2018-05-14 PA WGM Minutes

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Patient Administration Work Group Minutes - May 14, 2018

Monday Q1

HL7 Patient Administration Meeting Minutes Location: Maritime Hotel, Cologne, Salon 20 Fulda		Date: 2018-01-29 Time: Monday Q1
Facilitator	Line Saele	Scribe	Alex de Leon
Attendee	Name	Affiliation
X	Irma Jongeneel	HL7 Netherlands
X	Alex de Leon	Kaiser Permanente, USA
X	Line Saele	HL7 Norway
X	Brian Postlethwaite	Telstra Health, Australia
X	Cooper Thompson	EPIC, USA
X	Christian Hay	GS1, Switzerland
X	Bidyut Parruck	Interface ED, USA
X	Simone Heckmann	HL7 Germany
X	Hans Buitendyjk	Cerner, USA
X	Andrew Torres	Cerner, USA
X	Kathy Pickering	Cerner
Quorum Requirements Met (Chair + 2 members): Yes

Agenda

Agenda Topics
Welcome/introductions

• Approve agenda
  
• Review PA mission & charter
  
• Review PA decision making practice
  
• Review PA 3-year work plan
  
• Review SWOT Analysis
  

Supporting Documents

• PA mission & charter
  
• PA decision making practice
• PA 3-year work plan
  
• [SWOT
  ===Minutes===

Minutes/Conclusions Reached:
Introductions
Hans attended this session and asked for a few minutes of this quarter to discuss v2 items to be included into v2.9, as publishing has opened up the publication for substantive changes. Specifically, he wanted to discuss proposals 716 and 857.

Proposal 857 covers incorrect table reference in the example for PV1-4 and change of fields NK1-40 and NK1-41 as repeatable for backwards compatibility.
Motion to accept Proposal 857 made by Hans, seconded by Alex.
Discussion: These should be simple changes to chapter 3.
Vote: 6/0/2

Proposal 716 concerns inclusion of the PRT segment to optionally associate a person or an organization without a specific person identified. This proposal outlines adding the PRT segment under both the AUT and RF1 segments to indicate who the person or organization is who is athorized or being referred to. This will also require addition of 4 new values in Table 0912 (Participation).
After discussion the group felt the need to update the ROL segment with the new PRT segment and start the deprecation process.
Hans moves to accept proposal 716 with the friendly amendment to also replace ROL where found in chapter 3, 8, and 11 with the PRT segment for next ballot round in May. Second by Alex.
Discussion: Hans will check with Frank Oemig and InM on how to include the PRT segment in the OBR when choices of following segments are involved.
Action: Need to follow up with who is editing for Chapter 11.
Vote: 6/0/4

The WG reviewed the agenda for the week.
Moved Brian /Irma Approve Agenda
Vote: 9/0/0
The group reviewed the Mission and charter. All seems well with this

THe group then reviewed the Decision Making Practices (DMP). The Line and Brian noted that HL7 has now changed the requirements for the DMP. Now HL7 Headquarters will provide a base, or default, DMP. If the group has something that adds or differs from the default, then the Work Group will provide an addendum. The group then reviewed and compared the default requirements in the DMP against what we currently have. Focus was especially on, quorum, and evoting.

Motion: A motion for was made by Brian to accept the default DPM, Drew seconded. Discussion: None
Vote: 9/0/0

Action: Line will send an email to the Steering Division that we accept the default DMP.

The WG continued with the review of the 3 year work plan. The WG discovered that a new PSS needs to be created based on the last one for project 1102. The next one will define FHIR resources being normative and defining those. Action Item: Alex to create a base FHIR PSS using the latest PSS template and the base information for the PSS for project 1102.

Action Item: For the new resources Brian will coordinate the creation of new resource proposals.

The WG discussed some of the upcoming resources. Some are in the domain of Financial Management. Irma commented that the work we do to create/enhance FM resources might take away from the resources within Patient Administration domain. The concerns are around people to update, the scope, and the differences in thought processes around resources in which both FM and PA have a stake. This still leaves open the question of who does the work. This will still need to be discussed. Brian also noted that Paul Knapp (co chair of FM) suggested that any joint sessions be done earlier in the WGM week so that joint subjects can be discussed before decisions are made within the meeting.

SWOT was reviewed by the group. It is approved by the group.

The WG then proceeded to discuss participation, telecons and efficiently doing the PA work. THe group discussed perhaps using Zulip for many of the discussions and using telecons for contentionous or subjects that need the PA brain trust. This might allow for reduction of frequency of calls. THe WG decided to keep it on Tuesdays.

Action: Brian will arrange for a Zulip channel.

Meeting Outcomes

Actions (Include Owner, Action Item, and due date) Action:

Next Meeting/Preliminary Agenda Items .

Monday Q2

HL7 Patient Administration Meeting Minutes Location: Hilton New Orleans Riverside, Durham Conference Room		Date: 2018-01-29 Time: Monday Q2
Facilitator	Brian Postlethwaite	Scribe	Alex de Leon
Attendee	Name	Affiliation
X	Brian Postlethwaite	Telstra Health, Australia
X	Irma Jongeneel	HL7 Netherlands
X	Alex de Leon	Kaiser Permanente, USA
X	Line Saele	HL7 Norway
X	Cooper Thompson	EPIC, USA
X	Kathy Pickering	Cerner, USA
X	Christian Hay	GS1, Switzerland
X	Simone Heckmann	HL7 Germany
X	Bidyut Parruck	Interface ED, USA
Quorum Requirements Met (Chair +2 members): Yes

Agenda

Agenda Topics

1. FHIR New Proposals
2. Feedback from Connectathon

Supporting Documents

Minutes

Minutes/Conclusions Reached:
Introductions

Brian asked if there were any proposals for new resources.

Simone spoke about continuing to define the ChargeItemDefinition resource as a new resource. She believes she can craft a proposal, but it will be very generic. This resource will be the place where the “rules” of how to process the ChargeItem for billing. May be part of the Catalog profile on Composition.
Brian asked whether PA should retain “ownership” of this (as we have with ChargeItem) or not. The group decided it made no sense to separate the two since they essentially cover the same subject.

Invoice resource – Draft created for review this WGM
ONC/CMS eLTSS Presentation for Thurs Q4 (from Evelyn This is scheduled for joint meeting Thursday Q4. The WG reviewed the slide presentation sent by Evelyn Gallegos. May need to add EpisodeOfCare. ChargeItemDefinition and HealthcareService may be relevant.

Connectathon feedback. Brian as our FHIR facilitator reported back that he ran 2 tracks: Patient Match and Provider Directory. There was little participation in both, but EPIC (Cooper) implemented Patient Match. There was one other participant for Provider Directory. Brian noted that even though this other participant built a model for resource relationships and process, they came up with the same as the Australian model. Brian showed the model.

Cooper reported back on the Scheduling track for the connectathon. While there were few actual connections, there were many discussions regarding scheduling. One discussion had to do with subscription style scheduling to reduce having to “pull down” entire schedule slots to determine scheduling. Subscription on schedule, then search for slots in update schedule (via operation). So only when changes are done will subscriber receive change.

Alex reported back that Kaiser Permanente is starting to “ramp up” their interest in FHIR. This WGM, Kaiser Permanente participated in the Patient Track, collaborating with QRiva on Saturday to run through the scenarios presented (Register, Read, Update and Delete a patient [CRUD]), then version read a patient and search. On Sunday, the creation of an patient ID as a client, then as a server was tested with QRiva through the HL7-sanctioned Aegis Touchstone FHIR server to validate compliance. All tests passed successfully.

Meeting Outcomes

Actions (Include Owner, Action Item, and due date) None

Next Meeting/Preliminary Agenda Items .

Monday Q3

HL7 Patient Administration Meeting Minutes Location: Hilton New Orleans Riverside, Durham Conference Room		Date: 2018-01-29 Time: Monday Q3
Facilitator	Line Saele	Scribe	Alex de Leon
Attendee	Name	Affiliation
X	Irma Jongeneel	HL7 Netherlands
X	Line Saele	HL7 Norway
X	Brian Postlethwaite	Telstra Health, Australia
X	Alex de Leon	Kaiser Permanente, USA
X	Toril Reite	HL7 Norway
X	Cooper Thompson	EPIC, USA
X	Oyvind Aassve	HL7 Norway
X	Michelle Miller	Cerner
X	Tricia Chitwood	Cerner, USA
Quorum Requirements Met (Chair + 2 members): Yes

Agenda

Agenda Topics

1. FHIR Ballot Reconciliation

Supporting Documents

• 14333 - Provide more clarity between administrativeGender, sex, and gender identity

• 14154 - Searching a patient by Identifier Type

• 14099 - Guidance on how to request a new identifier (e.g. MRN)

• 14341 - Replace "hermaphrodite" with "intersex"

• 14174 - herd should be able to reference the owner

Minutes

Minutes/Conclusions Reached:
Introductions

14866 - Multiple birth order should be a positive integer (not an integer) - 2018-Jan Core #206
The WGreviewed the tacker item and considered this reasonable.

1. 14719 - Patient Gender representation is lacking
   

Existing Wording: In addition, to this gender, other kinds of gender may be represented
Proposed Wording: Add link to US Core Birth Sex extension, and develop guidance for sending Clinical Gender
--- The current description notes "other types of Patient Gender may be represented but gives no guidance" Add link to US birth Sex extension, Add link to Observation resource or create specific profile.

The WG was a little confused about the need for this. After discussion, it seems the submitter wanted hyperlinks to Observation. When reviewing the Patient Gender section, it appears all information is clear there.

In an attempt to clarify, the reference to “Meaningful Use” will be removed. The last sentence in that paragraph will now say “The US realm defines the US specific extension for this for concept,”
An example will be created for the clinical Gender and referenced

The new Gender Identity standard extension will be included in the bulleted items tracker #13843
Moved Brian, second Cooper.
Vote: 7/0/2

1. 14754 - Gender can't drive clinical processes if it's administrative - 2018-Jan Core #91
   

Administrative Gender - the gender that the patient is considered to have for administration and record keeping purposes.

Needed for identification of the individual, in combination with (at least) name and birth date. Gender of individual drives many clinical processes.

The gender might not match the biological sex as determined by genetics, or the individual's preferred identification. Note that for both humans and particularly animals, there are other legitimate possibilities than M and F, though the vast majority of systems and contexts only support M and F. Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific gender aspect of interest (anatomical, chromosonal, social, etc.) However, because these observations are infrequently recorded, defaulting to the administrative gender is common practice. Where such defaulting occurs, rule enforcement should allow for the variation between administrative and biological, chromosonal and other gender aspects. For example, an alert about a hysterectomy on a male should be handled as a warning or overrideable error, not a "hard" error.
Proposed Wording: Requirements
Needed for identification of the individual, in combination with (at least) name and birth date.

Suggest you remove the statement "Gender of individual drives many clinical processes." since this contradicts your comments on "Administrative Gender", e.g. (The basic gender included in Patient.gender has a limited use, that of the administrative gender: the gender that the patient is considered to have for administration and record keeping purposes.)

To support your statement "Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific gender aspect of interest (anatomical, chromosomal, social, etc.)." suggest referring to LOINC codes for Sex assigned at birth (768909) since it may be different from the current Administrative Gender. Also suggest adding reference to LOINC code for Gender Identity in this section.

Cooper moves to disposition this persuasive with mod, Brian seconded.
Discussion: None
Vote: 5/1/3

14756# - Provide LOINC code for sex assigned at birth - 2018-Jan Core #93

Submitted by: Freida Hall (Quest Diagnostics)
On behalf of: Freida Hall (freida.x.hall@questdiagnostics.com)
Existing Wording: Tracking a patient's gender presents a number of challenges due to biological variations, differing cultural expectations and legal restrictions, and the availability of various kinds of gender re-assignment. The basic gender included in Patient.gender has a limited use, that of the administrative gender: the gender that the patient is considered to have for administration and record keeping purposes. In addition, to this gender, other kinds of gender may be represented:
•Birth Sex - the sex assigned at birth / on the birth registration. Some countries allow variations such as not yet determined, unknown, or undifferentiated, while others do not. The US realm defines a US Specific extension for this for Meaningful Use
•Clinical Gender - an observation about the patient, typically using the LOINC code 76691-5 ). LOINC also provides a set of possible codes , or SNOMED CT has the descendents of 285116001 : Gender identity finding

Since you provide a LOINC code for Clinical Gender in the 2nd bulleted section, suggest also providing the LOINC code for "Sex assigned at birth" (76689-9) in the 1st bulleted section text description.

Provide LOINC code for sex assigned at birth
Michelle moved seconded by Brian to accept this with additional wording “Alternatively, if you were reepresentint this concept with an observation you could use the LOINC code 76689-9.”
Vote: 8/1/0

1. 14099 - Guidance on how to request a new identifier (e.g. MRN)
   

See https://chat.fhir.org/#narrow/stream/implementers/topic/Create.20Identifier.20(MRN)
Need consistent guidance in the spec on how to request a new identifier be created (e.g. MRN). Brainstorming ranged from:

• An operation
• Use data absent reason extension to convey Identifier.value is "not yet assigned, so please assign it"
• An Identifier.assigner populated without Identifier.value populated

After discussion, An Identifier.assigner populated without Identifier.value populated
To be continued

Meeting Outcomes

Actions (Include Owner, Action Item, and due date) Action: Action:

Next Meeting/Preliminary Agenda Items .

Monday Q4

HL7 Patient Administration Meeting Minutes Location: Hilton New Orleans Riverside, Durham Conference Room		Date: 2018-01-29 Time: Monday Q4
Facilitator	Irma Jongeneel	Scribe	Alex de Leon
Attendee	Name	Affiliation
X	Irma Jongeneel	HL7 Netherlands
X	Line Saele	HL7 Norway
X	Brian Postlethwaite	Telstra Health, Australia
X	Alex de Leon	Kaiser Permanente, USA
X	Christian Hay	GS1, Switzerland
X	Cooper Thompson	EPIC, USA
X	Hanhong Lu	EPIC, USA
X	Simone Heckman	HL7 Germany
X	Drew Torres	Cerner, USA
X	Isabel Gibaud	HL7 France
X	Tricia Chitwood	Cerner, USA
Quorum Requirements Met (Chair + 2 members): Yes

Agenda

Agenda Topics

1. FHIR Ballot Reconciliation - Encounter

Supporting Documents

Minutes

Minutes/Conclusions Reached:
Introductions

1. 14099 - Summary: Guidance on how to request a new identifier (e.g. MRN) (cont.)
   

Guidance will be provided in the section “8.1.3 Patient Id’s and Patient resource id’s”. Where there is a need to implement an automated MRN Identifier creation for a patient record, this could be achieved by providing an identifier in the patient with the MRN type, an appropriate assigner and no value assigned. Internal business rules can then detect this and replace/populate this id with 1 or more ids (as required).
Drew moves/Brian
Persuasive
Vote: 8/0/2

1. 14823 Add search for Encounter.account –
   

Brian moves/Drew seconds to accept as persuasive.
Vote: 9/0/1

1. 14824 - Encounter.class should be 1..1
   

Class cardinality should be 1..1 as mentioned in section 8.11.4 Notes
The class element describes the setting (in/outpatient etc.) in which the Encounter took place. Since this is important for interpreting the context of the encounter, choosing the appropriate business rules to enforce and for the management of the process, this element is required. Moreover in class history it is marked as 1..1, so unless it is mandatory in current encounter, there won't be way to have it mandated in history

Encounter.class should be 1..1
This seems reasonable to the WG.
Alex/Simone second
Vote: 9/0/1

1. 14499 - Encounter.class description/definition contains duplicates (not in value set)
   

Description/definition says "inpatient | outpatient | ambulatory | emergency +"
The format of that description/definition usually implies those are specific codes in the value set, but the value set doesn't differentiate between outpatient and ambulatory. There is a single code for ambulatory, so it seems a bit misleading to imply there are codes for both.
The WG discussed this and decided upon a different description.
“Concepts representing classifciatin of patient encounter such as ambulatory (outpatient), inpatient
Simone moves/Line seconds
Vote: 9/0/0

1. 14758 - Summary: Add example to Encounter.diagnosis.rol to address principal diagnosis for an Encounter as noted in the comment provided (or add an additional role of principalDiagnosis). - 2018-Jan Core #95
   

Clinical quality measures need to address the concept of a Principal Diagnosis defined by statute as the coded diagnosis/problem established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The roles provided do not directly address principal diagnosis. FHIR tracker (https://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10544) suggest that encounter-primaryDiagnosis and encounter-relatedCondition extensions will be removed as they are redundant with the core resource (using Encounter,diagnosis.role and Encounter.diagnosis.rank. However, the extension remains. And the example in Encounter.diagnosis.role does not address principal diagnosis. Encounter.diagnosis.role should include an example for definiing Principal diagnosis (e.g., role = billing diagnosis AND rank = 1, or role = discharge diagnosis AND rank = 1. Alternatively, add a role of "principalDiagnosis" to enable clinical quality measures and clinical decision support.

Add example to Encounter.diagnosis.role to address principal diagnosis for an Encounter as noted in the comment provided (or add an additional role of principalDiagnosis).
The encounter-primaryDiagnosis and encounter-relatedCondition will be removed as being redundant to Encounter.diagnosis.role and Encounter.diagnosis.rank.
As for the example reference, Simone suggested to make this an example binding. THe WG determined to update example
The redundant extension will be removed.
Example f202 will be updated to remove the extension and clarify the usage.
Cooper Thompson moves and Tricia Chitwood seconds to make this persuasive with mod
Vote: 8/0/2

1. 14477 - Encounter.serviceType needs binding to value set
   

Encounter.serviceType needs a binding to a value set.
After some research, it seems the binding is there, but the references from the Encounter.type does not point to the existing binding set which is an example set.
Brian moves, Alex seconds to move this persuasive.
Vote: 8/0/1

1. 14451 - PA resources do not have a clean Workflow report
   

The workflow project has put together a report identifying places where resources don't align with patterns, as well as a mechanism for work groups to mark as "ignored" if they don't feel alignment is appropriate/necessary. Your work group has resources that are still showing up on the report - meaning that an alignment review has not been completed (or there are issues with the suppression process - in which case please let me know). Alignment is most critical for normative resources, but should be completed for all resources that are FMM3 or higher (and should be considered for resources with lower FMM levels)
After discussion our FHIR SMEs decided to “divide and conquer” the work based on the specific resources defined in the tracker item:

* ChargeItem - Simone

• Encounter - Drew
• EpisodeOfCare - Cooper
• AppointmentResponse – Brian
• Appointment - Brian

Meeting Outcomes

Actions (Include Owner, Action Item, and due date)

Next Meeting/Preliminary Agenda Items .

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