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PC Sept 2017 WGM

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San Diego, CA, WGM - Sept 2017 Patient Care WG Meeting Draft/Approved agenda:


Day Time Qtr Room # Event Host Joining Chair Scribe
Sept 10
Q5 Care Plan DAM harmonization discussion
Emma, Laura, Stephen
Others welcome ...
Day Time   Room # Event Host Joining Chair Scribe
Sept 11
AM Q1 Aventine ABCG Plenary
Q2 Aventine ABCG Plenary
PM Q3 Vicino Ballroom Mega Report Out EHR Accepted: PC Attendees: Emma, Laura, Stephen, Elaine
Q4a Aventine D Joint Session with FHIR & OO on FHIR workflow FHIR-I Accepted: Patient Care Stephen
Q4b Palatine B 20 Admin (i.e. approve past WGM minutes; review schedule; 3 year plan)
FYI - Mission and Charter are done; Decision Making Process - Wayne said general update is pending
Patient Care N/A Michelle Michelle
Day Time   Room # Event Host Joining Chair Scribe
Sept 12
AM Q1 Barcino 40 60 min - FHIR/PCWG - CIMI - Skin Care model meeting
30 min - Special needs children care plan
Patient Care Accepted: CIMI, EC Laura Emma
Q2 Palatine A 20 FHIR Change requests
  • GF#13743 Add AllergyIntolerance, Observation, RiskAssessment, and List to CarePlan.addresses

Nutrition Care Plan IG PSS

Patient Care Declined: FHIR-I Michelle Michelle
PM lunch ?
Q3a Portofino A 20 FHIR Admin, Planning, Issues, and Change requests Patient Care Accepted: FHIR-I Michelle Michelle
Q3b Aventine E SD Hosted Joint Quarter: CDA Product Family -This meeting is to provide an update to all interested work groups regarding the formation of a CDA Product Family. There will be many work groups invited to participate, so send representatives only SD N/A Stephen
Q4 Aventine F 40 Negation + other vocab topics
Problem status value set (SNOMED doesn't share the same hierarchy of codes as valueset-condition-clinical)
Patient Care Invited: Clin Genomics
Accepted: Vocab, CIMI, EC, SD, OO, FHIR-I
Jay / Rob Emma
Day Time   Room # Event Host Joining Chair Scribe
Sept 13
AM Q1 OO-Studio Suite 310 (PC was in Portofino A, but PC is joining with OO in Studio Suite 310) 20 FHIR Change requests - Joint with OO to discuss adding instructions to ProcedureRequest Patient Care Accepted: FHIR-I Emma Emma
Q2 Guest Room 311 N/A PA hosted joint meeting -- Episode of Care; Care Team PA Accepted: PC N/A Michelle / Stephen
PM lunch Palatine B
15 Clinician-On-FHIR Preperation meeting Patient Care Russ Emma
Q3 Vicino Ballroom 40 55 minutes - Boundaries between ProcedureRequest/Procedure vs MedicationRequest/MedicationAdministration for blood transfusions and radiation (i.e. anything with a dose, but isn't a medication)

Do we need a new resource for BiologicallyDerivedProduct? Boundaries between Specimen / Device / Medication boundaries

Related Zulip discussions:

Related trackers:

20 minutes -- HL7 approach to Appropriate Use Criteria [1]

Patient Care Accepted: CQI, CDS, Pharmacy, OO, FHIR-I Michelle Mike / Stephen
Q4 Rhodes 20 Allergy/Intolerance topic meeting. Drug list approach & Issues. Allergy resource maturity Patient Care Accepted: Pharmacy, Vocab Elaine / Jay Emma
Day Time   Room # Event Host Joining Chair Scribe
Sept 14
AM Q1a Syros 25 Care Plan -invite FHIR, Structured Docs, Pharmacy
  • HL7 C-CDA 2.1 Care Plan Document Template - Lisa Nelson
  • HL7 Care Plan Domain Analysis Model/FHIR Harmonization - Laura Heermann/EMma Jones
  • HL7 Care Coordination Services (CCS) functional model - LH/EJ
  • HL7 CDA R2 Personal Advanced Care Plan Document - Lisa Nelson
  • HL7 FHIR Care Plan Resource - LH/EJ
  • IHE PCC Dynamic Care Planning Profile- EJ
  • IHE PCC Dynamic Care Team Management - EJ
  • IHE QRPH Early Hearing Detection and Intervention (EHDI) Plan of Care- Lisa Nelson
  • HL7 Clinical Oncology Treatment Plan and Summary - Jeff Brown
  • NCPDP/HL7 Pharmacist Care Plan - Shelly Spiro
  • Care team members definition update (Laura/Emma)
  • Essential Information for Children with Special Health Care Needs - Mike Padula
  • Naming convention for Care Plans?
  • Care Plan/Care Team Implementations
Check the minutes ....
Patient Care Accepted: LHS, Pharmacy, SD Laura Emma
Q1b Delphi A Joint meeting with OO, CDS, PC, Templates OO Accepted: Patient Care Stephen
Q2 Aventine F 25 Joint meeting with SD and Templates

Proposed agenda:
CDA Value Sets with Proposed Changes (Allergy/Intolerance, Clinical Status and others ...)

Template update (Template co-chair/rep)
Template versioning;
Structured Doc/CDA update (SDWG co-chairs)
Patient Care update:
Allergy/Intolerance harmonization
Care plan harmonization; Health Concern*
C-CDA Care Plan templates
Care plan, template .... naming conventions

Patient Care Invited: Templates
Accepted: SD
Stephen Emma
PM lunch Aventine F
10 Co-Chair Admin Meeting Patient Care Michelle Michelle
Q3a Syros 20 FHIR Change Requests - Joint with BR&R to discuss AdverseEvent / AdverseReaction
  • GF#13302 Vocabulary issues with AdverseEvent
  • GF#13698 AdverseEvent.suspectedEntity.instance should allow CodeableConcept
  • GF#11021 Increase cardinality of substance and make certainty relation to substance, not reaction - 2016-09 core #40
Patient Care Accepted: BRR, FHIR-I Michelle Michelle
Q3b Andros Joint meeting with CS, OO, and PC.
Per Hans, typically this one is very short (as it is in maintenance mode). Rest of the quarter is strictly OO. OO doesn't want to lose it from the radar, but no problem if PC declines, or puts down one representative who can check whether anything worthwhile comes up
CS Accepted: Patient Care Stephen
Q4 Palatine A LHS - CareTeam DAM LHS Accepted: Patient Care Stephen, Emma, Laura?
Day Time   Room Event Host Joining Chair Scribe
Sept 15
AM Q1 ClinFHIR  
Q2   ClinFHIR        
PM Q3   ClinFHIR        
Q4   No meeting        

San Diego, WGM - Sept 2017. Patient Care WG Meeting Meeting Minutes

Sunday, Sept 10

International Council Meeting
  • PCWG Care Plan
Discussion re: CP DAM 2.0
- Attendance:
- Emma Jones
- Laura Heernman
- Stephen Chu
- Notes:
Discuss Care Plan DAM 2.0: What to include/what does 2.0 look like:
• Orders (pull it up more visible). Figure 6 in the DAM. We need to improve the figure to represent activities and orders into other (higher level diagrams Level 0, or 0.5? Unpack the order set concepts. (what has been done in the FHIR Connectathons – how the library of activity definition fits into the activity box itself to form into Order Sets.
• Address Order Sets – how are they derived? How do they fit into the Care Plan? Address protocols… Evidence based guidelines.
• Advance Directives – is there stuff we need to do there? Write to it? How do they fit together?- Are these the same as Patient Orders? A Patient Specified Protocol?
• Health Concern – bring in the latest and greatest from the work that has been done there.
• Reconciliation – being in the latest and greatest from the work that has been done there.
• Care Team – bring in the latest and greatest from the work that is being done there.
• Allergies - bring in the latest and greatest from the work that is being done there.

- Make any changes to the diagram as learned from the FHIR harmonization.
- Write a paragraph – or section regarding FHIR and the harmonization work.

CCDA? Write a paragraph/section to that?

Patient Care WGM, Monday, Sept 11, 2017

Patient Care Monday Q1


General Plenary session No meeting from Patient Care

Patient Care Monday Q2

General Plenary session No meeting from Patient Care

Patient Care Monday Q3

Chair: EHR



Patient Care Monday Q4

Q4B Chair: Michelle Miller
Scribe: Michelle Miller



  • Approve May_2017_WGM_Madrid,_Spain:_May_6_to_May_12 -- not enough attendees who were at the Madrid meeting to approve minutes
    • Ask Emma to add WGM meeting minute approval to upcoming PC general (bi-weekly) call
  • Review schedule
  • Eyecare PSS - motion to approve: Mike/Jay - abstain (0), against (0), for (4)
    • Follow-up with OO to ask if any of the 3 implementers are server vs client (should have at least one each).
    • Follow-up with OO to ask if retinal exam findings is within scope for all ages (including infants)
  • 3 year plan -- notes are in attached Excel HL7PatientCareProduct_Matrix_2017Sep-v010
    • Ask Emma to add 3 year plan to upcoming PC general (bi-weekly) call

Q4A - FHIR workflow with OO

FHIR Workflow Update

  • Lloyd will post his slides here [[2]]
  • Agenda
    • Pattern changes
    • Pattern Changes report
    • WorkflowExample resource
    • Change request

Standardizing workflow patterns

    • workflow is about getting things done
    • Need to get the request acted on by some other parties
    • Variation of who own what
  • Runs under FHIR infrastracture and participated in by a number of different WGs
  • Conference calls 2Xweek


  • Logical models
  • defintion - points back to the orderset this is based on
  • change event.reasonNotDone to reasonNotDoneCode and move it beside reasonCode
  • Can reflect something that is 'happening'
  • Collapse event.performer to be reference with the same resource as event.performer.agent, getting rid of agent, onBehalOf ...
  • Add care tean to event.performer
  • performerFunction - what it is that they are doing - this can be an extension if it's not in the 80%


  • Collapse request.requester in the same wayas event.performer
  • Add careTeam to Request.performer
  • Add diagnosticeReport to request.reasonReference
  • add healthcareService to request.performer
  • add as 0..* Reference (coverage|claimResponse)


  • remove healthcareService from definition.performer

resource workflowExample - new resource

  • not workflow definition
  • identification and description of the actors involved
    • gives the sequence
    • gives description of what's being accomplished
    • purpose is to create a story and present in a consisten style
    • work thru a scenario where you pass back collections of resources
    • Not for implementers to use but to be used to convey a sample of what is being done.
    • Taking a collection of examples and explain how it's exchanged.
    • Change name to exampleScenario

Change request -

  • gForge 11217 - Thoughts on combining SupplyRequest, DeviceUseRequest and VisionPrescription - 2016-09 core #371

Patient Care Monday Q5: Placeholder for extra meeting if necessary

  • No PCWG meeting



Patient Care WGM, Tuesday, Sept 12, 2017

Patient Care Tuesday Q1

Chair: Laura

Scribe: Emma

[Please see here for attendance list]


  1. Skin Progress report
    1. Spreadsheet for SME input; latest changes.
    2. SOLOR authoring in process. Demo of TermSpace, publication 10/30.
    3. Target January for full CIMI publication of skin and wound assessment domain with all bindings
    4. Update to LOINC panel; update to DAM
  2. Process/methodology discussion: CIMI @ CIC Wed Q2
  3. Special Needs Children Care Plan

30 min - Essential Information for Children with Special Health Care Needs - Care Plan

60 min - FHIR/PCWG - CIMI - Skin Care model meeting Jay's Slides

  • CIMI ballot postponed
    • Jan target for full skin assessment
  • Terminology authoring in progress
    • CIMI is trying to get the concepts created by using SOLAR - SOLOR content is due to be published october
    • New use cases - tissue app, podiatry
  • Will eventually get loaded into VSAC
  • Currently working with the modeling infrastructure
  • First phase is the wound pressure injury
  • Meeting with CIC about the process and methodology
  • Discussion about data quality issue - equivalence depends on definition
    • mapping of the SNOMED codes to the CIMI model
    • Architect model approach is similar
  • Review Model request process
    • uses spreadsheet to request content. The spreadsheet is the initial input for the tooling.
    • use of present/absent - use is to qualify clinical statement. this is the highest level of the abstract model, not expected as part of the implementation.
    • Initial attempt is to have the information to get started
    • Question is the assertion, answers are in the value set
  • Podiatry use case
    • Foot wound has additional attributes
    • Identifying not only what the wound looks like but the etiology of the wound and additional attributes to understand options for treatment.
    • Using the same attributes in the model but will have different value set
  • Interest in looking at the evidentry source information - will CIMI capture the source of where the information came from? DOJ can not copy. Is it in scope that the foot wound source information was not copied from the PE 6 months ago
  • CIMI has an extensive provenance infrastruture
  • Implementation is not in the model
  • Missing extra properties that may be needed. This is the first pass with the goal of getting the process in place. Next stage will be the analysis
  • Have to start modeing based on the requirements you have. The model will evolve.
  • Project meets friday morning weekly
  • Interest from DEEDs on how to consume it. How do we reference it?
    • This is related to the governance. Need to know who is using what so if changes will need to notify the user.
  • Adverse event CIMI modeling - PC Thursday Q3
  • Challenges - more thatn one way to represent information. In a given situation, what is the information I should collect?
    • Need to differentiate the preferred way to collect the information is being dealt with the CIIC group.
    • CIIC have broad represention from care providers of multiple discipline. Specialty societies is represented.
    • Next meeting is DEC 5-6 in New Orleans as part of HL7 interoperability Conference

Patient Care Tuesday Q2

Chair: Michelle
Scribe: Emma

[Please see here for attendance list]

Nutrition PSS

  • PSS
  • HL7-Sept-2017-CCDA-Nutrition-IG
  • Academy of Nutrition and Dietician have seventy thousand national and international members
  • Majority work in clinical care
  • HITECH ACT -2009 - got involved to get non-providers input included
  • Goal is to get nutrition to go with the patient wherever they're going
  • Nutrition Standards exists
  • Contributes to key HL7 projects
  • PSS - Nutrition in C-CDA Based Care documents
    • PC as interested party or co-sponsor?
      • Patient care wants to be co-sponsor due to ownership of care plan. Elaine will be PC liason
      • Stephen moved, Jay Second - 0 abstain/0 against/18 for - motion pases
      • PC request formal content review prior to ballot. PC will get monthly updates
  • Nutrition centered use cases to support patient needs, provider needs, quality reporting and public health
  • Great presentation
  • PSS -
    • Harmonization with CCDA and FHIR will be handled as part of the analysis
    • Nutrition assessment correlates with clinical impression. Discussion
    • Requirements for vendors (in progress)
    • Modeling facilitator
    • Suggestion for CBCC to be a co-sponsor
    • Goal is a concise way to update the existing templates to support nutrition domain needs
    • Disadvantages of making section in the CDA document required when data is not always present
    • Who are the transaction partners - folks interested in implementing?

carePlan.addresses reference only condition discussion


Patient Care Tuesday Q3

Chair: Michelle Miller
Scribe: Michelle Miller



  • FHIR Admin FHIR_Ballot_Prep
    • QA guidelines have changed: FHIR_Conformance_QA_Criteria
    • New QA guidelines for value sets, profiles, etc. FMG is talking about RIM mappings, but haven't dropped it yet. RIM mappings will now be needed for extension as well.
    • Extensions will have their own FMM (can be different than core resource)
    • QA Checklist will capture date, not just 'x'
    • No PC resources are currently targeted for normative, but we can still evaluate
    • Need an updated gap analysis against workflow patterns - report of gaps will need to be evaluated to see if the gap was intentional or not.
    • What are target FMM levels for R4?
      • AllergyIntolerance - questions about reaction/AdverseEvent - is this just writing down boundaries?
      • Condition - questions about health concern/linking - need Connectathon planned around concern management, need use cases (from domain analysis) and scenarios to test and recruit implementers to participate
      • Procedure - questions about splitting Procedure (performed) vs ProcedureStatement (history/ patient stated) - need to draft resources as a starting point
  • GF#13705 Communication.topic and CommunicationRequest.topic underdefined and overlap with .reasonRequest
  • GF#13389 Clarify Communication Scope and Usage
  • GF#10352 Change Encounter or and element to remove referencial limitation to on Encounters -- Paul was not available and we ran out of time, so we did not discuss

Patient Care Tuesday Q4


Chair: Jay

Scribe: Emma

[Please see here for attendance list]


  1. Problem Status value set
  2. Negation Requirements
  3. CDA human readable rendering

Clinical Status - Stephen Chu

  • Proble status valueset - condition and allergy status clinical status
  • Agreed to two value set - both PC and SDWG acceptance
  • CQI raised a question about patient safety - PC explained the hierachy. they complained that C-CDA did not show the hierachy
  • Question - what is the solution to this issue?
  • FHIR: required to be FHIR defined but can have SNOMED mappings
  • SNOMED concepts don't have the same concept of the hierachy
  • Question: what if the condition is poorly controlled relapse?
    • Clinical judgement is made on how this is used.
    • Mixes two concepts
    • Three things: 1)whether the problem is ongoing; 2)do you want on your problem list; 3)just something you want to know because its episodic
  • Problem clinical status in CDA - active, inactive, resolve. Has nothing to do with if this is on the list or not on the list. In CDA, the problem concern puts it on the list
  • FHIR - problem list does not have anything to do with this. its all about the existance in the subject.
  • Stephen expalined the status concepts with examples
  • Vendors input at time of valuset construction - Well controlled; poorly controlled - not used as clinical status values by cerner, epic and Allscripts
  • not just used by cancer conditions but also used for psychiatric conditions
  • Not too far off from what is done. Is it worth trying it?
  • Why did we invent a different valueset for FHIR from CDA?
    • Came to the conclusion that the CDA valueset was not adequate
  • Suggestion to take well-controlled and poorly control off the list and move forward with the other values
  • Difference between the status of a problem and the state of the disease
  • Agreement these are 3 different concepts 1)disease phase - 2)response to therapy - 3)status
    • Disagreement with this definition with explanation as to how this was derived. How do we progress this forward?
  • Suggestion to take well controlled and poorly controlled in a different element. Need to represent active when it's active for the first time.
  • Agree that SNOMED need to do some work on this.
  • Next steps -
  • gForge13026 - will discuss this during the next thursday PC FHIR call
  • CCDA and SNOMED mapping will be based off the FHIR decision

Negation - Jay Lyle

  • slides
  • Have not made much progress
  • want to get it back in the Jan ballot
  • Need to do the planning for gettting this done
  • Plan on providng guidance on
    • translation/transformation
    • consistency
    • Inference
  • Group meet bi-weekly on wednesday mornings
    • Suggest making the meetings weekly meetings
  • CIMI dealt with the problem of present/absent - suggest picking one of the meetings to discuss this.
  • Tasks
    • Include examples (SDWG examples)and consumptions cases (e.g. quality measures; CDS rules)
    • Confirm classification
    • Define outcome
      • best practices
      • Policy recommendation
    • Writing

CDA Rendering - Lisa Nelson

  • Explain how to do narrative text linking where the human readable is linked with the machine part
  • Document describing how to go about linking the narrative
  • Review of the document
  • Can this be used for NLP where the entry is pulled from the text?
  • In CDA the human only looks at the human readable
  • would this be used in FHIR?
    • Opted to not include this in the FHIR core spec. Can stick ID elements where you want and place extension to be able to render.

Patient Care WGM, Wednesday, Sept 13, 2017

Patient Care Wednesday Q1

Chair: David
Scribe: Eric/Rickie


OO (hosted quarter)/Patient care

VS profileconstrains the .value and component.value to Quantity (a number and includes a unit and a few other things). CP is to relax the dataType

Will discuss futher with FM.

  • ProcedureRequest name change to service request. Will float name change on Zulip for input.

Patient Care Wednesday Q2

Chair: Brian P. (Patient Admin hosted quarter)
Scribe: Michelle Miller


  • GF#13786 - Clarify Practitioner classification extension (and PractitionerRole.specialty) -- remove extension
  • GF#13517 - has the wrong definition - update definition
  • GF#12940 - PractitionerRole should leverage existing security role valueset - update PractitionerRole.code value set, but don't use the security value set

Patient Care Wednesday Q3

Chair: Michelle Miller
Scribe: Riki Merrick



Blood Transfusion Background (55 min)

Related Zulip discussions:

Related trackers:

  • GF#13047 (request to add DosageInstructions to Procedure)
  • GF#12993 (request for a new Administration resource)
  • GF#8458 (request asking for a new BiologicallyDerivedProduct resource)

CQI - Appropriate Use Criteria (20 min) - Floyd

20170913_HL7WGM_PC_OO_FHIR_Notes Agenda review Bloodtransfusion topics: Zulip questions on FHIR side on for blood donations and organ donations BiologicallyDerivedProduct ADD link: Capture the thing that comes from one individual to another Looked at specimen and device, and that didn’t work Discussion summary of PC, OO and Pharmacy Type and cross matching are lab orders Request for blood administration – uses the same workflow as medication dispense /administration / statement Did put out zulip chat, but did not get a lot of feedback there, hope we have implementers here now: added feedback on particular order details around transfusion orders to the wiki page Cerner & Epic perspective: Derivative products are med administration Blood transfusion is special order, but in MAR we are using similar structure to medication structure like dosage etc – but that is also needed for other use cases (radiation oncology) Dan is working on IHE front on administration and then moving backwards – working with transfusion experts from Duke – derived products are handled as pharmacy For blood transfusion orders there are special order messages in v2.x with dedicated segments Do look at the v2 and v3 models and the blood donation services work get that from Patrick – we still have blood banking listserve – maybe re-energize that Need to use a resource similar to medication order = same structure is derived products limited to products off the shelf – vs live products like tissue for grafting need to cover all use cases, including radiation oncology (machine administered or implanted) Summary from OO discussion from Q1 earlier – discussed that procedureRequest needs instructions as well as may be renaming – Eric will draft Process of administering medication prior to CT scan or X-ray like constrast is medication admin Request for typing to determine the correct blood product = procedureRequest Request for supply of the blood product = SupplyRequest, though sometimes folks do specify the rate of transfusion Request for the blood units = ?? genericize medicationRequest to substanceRequest Maybe add dosage to procedureRequest – that will get the rate and the instructions – who needs to be involved: Patrick / OO, PC, Pharmacy, CQI, also include other stakeholders, like Bob Milius needs to describe the thing that needs to get transplanted = goal is May 2018 ballot – this does not currently have a separate PSS right now – might be good to focus the FHIR development, since this is aimed at discovery of requirements and this is cross-WG; do we need the business need defined FIRST before we map it into FHIR resources after that (the later may not need a separate PSS, but the first may be for DAM) – OO to sponsor Order may need more of the data elements from dosage than the medication administration For IHE work we look at adverse reaction in addition to the administration – looking to make that more generic = adverse event consumer as the actor that receives the information – this is in v2, not FHIR yet, in v2 we do need to cover the adverse event – this is not really an allergy, but can cause an adverse event Haematopoetic domain has map to the BRIDG model – can use that as CQI also maps their data elements to FHIR elements Genericize medication to substance – we do that also in CQI CQI also mapping adverse event to FHIR element Adverse event resource is owned in Adverse reaction how to handle when it is cause by something that is not an allergy Do we have implementers for this? Yes Bob’s organization Need to determine if any of the resources impacted by this project are on the normative track (observation / patient) Patient – how to tag donor vs recipient - looking for guidance that is PA question – so add them on to the stakeholder list Appropriate use criteria: Background introduction – ADD link to the CMS website: HL7 provided feedback on the AUC proposed regulation to CMS in time for the deadline Want to make these WGs aware of this upcoming needed work, since the regulation becomes effective in January 2019 – need to develop roadmap going forward OO has raised these questions with IHE a few month ago, since they have defined several of the profiles suggested for use – will need to make adjustment to these – communication between ordering, furnishing and claims system We need to harmonize these elements across all levels of the communication IHE spec is pretty close to what is currently planned, may need a few adjustments – need to add “does it conform” concept that was recently added – hopefully there should be Suggested CDS hooks for ordering provider to CDM – already have some work there Guidelines appropriate ordering (GAO) – Keith brought that to HL7 for consideration in FHIR and has been implemented, but we are now using CDS hooks, which can achieve the same goals – will be balloted in Jan 2018 ballot OATH has been given some guidance on use of OBX elements to use – there are many ordering and charting system out there – need to be sure the elements we need are actually available X12 is also working on the reporting to the billing system A37 transaction – meeting in 2 weeks on that Provider led entities = these are qualified to define the AUCs Clinical Support mechanisms = entities that have met the qualifications for mechanism function Priority Clinical areas: CAD, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, cancer of the lung, neck pain Should discuss the development for the clinical decision support with the IHE group that developed GAO, so we keep approach the same across SDOs

Patient Care Wednesday Q4

Chair: Jay

Scribe: Emma


  1. Allergy Substance ballot comment overview
    1. Key negatives
  2. Allergy resource maturity
  3. Allergy terminology harmonization


  • Allergy intolerance ballot reconciliation

Ballot Decisions

  • Persuasive comments -
    • Elaine Ayres move to accept the persuasive comments
    • Scott Robertson second
    • Rob McClure adds a friendly amendment: when the clarificatin is made, proposed change will be communicated to he commenter so the commenter can agree/disagree with the change or not
    • Elaine accepted the ammendment; Scott accepted the ammendment
    • Further discussion - Plan is to review the persuasive comments
    • Vote - 0 oppose/6 abstain/13 Approve
  • Discussion about the heuristic used that was the reason for this project
    • VA (Larry) can provide a frequency list of UNII codes - will send to Jay
    • Clinical purpose of this list is as a patient safety tool
  • Comments that need clarification from submitters
    • Plan to email request for clarification to the submitters if not present to discuss today
    • Amit move to send request for clarification to the submitter
    • Chris Hills Second
    • No further discussion
    • Vote - 0 oppose/2 abstain/18 Approve


  • Cutoff
    • Suggestion for deciding on a statistically relevant drop-off point as a policy
  • Vaccines
    • Need to determine the class of substances needed to determine the allergen.
    • Will punt to Russ and SME to assist
  • Synonymy
    • What to use?
    • rxnorm or snomed
    • this will mean systems will have to keep two codes in their validation logic
    • Discussion about cross-reactive class definition
      • Need immunologist experties to come up with process
      • This isn't only about allergy, it's about reactivity as well
  • Guidance: include or not
    • This list is an order avoidance list
    • All sort of allergy intolerances are being documented. Need to be able to use this list to map to RxNorm, snomed, etc, to support workflow
    • Broke the list up into 3 for analysis purposes.
    • Can have the same substance on all three groups
      • Enviromental Allergen
      • Metals - on the list
      • Latex, Adhesive agent - on multiple lists
    • Suggest tagging the items to determine the origin

FHIR: Maturity of the Allergy and intolerance resource

    • Should we push to move this along?
    • Stephen has interest in pushing to segregate the allergy intolerance from the reaction. If moving forward with the seperation should we wait or seperate now?
      • Suggestion to take this topic back to the thursday calls


  • Adverse event discussion is Q3 tomorrow
  • Allergy calls will resume Sept 27, 2017

Patient Care WGM, Thursday, Sept 14, 2017

Patient Care Thursday Q1

Chair: Laura
Scribe: Emma

  • HL7 C-CDA 2.1 Care Plan Document Template - Lisa Nelson
  • HL7 Care Plan Domain Analysis Model/FHIR Harmonization - Laura Heermann/EMma Jones
  • HL7 Care Coordination Services (CCS) functional model - LH/EJ
  • HL7 CDA R2 Personal Advanced Care Plan Document - Lisa Nelson
  • HL7 FHIR Care Plan Resource - LH/EJ
  • IHE PCC Dynamic Care Planning Profile- EJ
  • IHE PCC Dynamic Care Team Management - EJ
  • IHE QRPH Early Hearing Detection and Intervention (EHDI) Plan of Care- Lisa Nelson
  • HL7 Clinical Oncology Treatment Plan and Summary - Jeff Brown
  • NCPDP/HL7 Pharmacist Care Plan - Shelly Spiro
  • Care team members definition update (Laura/Emma)
  • Essential Information for Children with Special Health Care Needs - Mike Padula
  • Naming convention for Care Plans?
  • Care Plan/Care Team Implementations


HL7 C-CDA 2.1 Care Plan Document Template - Lisa Nelson/Gay Dolin

  • Challenge with LOINC care plan updates
    • 52521-2 (deprecated by LOINC)
    • Background: treatment plan, care plan, plan of care - decided one LOINC code was needed. LOINC came up with a code. C-CDA was using two codes - section code and document code

LOINC changed the definition of the section code and recommended it be the document code. Deprecated the document code. Took the deprecated code and mapped to two codes. One code for treatment plan and the other code forthe overall plan of care/advance directive which is a panel code.

    • LOINC has a meeting in 2 weeks (Sept 26-28)- strategy is to have codes that can be used as section and document codes
    • Next steps: need a tiger team to come up with a strategy and also meet with LOINC
    • Valueset for types of carePlan - gay is working on this.

Representation of problems

  • Need a common understanding of how to represent problems and make sure its represented the same way for CDA and FHIR. Need to make decisions because it effects structure.
    • ProblemStatus is an example of how there are two ways of representing status in CDA
    • Structural problem because of the wrapping of problem observation, creates 2 spots in CDA
    • ConcernAct wraps the problem observation creates the two spots
    • Concern status is about tracking the problem. FHIR has tracking ability that needs agreement with CDA
    • Preference is to discuss this topic during Thurs FHIR calls
  • SDWG is doing an errata update - will be published in the next few weeks - by end of OCT
    • Action - Lisa will send out announcement to PC listserve

Care Team

  • Function codes in VSAC
    • Who will do the work and become the steward of this valueset?
    • Have the started set - some missing codes - need to get codes from SNOMED. Then need to add them to the valueset
    • LHS has been working on the valueset
    • Patient Care owns careTeam and the valueset. If changes needed to the valueset will need to do a tracker item
  • LHS working on the CareTeam DAM
    • Relatioship between the patients and the members of the careteam and relationship between care team members.
    • Working on storyboards to reflect this
    • Next step is modeling. Planning on taking this to ballot next year

HL7 Care Plan Domain Analysis Model/FHIR Harmonization - Laura Heermann/EMma Jones

  • Published a few years ago.
  • Working on updating the DAM - Planning on how to best approach 2.0

HL7 Care Coordination Services (CCS) functional model - LH/EJ

  • IHE uses CCS FM for IHE dynamic Care Team Management profile

HL7 FHIR Care Plan Resource - LH/EJ

  • Ongoing changes
  • Concern with design of the activity part - need to determine from an implementation perspective how this will work.
  • Mapping the CP DAM to FHIR to see if FHIR is able to represent the DAM
  • ClinFHIR scenario builder tool - use this to review care plan and provide feed back on carePlan resource
  • How to find extensions? It is difficult to find extensions.
    • There is a tracker for tooling to better expose the extensions

IHE PCC Dynamic Care Planning Profile- EJ

  • Update to STU 3 - submitted and awaiting publication

IHE PCC Dynamic Care Team Management - EJ

  • New IHE profile - will be available for IHE Connecthathon Testing in Jan 2018
  • Does this profile use CDA templates? No but could be updated to do so.

IHE QRPH Early Hearing Detection and Intervention (EHDI) Plan of Care- Lisa Nelson

  • No new updates

HL7 Clinical Oncology Treatment Plan and Summary - Jeff Brown

  • No updates
  • New oncology project group in HL7

NCPDP/HL7 Pharmacist Care Plan

  • Update
    • Ballot - 18 negatives
    • 23 vendors trained to do the care plan
    • Expanded to additional states
    • Community Care of NC have been receiving care plans and have started doing the quality assessment
    • Schema validation available but no validation tools as yet. Suggestion given for update to SITE
    • MDHT - adding additional documents is a matter of adding new Jars
    • ONC is testing care plan - no rules for care plans yet in the SITE tool. For new document templates that are not in MU, will not have rules in the SITE tool
    • Pharmacy care plan ballot came out with CDA and FHIR implementation guides at the same time. provides an opportunity to assess and learn from the CDA to FHIR mapping that was done

Nutrition Care Plan - Lindsey Hoggle

  • SDWG sponsoring PSS for a nutrition care plan
    • Call times have not been set up but will come out of SDWG. Lindsey will send out call info

Care team members definition update (Laura/Emma)

  • care team function - Lisa working on the schema for entry

Essential Information for Children with Special Health Care Needs - Mike Padula

  • Clinical reference for when children tranfer to a new environment - can communicate their essential needs
    • Current status: Mapping story boards to CDA and FHIR
    • part of Care Plan calls - every other wednesday
      • May need a project specific call
    • initially doing analysis to determine if will need a new document type or will use existing CDA document type
    • Mike slides are uploaded to Tues Q1 minutes

Naming convention for Care Plans

  • Is this an issue?
  • If PC doesn't name them, LOINC will name them
  • Naming convention need is widespread and should apply to templates as well. Suggest bringing this topic up in the next quarter with the template folks
  • Topic for patient care to work on
  • have a repository for FHIR profiles - may be a question for them as well

Transforms between CDA care plan doc and carePlan resource - Lisa

  • Struggling with cutting across the sections that have linking between the sections
  • Linkages across entries need more exposure - would like for PC to take a more active role
  • Lisa will report back as she discover things or have questions.
  • Will use the care plan calls for this topic

Patient Care Thursday Q2

Chair: Stephen
Scribe: Emma


Joint meeting with SD and Templates


Template update (Matt, John)

  • Template versioning
    • ITS passed ballots in May. Resolved all the negatives. Have not issued the final document
      • Feedback: ITS is a problem. Have 3 variations that are not exchangeable. Processing templates using different changes. Applying errata can become a problem.
      • Action: Need to come back to this issue with a governance approach
    • Some question about versioning of templates
      • How to manage a IG after publication and there are technical correction? It's not possible to issue a new version when a govt agency has approved a particular version.

Govt agency can issue a spreadsheet to deal with errata

      • SDWG implements erratas on the version the template is on and it does not cause versioning issues. The list of errata is made available view a download kit.
      • the list or set of list gets published with the standard.
      • Periodically applies the errata to the template with a list of recent changes
      • Version is applicable to designers - make a new version of the template
      • Need rules around when to make a new version
        • Need to list a set of possibilities -
    • Exploring a PSS for creating a gap analysis of moving from one representation to another
  • Naming convention issue
    • this question came up with CarePlan
    • Are there a set of priciples for naming convention?
      • Template does not have one as yet. Have been concentrating on how to produce and share templates
      • Have an informance document for creating a registry to be used to manage template across institutions
      • FHIR registry just announce. Lantana, MDHT, Art Deco have defacto registries. Currently human process
      • Action: Part of a governance solution that is across the board - CDA and FHIR

Structured Doc/CDA update (Gay)

  • Update provided in Q1 - see meeting notes

Allergy/Intolerance harmonization (Elaine)

  • Severity has been reduced to 3 code values
  • Heuristics in CCDA for capturing substance
    • PC balloted work to identify most frequent allergens in a valuset that PC will maintain in VSAC
    • This work will impact CCDA, FHIR work
    • Can updated allergy templates point to this valuset
    • Note - this is a suggested valuset but always have the ability to enter something else.
    • Allergy list has become actionable
    • Would like to overlay criticality - e.g. if peanut allergy on a list, it's highly critical and should be actionable
    • SDWG should take a note of this valuset
    • Debate for a template that is not implementable

Adverse Event

  • FHIR resource originated in RCRIM and PC has agreed to take this on. Relatively new resource
    • Will be doing this work with BRR
    • Ongoing work discussion during the PC FHIR call


  • Need a way to represent preferences in FHIR
    • Difficult to do this with the CDA mapping to FHIR - currently using observation
    • CP DAM addresses preferences. Examples provided on when preferences are needed
    • Need to create preference resource
    • Pharmacy did not find this on care plan

Adverse Reaction Resource

  • Finding a need to have an adverse reaction pattern e.g. to be used for documenting reactions during blood transfusion
  • Are implementers using manifestation under allergies?
    • Manifestation can change from time to time
    • Concept of criticality is applied at the condition level
    • How is presumption of conditions captured? This is a good example for allergy and a good use case to consider

Clinical Status Valueset

  • Overview of Stephen's slides
  • This approach was previously approved by SDWG, PC
  • Will continue this discussion on PC FHIR call on thursdays

Patient Care Thursday Lunch: Co-Chairs Meeting

Chair: Michelle Miller
Scribe: Michelle Miller

Attendees Elaine, Jay, Michelle, Emma, Stephen, Mike, Laura


Patient Care Thursday Q3

Chair: Michelle Miller
Scribe: Michelle Miller



  • CIMI is working on patterns, including AdverseEvent and AllergyIntolerance. Weekly requirements meeting on Tuesdays
  • BR&R update on ResearchStudy and ResearchStudy - plan is to semantically align with BRIDG model - subgroup within BR&R - goal is to identify scope and boundaries
  • Elaine's presentation FHIR-AE-San-Diego-2017.pptx
  • FHIR_Adverse_Event_Resource Wiki page
  • GF#11021 Increase cardinality of substance and make certainty relation to substance, not reaction
    • Past ClinFHIR discussion - first time, allergic reaction -- it's NOT an adverse event (because no one knew)
    • The resulting condition is not the adverse event, but rather the adverse event is the adverse workflow
    • What is the boundary between between event vs reaction? Is it driven off of regulatory reporting requirements or driven by the distinction between an admin substance vs event?
    • Reportable event is not equivalent to AdverseEvent or AdverseReaction
    • Why do we need anything more than Condition to represent the rash? Which elements are missing on Condition?
    • Reaction has 2 sides to it: symptom (describable through condition) + assertion that there is a causal agent
    • Condition lets you establish relationships of A caused B
    • AdverseEvent can be used for reporting, but use it for clinical
    • Lloyd's summary
      • Observation -- any measured assertions (temperature, discoloration on arm)
      • Condition -- diagnosis, tracked, managed, has life cycle evolution
      • AllergyIntolerance -- propensity or risk of reaction when exposed to a substance
      • AdverseEvent -- something bad that happened or almost happened, but let's determine WHY from a risk reduction perspective -- it may result that a patient has an allergy or change to protocol or stop drug from going to market. It is something to track and evaluate.
    • Do we need to rename AdverseEvent (didn't name it AdverseReaction since not everything in scope is a reaction - e.g. patient fell)
    • Multiple views of the resource - view as used for reporting to regulatory agencies as part of internal risk management boards as well as view internal to care team while they try to figure out what is going on.
    • Actions taken to reduce risk (e.g. put up bed rails as part of protocol) is NOT the same as a potential (near miss) event, such as practitioner caught patient who fell.
    • Need to harmonize with V2
  • GF#13302 Vocabulary issues with AdverseEvent
    • If using AdverseEvent is used for different purposes, then don't restrict to a code and one coding system
    • We don't need to nail down codes, variation exists per regulatory system. For now, look for existing code systems, such as V3. Let implementation guide determine category value set. Relax cardinality.
    • AdverseEvent.category - change cardinality to 0..*, CodeableConcept, preferred binding

  • GF#13698 AdverseEvent.suspectedEntity.instance should allow CodeableConcept

Thrusday Q3

  • Clinical Statement (CS) Pattern update
- CS pattern in holding pattern. No new work done. Nothing new to report.

Patient Care Thursday Q4




Patient Care WGM, Friday, Sept 15, 2017


Patient Care Friday Q1




Patient Care Friday Q2




Patient Care Friday Q3




Patient Care Friday Q4