2016-07-11 Rx Conf Call

Related Links Pharmacy Home Page Conference call minutes

Attendees

• Melva Peters (Chair)

Harmonization Meeting

• Review of Proposals
• Link to Proposals
  • primarily V2 related

DESD Co-Chair Election

• Need to vote on co-chair before July 31 - it is a Work Group Health metric

ListServ / Zulip Discussions

• Topic: Multiple route of administration on a single order
  • Comments received from Lee - in a protocol where a medication could be given orally or Intravenous
  • can use multiple dosage instructions
  • multiple dosage instructions - Lee assumed it is "and" - how do we handle "or"? -
    • timing could be used to indicate when each of the medications are to be administered
  • Consider GF 10066 - Should route and site be inside dosage instruction line as part of this discussion

Action:  determine what additional guidance should be included to distinguish and/or or what we support - Melva - call with Lloyd scheduled June 27 - complete
Action:  Ask Lloyd - if and/or is supported anywhere else - how is it being done - Melva  - call with Lloyd scheduled June 27 - complete

• MedicationAdministration dosage.text
  • GF #10216
    • Proposed wording
      • Free text dosage (instructions) can be used for cases where the (instructions) dosage administered are too complex to code. When coded dosage (instructions) are present, the free text dosage (instructions) may still be present for display to humans (taking or administering the medication).
      • The dosage instructions should reflect the dosage of the medication that was administered.

FHIR Maturity

• Getting our resources to Level 2 and 3
• Have identified several vendors that are using some of our resources which collective use all of our resources. Need to determine specifics of who and what, as well as, what documentation would be required to prove level.
• Response from Lloyd: For level 2, the requirement is that in some sort of real or test environment, at least 3 independently developed systems have shared the resource covering at least 80% of the data elements. You can capture the name of the connectathon or just a date and a list of the system vendors if it was done outside of connectathon (e.g. through Argonaut)
• Additional information provided by Michelle that can aid in collecting FMM evidence
  • Argonaut sprint testing schedule: https://github.com/argonautproject/implementation-program/wiki
  • Argonaut implementation guide: http://argonautwiki.hl7.org/index.php?title=Implementation_Guide#Data_Element_Query
  • Specifically, MedicationOrder and MedicationStatement (http://argonautwiki.hl7.org/index.php?title=Medications) are scheduled for Sprint 3 (July 2016)
• Email has been sent to Pharmacy List asking implementers to provide information

Action:  Add FDB news release
Action:  Daniel to provide Epic information

FHIR Discussion Items

• SEE SPREADSHEET OF OUTSTANDING CHANGE REQUESTS 2016-01-25 IN DROPBOX

July 11 items

• CDS Request
  • The CDS Work Group as part of reconciling ballot comments for the CQF-on-FHIR Ballot has created a resource in FHIR that can be used to describe "templates" for intent resources like MedicationOrder, ProcedureRequest, etc. The resource is called ActivityDefinition (https://hl7-fhir.github.io/activitydefinition.html).
  • As part of specifying the template for a MedicationOrder, we need to be able to specify the dosageInstruction and dispenseRequest elements. Rather than copying the element from the MedicationOrder resource definition, we are planning on defining a DosageInstruction and a DispenseRequest type that we could reference, rather than duplicating the maintenance of those elements.
  • Do you have any questions or concerns with this approach? The initial step is just to define the data types based on the MedicationOrder structure and will not involve any changes to the MedicationOrder resource.
• GF 10123 - Exemplar value set for Medication Hierarchy - on all resource -
  • currently some of the new biologicals are not in the hierarchies proposed as the exemplar value set
  • Propose to include Snomed CT Hierarchy 106181007 Immunologic Substance (substance) as a 3rd hierarchy on all resources for MedicationCodeableConcept
• GF 10084 - MedicationDispense.dispenser should allow Organization
  • Propose that we add attribute to MedicationDispense - "dispensedAt" with a reference to an Organization resource
• GF items related to Examples
  • GF 9032 - Add examples based on CR 8697 - change to timing data type
    • examples are added in draft material
  • GF 8475 - Single ingredient dispensed as multiple products
    • examples are added in draft material
  • GF 8108 - Add example for Medication resource to reflect "little pink pill" (i.e. unknown medication)
    • examples are added in draft material
  • GF 7741 - 2015May core #1032 - Fix example.
    • examples are added in draft material
  • GF 7740 - 2015May core #1031 - Fix example.
    • examples are added in draft material
  • Propose that 9032, 8475, 8108, 7741 and 7740 are approved - examples will be ready for review in Current Build in the next couple of weeks

Outstanding June 20 items

• 10036 - re-consider - can not make this change - should be not persuasive
• 10141 - Categories - long discussion of proposed changes
  • July 11 Discussion/Proposals:
    • MedicationOrder
      • Inpatient - includes orders for medications to be administered or consumed in an inpatient or acute care setting
      • Outpatient - includes orders from medications to be administered or consumed in an outpatient setting (for example, Emergency Department, Outpatient Clinic, Doctor's office
      • Community - includes orders for medications to be administered or consumed by the patient in their home
    • MedicationStatement
      • Inpatient - includes statements about medications to be administered or consumed in an inpatient or acute care setting
      • Outpatient - includes statements about medications to be administered or consumed in an outpatient setting (for example, Emergency Department, Outpatient Clinic, Doctor's office
      • Community - includes statements about medications to be administered or consumed by the patient in their home
      • Patient Specified - includes statements about medication use, including over the counter medication, provided by the patient, agent or another provider
  • Discussion of the term for #4 "community prescription" rather than "prescription"
  • Discussion of whether this is part of the 80%
  • Brought forward for previous discussion
    • Understand Lusia Li requirements and enter tracker item (if Lusia Li attends this session)
      • Home Medications
      • How to query for home medications?
    • If we add a category (to both MedicationStatement and MedicationOrder), then at minimum, we'd need 4 categories:
      • Inpatient (what is administered during the inpatient visit, which does NOT include discharge medications)
      • Outpatient (what is administered during the outpatient visit, e.g. ED visit or Oncology visits)
      • OTC/Hx (e.g. a subset of Med Statements that are modifiable because they don’t represent “real” orders in the system, but rather patient statements)
      • Prescription (e.g. “real” prescription orders, often filled by a retail pharmacy and is administered outside of the context of an encounter, often at home)
    • We did discuss category being applicable within both MedicationStatement and MedicationOrder.
    • The question about how to represent “knowledge of externally stored orders” wasn’t explicitly discussed that I recall, but warrants clarification – as our system implemented those as MedicationStatements, which are a mix of explicit medication compliance/use statements as well as implicit compliance of both over-the-counter medications as well as knowledge of externally stored orders (from patient statement about another provider who prescribed the med). A ‘patient statement’ (regarding OTC meds or prescriptions from other providers/external orders) is implicitly communicating compliance/use = was taken – otherwise, the patient wouldn’t have made the statement at all.

 Action:  Daniel will check if the inpatient encounter id is associated with discharge medications (written at the end of the inpatient encounter) - Response from Daniel - I verified that discharge meds were placed in the inpatient encounter in Epic. It won’t be feasible to tell if a med order is inpatient vs. outpatient based off the encounter type.
Action:  Define terms and definitions for MedicationStatement and MedicationOrder for review and voting on next weeks call.
Action:  Melva to work on categories and definition and bring back for discussion next week - deferred to July 11

Outstanding June 13 items

• 10125 - International Realm Pharmacy extensions Profile
  • Each resource is supposed to have a core profiles

Action:  review the pharmacy-extensions-spreadsheet.xml to determine which should be moved to core - MedicationOrder and Medication Dispense

June 6 Items

• 8783 - Medication order status
  • Epic is withdrawing the gForge issue due to the recent addition of MedicationOrder.eventHistory.

 Action:  Marla to follow up with Lloyd to check if workflow will impact this (e.g. removal of MedicationOrder.eventHistory) - will be discussed with Lloyd on June 27

Renaming MedicationOrder to MedicationRequest Discussion

• Email received July 4, 2016 from Lloyd
  • The FHIR Workflow task force has been working for almost the past year to come up with guidelines to improve the consistency of how workflow (the process of requesting something to happen and then reporting the results of that request) are handled across all FHIR resources. Its scope encompasses clinical, administrative and financial resources. We've had relatively broad participation in the bi-weekly calls and very broad participation in the face-to-face sessions at HL7 WGMs.
  • While the project is still testing the recommendations using a variety of use-cases, we are sufficiently confident in the stability of the recommendations, that we voted last week to request all impacted work groups to apply the relevant changes to their resources for inclusion as part of the upcoming STU 3 ballot.
  • We recognize that the timelines for making this occur are tight. In the event that a work group cannot make the changes requested, we invite them to, at minimum, provide an implementation note highlighting the intention to adjust each affected resource to align with the workflow pattern and to include a hyperlink to the "workflow.html" page. (This page doesn't exist yet, but it will.)
  • We also recognize that not all of these recommendations will fall into the 80% for all resources. Work groups are asked to do the following for each recommendation:
    • Apply the recommendation from the FHIR workflow task force as part of core
    • Create extensions to support those data elements that are relevant but not commonly used by the domain
    • Indicate that they feel the recommendation should not apply to their resource by posting an email to the fhirworkflow list server indicating why they believe a given recommendation is inappropriate for a given resource.
    • ((The list of resources believed to be impacted by the FHIR Workflow recommendations are provided in the attached spreadsheet. Most of the listed resources are categorized as either a "request" - a resource that indicates a specific intention for something to occur; or an "event" - a resource that represents a specific occurrence that could have been done in response to a request. A few event resources are marked with a question-mark as it's not clear whether they are requested or not. It's possible that one or more resources in the spreadsheet that were not categorized should in fact be listed as a "request" or an "event". Feel free to apply the workflow recommendations to uncategorized resources if you feel they should apply.
  • In addition to these categorizations, the workflow project calls for the Order and OrderResponse resources to be removed. They are superseded by Task. As well, the scope of ProcessRequest and ProcessResponse should be revised to leverage Task for the purpose of requesting the current state of a resource and for soliciting a state change.
  • The recommendations are as follows:
    • Request
    • Add a note in the introduction section that the resource is a "request" resource from a FHIR workflow perspective, including a hyperlink to workflow.html#request.
    • Rename the resource to [xxx]Request instead of [xxx]Order (request resources are used for plans, recommendations and proposals, not just orders
    • Ensure all of the data elements present in the "request" pattern document (attached) are present in the resource, keeping consistency with the naming where possible and adapting definitions to reflect domain-specifics
    • Ensure the status element for the resource has a terminology that aligns with the "request" states as well. (Note that all statuses related to fulfillment progress are now handled by Task.)
  • Event
    • Add a note in the introduction section that the resource is an "event" resource from a FHIR workflow perspective, including a hyperlink to workflow.html#event.
    • Ensure all of the data elements present in the "request" pattern document (attached) are present in the resource, keeping consistency with the naming where possible and adapting definitions to reflect domain-specifics
    • Ensure the status element for the resource has a terminology that aligns with the "request" states as well. (Note that all statuses related to fulfillment progress are now handled by Task.)
• From January 25 meeting: Lloyd shared the proposal to rename all request type resources to <resource>_Request. Seeking consistent name for all resources and term that encompasses larger swath of types of requests. An element beneath the tag instance would state the particular request, such as 'order'. This impacts the current Pharmacy Medication Order FHIR resource.

 Completed Action: Rx WG to discuss to determine if we agree or not. - agreed (with no vote) to comply with change but not needed to be made yet, per Lloyd

• Lloyd suggested that we hold off on making the change, if we decide to make the change. Wait for FHIR Infrastructure group to workout additional details before we make the changes. May have impact on how other data elements are name or included.
• Discussion: If we agree to the change, we'll need to review the description and other content for our resource to ensure that it accurately reflects the usage. This type of change will mean changes for implementers and it may not be as intuitive for implementers.
  • No decision to be made today. Will consider on a future call

 Action: to followup with Lloyd to find out status and/or next steps - to be discussed June 27 - complete

FHIR Workflow Meetings Status

• Status - there were no workflow meetings week of March 14th.
• Discussion of Pharmacy Workflow Mockup (John)
  • Pharmacy has been providing input into the workflow meeting discussions. One suggestion is that Pharmacy create a Pharmacy specific workflow case similar to the one that is being created for lab. This work has not started yet, but John will start working on this in April.
• Jun 13 discussion - meetings are continuing

Next meeting

• Monday, July 18, 2016
• Agenda