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September 2016 WGM Baltimore: Sep 18 to Sep 23

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

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

Monday Q1

  • Plenary Session
- No PCWG meeting

Monday Q2

  • Plenary Session
- No PCWG meeting

Patient Care Monday Q3


  • 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

-- QA: switch category value set to SNOMED

-- ask for balloter feedback on data type and binding strength of category

-- add more codes to value set for problem and concern

-- add more codes to value set for problem and issue

-- which category to use when it's a condition due to a procedure in the past

-- medical history

-- QA: include concern in scope

-- support for required binding strength of Conditon.category

-- 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)


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


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



Patient Care WGM, Tuesday, May 20, 2016

Patient Care Tuesday Q1 FHIR/PCWG/ECWG/CIMI


  • SDC update from CIC (~ 15 min) - CIC not present
  • CIMI - Skin Care model meeting


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


  • 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


  • 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

Main topic is the resource Condition ( Scope, Boundaries):

  • Category : complain symptom, finding, diagnosis. Could we use a value set with these values?
  • Feed back : mentioned in comments in various Gforge issues.
  • Sub categories: necessity to use labels such as chief complaint. This has overlap with extensions in encounters, where role describes these characteristics.
  • Simplify: One issue suggests to simplify the value set.
    • Billing diagnosis
    • Problem List
    • Other concern.
  • Purpose: What is the purpose of category? One of the reasons is to know in which dataset to register the condition. Larry points out, that the context in which the condition was registered is essential.
  • The boundaries between observation and condition has been described in Gforge 8872.
  • In the following discussion we review which values of category should be kept. Symptom is discarded.
  • Jim objects: encounter and billing diagnosis are different kinds of diagnosis. An billing diagnosis could be changed separately from the encounter finding.
  • Discussion what the meaning of other concern should be? In Larry’s view this is just another view from another care provider. For example : the dietitians list; This option is discarded.
  • The definition of the problem list looks almost like the definition of Health concerns. There is a similarity with Health Concerns as long as the (SNOMED) code does not change. The health concerns is used to link different Conditions, when the condition of the patient changes ( for example aggrevates).
  • Josh puts the motion forward to use the following values. Larry seconds;

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 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

  • Vote to accept the motion: 0 abstentions. 0 against, 19 in favour.

  • Issue … Should use a reference to the resource Body-site instead of a value set.
  • Issue 11212 Should use a reference to the resource body site instead of a value set.
  • The requestor asks to change body site into a choice of datatypes: Codeable concept or a reference to the bodySite resource.
  • Lloyd has written a directive to stay consistent with use the body site extension ( issue 10735.) Body site of manifestations.
  • Motion moved by Josh, second by David;
  • Vote: 0 abstentions, 0 against, 17 in favour. BodySite should be a reference to the resource instead of a just a codeable concept - 2016-09 core #366
Resolved (Not Persuasive):

  • Issue 11117 abatement info type is quantity. Description says description abatement as a string. This is not consistent. Motion to change into abatement string and the type string.
  • Vote 1 abstention , 0 against, 18 in favour.

  • Issue 11157 Issue with Condition onset cardinality and condition onset Range. Relax cardinality to 0..*. The example given is the use case that the patient does not know exactly when the condition has occurred. There are similar issues, where the requests was not accepted, because it is seen as an exceptional case. In such cases the concept of a string should be used. Resource versioning can be used to track multiple abatement periods.
  • Motion moved by David, second by Josh
  • Vote : 0 abstain, 0 against, 19 in favour. 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

Related to An extension ( 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 ( )

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)


  • 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.


  • 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


  • 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


  • 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



  • 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

Patient Care Wednesday Q1



Patient Care Wednesday Q2

Minutes of PA/PC Joint Session (PA hosted):
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


  • Allen, Kurt - PenRad
  • Blake, Tim - Semantic Consulting
  • Brammen, Dominik -
  • Buitendijk, Hans - Cerner Corporation
  • Carlson, Dave - U.S. Department of Veterans Affairs
  • Connor, Alex - Pareto Intelligence
  • Constable, Lorraine - HL7 Canada
  • Couderc, Carmela - Intelligent Medical Objects (IMO)
  • Craig, Patricia - The Joint Commission
  • de la Garza, Jorge - InterSystems
  • Denning, Paul - The MITRE Corporation
  • Dittloff, Margaret - The CBORD Group Inc.
  • Eisenberg, Floyd - iParsimony LLC
  • Finseth, Myron - Medtronic
  • Friend, Danielle - Epic
  • Gagnon, MariBeth - Centers for Disease Control and Prevention/CDC
  • Gregory, William - Pfizer
  • Hall, Freida - Quest Diagnostics, Incorporated
  • Halperin, Bobby - Epic
  • Harrison Jr., James - University of Virginia, Public Health Sciences
  • Hay, David - HL7 New Zealand
  • Heermann Langford, Laura - Intermountain Healthcare (chair)
  • Heras, Yan - Optimum eHealth
  • Holzer, Karl - CGM Clinical Österreich GmbH
  • Jenders, Robert - Charles Drew University/UCLA
  • Kawamoto, Kensaku - University of Utah Health Care
  • Krauss, Oliver - University of Applied Sciences Upper Austria
  • Kuhn, Thomson - American College of Physicians
  • Macary, Francois - HL7 France
  • McKenzie, Lloyd - Gevity (HL7 Canada)
  • Mehra, Raj - Cerner Corporation
  • Merrick, Riki - Vernetzt, LLC
  • Miller, Michelle - Cerner Corporation (scribe)
  • Parker, Craig - Intermountain Healthcare
  • Pitkus, Andrea - Intelligent Medical Objects (IMO)
  • Rhodes, Bryn - Database Consulting Group
  • Rubini, Juliet - Mathematica Policy Research
  • Rutz, Daniel - Epic
  • Schirle, Justin - Epic
  • Shapiro, Ron - Qvera
  • Skapik, Julia - Office of the National Coordinator for Health IT
  • Smith, Anne - NCQA
  • Smithies, Rik - HL7 UK
  • Surprenant, Lee - IBM
  • Thun, Sylvia - HL7 Germany Chair
  • Tracy, Wayne -
  • Vreeman, Daniel - Regenstrief Institute, Inc.
  • West, Chana - ESAC Inc
  • McKnight, Larry - Cerner Corporation
  • Thunman, Oskar - Callika
  • Hadley, Marc - The MITRE Corporation
  • Strasburg, Howard - Wolters Kluwer


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 whereas a 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 ballot reconciliation calls are Wed at noon Eastern, but 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 ( The order set is a PlanDefinition and can contain choices.

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

Order Catalog
Catalog presentation
Scope includes formulary.
No timelines set -- order catalog specification with order service is in OMG submission phase -- Nov is initial draft, final in 8 months
The receiver of the catalog must/can then further modify the information into the order entry system, as there may be more than one lab to order test A from

RCRIM is defining AdverseEvent resource
RCRIM calls are on Fridays at 10am Eastern.
Ask that AdverseEvent is broader than clinical trials only.
FMG approved resource with the understanding that AdverseEvent is about the quality, tracking, and reporting pieces (e.g. regulatory reporting or organization improvement).
FMG expects that other resources will be used if it needs to be in the clinical record (e.g. fracture = condition; adverse reaction = AllergyIntolerance), but the supporting information (patient fell that caused fracture) might be AdverseEvent

Keep this same quarter at next WGM

Patient Care Wednesday Q4

Present: David Susanto, Michelle Miller, Jay Lyle, Viet Nguyen, David Parker, Genny Luensman, Robin Williams, Lamah Asadullah, Taima Gomez, Swapna Bhatia, Angelique Cortez, Caroline Coy, Evelyn Gallego, Swapna Abhyankar, Russ Leftwich, Thomson Kuhn, Larry McKnight, Danielle Friend, Michael Tan


  • Caroline Coy ONC standards & technology, gave a presentation on ELTSS initiative.
    • CMS funding via TEFT program of ACA.
    • Electronic standards for interoperable service plans to improve coordination of health and social services. No current ballots; work in progress on wiki.
    • Round 2 pilots starting up. Aiming to present data set for ballot late 2017.
    • eLTSS describes funding and resources necessary to meet a patient’s goals.
    • Plan signatures are included, but do not seem to have semantic constraints.
    • See S&I framework wiki.
    • Especially interested in staying informed on PC work on other non-clinical or behavioral care, e.g., social barriers.
    • Question: How to capture social issues in FHIR: expected to be in the condition resource.
  • Ballot reconciliation focusing on maturity of key resources: Allergy, Condition, Procedure, Care Plan
    • Condition first; Allergy tomorrow.
    • 11157: increase condition onset cardinality from 0..1 t 0..*
      • Viet moves No. Larry seconds. 1-0-12, motion carries
      • Michelle or Larry will enter a GForge to remove periods from Onset data type options.
    • 10618: Condition clinical status value set. Active relapse resolve remission.
      • FHIR: exclusive or hierarchy: relapse should be a kind of active.
      • Jay moves adopt recommendation. Viet seconds. 0-0-14
      • Need a separate request to request “unknown” status; MnM to discuss because this is a modifier element. Could be “stale” or “expired.”

Patient Care WGM, Thursday, May 22, 2016

Patient Care Thursday Q1


  • Laura Heerman (Chair) - Intermountain
  • Michael Tan - Nictiz
  • Brian Scheller - Healthwise
  • Rick Geimer - Lantana
  • Gay Dolin - IMO
  • Karl Holder - CGM Clinical Austria
  • Oliver Krauss - Upper Austria University of Applied Sciences
  • Karen Nocera - CBORD
  • Margaret Dittloff - Academy Nutrition and Dietetics
  • Lisa Nelson - Life Over Time Solutions
  • M'Lynda Owens - Cognosante
  • Sheryl Taylor - NIST
  • Chris Melo - Phillips Healthcare
  • Tim McNeal - SureScripts
  • Daniel Vreeman - Regenstrief
  • Sue Thompson - NCPDP
  • Shelly Spiro - Pharmacy HIT Collaborative
  • Robin Williams - Lantana
  • Peter Gilbert - Meridian Healthplan
  • Richard Kavanagh - NHS
  • Dave Carlson - VA
  • Dan Morford - VA
  • Mark Kramer - MITRE/IPO
  • Bryn Lewis - Intelsoft
  • Corey Spears - Infor
  • Lloyd Mckenzie - Gevity
  • Emma Jones (Scribe) - Allscripts
  • Lenel James - BCBS
  • Viet Nguyen - Leidos


  • Overview (Laura Heerman)
    • Lots of care plan projects in flights. Goal of this meeting to allow folks that are involved in different care plan projects to provide an update of where they are with their projects.
    • Note that some projects are structural related projects Vs Content related projects.
    • Care Team work is included in this session - it relates to care coordination.

SDWG update (presented by Gay Dolin)

  • Care plan document type LOINC code was retired. Used for C-CDA Care Plan document code. SDWG plan on providing an errata to change to the updated LOINC code.
  • Currently working with the CCDA companion guide group to leverage this change.
  • SDWG Need to make ONC aware of the change

Pharmacy Care Plan - presented by Shelly Spiro

  • Have already identified implementers - community Care of NC and Great plains area for Indian Care services
    • community Care of NC want to use the pharmacy care plan for high risk patients
    • Great plains area for Indian Care services - value based payment model
  • Pharmacies are ready to go
  • Part of HIT policy and standards - NCPDP/HL7 Pharmacy eCare plan is listed
  • Currently IG open for comments. Can be found on NCPDP collaborative workspace - [] - publicalble available - pharmachist ePlan draft is there
  • See NCPDP guidance under resources - [] - points to the balloted version
  • Have four use cases
    • The 4th use case (4) is about opioid use.
  • Project Timeline - put the ballot on hold in May. Wanted to complete the modeling. Ran out of funds. Waiting for the modeling and schema to be completed. Using Trifolia.

Have been working with the implementers.

  • The IG Points to the balloted version of CCDA so that it can be used as an example
    • Implementation pieces is using CCDA balloted versions.

Other Care Plan Projects - By Lisa Nelson

  • BCBS - work is on the Patient Care wiki site. Has been extended by a New York health HIE project.
  • IHE - EDHI Profile - new born hearing screening. The sections and entry clinical statements have been lined up with care plan.
  • Patient Generated data - Personal Advance care plan document - gives people the ability to record their goals and preference for care. Published standard. HL7 SDWG project
  • Survival ship plan - SDWG
  • Lenel James- attachment tract - taking CDA as PDF and using FHIR. Ties to care plan using string. An interest for payers in moving payers care plans . Want to move a CDA pay load using FHIR in the future. Want to do CCDA on FHIR version of the care plan.
    • Question from Viet Nguyen - What is the approach on working on reconciling the various types of care plans -
    • Response: One of the main goals of the IHE dynamic care planning profile to be able to collect multiple care plans
    • Lisa - human interaction is needed to accomplish the reconciliation aspect.

C-CDA on FHIR: care plan template (Rick Geimer)

  • SDWG did a narrative document for this ballot round. Will only add coded data where DAF has specified. Went thru for comment ballot. Had a lot of tooling bugs
  • Next round is for January - STU comment ballot

Care team members definition update project (Lisa Nelson)

  • Meeting on Friday afternoon.
  • Working on ability to Understand different types of care teams - see confluence site [4] for minutes.
  • Looking at types of care team members - Licensure, roles, responsibilities, looking for a moderate level of granularity.
  • What is the target for the Friday work? - focusing on an operational executional work. ONC is getting request from various entities as to what to reference.
  • May need to align multiple references.
  • Would like to update some of the values sets in HL7.
  • Work to date is not ready for primetime.
  • Suggestion made - Need to connect with DAF care plan and DAF care team
  • Go forward - will work with Russ Leftwich (Learning Health Systems - LHS work group). May fall into the LHS project.
  • Dave Carlson - Suggest that someone from DAF participate. Want to have practical approach to do the same thing using the various flavors of standards as the DAM is being worked on.
  1. Care team
  2. FHIR piece - need to get involved. (Clinicians on FHIR piece need to get tied in. Clinicians on FHIR calls on Tuesdays). Need some pre-planning for January.
  • Note made that Pharmacy currently using NPI and Taxonomy
    • Response that taxonomy is focus on licensing and qualifications - real roles are more functional and broad level of categorization. Not useful for a functional role. This would be additional beyond that. This would be broad guidance that would effect all CDA docs.

Learning health systems care team domain analysis (Evelyn Gallego)

  • Russ Leftwich Co-Chair - learning health systems work group. Running it as a DAM.

DAF - care plan (Dave Carlson)

  • Also need to look at the Argonaut use case.

Suggestion made to have a place where all the care plan projects are listed

  • Start with Evelyn's list or projects related to care plan which is found at Care Plan Project - PCWG (scroll down)
    • DAF
    • Care Team project
    • Care team DAM (LHS)
    • CCDA on FHIR
    • DAF core (is under as an IG)
    • Argonaut project
    • Survival ship plan - SDWG

Update of Care Plan Implementations (Evelyn Gallego)

  • NIH - chronic kidney disease management - validating the data set. Not changing the standard but porivding additionsal guidance
  • AHRQ - evidence surrounding care plan

Action items -

  • Update the list of care plan projects and post on Wiki - Laura will provide the list
  • Follow up with Dave Carlson to get Clinician-on-FHIR connected to DAF work - Need to connect with DAF care plan and DAF care team work
  • Keep this time for next WG meeting.
  • Next time - Evelyn will provide an update of real world implementations

C-CDA - clinical oncology treatment plan (Jeff Brown not present for update)

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


  • CDA updates
  • Clinical status & act
  • PC attending SDWG for RnP presentation



Patient Care Thursday Q3

Present: Session was hosted by CS. Attendee list is with CS.


Rik Smithies: CS is now actually non very active. Is there a link with Alexander Henket of CDA 2.1. No there is no link. Clinical Statements have gone further than CDAr2.
David Parker presenting Allergies: In January he gave a presentation about the terminology for allergies. There were more than 200000 codes with large overlap. 99% are only using 10% of the codes. 30% values make up 85% of the allergies. Brandnames are not usefull for the allergies. Ingredient level terms are more relevant. There are about 2119 ingredients that are responsible for allergies .
Foods: 169 ingredients make up 99% of the food allergies. SNOMED can cover all food ingredients. Recommendation to use only SNOMED and RxNorm. Unii can be removed. Note that at a certain points there were more people allergic to peanut oil. This was because peanut could not be chosen and people just pick, what is best.
Cerner presentation: from various systems with institutions under contract with Cerner. Also here a lot of duplication. A lot of the free text items could be mapped to a code. A small number of ingredients are responsible for most of the allergies. RxNorms contains all the ingredient information in their standards. The focus should be on the ingredients ( not the trade product). Free text are a special problem, most could be analysed and mapped to a single code. The junk makes artificial intelligence difficult. Systems will generate false alerts. The question is who is going to maintain the allergy list?

  • Medication ( RxNorm)
  • Food ( SNOMED)
  • Environmental (SNOMED).

Patient Care is appointed as the formal group where this value set should be maintained.

Assessment Scales
Assessment scales has gone for ballot. There were 28 comments returned. Dealt with 2 ballot comments from the Assessment Scales ballot. The dispositions are entered in the spreadsheet.

Patient Care Thursday Q4


  • Laura Heerman (Chair) - Intermountain
  • David Pyke - Ready Computing
  • Larry McKnight - Cerner
  • Robin Williams - Lantana
  • Emma Jones (Scribe)- Allscripts
  • George Cole - Allscripts
  • Michelle Miller - Cerner
  • Farrah Darbouze - ONC
  • Bryn Lewis - Intelsoft
  • Qanrelle Friend - Epic
  • Michel Rutten - Furore
  • Michael Tan - Nictiz
  • Ioana Singureau - Eversolve
  • Julia Skapick - ONC
  • Dave Carlson - VA


DCP - how to get visibility of the IHE Profile in HL7 (George Cole, Emma Jones)

  • Ongoing question on the plan to get IHE FHIR based profiles prominent visibility in HL7. There have been various approaches.
  1. points to the IHE page
  2. GAO invented at IHE and then transfer the IP to HL7
  • What is the go forward plan? Discussion as to this is still an un-answered question.
    • Recommendation made to update the IHE FHIR based profile page to include DCP.
      • Emma will send email to FMG (John Moerke) to get it added

David Pyke (HSI) presented the following PSS.

  • MHD, MHD-I, PIXm, PDQm and IUA to HL7 to ensure cooperation between ITI and Radiology and ensure alignment of the FHIR resources with the equivalent IHE profiles.
  • The resulting implementation guide would be wholly maintained within HL7 and referenced by IHE.
    • During development, the plan is to reference text where it's the same, where not, paraphrasing will be done.
    • IHE/HL7 Harmonization has been going on forever. This is an exercise of harmonization. HSI was invented for coordination between the two SDO
    • The PSS has 4 co-sponsors - FHIR-I, SDWG, Security, II
    • This FHIR IG will be a harmonized version between A and B
    • PSS is STU. Comments period for both HL7 and IHE.
    • SDWG will co-sponser with the condition that this will be an HL7 IG. This will end up being one IG.
    • Question asked - What lives in vs How to update when in both places? Is there any plan to have a formal relationship between the two sets of profiles? *** Goal is to have the MHD profile in HL7. Once the politics iron themselves out.
      • SD owns the the DocumentReference, DocumentManifest and AuditEvent but plan is the it will be owned by HSI.
      • * Has there been any life cycle? None of these are at final text.
      • Until FHIR gets normative can't lock down the profiles.
      • Nothing needed from PC. This discussion is to just inform PC about how this project will align with IHE.

Cross-Paradigm IG for medical device data sharing with patient care system - Health care devices work group. (Ioana Singureau)

  • Med Device will be co-sponsors. Thinks it's patient care related. Bringing in patient treatment so patient care WG domain
  • Can use a FHIR resource. Folks are using adt transactions to admit the patient to the devices.
  • Today, Devices are not communicating very well with the enterprise. Trying to harmonize with work others have done. Want it to work with existing implementation.
  • Co-sponsors - OO, Conformance WG
  • UDI is part of this.
  • Suggest adding FDA as interested party
  • May provide examples of IHE PCD
  • Is there room in PC for another project? - Patient care is definitely of interest but need to discuss internally
  • Ioana Will come to next co-chair meeting in Oct
  • Timeline: Planning on balloting in May - 2017
  • Going to mobile health next. And CDS.
  • Julia (ONC) is interested as well.

Patient Care WGM, Friday, May 23, 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

Agenda: open

Possible: Clinical Connectathon