September 2016 WGM Baltimore: Sep 18 to Sep 23

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Baltimore, WGM - September 2016 Patient Care WG Meeting Approved agenda:

• Patient Care WGM September 2016 Baltimore_draft_v013

Note - All PCWG members: Due to Plenary Sessions and joint meetings with other WGs, the PCWG Administrative and House Keeping meeting quarter has been moved to Sunday Q4. Please join this meeting as there are important agenda items that need to be discussed and approved by PCWG members. Thank you

Baltimore Plenary and WGM - September 2016. Patient Care WG Meeting Meeting Minutes

• Sunday, September 18 - International Council Meeting

- No PCWG meeting

Patient Care WGM, Monday, May 19, 2016

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Monday Q1

• Plenary Session

- No PCWG meeting

Monday Q2

• Plenary Session

- No PCWG meeting

Patient Care Monday Q3

Present:

• Jones, Emma (Allscripts)
• Lyle, Jay (Ockham Information Services LLC)
• Mandel, Josh (Boston Children's Hospital)
• McKnight, Larry (Cerner Corporation)
• Miller, Michelle (Cerner Corporation) -- chair/scribe
• Shekleton, Kevin (Cerner Corporation)
• Tan, Michael (NICTIZ Nat.ICT.Inst.Healthc.Netherlands)

Minutes (joint with FHIR-I):

PC agenda includes gForges related to Condition.category and scope of Condition

-- http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10091 QA: switch category value set to SNOMED

-- http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10404 ask for balloter feedback on data type and binding strength of category

-- http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10611 add more codes to value set for problem and concern

-- http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11156 add more codes to value set for problem and issue

-- http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10614 which category to use when it's a condition due to a procedure in the past

-- http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10662 medical history

-- http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10090 QA: include concern in scope

-- http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11211 support for required binding strength of Conditon.category

-- http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10544 Add condition extension(s) to represent a role in context of Condition.encounter (e.g. Primary/Sequence Admit Discharge etc.)

Discussion, but no vote....

Condition.category 0...* CodeableConcept with extensible binding to value set with codes:

1. Chief Compliant -- in context of encounter
2. Symptom -- review of systems or HPI - very close to "S"ubjective of SOAP
3. Past Medical History - includes conditions as a result of procedures
4. Assessment Problem from "A"ssessment and "P"lan (of SOAP) -- includes diagnosis
5. Problem on Problem List -- if homeless or financial barriers or lack of transportation are being managed, then it could be a problem; clinician expresses concern about social history; can be patient-stated concerns (doesn't need to be on a clinician's problem list) such that asserter will differentiate between them -- could include risks / fears as well.
6. Discharge Diagnosis -- in context of encounter
7. Billing Diagnosis- in context of encounter, In US, would have ICD-x (one problem has 0..* billing diagnosis codes)

or

Condition.category 0…1 CodeableConcept with extensible binding to value set with codes:

1. Billing Diagnosis - In US, ICD-x, in context of encounter
2. Problem - In US, SNOMED, on the "problem list" and managed over time by provider - includes pregnancy
3. Other Concern -

Other discussion topics:

• Category is like the C-CDA Problem Type, but hard to define codes to be mutually exclusive
• Use Observation for exam findings
• Use FamilyMemberHistory
• Use Questionnaire/Observation if captured as part of Social History

Patient Care Monday Q4

Present:FHIR WG, OO WG

Minutes:

Reviewed the following GForge Ballot comments

• Resource: DiagnosticRequest
  • "Stage" is a poor name #11190 [1]

• Revamp scope and direction of workflow module #11492 [2]

• Additions to Definition Pattern #11466 [3]

Patient Care Monday Q5: Placeholder for extra meeting if necessary

Present:

Minutes:

Patient Care WGM, Tuesday, May 20, 2016

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Patient Care Tuesday Q1 FHIR/PCWG/ECWG/CIMI

Agenda

• SDC update from CIC (~ 15 min) - CIC not present
• CIMI - Skin Care model meeting
  • Recap patterns from yesterday (Q4 CIMI semantics)
  • Review elements for Skin exam question & Lesion in spreadsheet
  • Meeting agenda Jay's Presentation

Present:
Attendees:

Last Name	First Name
Emma	Jones (Scribe)
Laura	Heerman (Chair)
Stan	Huff
Nona	Hall
Steve	Hufnagel
Robert	Tray Nall
Jay	Lyle
Harold	Solorfa
Linda	Bird
Patrick	Langford
Bryn	Lewis
Rien	Werther
Susan	Matney
Russ	Leftwich
Larry	McNight
Inger H. S.	Khateeb
Dan	Soule
Jim	McClay
Brian	Scheller
Margaret	Dittloff
Michael	Tan
Richard	Esmond
Andrew	McCaffrey
Shafa	al-Showk
John	Kilbourne
Steve	Emrick
Marie	Swall
David	Pyke
Dan	Morford
Richard	Kavanagh
Simon	Knee
Sadamu	Takasaka
Masaaki	Hirai
Yukiuoli	Koniski
Kurt	Allen

Minutes:

• PSS from CIMI with request for patient care to be co-sponsor
• Jay presenting - PC CIMI POC
  • Scope tightened to exclude drugs, devices, conditions.
  • Limited to physiologic assessment
  • Using the assessment pattern - question and answer. Skin color is an example.
  • Added in ability to assert things like wounds and lesions.
  • Need to be able to associate the asserted thing with the assessment.
  • Patterns align with SNOMED CT concepts models but is not the same as SNOMED CT.
  • Model as a physical examination observation
  • CIMI demonstrated what they are trying to achieve as far as the modeling.

• Pressure ulcer advisory changes - CIMI has done a gap analysis identify changes
  • In the last year some of this has changed - instead of pressure ulcer, it's now pressure injury
  • ONC has a version that was developed as part of a grant - not based on a modeling paradigm.
• CCDA wound observation is not correct - working with CMS on fixing it.

• Suggestion that data set and data elements for DEEDS to be used to create CIMI models.
• Clinical LOINC codes can be used to transform into the modeling if the pattern is known. Need a process to use especially if already has a defined code system.

Stephen Hoffnagel - PSS - Investigative Study "Information Model Integration"

• Currently doing a pilot.
• Extend an invitation to Patient Care to participate
• Has slides - will send to PC list serv (has not come thru as yet)
• Overview presented
  • Foundation of a Learning Healthcare System is accurate, computable, data starting with the integration of CIMI, FHIM, DAF, etc.
  • FHIM value is used very little
  • Objectives
    • Accept various models and provide a suite of clinical models
  • requesting the involvement of patient care - they are working with Susan and Jay already
  • Involvement include assisting with prototype of the project
  • Participate in meetings
  • Follow the work they are doing
  • See if the pilots are of interest to patient care
  • Govt agency wants to use the CIMI modeling, CCDA docu, FHIR
  • Need to involve patient care in some way for the clinical pieces
  • Susan document is the PSS for the work with the govt agency.
  • Jay is aware and will bring more info to Patient care.

Patient Care Tuesday Q2

Present:

• Michell Miller ( chair)
• Michael Tan ( scribe)
• Viet Nguyen
• Dennis Patterson
• Rik Smithies
• John Donnelly
• Craig Parker
• Rashedul Hasan
• Jim McClay
• M'Lynda Owens
• Larry McKnight
• Tim Blake
• David Tao
• Dan Soule
• Joshua Mandel
• David Pyke
• Simon Knee
• Geoff Low

Minutes:
Voted on resolution to gForges (from Mon Q3)

Condition.category 0…* CodeableConcept with example binding to FHIR-defined value set with codes:

1. Encounter Diagnosis – point in time diagnosis (e.g. physician, nurse) in context of encounter
2. Problem List Item – an item on a problem list which can be managed over time; which can be expressed by either a practitioner (e.g. physician, nurse), patient, or related person

http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11117 Update search type for the "abatement-info" search parameter. - 2016-09 core #271
Resolved: Rename abatement-info to abatement-string and change type to a string

http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11158 Condition.abatement from 0..1 to 0..* - 2016-09 core #312
Resolved (Not Persuasive):
abatementString can be used to convey edge use cases like 2-4 months in 1985 (when date is not known)
abatementPeriod can be used to convey specific dates in 1985 (e.g. 1/1/1985 through 4/1/2985)
Resource history/versioning can be used to track multiple abatement periods

http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11212 BodySite should be a reference to the resource instead of a just a codeable concept - 2016-09 core #366
Resolved (Not Persuasive): Related to http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10735 An extension (http://hl7.org/fhir/extension-body-site-instance.html) can be used, where needed.

Patient Care delegate to SOA meeting (Laura and Emma)

Publication of CCS update provided by Laura Heerman

• Laura provided update on where in the process the publication request is
• Ken Rubin/cc Diana will proof read after Laura sends to Ken (diana.proud-madruga@va.gov )

CCS OMG submission Update provided by Ken Rubin

• OMG met last week
• Submitters wants to extend the dates - Mediscape is requesting to open the gates to allow new submitters. Open for submitters until 12/31/2016. Working with the State of New York to become submitters
• Old submission is thrown out
• New submission date is march 2017.
• Technical updates -
  • Assessing how much they want to base the spec on FHIR
  • Expect patient care to provide resources around care plans
    • Encourages Patient care to be part of the submission team and drive the submission
    • Next steps - continue to have a joint meeting. Target Thurs Q1 for SOA to join PC care plan report out meeting.
    • HL7 Participate as supportive with periodic attendance at OMG. HL7 has a member vote in OMG matters. 2 times a year to go to meeting.

Scheduling service:

• Couldn't get any interest in the past
• Relates to CC - timing right
• Convene a group involved in the project
• Has a rough draft PSS - will do the heavy lifting. PA agreed to be the primary owner - SOA, PHIR, PC are co-sponsors. No specific ask of PC
• Relationship with FHIR - in the process of figuring out what adaptation is needed. Very interested in scheduling using FHIR. FHIR will be vetting the new process. PA folks know it is something new.
• Does PC have enough interest to be listed as co-sponsors? Will take to the WG for voting. Can indicate level of involvement - quarterly involvement
• Meetings Scheduling - currently meeting Thursday at noon EST. Planning STU Jan 2018
• Next steps: SOA is working on new PSS
• Patient care has expressed interest in the Scheduling service.

Patient Care Tuesday Q3

PC hosting CQI and CDS (not present)

Present:

• Laura Heerman Langford (Chair)
• Emma Jones
• Juliet Rubini
• Anne Smith
• Leslie Kelly Hall
• Chana West
• Linda Michaelson
• Paul Denning
• Marc Hadley
• Bryn Rhodes
• Angelique Cortez
• Jamie Parker
• Stan Rankins
• Robert Koyes Telligen
• Kanwarpreet Setti
• Viet Nguyen
• Larry McKnight
• Walter Surez
• Michael Tan
• Chris Millet
• Seth Blumenthal
• Michelle Miller
• Margaret Dittloff
• Sheryl Taylor
• Muhammed Asian
• Martin Rosner
• Robin Williams
• Shafa Al-Showk
• Johanna Goderts
• Oskar Thurman
• Alex Connor
• Patty Craig
• Mary Visceglia
• Lee Surpregnant
• John Hutem

Minutes: Agenda

CCDA harmonization with QRDA and CQI

How to engage clinicians across workgroups on topics

• Julia suggests a monthly call for clinicians to participate
  • Used to provide a unified clinical voice
  • Proposal to increase communication by consolidating meetings around common content
  • Viet suggests finding the clinicians that are on the various work groups and poll if or when we should have a regular meeting
  • Reasonable request to have a meeting to discuss the CIMI modeling of FHIR concepts
  • Co-chairs will need to coordinate this.
  • Need to decide who will be the facilitator, need agenda items, call info.
    • Goal is an intentional approach of merging various data model into a stack that can be used.
  • CQI and CDS has been balloting the same content for some time. A means of maximizing effectiveness with

What is QDM?

• QDM used for all HHS quality measures
• National deployed model
• Question asked if consumer vocab is used for goals - response: used both for provider and patient goals.

Clinicians-on-FHIR

• Hosted by PC but involves many other workgroup
• Not focus on the interoperability part
• Look at value set and cardinality

Patient Care Tuesday Q4

Joint meeting - PCWG, OO, FHIR, Vocab, Clinical Genomics - CIMI, Struc Docs. Topic: Negation, others

Agenda

• Survey of draft document
• Review of principles & open issues
• Review of pattern description
  • including open questions for deficits, goals
  • including proposal for "query" chapter of requirements
• How to make patterns useful

Present:

• Chair: Jay Lyle
• Scribe: Emma Jones
• Michelle Miller
• Margaret Ditloff
• George Cole
• Chris Hills
• M'Lynda Owens
• Kurt Allen
• Bill Repper
• Ammon Shabo
• Thomson Kuhn
• Susan Matney
• Juliet Rubini
• Justing Schirle
• Sorin Voicu
• Hank Hikspoors
• Chana West
• Linda Michaelson
• Craig Parker
• Marla Kramer
• Jorge de la Garza
• Michael Tan
• Wendi Castillo
• Susan Barber
• Viet Nguyen
• Larry McKnight
• Rob McClure
• gay Dolin
• Carmela Coudere
• Jeff Brown
• Lloyd McKenzie
• Rob Hausam

Minutes:

Overview

• Purpose
• Principles
• Requirements -
  • Ask: confirm requirements
  • Ask: ways to make product useful for design teams
  • New Ask: query requirements

Discussion Points

• Rob: need to look at positive assertion vs something that is negated. Should it be represented the same way the positive statement is represented (i.g go on the problem list?)
  • Clinical way to indicate
    • List of negated cases that have been collected.
    • NPO - is a positive assertion of an observation
    • Not NPO (observation)
    • No peanuts - is an assertion
• Imperatives Vs preference
  • Family member pedigree - maternal aunt does not have breast cancer
  • Need to be able to query and see what the query looks like.

• • Is there eating restrictions on the paitent - this is an inference. All the observations and information is data. To draw conclusion about what to do with the patient is inference. A lot of what we're doing is to whip the raw data into inference. We need to be working on robust query to be able to make the inference.

• • Does your grandmother have breast cancer - question answer format
  • Grandmother does not have BC - is a statement

• • • This is 2 different way to represent the same information but how to do it is different.
    • Specific implies the general - acute MI implies MI.
    • What type of query to run on the data -
    • For example, ACOG pregnancy form has a lot of pertinent negatives

• • • Diabetic yes/no
      • Diabetes on the patient problem
      • Is there a means of deriving that the patient is diabetic

• • Here are 3 ways of looking for diabetes that are not direct - will have different patterns. All 3 ways may be used depending on the vendor.

• • Absence of information - is commonly documented for rad findings. Reading normal: No xxx …

• • • This is assertion. Although the thing is not there, we are asserting that it's not there. Therefore end up with assertion of the presence of the thing being asserted.

• • Is the goal to try to come up with a way or the ways to do this? Suggest there is a preferable way to do this. SNOMED - created a model of inferences have to say presence of absence. V3 tells negation in the structure as well as negation in the flag. V3 was too broadly scoped. Term Info went with making positive insertion and not use the negation flag. CDA uses negation indicator but doesn't tell whether the negation is on the entire act or on the value in the act.

• • Go forward plan:
    • groups can look at the inputs (list of exapmles) and see if something is not there
    • Recommend doing it any other way. Look at the patterns and determine if there is a way to do it differently.
    • Query for negated items - how will it be found?

• • Consent added to the list.

• • Will get confusing if merging the idea of what is recorded with what is queried.

• • Most observations are negative so may need to have codes for it.

• • All discussed have been positive assertions

Patient Care WGM, Wednesday, May 21, 2016

• Back to Patient Care

• Back to Patient Care Work Group meeting Agenda and Draft Minutes

• Back to 2016 PCWG WGM Agenda and Minutes

Patient Care Wednesday Q1

Present:

Minutes:

Patient Care Wednesday Q2

Present:

Minutes of PA/PC Joint Session:
http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10544
Resolution: The encounter will be update to include the following new backbone element diagnosis replacing the indication property.
Encounter.diagnosis 0..* backbone element
Encounter.diagnosis.condition 1..1 reference(condition)
Encounter.diagnosis.role 0..1 codeableconcept (new valueset with admission diagnosis, discharge diagnosis, chief complaint, comorbidity, pre-op, post-op, billing)
Encounter.diagnosis.rank 0..1 positiveInt (this is to be sequential per role type)
The hospitalization.dischargeDiagnosis and hospitalization.admissionDiagnosis will also be removed.
The description on the reason property will be updated to indicate that its purpose as a more patient centric valueset/concept.
The encounter-primaryDiagnosis and encounter-relatedCondition extensions will be removed, as they are now redundant, and represented in the core resource.

Short discussion on CareTeam.participant.role value set (no vote)

Patient Care Wednesday Q3

Present:

Minutes:

PlanDefinition (CDS)

History -- started out with order set, doc templates, event/condition/action rules - tried using profiles and extensions - then tried having distinct resources (e.g. order set) - merged order set + protocol + decision support rule into single PlanDefinition for protocols, guidance, event/condition/action rules -- but not currently scoped for doc template (Questionnaire resource supports defining Q&A).

PlanDefinition has an apply operation to apply to a patient - CarePlan would be the realization of the PlanDefinition.

New GuidanceResponse resource (ask for guidance, get response back, and provider then decides what to do) represents options. Options are a set of things considering doing, but not as strong as an order or proposal.

ActivityGroup - set of options that you may or may not perform; available via continuous build; CarePlan could reference ActivityGroup

PlanDefinition is like an Oncology template. Oncology templates contain one to many drugs where each drug is represented in an ActivityDefinition.product that references either a Medication or CodeableConcept.

PlanDefinition is patient-independent without a specific patient in context CarePlan is patient-specific -- it has a context

Pharmacy is creating a data type for doseageInstructions to avoid extensions

Activitygroup -- set of options that were derived from ActivityDefinitions -- when apply order set, output might be CarePlan that says do X, Y, and Z, but other times it might be "pick 3" or "apply after lab result comes back"

CDS calls are Wed at noon Eastern -- ballot reconciliation Some discussions occur during sub-group meeting where resolutions are drafted

Within PlanDefinition, there are behavior elements for the rules. When realized into an ActivityGroup, it will be carried forward (e.g. timing, etc.)

Reviewed example order set (http://hl7-fhir.github.io/plandefinition-example.xml.html) Order Set is a PlanDefinition and can contain choices (e.g. Behavioral or Medication)

May need a diagram in CarePlan to see relationship with other resources

Order Catalog

Patient Care Wednesday Q4

Present:

Minutes:

Patient Care WGM, Thursday, May 22, 2016

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• Back to Patient Care Work Group meeting Agenda and Draft Minutes

• Back to 2016 PCWG WGM Agenda and Minutes

Patient Care Thursday Q1

Present:

Minutes:

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

Agenda

• CDA updates
• Clinical status & act

Present:

Minutes:

Patient Care Thursday Q3

Present:

Minutes:

Patient Care Thursday Q4

Present:

Minutes:

Patient Care WGM, Friday, May 23, 2016

• Back to Patient Care

• Back to Patient Care Work Group meeting Agenda and Draft Minutes

• Back to 2016 PCWG WGM Agenda and Minutes

Patient Care Friday Q0: PCWG Co-Chairs meeting

NOTE: co-chairs to determine whether this will be moved to Thursday Q-Lunch

Present:

Minutes:

Patient Care Friday Q1

(1) Template WG meeting

- PCWG representative(s) to attend

(2) Agenda: open

- Possible: Clinical Connectathon

Present:

Minutes:

Patient Care Friday Q2

Agenda: open

Possible: Clinical Connectathon

Present:

Minutes:

Patient Care Friday Q3

Agenda: open

Possible: Clinical Connectathon

Present:

Minutes:

Patient Care Friday Q4

Agenda: open

Possible: Clinical Connectathon

Present:

Minutes: