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Minutes: Michael
*Stan Huff presenting CIMI viewpoints: CIMI has now become a HL7 workgroup.
*Stan Huff presenting CIMI viewpoints: CIMI has now become a HL7 workgroup.
*Searching collaboration between CIMI and other WG's that have DCM's.
*Searching collaboration between CIMI and other WG's that have DCM's.

Revision as of 19:56, 13 January 2016

Orlando, WGM - January 2016 Patient Care WG Meeting Approved agenda:

Orlando WGM - January 2016. Patient Care WG Meeting Meeting Minutes

  • Sunday, January 10 - International Council Meeting
- No PCWG meeting

Patient Care WGM, Monday, January 11, 2016

Patient Care Monday Q1

Attendees Jay Lyle, Russ Leftwich, Elaine Ayres, Emma Jones, Michelle Miller, David Pyke, Larry McKnight, Michael Tan

Chair Jay Lyle

Scribe Michelle Miller

Agenda check

Approval of prior minutes (Atlanta)
David/Emma: 0 -2 abstain – 4 approved

Week's agenda Approval for Elaine to be a co-chair designee for the week. Michelle/Emma: 0-0-7

Anesthesia wants to meet.
Stephen suggested to Anesthesia already, but they may only be here Mon/Tues. Suggested times:

  • Monday Q3 (same time as workflow)
  • Tues Q5

SDC wants to discuss Health Concern (and PC wants to discuss goals with ONC) SDC can’t attend existing session. Jay will reach out to SDC with options:

  • Wed Q2 (Emma, Elaine could attend)
  • Wed Q3 (Genomics declined, so FHIR topics such as Questionnaire/QuestionnaireResponse, Clinical Impression)
  • Thurs Q1 check with OO to see if PC needs to attend

Elections Please vote!

Workgroup Health Good job! Keep an eye on

  • Decision making processes
  • SWOT
  • Charter
  • Harmonization - Rob H. was designee
  • 3 year plan – list of projects that are in the register (some are active, proposed, linger); review and see if any can be closed out;

3 yr planning Jay will own cleaning up this week. Send Dave Hamill an email.

  • Detailed Clinical Models Release 1 (320) - not an open project, just needs to be recirculated
  • Care Provision: Assessment Scales Topic (664)– never got published, ask William about that
  • HL7 Care Coordination Service (CCS) (924) – ready for publication; Laura will clean up and submit it for publishing; publish for HL7 members only for 90 days before publish to the public
  • Care Plan Initiative (932) – DAM not published; take all story boards, except one, and move them to the appendix; Laura owns that action item
  • V3 Allergy and Intolerance Clinical Models (1004) – published and available for comments; project is done; close project
  • Care Plan Clinical Models (1085) – check with Laura to see if it can be closed
  • PCWG Develop FHIR resources and profiles for the second DSTU release.

New projects None

FHIR Update from Sunday’s Q4 meeting

  • Maturity Review - what to ballot when (2.1 in May 3 in Sept?) – need work groups to look at resources and find out which resources are projected to have which maturity levels by next release; FHIR health –DSTU comments – check that the changes were made; any outstanding issues?
    • Need clarification in FHIR maturity model to know if there is production use (instead of production systems) and/or what constitutes a connectathon
  • Naming – FHIR could be dropping DSTU label because it isn’t part of ANSI’s process; FHIR is thinking about calling it informally a “working” standard, but Patient Care’s concern is credibility about losing the “draft standard” label. The maturity levels are per resource, not for the entire standard.
    • David will own drafting Patient Care’s statement/response back to FHIR
  • Error list in FHIR build – confirm with Lloyd that he is fixing any errors on Patient Care’s error report

Adjourn 1/11/2016 at 10:33am Eastern

Patient Care Monday Q2

No PCWG meeting

Patient Care Monday Q3

No Patient Care hosted meeting; Patient Care attending FHIR Infrastructure - Workflow meeting

Patient Care Monday Q4

No Patient Care hosted meeting; Patient Care attending FHIR Infrastructure - Workflow meeting

Patient Care Monday Q5: Placeholder for extra meeting if necessary



Patient Care WGM, Tuesday, January 12, 2016

Patient Care Tuesday Q1


Minutes: Michael

  • Stan Huff presenting CIMI viewpoints: CIMI has now become a HL7 workgroup.
  • Searching collaboration between CIMI and other WG's that have DCM's.
  • CIMI produces Clinical Information Models. The thought behind the models is, that systems do not need to know the structure of information from other systems. It uses the information models from webservices to map and share data.
  • The CIMI produces clinical requirements.
  • CIMI's goals are to create a shared repository of detailed clinical information models.
  • The repository is free of license.
  • Models contain formalism:
    • Achtetype definition language (ADL)
    • Archetype modeling language (AML).
    • Models have a binding with a value set.
  • The model can be rich and full, while the implementation only uses a small part of the CIMI model.
  • How should the repository look like?
    • It does not exist yet.
    • It should contain a name, status, version, isosemantic familiy, ownership, approval.
    • What is the relationship between CIMI and the PCWG.
  • Jay draws the landscape of CIMI, DAM's, DCM.
  • What should we do to accomodate the CIMI group? Susan suggests to pick up allergies and intolerances as an example to see how this would work out. Skin intolerances/skin assessment? A project would be started with CIMI as driver and PCWG as collaborating WG to investigate how this would work out. Is the PSS a study or a demo. The study would include a demo. The demo would include an implementer.
  • PCWG would first like to review the PSS. This does create some pressure, because the deadline for PSS is January 22nd.
  • William places a motion to have undertake a pilot to use skin assesment for the collaboration between CIMI and patient care. Steve Hufnagels material is available.
  • Steve Hufnagels PSS will be distributed among PCWG to review this week, before giving approval to co-sponsor the PSS.
  • CIMI will send a invitation for a joint meeting with PCWG for Montreal on Tuesday Q1.
  • action item PC. The PCWG will review the PSS, before the deadline for new PSS and provide feedback to CIMI.

Patient Care Tuesday Q2

Chair: Michael Tan
Scribe: Michelle Miller


Last Name First Name Organization
Cole George Allscripts
Dasgupta Amlan Epic
Dolin Gay Intelligent Medical Objects (IMO)
Fine Steven Cerner Corporation
Goossen William Results 4 Care bv / HL7 Netherlands
Grieve Grahame Health Intersections Pty Ltd
Jones Emma Allscripts
Knee Simon HSCIC
Lyle Jay Ockham Information Services LLC
Majeed Raphael
Mandel Joshua Boston Children's Hospital
Marquard Brett River Rock Associates
McKnight Lawrence Cerner Corporation
Miller Michelle Cerner Corporation
Moore Sean Epic
Nelson Lisa
Pyke David Ready Computing
Shapiro Ron Qvera
Skapik Julia Office of the National Coordinator for Health IT
Torres Andrew Cerner Corporation
Wang Yunwei Intelligent Medical Objects (IMO)
Wright Colin McKesson Corporation
Jorgenson Don Inpriva
Terry May Flatiron


Health Concern vs Problem

Patient Care's view

  • A concern is a higher level abstraction than the problem (ex. concern of obesity) that connect problems into a concern
  • A concern connects events and tracks progress over time (what started with and what it has become) - Example: back pain grows worse into hernia
  • DAM is sufficiently abstract such that it supports knowing who expressed concern; DAM can handle either objective or subjective
  • Patient Care DAM is saying concern is greater than problem; problem can be a subset of concern
  • Concerns are both Problems and Additional Health Concerns - and each is represented in its own CDA section

Structured Doc's view based on ONC's proposal (attachment in Patient Care listserv [1] )

  • Active problems are in the problem concern section
  • The "Additional Health Concerns" section is used for additional concerns, such as concerns from the patient or other care team members
  • Clinician owns the problem list whereas concerns are open to others, such as chaplain
  • Note: Unhealthy family relationships and drug/alcohol abuse could be concerns, but may not be endorsed by patient
  • Clinicians don't need to reconcile additional health concerns, but there is no legal requirement for the clinician to reconcile problems on the problem list - yet they should reconcile a concern of sick parent after parent is deceased
  • Goal is to allow the patient and other care team members to express concerns (e.g. financial instability, homeless) to flow into the longitudinal care plan
  • The MU requirement is to allow health concerns to be entered into the record
  • Intent is that additional health concerns are viewable, clinician considers them, clinician follows them, but clinician doesn't necessary endorse (or agree with) the concern; The clinician should ask patient about concerns, but not the clinician's job to agree or disagree with patient.
  • The Problem concern is more objective whereas the Additional Health Concern section is more subjective
  • The Additional Health Concerns section is not intended to duplicate the concerns in the problem concern section


  • Motion is for Patient Care agrees that the ONC proposal (attachment in Patient Care listserv [2]) is not in conflict with the DAM
    • Jay/Larry: 0-abstain; 0-negative; 22-approval
  • Motion to recommend that SDC modify the ONC proposal: When the document contains both a Problem Concern and a Health Concern section, then the section title will be the "Additional Health Concerns" and keep the same LOINC code.
    • Jay/Brett: 1-abstain; 1-negative; 20-approved

Patient Care Tuesday Q3

Present: Laura Heermann Langford - Chair, Elaine Ayres - Scribe Attendees: Patty Craig, Ewout Kramer, Eivind Kristiansen, Oyvind Aassve, Donna Quirk, Amlan Dasgyli, Daivd Dunering-Stuekl, Justin Schiirle, Casten Quinlan, Senlthil Nacimuthen, Joe Kunisch, Bruce Bray, Larry McKnight, Martin Rosner, Peter Hendler, March Hadley, Mark Kramer, Bryn Rhodes, Julia Skapik, M'Lynda Owens, Muhammad Asim, Andrew McIntyre, Kensaku Kawamoto, Yan Heras, Tony Schweth, Latasha Archer, Daniel Lanphelt, Ann Phillips, Juliet Rubini, Charis Markle, Non Hall, Nancy Orvis, Graham Grieve, David Sattara, Matt Burton, Michael Tan, Lenel James, Richard Esmond, Claude Nanjo. (41)



  • Care Plan and Order Set Resource (CDS)
  • Updates to C-CDA and updates to CQI products - allergy content
  • QRDA and exchange of provider information necessary for quality reporting

Care Plan and Order Set Resource

The Care Plan takes a multidisciplinary point of view. An order set would contribute to the overall plan for the patient. In the care plan model - the care plan is in the middles with goals, risks, problems and the health care team are associated with the care plan. With an activity will see orders. an order can be a single order or an order set. So, from a care plan view, not repetitive to have a resource for order set. An order set is a natural component of a care plan. Orders may need to be elevated within the model to be more visible.

Are there descriptions or definitional items that assist with building order sets? Can discuss the various levels of a care plan. Can have goals related to all issues or one issue. Can have an entire care plan around one condition, or topic. Plans can be nested. The FHIR Care Plan was created without necessarily aligning within the Care Plan DAM. Now harmonizing the two. Will the FHIR Care Plan go through changes in the next release? This is unknown, but could be likely. For the proposed order set resource -- from a care plan perspective would point to the order set resource.

Care plan vs. care process model? Could use the care plan model as a care process model. However, current model addresses data only, not authority or process. Is this a point in time or over time plan? It is designed to be both a static plan snap shot as well as a longitudinal plan. Designed to be fluid between care team members. Is it definitional -- e.g. for a patient with Diabetes do this specific plan of care -- can use it in this way. It can also be customized to each individual patient. For a protocol (form) plan of care, may not have preferences or barriers. The model is designed to be flexible and adaptable to various care models. For exchanging or sharing plans, how might this work. The standard does not mandate consistency but encourages it.

Looking at the order set build in FHIR - the meta data is harmonized with HQMF reference. The library data elements applies logic based on condition (not the FHIR resource). The orderable items are references to other resources like a med order with any number of items. Are these prospective or retropective -- probably neither. This is a point in time. In the RIM have mood codes, in FHIR have deinitional resources as well as prospective vs. retrospective states. CDS is the "owner" of the order set resource.

A care plan may have a dependency on the order set -- to keep up the lifecycle of the care plan. Can you use order sets without a care plan? Can an order set be a proxy for a care plan? Actual care benefits from the context of the care plan, rather than a list of orders. This enhances the coordination of care. The order set is actually similar to a care plan template. Future -- include CDS/CQI for Thursday FHIR calls. Same schedule for PC/CDS/CQI/FHIR for Tuesday Q3.

CQI and Allergy Topics The issue is the consonance between C-CDA version and derivative QRDA products. Note that the development cycles are not the same. CQI asks that if PC/SDWG makes a change that will impact the QRDA, changes should be submitted to CQI as well.

CQI White Paper to look at use cases for QRDA Data from provider to provider related to quality measures. Are there any standards for continuity of care data outside of QRDA? Orders a mammogram but returned data may not be sufficient for quality reporting measures. The Care Coordination Service may address this issue (Patient Care and SOA).

Patient Care Tuesday Q4

Chair: Elaine Ayres
Scribe: Michelle Miller

Last Name
First Name Organization
Aassve Oyvind HL7 Norway
Ayres Elaine NIH/Clinical Center
Brown Jeff American Society of Clinical Oncology
Burgess David Laboratory Corporation of America
Campbell Keith U.S. Department of Veterans Affairs
Couderc Carmela Intelligent Medical Objects (IMO)
Doerr Lisa McKesson Corporation
Gonzaga Zabrina Lantana Consulting Group
Grain Heather eHealth Education
Hausam Robert Hausam Consulting LLC
Hoggle Lindsey Academy of Nutrition & Dietetics
Jones Mark Orchard Software
Kreisler Austin Leidos, Inc.
Kristiansen Eivind National ICT
Lyle Jay Ockham Information Services LLC
McClure Robert MD Partners, Inc.
McKenzie Lloyd Gevity (HL7 Canada)
McKnight Lawrence Cerner Corporation
Merrick Ulrike Vernetzt, LLC
Miller Michelle Cerner Corporation
Nanjo Claude Cognitive Medical Systems
Nelson Lisa
Owens M'Lynda Cognosante, LLC
Parker Craig Intermountain Healthcare
Patterson Dennis Cerner Corporation
Quirk Donna Lexington Medical Center
Rhodes Bryn Database Consulting Group
Schueth Tony Point-of-Care Partners, LLC
Shabo Amnon Philips Healthcare
Solbrig Harold Mayo Clinic
Tan Michael NICTIZ Nat.ICT.Inst.Healthc.Netherlands
Taylor Sheryl National Institute of Standards and Technology
Wang Yunwei Intelligent Medical Objects (IMO)
Warner Jeremy Vanderbilt University Medical Center
Nguyen Viet Systems Made Simple
Haug Peter Intermountain Healthcare
Boumann Steven McKesson Corporation
Gerlach Chuck McKesson Corporation
Richesson Rachel Duke

Problem statement
The ways current interoperability standards handle negation or propose to do so,

  • are inconsistent & may not support transformations
  • may not support representation requirements (e.g., patient does not have ebola)
  • may not support computation requirements (e.g., description logics constraints)

Motion to approve problem statement passes: Viet/Jay: 3-abstain; 0-negative; 39-positive

Goal statement
Draft: Provide concrete requirements from clinical experts to interoperability solution designers to enable these designers to ensure that their solutions meet requirements, including.

  • information requirements & examples ("assert absence of symptom"; "no rash")
  • impl/communication requirements (how do I represent "no rash")
  • transform requirements (?)
  • [other, e.g. DL negation concern]

Do we agree that we need a consistent approach to negation except where requirements prevent it?
FHIR design is driven by implementation requirements.
Assume consistency until told about exceptions, but is consistency is prioritized higher than other things that are good to have, such as quality
Default position is that you can assert semantics

Example Use Cases
Clinicians on FHIR - via the process of testing FHIR resources, Clinicians on FHIR will identify issues that warrant additional analysis; create use cases to test negation

Atlanta (Oct 2015) Clinicians on FHIR discussed the inability to communicate negated family member history

Note: Negation can be handled via terminology or the information model.

Clinical certainty (no known vs not known) -- categories of negation

Consider regulatory requirements (no known problems)

There are some older project scope statements (PSS), but need to see if they are still appropriate to determine if a new PSS is needed or not. Suggested that we create a new PSS.

Motion: Create PSS to define negation requirements Keith proposed amendment to include several approaches and evaluation of approaches to solve the issue Note: CQI should be involved since they recently discussed and may have some resolutions Vote: Jay/Rob 0-abstain; 0-negative; 37 positives

Contributors going forward will include SD, OO, FHIR, CQI, CIMI, Vocab
Keep the same WGM session in May 2016, with the addition of CQI

Patient Care WGM, Wednesday, January 13, 2016

Patient Care Wednesday Q1

Present: Chair: Laura Heeermann Langford, Scribe: Laura Heermann Langford, Presentor: Mike Padula, Attendees: Russ Leftwich, Gaye Dolin, Larry McKnight, David Pyke, Masoud Hosseini, Sylvia Thun, Dominik Bremman


  • Review of Child Health's work re: Essential information for Child with Special Needs.
  • Discussion of how this document is useful beyond pediatric patients. But could be used with others with special needs, chronically ill, repetitive visits etc.
  • It is becoming apparent how important the style sheet is to the overall use of the document. Style sheet is not currently part of the scope. Explored options of participating in the style sheet competition - or perhaps hold a separate competition just for this project.
  • Comment re: the use of coded data and textual data. There may be a need to have more textual data.
  • Discussion on how much and methods to use to provide more guidance on the style sheet. If we could get more information out it is believed providers could and would encourage their vendors to implement it.
  • Method of delivery (elelctronic/paper) is also an important part of the overall workflow and design. It is reality that the use of electronic tools is targeted, but for some instances (camp) a paper document may also be needed.
  • The relationship between this document and the Care Plan is tight. This document may be the shortened "tweeted" version of the care plan. Would like to explore how the content for each is entered and reused to accommodate the needs of both.
  • Next steps
    • clean up the storyboards to include a representation of the output (the data elements used and what would be included in those data elements) include things like "the parents provide access to xxxx".
    • make one storyboard about the paper document - (reality of the need)
    • explore companion guides.... is this a companion guide?

Patient Care Wednesday Q2

Present: Elaine Ayres, Susan Matney, Martin Hurrell, John Walsh, Lori Singer, Larry McKnight

Minutes: This session was a brief update from the Anesthesia WG. The Anesthesia WG is continuing to work on the Anesthesia DAM and hope to ballot within the next six months. The DAM includes use cases, UML models and SNOMED CT coding. At this time, the co-chairs of the Anesthesia WG have encountered funding difficulties for co-chairs. The group will continue to work on their projects but the co-chairs have spoken with HL7 HQ about alternative administrative options for the group. Medical Devices has expressed an interest in supporting ongoing Anesthesia work. A final resolution is still pending, but Anesthesia will keep PC updated on status.

Patient Care Wednesday Q3



Patient Care Wednesday Q4



Patient Care WGM, Thursday, January 14, 2016

Patient Care Thursday Q1



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



Patient Care Thursday Q3



Patient Care Thursday Q4



Patient Care WGM, Friday, January 15, 2016

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

(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


No Clinician-on-FHIR session (to be concluded Friday Q3)

PCWG will meet if there are topics of interest