions (post CABG instructions to patient (the full written page of instructions), post colonoscopy intsruction sheet) 
: - Examples:
:: [http://digestivehealth.ca/post-colonoscopy-instructions/ Digestive Health Clinic, Canada: post-colonoscopy patient instructions]
:: [[Media:Post-CABG-discharge-patient-instructions.pdf | Post-CABG discharge instructions for patient]]
* Goals - MU allows text only.    
:-a. Get rid of intermittent fever that is occurring every few weeks.
:-b. Need to gain more energy to do regular activities
:-"c. Negotiated Goal for Body Temperature
LOINC 8310-5 98-99 degrees Fahrenheit
Date-6/22/2015
Related problem: 386661006 SNOMED-CT Fever (finding)
6/22/2015 – Start Date
Active
"
* Health Status evaluation outcomes - 
:-"a. Outcome Observation #1:
:-i. Refers to Goal Observation for Weight
:-ii. Refers to the Intervention Act #1
:-iii. Progress Towards Goal of Weight – Goal Not Achieved as of 6/22/2015"
:-"b. Outcome Observation #2:
:-i. Refers to Goal Observation for Body Temperature
:-ii. Refers to Intervention Act #2
:-iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015"

NEED SCENARIOS for CARE TEAM

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''Processes''<br>


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===Conference call 22 November 2016===

* For discussion on: 22 November 2016 conference call<br>

Present:<br>
: - Stephen
: - Emma
: - Laura
: - Rob Hausam
: - Jim McClay
: - Joe Quinn

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Discussions on the scope of clinical documentation

Agreed that the scope can be extensive

Suggestions:

(1) Limit the scope to Condition, Procedure, Observation - use for Medical History <br>
(2) Incorporate Allergy/Intolerance and Clinical Documentation into Emergency Care Track

Quick overview of the Emergency Care workflow DAM

Decision: <br>
(a) to review the Emergency Care workflow DAM <br>
(b) to pick steps in the workflow and suggest FHIR resources for testing
(c) to discuss and finalise at the 29 November conference call


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===Emergency care===

* For discussion on: 29 November 2016 conference call<br>
: - Follow-up conference call discussion on 6 December 2017

''Track lead/co-leads'':<br>
: - Jim
: - Laura

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''Scope''<br>
- To include: Condition, Observation, Questionnaire, Questionnaire Response, Procedure, Referral Request, Clinical Documentation <br>
- Other possible candidate: Protocol, Standing Orders (order sets) (to be discussed further on 20 December conference call) <br>
- Focus on the Screening Needs of the ED (See EC DAM EC Screening Process) <br>
- Look at the triage section of the ED DAM with eyes on future use of the Triage date for decision support, research use etc.  

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''Goals/Objectives''<br>
- Complete intake/triage of patient <br>
- Complete Screening documentation for each of the screenings required in the EC DAM page 34.  


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''Lessons from previous Clinician-on-FHIR''<br>


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''Use cases / Scenarios''<br>
- Patient attended ED after return from overseas trip and presenting with complaints such as fever, headache ..... <br>
- Triggers intake/triage workflow <br>
- Triggers travel history screening <br>
- Triggers intervention protocol and standing orders (order set) as per CDC recommendations/advisory <br>

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''Action item''
- Create travel history questionnaires (to be done in advance) <br>
- Action owner: Dr Jim McClay  


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===Medication===

* For discussion on: 13 December 2016 conference call<br>

''Attendance'': <br>
* Stephen Chu
* Emma Jones
* Rob Hausam
* Russ Leftwich
* John Hatem
* Melva Peters

''Track lead/co-leads'':<br>
: - Melva
: - John Hatem

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''Scope'':<br>
: - To include: Medication, Medication Order, Medication Dispense, Medication Administration, Medication Statement

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''Goals/Objectives''<br>
* To test all medication resources: MedicationRequest, Medication Dispense, Medication Administration, Medication Statement
* To test medication reconciliation process

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''Lessons from previous Clinician-on-FHIR''<br>
* The medication resources had been quite extensively tested in the past clinician-on-FHIR events
* It will be useful to test the process/workflow through medication reconciliation process
* Participants comes either to explore/learn about medication resources, or come with use cases and want to test the resources per their requirements

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''Use cases / Scenarios''<br>
* Medication reconciliation starting with review of medication list and other medication resource instances including order/request, dispense and administration, reconciliation process resulted in updated medication list, new medication order/request ...
: - Questions: what about new instructions to patient? recommendation to prescriber?
* Plan medication management in CarePlan resource: medication order through to administration

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''Processes''<br>
* John Hatem suggested to use first half hour of clinician-on-FHIR to discuss and finalise test scenarios
* Emma Jones suggested to use medication test data from meaningful use for medication reconciliation, order, dispense and administration
* Stephen Chu to start email thread to explore the capability of clinFHIR in supporting clinical process (e.g. in ED screening and medication reconciliation

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===Diagnostic Request, Report and Observation===

* For discussion on: 3 and 10 January 2010 conference call<br>

''Track lead/co-leads'':<br>
: - Rob

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''Goals/Objectives''<br>
* To test the diagnostic request, report and observation resources using chronic disease (diabetes) management storyboard
* To test clinical workflow pertinent to these FHIR resources in collaboration with the Care Plan track

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''Lessons from previous Clinician-on-FHIR''<br>


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''Use cases / Scenarios''<br>
* Patient diagnosed with Type 2 Diabetes
* Care plan activities include:
: - Patient to perform daily BSL tests at home and record BSL readings (Observation resource)
: - Patient to perform weekly weight measurement at home and record weigh measurements (Observation resource)
* Patient to return to PCP clinic for follow-up in 4 weeks
: - Patient complaints of fever, productive cough, shortness of breath and lathargy on follow-up visit (chief complaints - observation resource)
: - Diagnostic test request
:: # Fasting lipids and fasting blood glucose (DiagnosticReqeust resource)
:: # Sputum for microbiology tests (diagnosticRequest resource)
:: # weigh measurement (observation resource)

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''Processes''
* Diagnostic tests performed
* Path lab returns test results to PCP (DiagnosticReport resource)
* Patient observation results integrated into Care Plan - for outcomes evaluation
* Path test findings integrated into Care Plan - for outcome evaluation

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===Family Member History===

* For discussion on: 20 December 2016 conference call<br>

''Track lead/co-leads'':<br>
: - Grant Wood
: - Gil Alterovitz

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''Scope'':<br>
: - To include clinical genomics

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''Goals/Objectives''<br>


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''Lessons from previous Clinician-on-FHIR''<br>


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''Use cases / Scenarios''<br>


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''Processes''<br>



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==ClinFHIR Tool Review==

* Date: 10 January 2017 Conference call
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* Details<br>

David Hay gave a demonstration of new clinFHIR tool:

* [http://clinfhir.com/ clinFHIR tool]



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=Appendix=
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===Allergy/Intolerance and Adverse Reaction===

* Discussed on 8 November 2016 conference call<br>

Allergy/Intolerance track to be incorporated into Emergency Care track

Contents set aside for future use

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''Goals/Objectives''<br>
: - To test changes to the Allergy/Intolerance resource since the last Clinician-on-FHIR event
: - To assess the clinical usability and quality of the Allergy/Intolerance resource (and as potential candidate for Level 3 maturity)

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''Lessons from previous Clinician-on-FHIR''<br>


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''Use cases / Scenarios''<br>
: (1) Documenting patient allergy/intolerance histories on:
:: - allergic reaction to a penicillin drug during a previous healthcare encounter
:: - parent assertion of history of allergy to a sulphur drug when patient was a child
:: - allergic reaction to ionized particles from a cobalt-chromium alloy knee prosthetic implant
:: - allergic reaction to an environmental agent (e.g.  Fel d 1 (a secretoglobin) and Fel d 4 (a lipocalin))
:: - allergic reaction to seafood
:: - adverse reactions after a meal at an Asian restaurant 
: (2) negation examples:
:: - no known allergy
:: - allergy to tree nuts but no known allergy to peanut
: (3) generating an allergy/intolerance list from allergy/intolerance and adverse reaction history
: (4) Decision support scenario
:: - Scenario 1: patient allergy/intolerance list shows previous mild allergic reaction to oral amoxicillin (e.g. rash, diarrhoea)
::: * patient is scheduled for prosthetic knee replacement 
:::: o Pre-operative prophylactic antibiotic prescription by junior registrar as per hospital protocol: cefuroxine 1.5g IV 60 min before surgery
:::: o DSS returns a caution/low criticality alert on cross sensitivity - patient has allergy to amoxcillin with previous mild allergy reaction
:: - Scenario 2: patient allergy/intolerance list shows previous severe allergic reaction to oral amoxicillin (e.g. severe rash, swelling of tongue, difficulty in breathing)
::: * patient is scheduled for prosthetic knee replacement 
:::: o Pre-operative prophylactic antibiotic prescription by junior registrar as per hospital protocol: cefuroxine 1.5g IV 60 min before surgery
:::: o DSS returns a high criticality alert on cross sensitivity - patient has allergy to amoxcillin with previous severe allergy reaction, cefuroxine is contraindicated


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