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=== Patient Care Friday Q0: PCWG Co-Chairs meeting ===
'''NOTE''': co-chairs to determine whether this will be moved to Thursday Q-Lunch
=== Patient Care Friday Q1 ===
=== Patient Care Friday Q1 ===

Revision as of 12:30, 24 May 2016

Montreal (Quebec) Canada, WGM - May 2016 Patient Care WG Meeting Approved agenda:

Montreal WGM - May 2016. Patient Care WG Meeting Meeting Minutes

  • Sunday, May 8 - International Council Meeting
- No PCWG meeting

Patient Care WGM, Monday, May 9, 2016

Monday Q1

Chair: Jay Lyle
Scribe: Michelle Miller


  • Ayres,Elaine (NIH/Clinical Center)
  • Campbell,Keith (U.S. Department of Veterans Affairs)
  • Duteau,Katherine (DDI)
  • Jones,Emma (Allscripts)
  • Leftwich,Russ (InterSystems)
  • Lyle,Jay (Ockham Information Services LLC)
  • Miller,Michelle (Cerner Corporation)
  • Newman,Shu-Fang (University Of Washington Medical Center)
  • Nguyen,Viet (Lockheed Martin, Health and Life Sciences)
  • Owens,M'Lynda (Cognosante, LLC)
  • Parker,David (Defined IT, Inc.)
  • Popat,Amit (Epic)
  • Pyke,David (Ready Computing)
  • Rehwoldt,Greg (Utah)
  • Spielman,Matthew (InterSystems)
  • Tan,Michael (NICTIZ Nat.ICT.Inst.Healthc.Netherlands)


  • Reviewed FHIR announcements
    • Timeline
      • Thurs, May 12 - Q3
      • Wed, June 1
        • All resource and IG proposals for STU3 have been completed, reviewed by WG and submitted
        • Connectathon tracks for Sept have been proposed
        • Feedback on gForge submitted to FMG
      • Sun, July 17 - Substantive content freeze for ballot -- core resources
      • Sun, July 24 - Total content freeze, start of QA
      • Wed, Aug 10 (midnight) - All QA changes applied
      • Fri, Aug 12 - FHIR ballot opens
      • Fri, Sept 12 - FHIR ballot closes
      • Fri, Sept 16 - FHIR triage complete and ballot content loaded to gForge (or alternate)
      • Sept 17-23 - Baltimore WGM
      • Sun, Dec 11
        • Reconciliation complete/substantive changes applied?
        • Just over 10 weeks
        • Will re-evaluate at Baltimore based on volume of ballot comments
      • Dec 31 - Publish
    • FMM level survey
      • One input, but could have other considerations
      • Take into account volume of responses
      • Prioritized resources -- top 20 -- goal is at least level 3
        • Patient
        • Observation
        • Practitioner
        • Medication
        • Condition -- owned by Patient Care WG
        • Allergy -- owned by Patient Care WG
        • Org
        • Encounter
        • MedOrder
        • DiagReport
        • Immunization
        • MedStatement
        • DiagOrder
        • MedAdmin
        • Bundle
        • MedDispense
        • CarePlan -- owned by Patient Care WG
        • Procedure -- owned by Patient Care WG
        • Conformance
        • Person
  • Work group health
    • Mission and Charter updated
      • Motion: Michael/Amit Abstain - 0, Negative - 0, Approve - 10
    • SWOT needs updated
      • Motion: Amit/Katherine Abstain - 0, Negative - 0, Approve - 10
  • FMM Level Goals
    • Resource (current FMM level) Goal
    • AllergyIntolerance (1) 3
    • procedure (1) 3
    • Goal (1) 3
    • Careplan (1) 3
    • Condition (2) 3
    • Careteam (0) 2 or 3
    • FamilyMemberHistory (1) 2 or 3
    • QuestionnaireResponse (2) 2
    • Questionnaire (0) 2
    • ClinicalImpression (0) 1 or 2
    • ReferralRequest (1) 1
    • ProcedureRequest (1) 1
    • Linkage (0) 1
    • Flag (1) 1
    • Communication (1) 1
    • CommunicationRequest (1) 1

Monday Q2

  • Plenary Session
- No PCWG meeting

Patient Care Monday Q3


  • This session was hosted by O&O. Please refer to their minutes.


  • An order does not represent a fulfillment request. To fulfill you need to post the resource with a tag.
  • Alternative is to use an operation or message.
    • Or use a Task resource.
  • The name order will be changed to request, such as MedicationRequest.
  • The term request would also refer to referrals, procedure and appointment.
  • Lloyd has displayed a request pattern slide.
  • The attribute category represents the different states of a request.
  • The request can be nested.
  • Also the request have response resource as answer.
  • The task resource has been developed.
  • Besides that there is also and OrderSet and Protocol resource.
  • How to use transaction reversal in combination with task is not yet done.
  • Test in Connectathon where a patient with a Iphone was requested to schedule a lab-test and after confirming the plan set out to make a ask for the lab. In the end the physician was instructed by a task to look at the results.
  • Discussion on the word or versus request. Some want to word order back again, but this is discussion that has already been dealt with.
  • Need for examples of use cases. These seem to have been worked out for certain use cases.
  • Discussion whether dosage instructions should be a datatype.

Patient Care Monday Q4


  • This session was hosted by O&O. Please refer to their minutes.


  • Continuation of the FHIR workflow discussion.
  • Using the requisition-id as the grouper.
  • Tasks itself has different states. What is going on with the task? There are separate business logic internal flows ( for example checking the authority of the order requester), the state of the tasks could be on hold.
  • The relationship between sub-tasks and supertasks is not been worked out yet.
  • Has the sequencing been sorted out. No.
  • Can it be integrated with BPMN? Graham doesn’t think so. When you have a high volume process where the steps are well defined BPMN will work, but it does not work with ad-hoc flows.
  • There are recommendations on the FHIR wiki when to use each method of workflow:
    • A tag is kind of throwing it over the wall.
  • There is some resistance from some IT vendors who do not feel comfortable with the idea that orders are not actionable.
  • HL7 has the ambition to write implementation guides to give guidelines for implementations.
  • The attribute category represents something like “mood” or “stage”.


Patient Care Monday Q5: Placeholder for extra meeting if necessary



Patient Care WGM, Tuesday, May 10, 2016

Patient Care Tuesday Q1

Chair: Jay Lyle
Scribe: Emma Jones


  • Heerman-Langford,Laura (Intermountain)
  • Matney, Susan (Intermountain)
  • Maclean, Andrea (Infoway)
  • Huff, Stan(Intermountain)
  • Lyle, Lyle (Contractor)
  • Linda Bird (Intermountain)
  • Demarmels, Marco (HL7 Switzerland)
  • Ryan, Sarah (Eckhorn Int Services)
  • Zaidi, Shirin (Gevity Consulting)
  • Popit, Amit (Epic)
  • Nanjo, Claude (Cognitive)
  • Rehwoldt, Greg (Deloitte)
  • Allen, Kurt, W (Penrod)
  • Esmond, Richard (Pen Rad)
  • Newman, Shu-Fang (Univ of Washington)

On phone

  • Patrick Langford
  • Ken Kawamoto

Minutes: Agenda:

  • PSS - investigative action - looking at a project to take existing patient care concepts and represent it in CIMI
    • PSS thru DESD (response) -
      • need to review dates,
      • choice of data, artifacts (need a list),
      • draft output patterns - some are in CIMI, others may be needed,
      • draft output of the composition - how large will CIMI get? medicalPsychiatric condition will be left out for now. CIMI will need to look at conditions/findings. Aim is to have the composition ready for review Sept 2016
  • Review of scope (the below are specific to ulcers)
    • Skin assessment model
    • Braden - note made that Braden Q is proprietary and request compensation to be used (ONC is aware)
    • review example ADL
  • Need to add FHIR as next phase
  • Inheritance Map review
    • Discuss the use of evaluation Vs observation
      • observation is direct observation. Evaluation involves a thought process - per OpenAir
      • the distinction is that the thing is done on a patient vs lab things. With things done on the patient can have measured high and low values rather than normal/abnormal
      • Need to consider other types of assessment/examination that might fall under this category - e.g. blood pressure and heart rate. May need to compare that modeling. Modeling was done by CIMI.
      • SNOMED bindings came from the nursing group working on this at the time it was CAP
      • Need to take into consideration the status
      • Stan: Root level bindings and code level bindings - in the end this is what's more useful. the root level binding should be to something that captures all the semantics. The code says what the value means - name value pairs. The semantic of the whole model is defined by those things. To be consistent, the binding for the SBP will be a compositon of these things. Intermountain has made a unique ID of the model and uses it as a concept. Therefore will have the whole thing together with all it parts defined and have it's own semantic meaning.
      • Linda: agree with Stan. Will understand the meaning of the model itself and the structure which has its own hiercharchy. Separate to that is the clinical concept that is the focus o fteh information recorded. Stan agrees.
      • there are different approaches to terminology bindings.
      • Skin assessment panel with all these observations that have the various observations
      • Code binding will use LOINC for that is used now.
      • complete is static -may need to change if needed
      • More discussion as to how to model. the example observation came from the lab
    • Model binding for the value for this instance. Note made that the logical models have attributes that are fixed that will not be included in the implementation.

Patient Care Tuesday Q2


  • Michael Tan (Nictiz) - chair
  • Jay Lyle (JP Systems) - scribe
  • Russ Leftwich (InterSystems)
  • Dennis Patterson (Cerner)
  • Philip Scott (HL7 UK)
  • Michelle Miller (Cerner)
  • Andrew Torres (Cerner)
  • Emmanuel Helm (HL7 Austria)
  • David Parker (DoD/VA)
  • Senthil Nachimuthu (3M)
  • Mark Kramer (Mitre)
  • M’Lynda Owens (Cognosante)
  • Simone Heckmann (HL7 Germany)
  • Simon Kntze (sic) (HSCIE)
  • Emma Jones (Allscripts)
  • Laura Heerman (Intermountain)
  • Danielle Friend
  • 7 more unreported


  • Phillip Scott, Chair HL7 UK presented Clinical validation of UK FHIR profiles on standardizing documentation format in clinical and social care in the UK, soliciting input from HL7 on best practices for closing a feedback loop in standards distribution, support, and maintenance.
  • Key suggestions included the observation that frequent connectathons have been critical to FHIR uptake, and that infrastructure support (viz., shared FHIR servers) is a critical factor for connectathons.
  • The group addressed an issue (Gforge 8872) concerning the definition of Condition: the boundary section leaves it unclear when to use condition vs. observation.

    • Jay presented an analysis of the two resources, suggesting that most of the properties are analogous and could be easily harmonized, resulting in consolidation into a single resource definition. This would simplify design and remove the need to adjudicate edge cases. It was observed that a great deal of work has been done on the existing archetypes.
    • Michelle Miller made a Motion to keep Observation and Condition as separate resources, but clarify the wording in the Boundaries & Relationship section of Condition
      • Danielle Friend seconded.
      • Abstain: 4; Against: 2; For: 17; motion carries

Meeting with SOA - Emma Jones attended

  • OMG RFP Initial Submission
    • Presentation by Ken Rubin
      • Received an update in March.
      • OMG process is not a consensus based process.
      • Tech spec developed by submitter teams

Participants are

  • Medisked - public health and human services work in NY
  • Allscripts -
  • VA - Walter Reed
    • Initial submission document available to OMG members

Discussion about CCS publication

  • Per Ken, Something got dropped. Patient care owns the CCS and can move forward with submitting to HL7 for publication. Nothing is needed from HSSP and there should be no issue with intellectual property. Caveat though - when the submission is done, PC need to consider submitting feedback on implementer experience during OMG process. Any errata can be handled thru the DSTU comment process.

Patient Care Tuesday Q3


  • Michael Tan (Nictiz)
  • Elaine Ayres (NIH)
  • Stan Renkins (Telligen)
  • Anne Smith ( NCQA)
  • Matthew Spienmann (Intersystems)
  • Linda Michaelsen (Optum)
  • Shirin Zaidi (Gevity)
  • Russ Buchanan (Gevity)
  • Richard Esmond (PenRad)
  • Terry McDonnell (Syapse)
  • Justin Schirle (EPIC)
  • Angela Flanagan (Lantana)
  • Esteban Anvert (Cognitive)
  • Laura Bright (LJB consulting)
  • Mark Kramer ( Mittre)
  • Martin Rosner (Philips)
  • Sheryl Taylor (NIST)
  • M'Lynda Owens (Cognosanti)
  • David Pyke (Road4Competition)
  • Walter Suarez (KP)
  • Rob Hausam (Gwasl)
  • Lloyd McKenzie ( lmckenzie)
  • Lindsey Hoggle (eatright)
  • Margeret Dittlof
  • Rik Smithies
  • Simon Knee
  • Panagiotis Telonis (EMA)
  • Chris Millet ( lazy company)
  • Amy Dohlman ( midtronic)
  • Julia Skapik (hhs)
  • Raphael Majeed (Uni Oldenburg)
  • Norman Gregory (FDA)
  • Craig Parker (Imail)
  • Sean Moore (EPIC)
  • John Kisen (ABBVIE)
  • Emma Jones ( Allscript)
  • Bill Friggle (Sanofi)
  • Laura Heermann Langford ( Intermountains)



  • Adverse reactions
  • Negation
  • Condition status
  • Care Plan
  • Consolidation of clinical workgroups.

Adverse event resource

  • RCRIM: Lise Stevens and Mead Walker, have done preliminary work, based on ICSR v3.
  • Issue is the scope of the resource to be usable for other settings.
  • This session is a restart of the initiative. Goal for today is get this project restarted.
  • Questions:
    • ICSR was built for adverse event reporting. What do we want now? Do we want to consider to use it also beyond regulatory reporting.
    • After starting with Allergy/Intolerance they quit this approach and started with ICSR reporting that is sent to FDA.
    • Nobody opposes to limit the adverse event to substance events
  • Question to Lloyd about the FHIR planning and deadlines.
    • Need content to be frozen by 15 July.
    • PC should give the statement of maturity of the product.
    • It will be published by the end of the year.
  • Team is now set.
  • Explanation of Mead’s concept model.
    • Identifier
    • Type
    • Subject
    • Date
    • Status
    • Outcome
    • Description
  • Field “ severity” is not available.
  • According to Julia, FHIR already has a value set for outcome.
  • How should you do the profiling? Excluding attributes and remove them from the profile?
  • This model will be discussed in the RCRIM group.


  • What are the thoughts of CQI about negation? The PSS for the negation project is to gather the requirements on the negation. Solutions is not the focus.
  • CQI will definitely be involved. What is the direction of PCWG for looking for the solutions.
  • In radiology: They have a matrix for each modality to decide what is normal. ( for example the size of the hart). The question is, how to decide what normal is in other context.
  • Rob Hausam has a slide presentation to explain.
    • Proposal 1
      • Align renaming of resources
      • AllergyIntolerance substance into AllergyIntolerance code.
      • The binding to the value set remains the same.
      • Create a new allergy-intolerance-negated-code value set.
    • Proposal 2
      • Follow the OpenEHR solution. Split it out in 2 separate resources that have only positive statements.
      • Discussion whether solution 1 would not lead to 2 profiles.
    • This discussion will be continued in Q4.

Consolidate workgroups.

  • Discussion to group workgroups together because of overlapping topics. This is a topic CVS, CQI are working on, but PC could also consider to be involved.
  • CIC might also consider participating to gather some clout.
  • Laura remarks that this is a recurring topic that returns every 8 years. In the end the burden of the WG becomes so large, that it would split into smaller groups again.
  • External parties have difficulty finding the right WG or the need to address different WG.
  • Lloyd suggests that the need to be in touch of the progress is to have a conference call once a month to report what each WG has done.

Patient Care Tuesday Q4

Present: Jay Lyle - Chair, Elaine Ayres - Scribe (total of 50 attendees) Andrea Pikus - IMO Lloyd McKenzie - Gevity Michael Tan - NICTIZ Lindsey Hoggle – Academy of Nutrition and Dietetics Margaret Dittloff – Academy of Nutrition and Dietetics George Cole - Allscripts Joey Cole - Intermountain Matthew Spielman – Intersystems Michael Lawley – CSIRO Keith Campbell – VHA Brian Wrighte – Mayo Clinic Esteban Aliverti – Cognitive Ron Shapiro – Quera Chris Chute – Hopkins Tom De Jong – HL7 NL Keith Allen Martin Rosner – Philips Senthil Nachimuthu – 3M Marla Albitz Rita Menial Sean Moore – Epic Michael Donnelly – Epic Daniel Rutz – Epic Greg Gustafson – Penrad Emma Jones – Allscripts Scott Robertson – Kaiser Permanente Sue Thompson – NCPDP Shelly Spiro – Pharmacy HIT David Burgess – Labcorp Craig Parker – Intermountain Michelle Miller – Cerner Dennis Patterson – Cerner Oyrind Aassave Sherry Taylor – NIST Claude Nanjo – Cogmedsys Susan Barber – State of TN M’Lynda Owens – Cognosante Ted Klein – KCI LLC Heather Grain – Ehe Australia Rob McClure – MDPartners Bruce Bray – HSC Utah Rob Hausam


  1. OO: multiple answers to a question in a questionnaire
  2. Negation
    1. PSS: asking MnM for participation; CQI & PA had expressed interest. Also need to articulate how to engage with existing design & guidance -- design constraints based on legacy environment are requirements.
    2. Plan
      1. Collection of use cases
      2. Classification of use cases
        1. Including cases out of scope to clarify boundaries
      3. Identification of principles
      4. Identification of what can be provided to design groups / how feedback can be addressed
    3. Review classification current state; solicit gaps


1. OO question re multiple answers to a question in a questionnaire – based on current coding in observation and observation component.

The group tried to recall why the invariant was included. The argument against – will the observation code will be misused?? Need to understand the boundaries around the component observation scenario.

Currently in Observation you have a code and components also can have a code, but the code at component cannot be the same as the observation.Code (invariant), so when a question has more than one answer - Example Alcohol type? = parent code as well as component code with 2 answers (beer and wine) currently not allowed.

QuestionaireResponse treating each answer as its own observation, so we want to remove the invariant.

Discussion: Looking for the argument to have the invariant – will this open up to use component for other things that we don’t want (need to clearly define the boundaries between code / component / related observation) – component should be used for items that cannot stand on their own.

Will take back to OO for Q1 Wednesday – PC feedback: yes we need more than one answer to the same question

2. Negation Project Scope Statement – went to DESD. Need to add MnM as per DESD feedback. This is a design pattern project. Issue is dealing with current design patterns in current standards vs. new recommendations. Key issue is not to use the concept of negation. The word negation is creating ambiguity. Need to first develop use cases of how the absence of findings are used, and then classify these use cases.

The spreadsheet on the wiki is located under the Patient Care site under the Negation project.



Spreadsheet has a category column: examples are:

a) Finding absent (exam) as opposed to not known

b) Finding absent (instrument)

c) Anatomical deficit

d) Anatomical deficit, congenital

e) Anatomical deficit, surgical

f) Condition absent – common in pathology. A previous history of MRSA, would note – absence of MRSA. Part of medico-legal response.

    1. 1. Part of the condition resource
    1. 2. In family history resource – my father had X but my mother did not

g) Condition refuted

h) Procedure not done

i) Encounter not held

Nesting of questions and answers make negation even more complex. What rules apply to nested observation structures? Need to look at use cases for example cancer reporting forms.

A finding/assertion may be absent, but multiple findings may be absent. A batch may have a mixed assertion pattern as well. Context conduction (a RIM artifact) may represent this issue, but perhaps not.

Noted that classification categories in spreadsheet are quite detailed. What about more general patient observations such as “no next of kin” or other types of observations in the social history?

Conditional prohibition – e.g. no food until pain subsides. Functional deficit – no vision in right eye Patient preference to abstain – assertion of patient not to breastfeed.

In spreadsheets have a mapping for similar statements – and looking at representation in V3 and FHIR resources to create harmonization across standards. (not in project scope but will help design teams).

On wiki there is a page that looks at negation principles that have been collected during the project discussions. For example – no double negatives.

Should negation be done in the model or in the terminology (pre-coordinated or post coordinated expression).

Depending on the code system the answer may vary. In SNOMED CT negation does not work in the description logic. Need to put negation into the information model. The pre-coordination does not work in SNOMED CT.

Negation in the code field as a post-coordinated expression will violate logic. In the information model it will work.

SQL supports negation – put where to you put it? If in that query it works. If you allow it in other settings, it does not work.

Head injury without loss of consciousness, and head injury with loss of consciousness. This is an observation result with a presence or absence stated in a separate place based on query systems (e.g. ICD-9 or ICD-10).

A query for loss of consciousness should return correct information.

Key is to represent negation in the information model, not the terminology. (IHTSDO)

For free text entry – the user interface becomes critical. Mom thinks there is an allergy but Dad disagrees. Should codified statements be separated in the model or for all use cases? Even with NLP parsing text, will need a consistent model for data representation analysis.

Not just negation itself, but what are you negating? There is some context.

Asplenia – (absence of a spleen) can be congential or surgical. These require different representations.

Plea is to keep negation out of the terminology, and put in the model. This should become a design principle.

MOTION: Keith Campbell/Michael Lawley

Motion to write a principle (Keith Campbell) Negation will not be allowed in a coded expression in the code field of a resource but will be allowed in a specified field of the resource. This field can be populated with a code from the terminology system.

Rewritten after the meeting as

Concept codes (or expressions) used in coded data element fields should not include semantic negation (including, e.g., finding absent, procedure not done, etc.). Information models should provide other means for asserting these modifiers, whether as a separate field in the information model, which may itself be populated with a code or expression, or in some other way.

Need a canonical representation for interoperability. The user interface may need to be pre-coordinated. In the reasoning, data entry needs to be separated (transformed) for data exchange. Should not be reported clinical statements in a classification.

How would this play out in the allergy and intolerance resource? In the condition resource – can add pre-coordinated context codes – would need to represent via the status.

MOTION to table: Keith Campbell/Kurt Allen Motion is tabled by acclimation

Summary: Bring use cases, review spreadsheet. Call is Wednesdays at 11 AM ET. Topic will be continued on Wednesday, May 11 during Patient Care Q4.

Patient Care WGM, Wednesday, May 11, 2016

Patient Care Wednesday Q1


Chair: Laura Heerman-Langston
Scribe: Emma Jones


  • Laura Heerman (Intermountain)
  • Emma Jones (Allscripts)
  • Michael Tan (Nictiz)
  • Katherine Duteau (DDI)
  • Pele Yu (Child Health)
  • Matthew Spielman (Intersystems)
  • Russ Leftwich (Intersystems)

Patient Care (PC) and Child Health (CH)

Chile Health - Presented by Feliciano Yu

  • Overwiew of CH work on children with special needs
    • Focus on finding standards that are relevant for children.
    • Work group has shrunk due to the lack of funding
    • Focus on 2 projects
      • developemnetal screening - working with EHR WG.
      • derived from the the EHR -FM
      • Need to come up with a conformative standard by Sept 2016
      • Using the tool to export relevant pieces. Explored using EA. Goal is to map CH conformance criterias to how EMR should behave in terms of developmental screening questions. The facilitators will then map the resuls of this to EA. Have learned that the criterias can map to multiple functions. The process is tedious. Intent to ballot in Sept.
      • Discussion about the funding incentive for this
      • Suggestion given the CCDA might be the immediate way forward
      • Need to be able to get more folks to participate in the calls. Suggestion made to change the call time. currently have much conflicts. Will send email or Doodle poll
      • Folks to work on this - Suggestion made to have graduate students with peds background get the work done. If unable to get payment for them could offer independent study credit

Netherlands Child Health Program - Presented by Michael Tan

Vaccination program

  • Information standard - Information data set has about 700 items
  • Uses HL7 messages care provision
  • Facilitates the transfer of information from one institution to another. Has a total of 60 institutions with a central location to manage the immunization information. Has been in place for 8-9 years. In the 2nd stage of implementing the EHR - FM. Now in the process of identifying the top 200 items to exchange. Plan to grow. The goal is to keep track of things that are public health related. Development of the child - height, weight. Obesity data. Uses a single patient
  • Uses identifier which is comparable to the SSN but seperate from the SSN. Need to deal with refugees who does not have the SSN number. does not use scanned docs because of sizing issues. the updates are done by batch overnight. Building in Art deco.
  • Discussion about how this is funded.

Patient Care Wednesday Q2



Patient Care Wednesday Q3

Present: Laura Heermann Langford - Chair, Elaine Ayres - Scribe,


  • Michael Tan
  • Riki Merrick
  • Lloyd McKenzie
  • Jay Lyle
  • David Pike
  • Dan Rutz
  • Sheryl Taylor
  • Cindy Jiang
  • Lorraine Constable
  • Patrick Loyd
  • Andre Torres
  • Michelle Miller
  • Panagioris Telonis
  • W. Gregory
  • Sylvia Thun
  • Raphael Majeed
  • Angus Millar
  • Rob Haursam
  • Julia Skapik
  • Han Buitendjke
  • Floyd Eisenberg
  • Martin Rosner
  • Viet Nguyen
  • Michael Lawley
  • Amy Dohlman
  • Bertil Roppen
  • Amit Popat
  • Matthew Spielman
  • John Donnelly
  • Ken Kwamamoto
  • Gay Dolin
  • Josh Mandel
  • Walter Suarez
  • Lee Surprenant
  • Andre Pikus
  • MariBeth Gagnon
  • Justin Shire
  • David Burgess
  • Thomson Kuhn
  • Linda Michaelsen
  • Eric Haas
  • Bryn Rhodes
  • Stan Rankins
  • Davide Sottara
  • Laura Bright
  • Peter Haug

Minutes: New Order Set resources created by CDS. The issue related to Order Set relates to the potential overlap with Care Plan.

There are two resources: One created by CDS - Order set which is a simple resource. Key elements are in ActiveDefinition. Alot of content in the metadata section. It is a collection of things that can occur. The other resources is called Protocol. (no official owner - part of the workflow project). In the definition space - so independent of patient and specific time but describes what should happen. Protocol includes research study, chemotherapy protocol......

The workflow project looked at the action definition and felt it was overloaded with details in the order set resource. In the protocol resource can identify the individuals involved, e.g. applies to anyone on this medication, the purpose of the protocol and steps and precondition rules. There are exist rules.

Have discussed merging the order set and protocol resources - order set would be a subset of protocol as a single resource. BOF Wednesday evening on this topic. Propose that this resource be owned by CDS. Will support all types of protocols -- research, clinical.

What are the issues for Care Plan? Care Plan can reference the protocol resource as will all other request protocols. This order is based on this step in the protocol. Can also use a specific protocol element instantiates a specific activity.

Hope to have the Protocol resources to be a draft by the next ballot - with a connectathon track with Care Plan and Protocol. Building a Protocol will not be simple for a Clinicians on FHIR event.

From and OO perspective -- are questions answered? The challenge has been with order sets the representation of simple vs. complex. The scalability will be essential. In FHIR an order set should be less problematic without the need for mood codes.

The Order Resource -- also in the definitional space, but very different. The goal is to keep the protocol resource as simple as possible. More sophisticated features will be extensions. On the FHIR website look at action definition in the order set resource (UML) and in protocol the UML to see how activities are linked. Will have a mapping to BRIDG, but can be profiled to represent BRIDG.

In order to understand the impact of the combination -- need to see the initial build of the combination over the next several weeks. With the same underlying structure can extensions and profiles make this workable. An order set is a type of protocol. A protocol can create other types of action items beyond orders.

The CDS group has discussed -- there is a high level of content overlap. Clinicians in CDS order sets are a point in time artifact -- common labs, admission. Protocols trigger activities automatically vs. order sets need to be triggered via an "order". A protocol can be automated but is not necessarily need to be automated. A protocol can have institutional variation -- order sets, pathways, flow processes. will the combination of the two resources will meet all needs. Agree that combining resources are critical to understand the utility.

Can you mix protocols -- admissions protocols vs. other types of protocols. Are vital signs a protocol??? A protocol could cover any type of activity. For example a financial protocol for requirements prior to transfer. But a protocol is never bound to a specific time, and never patient specific. These are not intentional activities. Semantically protocol, order set, guideline, pathway -- may not all be understood as a protocol.

For a drug protocol -- define parameters in a time and patient independent way. If a patient meets the parameters of the protocol, can them use the protocol as a framework for the care plan. The medication order also uses the protocol information. For optionality -- should the order set be triggered by a protocol?? The optionality may live inside or outside an order set. For a lab protocol - can look at processing of a sample and pending on the results of the test can have optionality of care or treatment.

If the purpose of this combined resource is too complex or not clear, will be problematic. This is trying to meet workflow as well as other needs.

Do we need a resource object criteria -- represents constraints? Many concepts are captured by observations (such as vital signs). What makes sense to the implementer community in their software?

There will be an intermediary between what the resource does and what the clinicians see in the context of care. For CDS on FHIR - tried to add conditionality. But the line is blurry and actual examples will be key. Looking for automation when possible. There are common components that should be used from both resources.

Next steps -- during CDS calls and on the FHIR chat. Will send out updates to the multiple lists with updates. Will keep this same quarter for Baltimore meeting.

Patient Care Wednesday Q4


  • Elaine Ayres (NIH) chair
  • Michael Tan (Nictiz) scribe
  • Michelle Miller (Cerner)
  • Linda Bird (IHTSDO)
  • Jim Case (NLM/ IHTSDO)
  • Sheryl Taylor (NIST)
  • Jon Zammit (IHTSDO)
  • Scott Robertson (Kaiser Permanente)
  • Jenni Syed (Cerner)
  • Andrew Torres (Cerner)
  • Dennis Patterson ( Cerner)
  • Keith Campbell (VA)
  • Rob Hausam (Hausam consultancy)
  • Julia Skapik (ONC)
  • Ron Shapiro (Quera)
  • Michael Donnelly (EPIC)
  • Tim McNeil (Surescripts)
  • Sean Moore (Epic)
  • Francois Macary (HL7 France)
  • Isabelle Gibaud ( HL7 France)
  • Laura Heermann Langford (Intermountains)
  • Omid Mavadati (National Board of Health and Welfare)
  • John Hatem (HL7 Pharmacy)
  • Marla Albitz (HL7 Pharmacy)
  • Angus Miller (NeHTA)
  • Tom de Jong ( HL7 NL)
  • W Gregory (Pfizer)
  • Dan Rutz (Epic)
  • Danielle Frierll (Epic)
  • Russell Leftwich (Intersystems)
  • Rob McLure (MD Partners)
  • Susan Matney (Intermountains)
  • Peter Jordan (HL7 NZ)
  • Clem McDonald ( PLM/LHC)
  • Susan Barker( TN Dept.of Health)
  • Daniel Karlsson (Liv)
  • Martin Rosner (Philips)
  • Mark Kramer (Mitre)
  • Michael Lawley (CSIRD)
  • Amit Popat (Epic)
  • Carmela Conderc (IMO)
  • Margeret Dittloff (Academy Nutrition & Dietitian)
  • Viet Nguyen (Lockheed Martin)
  • Jay Lyle


Motion about Negation

  • Motion on the negation has been changed and put forward for discussion:
  • The semantics of a code or expression in a code field shall not be altered by any kind of element that modifies the meaning of the code that is not native to the coding system being used in the code field.
    • E.g., the RIM negation indicator or other related constructs shall not be used to modify the meaning of an expression in the code field.
    • Clarification: this motion does not prevent the use of pre-coordinated codes such as “no known drug allergies.”

  • The motion has been drastically changed and does not seem to be related to the previous motion. The intent of the proposal was to be less wide sweeping. The original motion is gone and the current motion does not seem to be related to the topic of negation.
  • There seem to be different interpretation of the motion and the suggestion is made to defer the decision until a common understanding is found.
  • The question is called whether we should vote on the motion.
  • Motion to table the motion by Kramer. Second by Dittloff.
  • Abstain 1 , Oppose 1, In favor 51

Project Allergies:

  • There are many value sets in use:
    • CVX
    • NDFRT
    • RxNorm
    • UNII
  • Goal is to develop specific value set.
  • Optum requests requirements lists:
    • Collect data from various sources such as ADT.
    • Also looking for negation examples such as “no know allergies”.
  • This will be a difficult exercise because you cannot always translate a proprietary coding list.
  • Issues:
    • Question to use one or many standard terminologies?
    • According to Clem McDonald there are only a few drugs that really create an allergy. This is different for intolerances. Rob McClure disagrees with Clem. We need to get it right for drugs. There are several levels on which you can register and the question is how specific do we need to capture the data.
    • There are actually only 8 food categories. Not certain about the specificity of the allergy. Example of tree nuts. According to Clem we should not transfer the requirements for food allergies to drug allergies.
    • Rob’s view is on what level you can register the data and what is actionable.
    • There is data on peanut casualties (9 in Delaware), but little is known about tree nuts.
  • We definitely go drugs and foods.
  • Registration is meant to be done in SPL. SPL is maintained by the FDA and we have to review the fit of food in the SPL.
  • Question of what to expect from HL7 PC in the maintenance of value sets. The PCWG can own these value sets with perhaps the exception of FHIR.
  • USA does not have associations between the substances and the prescribed medication.
  • Many of the negation statements are free text. We need to think how to cater this.

Patient Care WGM, Thursday, May 12, 2016

Patient Care Thursday Q1

  • Chair: Laura; Scribe: Jay


  • Michael Tan (Niciz)
  • Shelly Spiro (Pharmacy HIT Collaborative)
  • Sue Thompson (NCPDP)
  • Ron Shapiro (Queva)
  • Peter Jordan (HL7 NZ)
  • Richard Kavanaugh (HSCIC)
  • Sarah Ryan (Ockham)
  • Egger Oliver (HL7 Switzerland)
  • M’Lynda Owen (Cognosante)
  • Bertit Repgens (sic)
  • Sarah Gaunt (Lantana)
  • Rick Geimer (Lantana)
  • Susan Matney (Intermountain)
  • Russ Leftwich (InterSystems)
  • Lisa Nelson (Lisa Nelson)
  • Shu-Fang Newmann (U of Washington Medical Center)
  • Elaine Ayres (NIH)
  • Emma Jones (Allscripts)
  • David Pyke (Ready Computing)
  • Omid Maundati (National Board of Health & Welfare)
  • Amit Popat (Epic)
  • Lloyd McKenzie (Gevity)


  • Update/Vote on CP DAM Publishing
  • C-CDA on FHIR
  • Pharmacy Care Plan - PSS
  • IHE Dynamic Care Plan Profile


  • Announcement: CP DAM vote for publication passed
  • CCS document completed 2 years ago not yet published. Re-vote to publish:
    • David moves; Emma seconds
    • Abstain: 1; Opposed: 0; Pro: 20
  • Rick Geimer presented an update on C-CDA on FHIR
    • Analysis of CDA to confirm composition resource can support header
    • C-CDA on FHIR analysis in process; leveraging Argonaut work.
    • Focus on C-CDA 2.1. SD will create profiles on Composition.
    • Leverage DAF profiles where possible. Where they don’t exist, engage appropriate work groups.
    • Wiki: C-CDA_on_FHIR; Google docs includes Argonaut mappings; gForge is home. Calls Wed 3ET.
    • Tools: Lantana Trifolia & Furore Forge. Ensure exchangeable.
    • Had Spring connectathon; planning Fall ballot. Targeting FML 3 for Composition.
    • All document types now based on US Realm header.
    • Aside: played with FHIR logical model capacity to digest CDA. Not an official task at this time.
  • Shelly Spiro presented use cases and slides on the Pharmacist Care Plan.
    • The Pharmacy HIT Collaborative ( consists of the nine major pharmacy professional societies. The project restricts the Care Plan CDA template to cases germane to pharmacists, and defines value sets for these cases. The IG effort is currently on hold due to funding issues; two payors and two vendors have agreed to implement. The task force is open for participation at; workgroup 10; MTM communications. The group may create an interim guidance document, but a tool is required to create a guide that supports testable implementations (as well as for ballot). Value sets are currently in the VSAC Collaboration site, also open for participation.
  • Emma Jones presented the IHE Dynamic Care Plan document, currently soliciting comment. One point that would benefit would be assumptions around the stewardship of the DCP and how various participants agree on information change control.
  • Lisa Nelson presented the status of the Personal Advanced care plan document IG.
    • Balloted January; 239 comments. Reconciliation completed 4/21. Aiming to complete 6/2 & vote. Pub 7/1. Will be on workgroup page.
    • Described areas of revision. Some involve stylistic differences between IHE and HL7 practice. Nesting of sections intended to support DCP aggregation. Some work on personal preferences and goals; value sets address goals identified by a wide variety of organizations. One extension added – sdtc:priorityNumber.
    • Included a calendar of review events to which everyone is invited.
  • We will keep this session for September.

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

Present: Jay Lyle - Chair Elaine Ayres and Emma Jones - Scribes

  • Michael Tan
  • Laura Heermann Langford
  • Shelly Spiro
  • Sue Thompson
  • Mark Scharfarman


Templates Update

1. Governance - creation of vs. use via the creation of a template registry. Create templates vs. use with the use of a new unique id. A registry will keep track of creation vs. adaption and use. There is also a user community of existing templates. Want to make sure this work is consistent with the use of the FHIR profiles.

See URL under documents and templates. HL7 Templates Registry Business Process Requirements Analysis, Release 1

2. Update of Sharing Templates STU. Will be dealing with posted STU comments for changes and modifications.

3. Also looking at FHIR resources and profiles for harmonization. Will look at experience with registries vis a vis FHIR.

4. Templates tutorial at the Fall 2016 WG meeting in Baltimore.

Structured Documents Update

1. C-CDA Product Family presentation by Austin Kreisler (Product line architecture group)

  • 2.X
  • FHIR
  • C-CDA

Products that share a common, managed set of capabilities that satisfy a specific market segment. A product line hsa a consumerperspective, and product family has a developer perspective.

Add Austin's slides.

Proposed product family is CDA and would include CDA, C-CDA, public health case reports, implementation guides and CDP1 attachments.

Base V3 standard governed now by TSC, the management is through SDWG and the methodology is through MnM and Vocab. Implementation guides are less clear because of multiple groups with an interest.

The goal is to have a single base standard and implementation guide for CDA product.

Governance will be through the TSC and SGB. The management will be through a new CDA management group - coordination and quality control (like FMG). The methodology has yet to be determined. There will be further discussions at the next WG meeting. Will involve every group that has developed an implementation guide and how to ensure the management group represents all stakeholders.

2. Need an update on clinical status -- where does this stand? Patient Care needs to provide a value set to SDWG for clinical status.

Stephen Chu was to work on this topic - and provide updated information perhaps during a call. This relates also to the FHIR Condition resource and make sure that the models align. The Problem status was under the problem observation -- the PC WG proposal should be consistent with FHIR.

There is an issue from ONC regarding concerns vs. problems. Need alignment within C-CDA as well.

From the Health Concern DAM -- does this use the problem concern template model? There is mis-alignment currently. The C-CDA concern template aligns better than the FHIR model for observation and conditions.

3. Relevant and Pertinent

Wiki site has the data collected through the survey process. There is also data from the C-CDA challenge.

Patient Care Update

1. Negation project - still lack of consensus on how to move forward. There are divergent priorities -- even for a requirements project (vs. a design project). There may be some design patterns where the use of negation is useful.

2. Allergy and Intolerance -- several outstanding items re terminology that PC will take care of. Then can complete STU tracker items.

Patient Care Thursday Lunch

  • Agenda:
  • Co-chair lunch action list:
    • Room Request : Laura
    • HL7 WGM survey Michael
    • Harmonization: Rob Hausam
    • Conference call meeting request: each co-chair
    • NIB: Assessment Scales: Michael
    • Post September Agenda : Michael

Patient Care Thursday Q3


  • Michael Tan
  • Simone Heckmann
  • David Pyke
  • Andrew Torres
  • Danielle Friend
  • Amit Popat
  • Sue Thompson
  • Russ Leftwich


  • Reconciliation
  • # 16: fixed, but text may be the wrong place. Jay to investigate.
  • # 36-71 all persuasive editorial
  • Except # 61 pneumonia: OPEN. reschedule on call; include Larry.
    • clinical problem: pneumonia isn't resolved. "pneumonia requiring hospital stay" could be considered resolved, but that's not a condition; it's a billing code. We all agree that the condition is not resolved but some other state approximating "active" or "current." The question is whether the concern itself is also current at discharge. It's certainly not "resolved," but it could be "inactive." But it would need to be in a state that would make it onto a discharge diagnosis list. The point of the example is that the PCP does get informed of it, and reconciles it with her own problem list. Is this a place where we should identify semantic codes from somewhere like SCT or FHIR to clarify the meaning?
  • Jay moves to accept changes for the following comments:
    • 14, 16, 26, 28, 36, 43, 61, 70, 80, 81, 84, 85, 86, 88, 89, 97, 100, 102, 137, 146, 149
    • Amit seconds
    • 9 total. abstain: 2; against: 0; 6 pro; motion carries

Patient Care Thursday Q4



Patient Care WGM, Friday, May 13, 2016

Patient Care Friday Q1

(1) Template WG meeting

- PCWG representative(s) to attend

(2) Agenda: open

- Possible: Clinical Connectathon



Patient Care Friday Q2

Agenda: open

Possible: Clinical Connectathon



Patient Care Friday Q3

Agenda: open

Possible: Clinical Connectathon



Patient Care Friday Q4

Agenda: open

Possible: Clinical Connectathon