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

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.

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
  

Track lead/co-leads:

- Laura

- Emma

Scope:

- To include: Instruction, Care Team

Goals/Objectives

- 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?)

Lessons from previous Clinician-on-FHIR

Use cases / Scenarios

- 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:

Digestive Health Clinic, Canada: post-colonoscopy patient instructions

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

Processes

Emergency care

• Conference call 22 November 2016

Present:

- Stephen

- Emma

- Laura

- Rob Hausam

- Jim McClay

- Joe Quinn

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
(2) Incorporate Allergy/Intolerance and Clinical Documentation into Emergency Care Track

Quick overview of the Emergency Care workflow DAM

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

29 November 2016 conference call

- Follow-up conference call discussion on 6 December 2017

Track lead/co-leads:

- Jim

- Laura

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

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

Lessons from previous Clinician-on-FHIR

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

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

Medication

• For discussion on: 13 December 2016 conference call
  

Attendance:

• Stephen Chu
• Emma Jones
• Rob Hausam
• Russ Leftwich
• John Hatem
• Melva Peters

Track lead/co-leads:

- Melva

- John Hatem

Scope:

- To include: Medication, Medication Order, Medication Dispense, Medication Administration, Medication Statement

Goals/Objectives

• To test all medication resources: MedicationRequest, Medication Dispense, Medication Administration, Medication Statement
• To test medication reconciliation process

Lessons from previous Clinician-on-FHIR

• 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

Use cases / Scenarios

• 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

Processes

• 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

Diagnostic Request, Report and Observation

• For discussion on: 3 and 10 January 2010 conference call
  

Track lead/co-leads:

- Rob

Goals/Objectives

• 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

Lessons from previous Clinician-on-FHIR

Use cases / Scenarios

• 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)

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

Family Member History

• For discussion on: 20 December 2016 conference call
  

Track lead/co-leads:

- Grant Wood

- Gil Alterovitz

Scope:

- To include clinical genomics

Goals/Objectives

Lessons from previous Clinician-on-FHIR

Use cases / Scenarios

Processes

Technical Connectathon

The HSSP community is running a project, which is a FHIR based Care Coordination Service.
The project:

- plans to define services and profiles that allow care coordination across clinical teams for a patient (e.g. manage teams, care plans, etc) - expects to use FHIR resources, profiles, operations etc to define a "Care Coordination Service" - has use cases, and some preliminary architecture - plans to hold a connectathon track at the January meeting - is working towards an initial submission date of Feb 2017, and is being lead by AllScripts

The project is seeking participation from the FHIR community, including all those that are already working on (or have in production) solutions around coordinated care, both inside USA and outside as well.

A proposal has been initiated for a Care Plan track to be run at the Jan FHIR connectathon (technical connectathon) that would focus on testing CarePlan, CareTeam, and Goal. And any any profiles that are available or proposed at that time, e.g. US-Core profiles and the IHE Dynamic Care Plan IG.

More details about the proposal can be found at this link:

http://wiki.hl7.org/index.php?title=201701_Care_Plan

Resource subscription function may be useful in care planning collaboration:

http://wiki.hl7.org/index.php?title=201701_Resource_Subscription_Track

Appendix

Allergy/Intolerance and Adverse Reaction

• Discussed on 8 November 2016 conference call
  

Allergy/Intolerance track to be incorporated into Emergency Care track

Contents set aside for future use

Goals/Objectives

- 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)

Lessons from previous Clinician-on-FHIR

Use cases / Scenarios

(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