2016-11-21 Rx Conf Call

Related Links Pharmacy Home Page Conference call minutes

Attendees

• Melva Peters (Chair)
• Scott Robertson
• John Hatem
• Marla Albitz (Scribe)
• Jose Costa Texeira
• Daniel Zhang

ListServ Discussions

• List Serve Postings
  • email from Grahame - fluid orders - sent to the Pharmacy list
    • 1. One of the issues concerns the Medication Resource and discussing several use cases for adding a notion of "active/inactive" for a medication.
    • 2. Another issue is related to the current use of either Substance or Medication on the Ingredient.
    • 3. there are several other issues listed below. One of them has been / or will be corrected, the use of "carton". - new tracker item has has been added (TR#12347)

Zulip

• MedicationStatement
  • related to "do not do" - as in patient not to be given a certain medication
  • may come out of Negation project from Patient Care
  • a number of items included in this Zulip chat
    • patient not to be given medication
      • not likely a medicationStatement - is this a negative order?
      • has not come up for Cerner - may infer something like this from an allergy
    • doctor recommends that GP prescribes drug ABC

Action:  Melva to reach out to Philip to post tracker item

FHIR Tracker Items

TR#10456 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
  • Discussion - July 11 Meeting
    • John described the change proposed - we can alias resource to include MedicationOrder
    • Moved by John - seconded by Marla to add note to introduction section to Medication Order 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. and to add 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. - 7/0/0 Carried
    • Moved by John - seconded by Marla to add note to introduction section to Medication Dispense, MedicationAdministration, MedicationStatement - 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. and to add 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. 7/0/0 Carried
• Discussion on August 22
  • John has done a mapping for MedicationOrder to RequestLogicalModel - See spreadsheet File:Mapping Med Order to Workflow Request logical model.xlsx
    • change name to MedicationRequest and add alias to MedicationOrder
      • identifier - recommend do not change cardinality
      • definition reference - add
      • basedOn reference to request - assume that we should add, but John to ask Lloyd for clarification
      • replaces - reference to request - we need to discuss this - we have priorPrescription - not sure if this is the same - should we have both - John to ask Lloyd for clarification
      • status - need to have a discussion with workflow team about codes - question about cancelled and stopped
        • change our cardinality to be 1..1
      • stage - add
      • reference to patient - change cardinality to 1..1
      • reference to Encounter/Episode of care - do not change
      • occurence - leave as is for now
      • requester - we only reference practitioner - need to consider if we should expand
      • performerType and performer - need to consider - may be related to who should administer the medication
• Discussion on October 10
  • See updated spreadsheet
  • Will continue discussion 10/17
• Discussion on October 17
  • File:Mapping Med Order to Workflow Request logical model.xlsx
  • Motion to add definition, basedOn, requisition, stage, reason reference (to observation), supportingInformation to MedicationOrder - moved by John - seconded by Yunwei - Carried 6/0/0
    • this deals with TR#12203 and TR#12174
  • Motion to add change name to MedicationRequest and add Medication Order as an alias - moved by John - seconded by Melva
    • discussion of concerns that the name MedicationRequest doesn't make sense from a business perspective, but when plans and recommendations are included, it may make sense
    • will be consistent with other resources that are orders
    • Vote: 4/0/2 - Carried
• Discussion on October 24
  • some changes have been made
  • Status discussion
    • propose we keep our definitions
    • add Cancelled to our statuses
    • leave "stopped" in
    • Motion: to add cancelled to our value set and keep our definitions and that we lobby Workflow to make their definitions more generic and add stopped to their value set - Scott-Michelle - 8/0/0

Action:  John to talk to Workflow about making definitions more generic.  November 3 - Follow up - do we have a tracker item, if not, lets create one. No answer from Workflow on this topic. 
Action:  John to talk to Workflow about adding "stopped" to Request status value set.   November 3 - Follow up from John, this needs to be raised in MnM. 

• Discussion on October 27
  • Subject - keep as is - do not add Group at this point
    • change cardinality to 1..1 and add guidance re: anonymized patient
  • Context - currently support Encounter; will add Episode of Care
    • Change name to context
  • requester - currently only reference Practitioner -
    • need to include comments that define the stages that can be done by what type of practitioner.
    • original order must be practitioner
  • performer type - who needs to administer
    • add it with comment - evaluating the use and terminology for this
  • Performer - do not add - would be considered an extension

Motion: by John - seconded by Marla to accept the Oct 27 changes - 5/0/0 carried

• Discussion - October 21
  • Occurence - discussion of use of this to support 1 tablet three times daily for 10 days started on Nov 3, 2016
    • Motion to make an update medicationRequest occurrence per list shown in GoToMeeting: Motion: Jose Second: Marla 5:0:0
  • workflow supports a choice for occurrence but the cardinality of 0..1 - need to change that cardinality

Action:  John to talk to Lloyd, FMG

• Discussion - November 14
  • performerType - agreed to add it with comment - evaluating the use and terminology for this - NEED TO DEFINE VALUE SET - LM THINKS THIS IS AN EXTENSION NOT CORE
    • Cerner may be able to use category
    • okay to treat as an extension
    • Motion: John/Michelle to treat performer type as an extension and not add to MedicationRequest - 4-0-0 Carried

• Discussion - November 21
  • Outstanding items
    • occurence[x] - need to refer to MnM
    • requester - need determine stages appropriate for requesters - Proposed:
      • Proposal – Patient, RelatedPerson, Practitioner, Device, Organization
      • Plan – Practitioner, Patient, RelatedPerson
      • Original order – Practitioner
      • Comments received - LM - add device to plan
      • Approved change as above - moved by Jose -seconded by Marla 5-0-0 Carried

TR 12340 - Guidance for Substance abuse

• Michelle Miller introduced on 11/10/16 call.
• should MedicationStatement be used to document substance abuse
• although, substance abuse tracking forms usually have more than can be documented in MedStatement. e.g., desire to quit
• John:
  • classic clipboard at visit, are you taking these meds - each is a MedicationStatement
  • other "active products" - tobacco, alcohol, abusable substances - are handled as observations
• but, if the clipboard asked "do you use illegal substances" ... need support Y/N/no response. This seems to be a MedicationStatement (need to support negation and no answer)
• broader consideration: how to support MedicationStatement negation - is it MedicationStatment.notTaken ?
  • similar to assertions of Condition Absence (see Condition resource ... 9.2.3.5)
  • Note this is in a Zulip chat as "Substance Abuse"
• November 14: Tracker item has been added - need to spend more time on this
  • observation could be used that would support Question/Answer as well for negative statement of use - Questionnaire
  • create an example

Action:  develop some wording about when medicationStatement vs social history could be used as well as create examples (positive and negated) - Melva

Harmonization of Statement with Event

• 11/10/16 brief discussion on mapping MedicationStatement to Workflow Event
• Nov 14, 2016: No discussion
• November 21, 2016: brief discussion - will continue on next call

GF#12148

• requests common search parameters across resources. One of the requests is for date across medication resources - but the medication resources do not have any common date related search parameters. I would suggest that there should be a 'date' on each of them.
  • MedicationRequest datewritten rename to date
  • MedicationAdministration effective-time - add date with same definition
  • MedicationDispense - whenhandedover rename to date
  • MedicationStatement - add date = MedicationStatement.dateAsserted
  • Some ideas:
    • 1 - I would have thought that when comparing MedicationStatements with MedicationAdministrations and other medication resources, the date of interest was the the 'date of medication use', not the 'date of assertion'. So MedicationStatement's search date should be based on effective.
    • 2 - This would be an opportunity to align the names of MedicationAdministration.effectiveTime[x] and MedicationStatement.effective[x].
    • 3 - The information that can be held by the combined data elements effectiveDateTime and effectivePeriod can also be held by two different data elements date and duration. That design would give a common date data element for searching without adding an extra data element just for searching.
    • Discussed 11/21 call, a common search parameters across resources.

 Action: John to ask Grahame (or someone on FMG) to join our call to discuss this with us.

• November 21, 2016:
  • rename MedicationAdministration.effectiveTime[x] to MedicationAdministration.effective[x]
    • Motion to make this change for both MedicationAdmin to effective[x] - Motion: John, Second: Marla 5:0:0

TR#12237 - make dispenseRequest it's own resource

• Presentation from the NL - Arianne van de Wetering
  • Requirements must support
    • multiple providers in chain of care
    • distributed data storage
    • can not update each other's data
    • Medication safety enforced by:
      • prescriber
      • pharmacist
    • Clinical Building Blocks
      • Prescribe
        • Administration Request - therapy
          • Prescriber and patient agree on patient to be taken
        • Dispense Request- Logistic
      • Dispense
        • Pharmaceutical Advise - Therapy
          • updated information and more concrete
        • Dispense- Logistics
      • Administration
      • Medication Use (Statement)
        • stock use
        • medication use
    • 1 medicationRequest can lead to multiple DispenseRequest
    • in a distributed system - hard to keep information together
    • Need an identifier to keep all records together that are related
      • "Pharmaceutical Therapy or Treatment" - the hook or id to keep everything together
        • may be the same drug but may not be
        • can only have 1 administration request valid at the same time
        • propose adding MedicationRequest for all types - including stops
    • want to have prescriber register dispense request separate to the medicationrequest
  • want to be able to query against building blocks separately - but dispense request doesn't have it's own identifier
  • Discussion of Use Cases
    • trying to only create new clinical data when something has changed
    • initial thought is that DispenseRequest should not be separated from MedicationRequest - believe can use existing resources

Action:  NL to share presentation
Action:  Pharmacy WG will review, discuss and respond
Action:  NL to look at updated resources based on workflow harmonization
Action:  Melva to followup with Arianne - complete

TR#12011 - MedicationStatement - entered in error status

• concern about the use of the status - of the record and the use of the medication
  • entered in error - is about the record itself
  • perhaps needs a second status to separate out the use of the medication from the record itself - recordStatus vs medicationUseStatus
  • there could be some additional statuses for the record - under review; suspicious
  • historical context - carried over from V3 models
  • PatientCare has split their statuses - clinical status vs verification status - on allergy and conditions
  • need to raise this up to FHIR Infrastructure - to see if there is a pattern that should be used across resources
  • consider updating our definition of the concept for status.
  • Motion: Persuasive with Mod - Update the definition of the status for all resources for what entered in error means - John/Tom - 5-0-0 Carried

Action:  need to create a new tracker item

TR#12175 - special authorization for ordering a drug

Action: reach out to Vince to get more information - concrete examples

TR#10478

• Need to update value set to add morning, afternoon, night or change to extensible

Action:  Talk to Lloyd about what it would take to change to extensible -

TR#12201 - option for days on timing

• Need to update value set to add morning, afternoon, night or change to extensible

Action:  Talk to Lloyd about what it would take to change to extensible -

TR#12347 - Adjust Medication.package.container value set to SNOMED CT Physical object hierarchy

TR#12347

Action: Melva to followup with tracker item author to ask which valueset she is proposing to use for container - complete

FHIR Workflow Meetings Status

• no further meetings until December, 2016

FHIR Maturity

• Current Maturity status
  • spreadsheet has been submitted - MedicationOrder, MedicationStatement and Medication - MM2
  • review of MedicationStatement Maturity
  • no further need for the resources to get them to MM2
• Update on MedicationDispense implementations

Order Service Catalogue PSS

• Update on project meetings

Next meeting

• Monday, November 28, 2016
  • Continue discussion on harmonization of status across resources.