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May 2014 WGM Phoenix: May 4 to May 9

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Phoenix WGM - May 2014 Patient Care WG Meeting draft agenda:





Phoenix WGM - May 2004. Patient Care WG Meeting Meeting Minutes


Patient Care WGM, Monday, May 5, 2014


Patient Care Monday Q1

Present:

• Stephen Chu (chair)

• Michael Tan ( Scribe)

• Elaine Ayres

• William Goossen

• Iona Thraen

• Christina Knotts

• Cathy Rice

• Jay Lyle

• Russel Leftwich

• Kevin Coonan


Minutes:


Agenda:

• Approval of minutes of San Antonio

• Agenda for the week - Phoenix WGM

• Review PCWG 3 year plan

• Any other business


Minutes of San Antonio:

• San Antonio WGM draft minutes available on Patient Care WG wiki within 48 hours post WGM

• There were no discussions.

• Elaine moved to approve the minutes, Russ second.

• Vote: 8 approved, 0 abstain, 0 agains.

• San Antonio WGM minutes approved as official record of the WGM


Agenda for the week:

• Need some time for new proposals:

New FHIR Clinical Document PSS discussion

• The agenda reviewed and spreadsheet is updated with scribe/ chair.

• Their is an interest for a joint project but Anesthesia does not have the bandwidth to carry out the work and relies on PCWG to do the work. Issue is whether we should carry on.

Need to discuss with Anesthesia WG re whether PCWG needs to dedicate a quarter for joint meeting

• Arrangement had been made for Tuesday lunch quarter meeting with FHIR

Agenda - to discuss clinical inputs to FHIR resources development and review
Need enough resources for the joint lunch with FHIR ( Hopi).

• Need to replan the September WGM with CQI.


3 year work plan:

o PCWG did not get their gold award, because we did not submit the ballot for Allergies.

o The project list has been cleaned up.

 New PSS for Allergy terminology will be submitted. This is a joint with IHTSDO.

 A new PSS for Care Plan Clinical Models will be submitted.

 The remaining projects were reviewed. Project 927 and 668 are about Vital Signs, but the material on the projects could not be found. It did not go into the DESD. 668 did have a RMIM that according to William could still be used.

 881 on the allergies is informative. Does a DAM go into normative? It has already been published.

 The project list is a list of active projects.

 Motion to remove projects 881 and 745:

Elaine moved the motion, second by William.
Vote: 8 approve, 0 abstain, 0 against

 Also 664 ( assesment scales) to be removed.

 661 (DAM Medical Device). A lot of good work has been done, but Sigoureay is no longer active and the VA is not sponsoring the project anymore. This was balloted in 661, but the ballot spreadsheet could not be found. William wants to keep this on the list, and will look for the ballot material in january 2015. (after September).

 320 is about DCM and this needs to be reballoted. This is not worth while.

 Elaines moves to close project 664 and 320. Second by William:

Vote: 8 approve, 0 abstain, 0 against.

 Question whether a PSS should be set up for FHIR profiles for extensions. The FHIR resource will only cover 80% of the use cases. The 20% would fall into extensions, that would have to worked out in these profiles. This will be deferred.


Patient Care Monday Q2

PCWG hosting CQI with representative from Clinical Genomics


Present:

Stephen Chu – Chair

Elaine Ayres – Scribe

Michael Tan

Enrique Menses

Patty Craig

Christina Knotts

Thomson Kuhn

Floyd Eisenberg

Rosemary Kennedy

Mollie Cullere

Kimberly Smuk

Kendra Hanley

Ken Rubin

Stan Rankins

Christopher Millet

Walter Suarez

Crystal Kallem

Russell Leftwich

Marc Hadley

Kanwarpreet Sethi

Evelyn Gallego

Best West

Kevin Coonan



Minutes:


Goal of Meeting: Look at CQI projects related to clinical outcomes. PC interested on how PC artifacts can support CQI initiatives.

CQI group presenting current project/measures as well as proposed new measures.

1. VTE-4 (Venous Thromboembolism) – relates to the Care Plan. Are there specific discharged instructions in the care plan and were they followed? QADM/QRDA not yet fully supporting. Need to know where the Care Plan instructions are captured, as well as how they are conveyed. Finding some plans are created by conditions. Instructions may span a variety of orders.

- QDM/HQMF representation, vs the QRDA – still not harmonized.
- Family history elements /genomics – looked at the family pedigree model vs. the family history in the Care Plan DAM.
- Looking at the Care Plan DAM vs. the CDA Care Plan – aligned at this point.
  • The Care Plan – identifies a health concern with resulting goals and monitoring.
  • The issue of an order is not addressed in the Care Plan DAM – that depends on the implementation, such as through Physician or Nurse order entry applications
- An order however may be captured as the instructions to the patient, but the order execution and completion is not.
  • Did the individual receive the instructions, vs. the outcomes of having received the intructions.
- To meet the goals in the care plan – results reside in the EHR.
  • Patient Care (Russ) displayed the Care Plan model overview slide. Note active problems with risks and concerns, goals and interventions/actions.


CarePlanProcesses.jpg


  • As a care plan is updated, how do you ensure that a quality measure is updated appropriately. Must consider both quality measures as well as CDS.
  • With a goal – did you meet the goal?
  • CMS will be looking for specific elements, and changing care planning may create a misalignment (e.g. dynamic care plans).

2. Measure Gaps Care Coordination

a. Where might measurements be done that don’t currently exist? A recent call for new measures did not result in any new measures.
b. Example – transfer a care plan to the next venue of care, is there a roster (list) of care team members and family members, are care barriers captured in the care plan, are interventions linked to each goal, is there progress towards the goal, is acceptance of the goals by the patient captured, has the care plan been sent to the patient/family or electronic access, is the care plan sent to active care team members in other organizations.
- Note that there is the Care Plan DAM as well as the Care Plan Services (CCS) and the C-CDA Care Plan document.
  • Enrique presented the Care Plan RMIM. Each care plan entry has actors, activities (orders, interventions, instructions, education for example), care barriers, risk (more health risk), patient preferences, goal review and plan review. These all fit into the health concern pattern.
  • Examples of barriers – functional limitation, language, financial.
  • Risks – can also be dynamically represented.
  • There is no specific follow-up for assessment progress toward goals in the care plan model. In the care plan there is a plan review (in total) and goal review and milestones. Is that sufficient to meet that requirement?
  • There is no “order” to do the follow-up, but there is a review step. Can also plan the next review. Currently there are no functional requirements but the next review is specified with day/time. Can also distinguish a planned review vs. a completed review.
  • Have not stipulated who might review the care plan. There is also an acceptance review (by the patient) and the outcomes review.
  • Chicago WG meeting – September – Wednesday Q2 offered as an alternative. Confirmed that day and quarter for the upcoming WG meeting.



Patient Care Monday Lunch Quarter


Allergy/Intolerance and Adverse Reaction Project: Terminology project meeting


Present:



Minutes:




Patient Care Monday Q3

Present:

• Stephen Chu (chair)

• Michael Tan ( Scribe)

• Elaine Ayres

• Iona Thraen

• Evely Gallego

• Farrah Darbouze

• Angelique Cortez

• Katherine Duteau

• Jim McClay

• Laura Heermann

• Christina Knotts

• Russel Leftwich

• Kevin Coonan


Minutes:


Topic of the session is on Health Concerns:

• the last model was constructed after the conference call of 17th April. Stephen explains the mind map. This has been agreed but Michael has problem with word event. Event implies a one time happening, while a concern could be chronic. This word was suggested by Larry.

• Iona questions about genetics related concerns. These genetics risc which will be put in family history. It is not the concern itself. Suggest to put it in the model, because this topic is a hot topic. The bucket for risks is bottomless. The picture will be adapted with dots.

• Suggestion from Kevin to tease the risks out and risk observation. This suggestion was not supported.

• The health concern event is the activity to document the health concern.

• Evelyn asks how health concern relates to problem list? A health concern has a technical and a clinical concept. The clinical concept has been defined in San Antonio in the wiki.

• A problem list is a contextual dependent translation of the health concern.

• Some discussion arises about the difference of health concern from care plan and from health concern.

• Are health concern and health concern event 2 separate classes? According to Laura this is where the exacerbation comes in.

• Suggestion from Laura to readdress the picture so that the focus is not so much on the event, but more on the health concern itself or put the health concern as a title.

• It has been decided to replace the word "trigger with the word "contains". Action Stephen.

- Action completed. Revised "Health Concern" conceptual model uploaded to Health Concern project wikil

• Kevin volunteers to make the logical models. This should be UML diagrams.

• Kevin brings in a motion to make a DAM with only mind maps instead of UML's.

• Iona places a friendly amendment to do both ( Mindmap and UML). Elaine seconds the amended motion:

- Vote : 1 abstain,1 against, 10 approve.


Patient Care Monday Q4

Present:

Stephen Chu (Chair + Scribe)

Laura Heermann Langford

Enrique Meneses

Iona Thraen

Michael Tan

Christina Knotts

Evelyn Gallego

Kevin Coonan


Minutes:


Care Plan DAM Project update and ballot reconciliation meeting

  • Stephen provided an update of Care Plan DAM second informative ballot package development leading to May 2014 ballot package submission.
  • Overview of ballot statistics:
54 (affirmative) 7 (negative) 56 (abstain) 24 (no vote)
Quorum: 82.98%
  • Overview of ballot spreadsheet was done
  • Ballot comment disposition began
details - see disposition decision and comments in aggregated spreadsheet



Patient Care Monday Q5:


Patient Care co-chairs attended co-chairs dinner meeting and DESD meeting


No PCWG specific meeting held for Monday Q5


Patient Care WGM, Tuesday, May 6, 2014


Patient Care Tuesday Q1


Care Plan DAM ballot reconciliation - total comments: approx 100.

Present:

Laura Heermann-Langford – Chair

Elaine Ayres – Scribe

Enrique Menses

Iona Threan

Kevin Coonan

Lenel James

Russ Leftwich



Minutes:


  • Lines #5 – remove author names – Persuasive
  • Line #6 – wording is excessive re payors and care planning. Rewrite to be more consistent with other storyboards. – Persuasive with mmod.
  • Line #7, 8, 9- Storyboards with actors – actor names are too long and confusing in the text. Persuasive with mod – will make shorter actor names. Laura will submit names to names registry.
  • Line #10 – Description of Health Plan Disease Management Nurse Care Manager Encounter – a complex use case with multiple actors, care crossing state lines, roles between payors and providers. Note that this is a universal document, not US realm only. Note that Figure 5 – Organizing Framework for Coordination of Care Interaction Models notes that Business Role or Policy is out of scope… comments are persuasive with mod. Simplify the use case, making it more clear who is doing what when. Look at diagramming the the CaseMan/DiseaseMan case using the diagram in the CCS ballot document.
  • Line #11 Encounter G – missing content. Comment is persuasive to add missing content.
  • Line #12 – Appendix of the storyboard – landed in the middle of the document on page 56. If the drug content is in the text, the appendix can be removed.
  • Line #13 – Appendix issue – determine if even needed. Persuasive with mod.
- VOTE on Block – Move to block vote: Motion: Lenel Abstain – O, Object – 0, Approve – 6


  • Line #63 - Line 1605- 1610 – Comment re inclusion of author who is not an HL7 member. Will remove non-member care. Persuasive with mod.
  • Line #64 – not best care practice. Persuasive with mod to rewrite.
- VOTE on Block – Move to block vote: Motion: Lenel Abstain – O, Object – 0, Approve – 6


  • Line #65 – insufficient info to describe condition – Persuasive with mod. Will add additional information. Note that a CDA can be used to share information, but not the only means for sharing. Discussion of Note # 3 - line 1660 (Page 46) – discussion of the various types of technology to drive information exchange. Continue to discuss this issue.
  • There are several more comments related to Storyboard 8.



Patient Care Tuesday Q2


Patient Care hosting Anaethesiology


Present:

Elaine Ayers (Chair)

John Walsh

Terri Monk

Russell Leftwich

William Goossen

Andrew Norton

Martin Hurrell

Farrah Darbouze

Michael Tan

Stephen Chu


Minutes:


  • History
- Detailed Clinical Model – started at Intermountain Healthcare with Clinical Element Models (5000). IHC do not have a binding to Loinc or Snomed, experts in clinical modeling in Brisbane came together in Hl7, problem with Computational explosion (2005-2007). Find different way of representing in HL7 without breaking HL7 messaging. Implementation issues associated with implementation.
- Can we have a registry to manage risk? What about patient safety issues? ISO would start on a standard for DCM using top ten, ie vitals, Bartel, Braden, Apgar scores. HL7 created a project #320.
- HL7 has asked to have work reballotted – where does the work need to be done – CDA, FHIR, SDC, S & I Clinical element repository. Recognition that clinical data element need to be standardized.
- NLM has protype that is being tested using CDE for clinical research and Patient Safety with AHRQ.
- The CDE repository approach using a federated approach, SDC would define syntact of the data elements, CMS would publish the algorithm of how the elements come together. All the CDE are using the same structure, would set up federated approach for finding a common data element. S & I defining the syntact of CDE. If sending out must map to the S & I structure for orders and observations.
- Need common ontology to form foundation. Least imperfect approach. Need name, definition, data type, expression, The axis of the domains should follow the ontology.
- ONC – is developing a registry for clinical research and patient safety reporting. Multiple driving factors fir DCM. CSRA – Cancer Registry for US as a beginning state. Multiple terminologies CADSR


  • Collaboration and joint work
- Done work to define subset of SNOMED terms need coding, Modeling anesthesia record. Need to take abstract model and translate into CDA. Some of the modeling may actually be a DCM that would need review.
- Need UML representation of DCM – BP as example. Need to specify the complexities associated with with the measure.
- HL7 and ISO spec matches 99% except for unclarities from clinical vs implementation. What is the methodology – collection use cases, start there, go to literature, basic text books, clinical common sense and knowledge behind it.
- Use cases exist. Take original work and update or take ISO work. Unless William takes on work Patient Care work group doesn’t have band width. HL7 wants heart rate re-balloted. Heart rate expression in FHIR into UML, XML, FHIR, etc
- Need generic information model which is expressed differently by individual technically. Every data element gets own UML class.
- Anesthesiology would provide a piece of what we are doing, could you look at it to see how DCM would look at it and give feedback –
- Need a project scope document with Anesthesiology as lead, and then submitted to Patient Care Plan Work group. Would allow William to function as content expert. ONC is part of source material and other repositories. Use ISO format to represent it as DCM (ISO TS 13792)
- Outcome of UML into XML – several examples with some proper XML missing for CDA or HL7 messaging.
- Example, ie catheter as device, insertion point, where headed, prep before, etc. ending in a very complex model. Properties become quite complex. Part of it is covered by health concerns and allergies but should not be mixed. Start with basics and then build model with components. Template initiative are bounded pretty simply, there are subtleties concerning their relationships in a dynamic manner.
- User community of this work would be? Particular vendor would reflect the proprietary ownership. No standard agreement on what should be considered. Each site does own thing.
- Are there common elements that can be exchanged across entities, significant adverse events, allergic reacdtions, need to look at the depth, continuity of care for patient care, quality of care,.
- The CDA project provides the structure – adding layers
- Examples of composition, APGAR and time, Development of birth development, Anethesiology does not know how it can be used until it is accessible.
  • What are the next step:
- Formalized Project Scope Statement or reuse Anesthesiology for this purpose. Already included but is old and needs refreshing. Matters discussed are already in scope as discussed. Update, discuss and get ready for ballot by Jan 2015.
- Is there a prioritized shopping list for dcms? have candidates and can rapidly prioritized. Current target is produce CDA implementation guide. Tried and tested methodologies could accelerate process by using an example.


  • Methods
- Start with DAM, creates story board, conceptual model and then logical model then put out for two cycles, then map logic model to CCD. Or start with subject matter expertise and then extract a use case from the knowledge as a way of demonstrating that the issues have been well considered. Need to determine if the use case has not broken the model.
- There is not a need for a DAM for vitals, can pull them in without doing a full process two DCMs are ready, only need an excuse to translate them. Data element from the various repositories needs to be brought in.
- Anesthesiology will talk about this in their next meeting and get back to Patient Care Work Group.
- How will DCM will be included in the CDA implementation.
- Please communicate with chairs.


  • William and co-chair will go to Anesthesiology. Joint meeting (Tuesday Q2) in Chicago will be cancelled.


  • Slide deck presented at this meeting:



Patient Care Tuesday Lunch Quarter

FHIR: Clinical engagement/inputs into FHIR resources development processes and Clinical connectathon

Present:

Stephen Chu (Chair)

Elaine Ayres (Scribe)

Laura Heermann-Langford

Michael Tan

Russell Leftwich

Jim McClay

Margaret Dittloff

Sandra Marr

Cathy Walsh

Lindsey Hoggle

Kevin Coonan

Lloyd McKenzie

Graham Grieve

David Rowed



Minutes:


  • Patient Care Core Resources
- Should enable best practices Need to support a wide range of implementations.
- Can ballot profiles as part of the FHIR specification.
- Have the same type of approach to value sets.
- What should be in the core – vs as an extension or a profile.


  • Question on clinical inputs
- With existing vendors – you do things because people buy them. Vs. best practice.
- So, is there core clinical content, that should drive resources. What is current clinical practice?
- Clinician input – what functionality will help be practice medicine better…
- FHIR is a platform where you can add new content without breaking the current process. In the CDA spec new info cannot be communicated. With FHIR can add new content (may not be recognized by a receiver…) but it can be sent.
- To move narrative text only, not an issue. For more function need more structure.
- Model driven work vs. FHIR model
- Problem/diagnosis vs. condition.


  • Clinical Connectathon – the technical specs are set, but need a review by the clinical community. Would allow users to access data, input and exchange. What is the representation of the data by various clinicians.
- Use two or three clinical scenarios. Clinicians will enter clinical records, then compare the outcomes of entry. Look at transitions of care.
- Stephen will organize the collection of use cases that will test processes. (Stephen has sent out an invitation email and will start the organisation process)
- Will need a size and scope of the connectathon. Have a general scenario and an ED scenario, with an ancillary case.
- Question – test the questionnaire resource.



Patient Care Tuesday Q3

Present:



Minutes:




Patient Care Tuesday Q4

Present:



Minutes:



Patient Care WGM, Wednesday, May 7, 2014


Patient Care Wednesday Q1

Present:


Minutes:



Patient Care Wednesday Q2


PCWG representatives to present updates to EHRWG

Present:

Stephen Chu

Laura Heermann Langford



Minutes:


Contents/details of PCWG updates - see the following slide deck:





Patient Care Wednesday Q3

Present:



Minutes:




Patient Care Wednesday Q4

Present:



Minutes:




Patient Care WGM, Thursday, May 8, 2014


Patient Care Thursday Q1

Present:


Minutes:



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

Present:


Minutes:



Patient Care Thursday Lunch meeting: PCWG and SWDG co-chairs

Present:



Minutes:




Patient Care Thursday Q3

Present:



Minutes:




Patient Care Thursday Q4

Present:



Minutes:




Patient Care WGM, Friday, May 9, 2014


Patient Care Friday Q0: PCWG Co-Chairs meeting

Present:


Minutes:




Patient Care Friday Q1

Present:


Minutes:



Patient Care Friday Q2

Present:


Minutes:



Patient Care Friday Q3

Present:



Minutes:




Patient Care Friday Q4

Present:



Minutes:



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