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Clinical Quality Information WGM May 2018, Cologne, Germany - Minutes

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D R A F T - T E M P L A T E for CQI WGM Minutes - Cologne Germany - May 2018

Attendance - DRAFT ATTENDANCE LOG for the full week May 14-18, 2018

CQI May 2018 Workgroup Meeting Attendance

Attendee Attendee's Organization Attendee's email Mon
14 May Q2
Mon
14 May Q3
Mon
14 May Q4
Tue
15 May Q1
Tue
15 May Q2
Tue
15 May Q3
Tue
15 May Q4
Wed
16 May Q1
Wed
16 May Q2
Wed
16 May Q3
Wed
16 May Q4
Thu
17 May Q1
Thu
17 May Q2
Thu
17 May Q3
Thu
17 May Q4
Abdulmausk Shaker HI3 abdumalil.shaker@hi3solutions.com . . . . . . . . . . . . . . .
Abrar Salam The Joint Commission asalam@jointcommission.org . . . . . . . . . . . . . . .
Alex Liu EPIC aliu@epic.com . . . . . . . . . . . . . . .
Alex Liu EPIC aliu@epic.com . . . . . . . . . . . . . . .
Amnon Shabo (Shvo) Philips amnon.shvo@gmail.com . . . . . . . . . . . . . . .
Andrew Gordon WoltersKluwer andrew.gordon@wolterskulwer.com . . . . . . . . . . . . . . .
Andrew Simms Cognitive Medical Systems asimms@cognitivemedical.com . . . . . . . . . . . . . . .
Ann Phillips NCQA Phillips@ncqa.org . . . . . . . . . . . . . . .
Anne Marie Smith NCQA smith@ncqa.org . . . . . . . . . . . . . . .
Ben Ghahhari CMS benjamin.ghahhari@cms.hhs.gov . . . . . . . . . . . . . . .
Ben Hamlin NCQA hamlin@ncqa.org . . . . . . . . . . . . . . .
Bryn Rhodes ESAC bryn@databaseconsultinggroup.com X . . . . . . . . . . . . . .
Chana West ESAC Inc chana.west@esacinc.com . . . . . . . . . . . . . . .
Claudia Hall Mathematica chall@mathematicampr.org . . . . . . . . . . . . . . .
Dan Donahue ESAC dan.donahue@esacinc.com . . . . . . . . . . . . . . .
Floyd Eisenberg iParsimony, LLC FEisenberg@iParsimony.com X . . . . . . . . . . . . . .
Gay Dolin IMO gdolin@imoonline.com . . . . . . . . . . . . . . .
Hafsa Subhan The Joint Commission hsubhan@jointcommission.org . . . . . . . . . . . . . . .
iIkka Kunnamo . jilkkakunnamo@duodecim.fl . . . . . . . . . . . . . . .
Jamie Lehner PCPI jamie.lehner@thepcpi.org . . . . . . . . . . . . . . .
Jenny Brush ESAC jennifer.brush@esacinc.com . . . . . . . . . . . . . . .
Joe Quinn Optum joseph.quinn@optum.com . . . . . . . . . . . . . . .
Juliet Rubini Mathematica jrubini@mathematicampr.com . . . . . . . . . . . . . . .
Kanwarpreet Sethi Lantana Consulting Group kp.sethi@lantanagroup.com . . . . . . . . . . . . . . .
Kathleen Connor . kathleen_connor@comcast.net . . . . . . . . . . . . . . .
Linda Michaelsen Optum linda.michaelsen@optum.com . . . . . . . . . . . . . . .
Lisa Anderson The Joint Commission landerson@jointcommission.org X . . . . . . . . . . . . . .
Lorraine Constable . lorraine@constable.ca . . . . . . . . . . . . . . .
Matthew Tiller ESAC matthew.tiller@esacinc.com . . . . . . . . . . . . . . .
Mitra Biglari The Joint Commission mbiglari@jointcommission.org . . . . . . . . . . . . . . .
Pamela Mahan-Rudolph Memorial Hermann pamela.mahanrudolph@memorialhermann . . . . . . . . . . . . . . .
Patty Craig The Joint Commission pcraig@jointcommission.org X . . . . . . . . . . . . . .
Paul Denning MITRE pauld@mitre.org . . . . . . . . . . . . . . .
Ping Jiang The Joint Commission pjiang@jointcommission.org . . . . . . . . . . . . . . .
Robert Dieterle Enable Care rdieterle@enablecare.us . . . . . . . . . . . . . . .
Robert Samples ESAC Inc robert.samples@esacinc.com . . . . . . . . . . . . . . .
Stan Rankins Telligen SRankins@telligen.com . . . . . . . . . . . . . . .
Sue Kent CCF kents@ccf.org . . . . . . . . . . . . . . .
Sweta Ladwa ESAC inc sweta.ladwa@esacinc.com . . . . . . . . . . . . . . .
Thomson Kuhn ACP tkuhn@acponline.org . . . . . . . . . . . . . . .
Walter Suarez Kaiser walter.g.suarez@kp.org X . . . . . . . . . . . . . .
Yan Heras Optimum Health yanheras@gmail.com . . . . . . . . . . . . . . .
Yanyan Hu The Joint Commission yhu@jointcommission.org . . . . . . . . . . . . . . .
Zach May ESAC Inc zachary.may@esacinc.com . . . . . . . . . . . . . . .

Monday, May 14, 2018 CQI WGM Minutes

Q1

  • No Meeting - HL7 Plenary Session

Q2

  • Agenda Topics
    • CQI Business Meeting
  • Chair - Walter Suarez; Scribe - Floyd Eisenberg
  • Discussion:
    • Walter reviewed the scope of CQI WG
    • Bryn volunteered to act as interim co-chair to support meetings through the week
      • Floyd moved to appoint Bryn Rhodes, Patty seconded, Vote - 10 approve, 0 abstain, 0 opposed
    • Walter reviewed the agenda for the week - Floyd updated the agenda as we discussed during the call
    • Floyd reviewed the new steering committee structure



Q3

  • Orders and Observations (OO) hosting CQI
  • Agenda Topics
    • Use of Observation Resources - Design Patterns
    • Order Set and Plan Definitions
    • Catalog resource definitions
  • Chairs: Lorraine - See OO agenda for attendance

Discussion

  • Alerting and Alarms
  • Order Catalogue
  • FHIR Tracker items
    • FHIR Tracker Items
    • 15942 – NutritionOrder – consistent modeling of .status Vs .intent with the rest of FHIR – modeling inconsistent with other FHIR resource modeling. Loraine was able to find the modeling now does include the intent metadata element in the STU 4 ballot. It has been harmonized.
      • Withdrawn by commenter
    • 15943 – NutritionOrder – NutritionOrder modeling - differences with ServiceRequest, MedicationRequest . The use case is the ability or order a specific dietary item. Nutrition order is modeled as the ability to order enteral diet, a nutritional supplement, a parenteral diet, etc. (E.g., oral diet - with types that include multiple diet type) - The NutritionOrder is a work in progress - needs to address a specific nutrient. The idea is to describe a nutrient modifier but the question is how to address "notDoneReason" and also to define a specific nutrient at the exclusion of all others.
      • There is always one diet for a patient active at any time, but supplements are different and might be addressed later on. See tracker item: 17164
      • Motion to break into 3 tracker items to follow and resolve each independently: Create tracker to harmonize the NutritionOrder to match the Request Pattern and handle NotDoneReason - see tracker item: 17166
      • Discuss how to handle boundaries and modeling when adding a supplement to an existing diet - do you entirely replace, or add? See tracker item: 17167
      • Motion by Ken McCaslin, second by Floyd Eisenberg - 26 approved, 0 opposed, 3 abstain
    • 15945 – SupplyRequest modeling (general) and related to blood products (SupplyDelivery, SupplyRequest, and BiologicallyDerivedProducts). This subject is currently under development. Supply request is not the correct resource. This is on Wednesday Q3 Patient care agenda this week.
      • Motion: Rob Hausam, Second Richard Esmond: Balloters will connect with project team (see link in FHIR traker)to assure use cases are covered in that material. Vote - 29-0-0
    • Immunization - the current modeling provides documentation details about immunization administration or a forecast (immunization recommendation) but not an order - referred to Public Health workgroup for follow up.
  • Order Catalogue
    • Claude Nanjo discussed work on Order Catalogue - joined forces with Francios Macary - to define the core FHIR resource to represent the catalog for order entry. Proposal - use composition resource and introduce in a future profile a notion of a catalogue entry - to wrap an item as part of a catalog. This discussion is consistent with managing order sets. The connectathon created a catalog and sought to query for a catalog and elements. The Catalogue profile - needs to capture the business content used in the V2 catalogue for lab which is the most complex in V2. Conceptually, the FHIR resources need to capture identified, contributor, version, status publisher, copyright, title, Catalogue entry (identifier, contributor serviceProvider, orderable, version, status status Date Title, ChargeInforation, SpecimenDefinition, SpecimentToLab, Container, Handling, Lab service, ObservationSpecification, Units. Lorraine showed V2 modeling - some of the details are included in the notes here. ---- Richard Esmond suggested there is parallel with Imaging Requests - work with registries to get LOINC identifiers defined - should join with RadLAC - coordinate with II (Imaging Integration). Needs to also address Appropriate Use Criteria and CDS Hooks - to perform, needs to trace all the way along if there is a recommendation to process and order - and track if the order occurred and how it was handled. This discussion addresses the catalogue of what can be ordered.
    • Other material addresses order management - fulfillment has not been sufficiently addressed.
    • Claude showed examples of the order catalogue content.Link to Order Catalog

Q4

  • Agenda Topics
    • CQI Meeting - Planning for September
  • Chairs: Walter Suarez, Scribe: Floyd Eisenberg

Discussion:

  • Decision Making Process - due to some edits to the default DMP, the CQI WG reviewed our individual WG addendum and believes that the addendum is still required.

Floyd Eisenberg moved to re-affirm our DMP addendum, Patty Craig seconded - Vote 6-0-0

  • Planning for September
    • 30-day Medication Reconciliation PSS under consideration. Plan is to review the PSS Wednesday Q2 and consider an STU ballot for September to address an implementation guide to manage publication of data by the EHR and subscription by a data analytic engine for the data, then aggregation and analysis for reporting to a reporting agency. The STU will use 30-day med reconciliation as the example.
    • Evidence-based Medicine (EBM) on FHIR (CDS primary) - approved by CDS and CQI - current plan is to ballot for comment only in September. The project facilitator (Brian Alper) will review with Biological Regulated Research (BRR) for potential co-sponsorship (perhaps during this quarter) and then bring modified PSS to CDS and CQI on Wednesday Q2 for review and possible re-vote if needed, then submit to FHIR Management Group and Clinical Domain for approval.
    • FHIR Quality for QI Core to ballot in September (Project 1125) and PSS is up-to-date. The work requires publication of QI Core / QUICK STU 3 based on the completed ballot reconciliation from January 2018. Then we need to update to FHIR STU 4 and US FHIR Core STU 4 for the September ballot.
    • No known need for new ballots for CQL-based HQMF (CQI managed) or CQL (CDS managed) but both PSS' are current and active


Tuesday, May 15, 2018 CQI WGM Minutes

Q1

  • Agenda Topics
    • CQI Meeting

  • Chair - Floyd Eisenberg, Scribe - Walter Suarez
  • Discussion:

From the agenda, we had already completed the project planning and PSS review for September ballots, and had coordinated ballot reconciliation for the week. We focused on the following items:

  1. Floyd and Walter provided a review of the discussion and actions taken during the Steering Division meeting. This was the first meeting under the new Domain Expert structure. CQI is now part of the new Clinical Steering Division (formerly Domain Experts).
  2. CQI has received a request from Arden Syntax to consider supporting their request to move from Infrastructure SD to Clinical SD (as they seem to work closely with CDS and, in some cases with CQI. The feeling among the CQI group was that Arden Syntax seems to be much more of an Infrastructure component of HL7 work, rather than a Clinical working group. Thus, we are deciding to not get involved in the request from Arden Syntax.
  3. During the Steering Division, we were informed of the need to review and update/approve the WG Mission and Charter. We discussed and updated the Mission and Charter - last updated in 2017. Several changes were made, mainly eliminating the detail listing of projects, which seem to be more appropriately moved to our 3-year workplan. The plan is to submit the revised M&C to the CQI List, and review it with the WG during our upcoming calls, and get it completed and approved in the next few weeks, well before the September deadline.
  4. The WG discussed a new issue - how to handle of transition from ED to Inpatient status, when there is an 'observation' period in between. The question is where would that be captured in the current system. We understand that in FHIR this will be addressed. We will do some research and find out with some other people think, and come back to this issue during one of our calls.
  5. We reviewed our next meetings.



Q2

  • CQI hosts CDS and FHIR
  • Agenda Topics
    • CDS Hooks 1.0 ballot reconciliation
    • FHIR Clinical Reasoning ballot reconciliation
  • Chair - Floyd Eisenberg; Scribe - Walter Suarez
  • Discussion:
  1. CDS Hooks 1.0 Ballot Reconciliation:
    • Main topics: Negative comments about security; comment about analytics; comment about response
    • Item 106: "prefetch" - recommend specifying that prefetch should only include data allowed within scopes. Discussion: Proposal is that this is not persuasive; in the document it is described

Moved as Not Persuasive: Josh; second: Bryn; 23 for; 3 abstentions; 0 oppose

    • Item 120: Current SMART scope specification seems too broad to meet HIPAA for minimum necessary. Discussion: this will be brought up to the larger overarching FHIR group to discuss implications of HIPAA.

Moved as Persuasive with Mod. moved by Ken; second by Bryn; 25; 0 against; 1 abstain

    • Item 150: Issue is that "Client_id" is included in the document, but no reference or description is given. Discussion: in the Jason Web Token (JWT) there is a field "sub" described as "Client_id of the EHR". However, nowhere there is an explanation of what Client_ID is. Our interpretation is that this is the OAuth2.0 identified. However, it is not described anywhere. Recommendation: Persuasive with Mod; recommending to remove the Client_id. We acknowledge that by removing it we would be not in compliance with JWT Profile for OAuth Authentication.

Moved as Persuasive with Mod; by Kevin; second by Josh. 26; 0; 0.

    • Item 115: Issue is about Analytic Endpoint. In general, this feature has not been widely implemented. Comment is that the Analytics Endpoint instead of being and endpoint, should be describe more generically. It should be provided as a part of service metadata. The CDS service should advertise the URL so the EHR knows where to go. Discussion: We recommend Persuasive with Mod, and should remove what little there is on Analytics from the specification, and focus on producing a stronger specification that allows more advanced use cases, and do a testing during an upcoming connectathon.

Moved as Persuasive with Mod by Isaac; second by Bryn. 26; 0; 0.

    • Item 127: Issue is about the CDS services respond to the EHR. CDS response can contain a suggestion. FHIR Clinical Reasoning has a new resource called Detectedissue. So Cards should also support this resource. Discussion: We like the generic notion of allowing Detectedissue to be included as a "suggestion" even though it is not an order. Recommend Persuasive with Mod; the desired functionality is persuasive and this is something we will consider for future use, including exploring other FHIR resources (in addition to the proposed Detectedissue), other card types, other interaction methods, etc.

Moved Bryn; second Isaac; 25; 0; 1

    • Item 134: On the CDS response there can be many cards. There is information about how to prioritize the cards (Info, Warning, Hard Stop). This value set is mixing urgency indicators with user experience. Discussion: we recommend that Info and Warning be considered common priorities; and rename Hard Stop to 'critical' priority. Recommendation: Persuasive with Mod. Rename Hard Stop to Critical.

Moved Josh; second Bryn; 25; 0; 0

    • Item 26: About Prefetch Token. When a CDS service defines a prefeth, the way to represent that is with various elements, including patient ID. It uses certain characters in the string, like french brackets. This is a prefetch token. They must exist at the context level/root level of the entire element. Comment is why the prefetch token must be limited to the content element? Spec is not clear that the prefetch token is limited to the content element. Discussion: The prefetch token must be limited to the content element, except when is referring to a user in context. So, if we move user to in context that would address the issue. Recommendation: Persuasive with Mod. Move the CDS Service request "User" field to the Hook Context and document that each hook author shall include the "user" field to the hook contect field if it is appropriate to the hook. We acknowledge this breaking change but feel now is the time to do this. In doing this, we will address the ballot comment (by clarifying that prefetch templates relat to context parameters) and possibly allow for non-user initiated CDS hooks calls.

Moved Josh; second Bryn; Discussion: As we define new hooks, remind people that they have to put it there. All hooks need it. All have user in context. We can add language that the document specify that this is needed. Modification was done and accepted to add that document in the spec that each hook author shall include the "user" field. Vote: 24; 0; 0


Q3

  • CDS hosts CQI and FHIR
  • Agenda Topics
    • Use of Observation Resources - Design Patterns
    • Order Set and Plan Definitions
    • Catalog resource definitions
  • Chairs: See CDS Minutes
  • Discussion



Q4

  • Agenda Topics
    • CQI Meeting - CQL-based HQMF Ballot Reconciliation (tentative)
  • Chairs: Interim Chair, Scribe: Floyd Eisenberg
  • Discussion:



Wednesday, May 16, 2018 CQI WGM Minutes

Q1

    • CQI Hosts CIMI and CDS
    • Agenda Topics
      • Agenda Topics (Tentative)
      • Presentation from European clinical sites regarding current activities and needs for standards for CDS and measurement
      • CDS KNART Project review (15 minutes)
      • CDS Hooks 1.0 Ballot reconciliation
      • Intermountain Discussion RE: Pulmonary Embolus CDS content/logic
      • QI Core content review with CIMI and future direction

    • Chair - Floyd Eisenberg, Scribe - Walter Suarez
    • Discussion:




Q2

    • CQI hosts CDS
    • Agenda Topics (proposed):
      • (CQL ballot reconciliation)
      • Proposal for Evidence-based Medicine (EBM) on FHIR
      • Presentation from European clinical sites regarding current activities and needs for standards for CDS and measurement
    • Chair - Walter Suarez; Scribe - Floyd Eisenberg; Scribe
    • Discussion:



Q3

  • CDS hosts CQI
  • Agenda Topics
    • FHIR Clinical Reasoning module review
    • CQL-based HQMF Ballot Reconciliation
  • Chairs: See CDS Minutes
  • Discussion



Q4

  • CDS hosts CQI and CIMI
  • Agenda Topics
    • QI Core content review with CIMI and future direction
    • CIMI for Quality
  • Chairs: See CDS Minutes
  • Discussion:



Thursday, May 17, 2018 CQI WGM Minutes

Q1

  • No Planned Meeting - Notes from PC meeting
  • Agenda Topics
  • Chair - n/a, Scribe - n/a
  • Discussion: