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October 2015 WGM Atlanta: Oct 4 to Oct 9

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Atlanta, WGM - October 2015 Patient Care WG Meeting Approved agenda:




Atlanta WGM - October 2015. Patient Care WG Meeting Meeting Minutes

  • Sunday, October 4 - International Council Meeting
- No PCWG meeting


Patient Care WGM, Monday, October 5, 2015


Monday Q1

  • Plenary Session
- No PCWG meeting



Monday Q2

  • Plenary Session
- No PCWG meeting



Patient Care Monday Q3

Joint meetings

Track (a) EHRWG
Track (b) FHIR/OO (this track extended into Q4 session)


Present:

  • Track A - See EHRWG attendance list - Elaine Ayre and Laura Heermann representing PCWG
  • Track B - See OO attendance list - Stephen Chu and Michael Tan representing PCWG


Minutes:

  • Track A - PCWG update slide deck:
WGM October 2015 Atlanta - Patient Care Update October 5, 2015


  • Track B - Meeting Note:
Topic: FHIR workflow issues
- There are inconsistencies in the current way that FHIR resources handle workflows.
~ FHIR resources that requires workflow management and related issues are captured in this document:
WGM October 2015 Atlanta - FHIR Workflow Issues and Workplan October 5, 2015
- Need to identify set of coherent, common patterns for handling workflows more consistently
- Look into leveraging existing industry workflow patterns
- Identify what infrastructure required to support workflow management in FHIR


- FHIR approach:
~ What kind of connectathon use cases need to be satisfied to deal with the workflow requirements
~ Develop the FHIR workflow solution to address the use cases, test in the connectathon until it is right (or close to right)
~ First to get something that is useful to be tested in connectathon
~ Once tested and improved to close to right, take to ballot
~ OO will coordinate the discussion – invite stakeholders to discuss, may spin off teams to work on domain specific problems and bring back proposals, solutions to the group
- This conversation needs to be carried forward after Monday Q4
~ FHIR to request a list to be set up and start a wiki page for this topic
~ Include interested WG to participate
~ Schedule call in 2 weeks to move things forward
~ To split off some taskforce to investigate the use of BPMN in workflow modelling
~ Get domain experts to contribute
~ Will work on designing RESTful patterns first to get understanding of what can be done in RESTful space (and the limitations) then take to services and asynchronous (messaging) spaces
~ After a set of patterns are identified, then work out which resource may be associated with a particular pattern, and which resources may need to be associated with more than one pattern
- Deliverables for next meeting:
~ Spreadsheet that compares resource contents in each category
~ Identify candidate connetathon use cases (interesting from “how will this work” as well as interesting to implementers), e.g. radiology image remote read; cross departmental use cases (admission, eligibility, orders, observations), medication order lifecycle, referral lifecycle, visit appointment; charge capture; protocol (dicision support, order set, composite order)
~ Primer on BPMN and related methodologies as they might apply to this problem space
~List of resource scopes



Patient Care Monday Q4

Present:
Elaine Ayres
Emma Jones
Bryan Schellar
David Pyke
George Cole
Larry McKnight
Iona Thraen



  • Minutes: Paris meeting approved
    • Move: Emma/David
    • Abstain: 1
    • Negative: 0
    • Approved: 5

Review of Agenda - Move: Emma/Larry; Abstain: 0; Negative: 0; Approved: 5

  • Tuesday
    • Health concern - Tues Q1
    • Meetings with FHIR
  • Wednesday
    • SOA on CCS
    • Child Care
    • Negation topic
    • Allergy and intolerance
  • Thursday
    • Care Plan
    • Clinical status with SDWG
    • Health Concern ballot Reconciliation
  • Friday
    • Clinician on FHIR

New Projects?

  • Maternal Health Proposal - Stephen Hasley wants to build a registry which may be beyond patient care scope for now.
  • Question about patient preferences/Patient goals - Lisa Nelson will discuss Wed Q1

Ongoing Projects

  • Care team domain analysis model
  • Care Plan EHR Functional Model
  • HSI RECON profile is in trial implementation




Patient Care Monday Q5 & Q6


  • Q5 - Co-chairs meeting
  • Q6 - DESD meeting


Present:
Elaine Ayre
Michael Tan
Russ Leftwich
Stephen Chu
Laura Heermann


Minutes:

  • Co-chairs meeting - See TSC and other presentations


  • DESD meeting - see DESD meeting minutes




Patient Care WGM, Tuesday, October 6, 2015


Patient Care Tuesday Q1

Present: Stephen Chu - chair, Jay Lyle - scribe, Michael Tan, David Pike, Iona Threan, Jason Goldwater, Tom Oniki, Christina Knotts, Margaret Dittloff, Laura Heermann, Nathan Davis, Emma Jones, David Tao, Larry McKnight, Danielle Friend, david Hay, Ewout Kramer, Michelle Miller, Susan Matney, Russell Leftwich.


Minutes:

  • DSTU FHIR2.1 has been published. Some of the PC resources are to be frozen. They have to have maturity level 5. The proposed resources from PCWG are allergies, condition., procedure. We have to decide on this list as PCWG.
  • PCWG will test some of these resources on the FHIR clinician connectathon ( care plan, condition, allergies and medication). It is suggested to decide either on Friday or on a call after the PCWG.
  • Our estimation now is that condition should be taken out of the proposed list.
  • The publication of DSTU 2.1 will focus on the workflow, messages.
  • FHIR Discussion Condition. Issue 5546 Input from Larry McKnight.
  • It is not really clear what is being represented:
  1. The actual physical process.
  2. A person can observe at a certain time. : I see X. This is a snapshot.
  3. Action on the concern.
  • Timing aspect is not clear. Lloyd's claim is that this could either be used to state a condition and follow action on the concern. Larry's view is that it is not sufficient, because 2 care providers could have different views leading to different resources. Example 2 different concerns on 1 intervention.
  • We suggest to create a seperate resource for concern.
  • How are concerns stored in EHR's. Most of care providers misuse problem lists while they are actually are concerns. In Larry's view you can select issues depending on the role for your concern list and discard issues.
  • Jay's questions Jim view on how to keep track on the evolution of the issue.
  • Why is the word "problem" not used in the discussion. This is historical. The naming has evolved from problem, condition to concern.
  • Emma: do we capture concerns? This is not clear in her implementation how to do that. According to Larry this is not done explicitly. A care provider put's it on a problem list and therefore define it as a concern. Emma confirms that the care provider can select or discard the conditions from the problem list.
  • David Pyke put forward Motion 1 :We identify a need for a seperate resource for health concern. We will sort out the different attributes between condition and concern.
  • The motion is amended: Need an anlysis of the distintion of data attributes in condition vs concern.
  • second Russ: Vote : 1 abstain , 1 oppose, 21 favor.
  • Iona add's that in the beginning of health concerns we were approaching concerns from the family point of view. Michael's view that input from the family was brought into the scope later on. Larry add's that it is actually the same.
  • Larry's Motion 2: clarify in the FHIR specification that this current resource of condition is to be used as a point in time observation of a condition.
  • David second: Vote : 8 abstained, 3 oppose, 11 in favor.



Patient Care Tuesday Q2

Present: Larry McKnight, Stephen Chu, Michael Tan, Jay Lyle, Dominick Brannon, Emma Jones, Yokinoh Konishi, Solomon Tabasaba, Masaake Hirai, David Tao, David Pyke, Larry McKnight, Susan Matney, Peter Park


Minutes:

Overview of Health concern project by Stephen

  • Concepts of health concern from clinical and technical perspective.
  • 3rd cycle of informative ballot

Overview of the Health concern DAM document by Michael Tan

Ballot Reconciliation

Textual and Grammatical changes

  • Move that Michael resolve all textual and grammatical changes and these will be handled by block vote
    • Moved: David; Second: Larry; Abstain: 0; Opposed: 0; Approved: 11

Negative Major Items

  • Comment from Jay Lyle - Chapter 3, section 4,5,6. Jay has proposed a change to this area.
    • Discussion around the room.
    • Stephen Chu contributed these section because of the confusion of the differentiation between the clinical and technical perspective. The goal was for the DAM to provide a view point of "what" it means without saying "how" this should be implemented. The intent of these sections were to provide clarity on the different perspective.
    • Proposal to circulate Jay's proposed change, group will review the proposed change and the group decide if the change will be adopted and the comment disposition.
    • Larry moved we table this for now and circulate the jay's proposed change for review then do a conference call discussion of the proposed change. Will treat as a block change.

Moved: Larry Second: David P. Abstain: 0 Opposed: 0 Approved: 11

  • Comment #42, 52: concernIdenfifier

Moved: Larry Second: David T. Abstain: 0 Opposed: 0 Approved: 11

  • Comment #46:reference to health concern section changed to health concern Act

Moved: Jay Second: David T. Abstain: 0 Opposed: 0 Approved: 11

  • Comment #53:replace "identifies" with "expresses"

Moved: Jay Second: David Abstain: 0 Opposed: 0 Approved: 11

  • Comment #54: subject of the health concern
  • Discussion about the use of "patient" in the model. Suggestion from David P to leave as 'patient' and allow others to use the model to extend this entity.
    • Move to Change to "The individual who is the subject of the care provision". Currently multiple individuals are out of scope

Moved: Jay Second: Peter Abstain: 0 Opposed: 0 Approved: 11

  • Comment #56: - Change to concernMonitor

Moved: Jay Second: David P Abstain: 0 Opposed: 0 Approved: 11




Patient Care Tuesday Q-Lunch

Present: Stephen Chu - chair, Elaine Ayres -- scribe, Russ Leftwich, Michael Tan, Michelle Miller, Jay Lyle, Lloyd McKenzie, Reuben Daniels, Linda Bird, Christina Knotts, Emma Jones, Grahame Grieve, David Hay, david Pyke, Dennis Patterson, Larry McKnight, Lise Stevens, Kevin Shekleton


Topic: Adverse Event vs Adverse Reaction
Minutes: Representatives from multiple WG's present. A clinical trial vs. a medical event. An event may or may not be related to a clinical trial. May be an adverse medical event on Non medical adverse event. Adverse medical event may be workflow or procedue related, clinical trial related or physiological (allergy/intolerance).

Can be related to patient safety or a clinical trial. Use cases -- reporting or decision support purposes. Create a Venn diagram of various states.

Reporting may be an internal institutional activity or may be a regulatory report.

What could we use now -- questionnaire? Is there enough consistency? Should this be packaged in a document?

Use cases - unanticipated reaction -- record, but don't report, known reaction risk and occurs - internal reporting, if on clinical trial, this would also be a regulatory report.

Do we treat this like another document -- with a specialized use case (profiles).

The questionnaire can be used for anything, but more difficult to query. Need to move data into a more specific resource. For queries, is there sufficient commonality to be useful. Could then take questionnaire from a variety of resources and then view and query collectively.

May want to look at diagnostic report vs. use for adverse event reporting.

Distinct resource need -- is this something that is distinct in most implementation systems? Is there a core set of information that is used across implementation? Is there a desire to have this in the FHIR environment?

Questionnaires may be driven by national reporting systems, vs. something more specific.

Currently there is a large degree of variability of current adverse event reporting data elements.

We are discussing both a resource and a package of data elements.

This will be much like clinical impression -- some core elements with additional information from many other resources.

Look at ISO for adverse event reporting. What about public health reporting -- that is different than adverse event reporting.

ISO 27953 Part I is for multiple use cases -- animal, food. Part II is more constrained for for regulatory reporting. FHIM also has a model. See EHR profile for public health.

Add to next PC/FHIR call.


Patient Care Tuesday Q3

Present: Stephen Chu - chair, Elaine Ayres -- scribe, Laura Heermann, Toni Sholemis, Floyd Eisenberg, Eric Larson, KP Sethi, Stuart Myerburg, Kimberly Smuk, Patty Craig, Thomson Kuhn, Keith Boone, Yan Heras, Larry McKnight, Bruce Bray, David Tao, Margaret Dittloff, Ian Wermhardt, Marck Hadley, Castan Quinlan, Justin Schirle, Daivd Sundaram-Stukel, Julia Skapik, Miariam Markhlent, Martin Rosner, Michael Tan, Emma Jones, David Pyke.



Minutes: This is a combined meeting of Patient Care, CDS and CQI Agenda items: 1. Discussion of Problem Status vs. Clinical Status, 2. Care planning and CDS and 3. CDS and FHIR adverse event profile.

Semantics of clinical status: Remission states: in remission, partial remission, full/complete remission, early full/partial remission, sustained full/partial remission. Also, relapse status - relapse, suspected relapse, relapse after partial remission, relapse after full remission. Can they be mapped up to active or inactive??

Are there phases of remission?

In V3 there are 8 status codes -- active, inactive or resolved. Is remission a type of inactive state?? Can't say a concern is inactive or resolved if there is an active clinical status.

QDM v. 4 -- presume active at the time you are doing the measure. These were removed in the revision -- because the problem list was not being updated. May use prior history -- e.g. prior history of hepatitis. Only report on what you know is available.

CDS and CQI wish to harmonize with point of care.

Do we need a domain analysis model for clinical status?

What are the principles for developing the value set?

With severity -- want gradations. Look at computability (active/inactive) as well as the communication with other providers.

Many of the proposed clinical status terms may not be commputable, but are necessary for clinical care.

A set of use cases would be helpful in supporting the use of clinical status.

F/U with CQI -- with NQF -- can you rely on a problem list to get to a level of granularity for clinical status. For a domain analysis model -- would apply across all standards. What is the workflow that is needed to process status information. Need the definitions to support.

CQI - QI core - profiles of existing resources with constraints CDS -- also has profiles.

Next steps with discussions -- create shared DAM. Invite CQI and CDS and SDWG. Have conference calls q2 weeks to investigate. This is a clinical care issue -- CQI will an interested party.

There is an need for analysis but does it merit an entire DAM? IHTSDO has a hierarchy of status conditions. Does CIMI need to be included?

Start from the point of a goal -- what is needed. PC needs to be the driver. The clinical community does need to express clinical status beyond the machine state status. CQI will be an interested party.


Patient Care Tuesday Q4

Present:Stephen Chu - chair, Elaine Ayres - scribe, David Pyke, Emma Jones, Michael Tan, Margaret Dittloff, Christina Knotts, Larry McKnight, Jim McClay, Michelle Miller, Lloyd McKenzie, Laura Heermann, Iona Thraen, Danielle Friend, Dominik Brammen



Agenda - Condition vs. Concern, Family Member History, Work on existing resources - including clinical impression and GFORGE work.

Minutes: PC/FHIR meeting. Continued discussion of condition vs. concern and the outcome of the discussion on GFORGE #5546. It is possible to have one condition that is shared variably based on role. What about evolution of the name of the condition? What about if different providers have different opinions on the status of the condition.

All resources can be looked at over time. Can point to current references or historical references. However the condition with history may be more difficult to represent. Hard to tell if conditions are current or historic.

Lloyd has suggested looking at a new resource that link resources together "linkage resource".

Next steps -- look at linking resource. Lloyd will put together a resource proposal -- will most likely be handled by PC.

NOTE -- clinical genomics not available. Schedule participation on a phone call.



Patient Care WGM, Wednesday, October 7, 2015


Patient Care Wednesday Q1

Present:


Minutes:



Patient Care Wednesday Q2

Present:


Minutes:



Patient Care Wednesday Q3

Present:



Minutes:




Patient Care Wednesday Q4

Present:



Minutes:




Patient Care WGM, Thursday, October 8, 2015


Patient Care Thursday Q1

Present:


Minutes:



Patient Care Thursday Q2 (PCWG, SDWG, Template Joint meeting)

Present:


Minutes:



Patient Care Thursday Q-Lunch: PCWG Co-Chairs meeting

Present:


Minutes:



Patient Care Thursday Q3

Present:



Minutes:




Patient Care Thursday Q4

Present:



Minutes:




Patient Care WGM, Friday, October 9, 2015



Patient Care Friday Q1


(1) Template WG meeting

- PCWG representative(s) to attend

(2) Agenda: open

- Possible: Clinical Connectathon



Present:


Minutes:



Patient Care Friday Q2


Agenda: open

Possible: Clinical Connectathon


Present:


Minutes:



Patient Care Friday Q3


Agenda: open

Possible: Clinical Connectathon


Present:



Minutes:




Patient Care Friday Q4


Agenda: open

Possible: Clinical Connectathon


Present:



Minutes:



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