Dental Summary Exchange Project

7/17/19

Reviewed the ADA's 1084 document and project intent/goals. Building out a timeline and schedule of expectations was discussed during this meeting.

1. Socialize this WG with the dental community to see who can participate
2. Socialize within DoD (Molly Jenkins, Kevin Parker, Steve..) --Russ sent email to Nancy 8/15
3. Create timeline/roadmap --WIP: Manisha drafting
4. Create a requirements list of data elements mapped to C-CDA --ongoing

7/31/19

Updates from Russ: Attachments WG's new WG name is PPIE (Payer/Provider Information Exchange). We need 2 more implementors before PSS approval. DoD is the only one so far. 

It was emphasized that logical groupings of dental information should remain separate (odontal, implantable devices, etc).

Reviewed the xls spreadsheet to explain intent for mapping data to C-CDA.

1. WG to identify two additional implementors for this effort. VA or the Legacy Army are possible POCs
2. Post new WIP sheet?
3. Set up meeting (8/13) with PPIE group for project approval

8/7/19

Meeting canceled

8/14/19

Russ reiterated to the WG the project intent and scope. Karen Clark, DSS presented a DENTRIX use case scenario which allowed the group to gain better context on defining and collecting dental data from an EHR.

There were some data elements that are not listed in the 1084; the group mentioned collecting the "to-be" data elements during requirements gathering for CCD dev. 

DENTRIX can grab CCD data now, but the intent for this project is to see how we can add those additional dental data elements within a structured framework. 

There was also a brief discussion on utilizing a FHIR connection vs. building a CCD This is a thought for consideration (but will push forward with CCD for now). 

1. Need to have someone from Henry Schein on the WG call.
2. Push for more federal representation on this call. Russ to speak to IPO.
3. Create timeline draft.

8/28/19

Greg, Russ, Manisha, Joel, Jean, Angie, Eric, Tony, LT Col Ford, CDR Stallings

Reviewed high level timeline and group approved. Once we get vendor perspectives, we can solidify timeline. 

There was some discussion around the nuance of focusing on CCD or FHIR for the IG version but in some respect can be interchangeable. Open for discussion with the vendors as well.

Shared the current spreadsheet and determined: out of 477 total data elements, 218 can be mapped to CDA; 258 will need structure. 

Noted that this WG progress will be discussed during Wed-Q1 at HL7 WGM in Atlanta.

1. Follow up with Will about Henry Shein participation.
2. Gather vendors for perspective on timeline and implementation format (CDA, FHIR)

9/11/19

Greg, Manisha, Jack (last name?), Eric Kirnbauer, Joel Bales, CDR Stalling, LT Col Kevin Parker, Jean Narcisi, Chris Brancato, Carla Evans, Karen Clark, Michael (last name?)

Greg reviewed the PSS and excel spreadsheet for new attendees. A question proposed was if CCDA is preferred over FHIR and it was mentioned that CCDA might be a better fit right now. 

Jean had a conversation with HL7's CEO, Chuck Jaffe, that potentially after balloting a first final of Dental Summary IG, joining this effort into the FHIR Accelerator Program would be a consideration (if it fits well). 

1. Compile slide deck for HL7 WGM, send draft to Greg and Jean for review.

9/17/19 (WGM)

Dental discussion occurred during Tues Q1 of PIE WG. Greg and Russ presented the Dental Summary Exchange Overview slide deck. 

Russ pointed that finalizing Ortho IG is top priority but will work simultaneously with this effort. 

HL7 is pushing for dual IG's (CDA and FHIR), so consider the strategy for that.

  1. Add ortho IG data elements (or note them) in Dental Summary Exchange mapping file.

2. Finalize what WG should review the PSS of this project (PIE, Patient Care, both?)

3. Consider FHIR R5 release when mapping to FHIR.

9/25/19

Tony Magni, Jean Narcisi, Chris Brancato, Greg Zeller, Russ Ott, Col William Baez, LtCol Tansel Acar, LTC Kevin Parker, CDR Steve Stallings, LtCol Jeff Ford, Bob Cox (CDS), Eric Kirnbauer (Tesia), Susan Langford

CDS cannot yet provide a CDA summary document

Henry Schein and DSS were involved in the development of the 1084

DSS and Henry Schein can both produce a CCD today

Col Baez - we've had some challenges with the FHIR interface between Dentrix and Millennium

• Perhaps Dentrix could test this in a smaller sphere, and then port it over to the DoD space
• What they do to configure or manipulate Dentrix enterprise has to go through the PEO DHMS
• For us, "we can get to yes faster with CCDA" than trying to do something with FHIR

LTC Parker

• Henry Schein has produced a CCD that goes to the JLV

Col Baez - we only view stuff within the JLV, but we'd like to be able to store data

• "I am really eager to provide a use case for this"
• This wouldn't only be for active duty, but requirements would be provided with them
• If someone was seen at a community provider location, and they could provide an essential dental record, we could add it to the record
• Also if someone were to newly become Active Duty, we'd want to capture their Dental status and history
• This is an opportunity to standardize the baseline information exchanged between dental providers
• Sometimes people are authorized for a limited set of treatments - that they didn't get billed for extra care.

Greg

• I'm not sure that we have a way to show the progress of Periodontal status is over time
• The caries risk and caries rate is something that the profession has some agreement

Bob (CDS) - We could do sandbox creation and testing of a CCD fairly quickly - within a few months

Col Baez - the focus should be on the Dental provider focus, rather than a Dental payer focus

Russ - For the next meeting - we'll review the data elements from the 1084 that map to the baseline C-CDA, and

Greg - If we start with simple straight-forward use cases to build from, that will help us get to meaningful pilots in short term.

Col Baez - the dental referral use case is a common one that is not unique to the military space.

Greg - from a perspective of readiness, the military has a very specific scale of readiness

LTC Parker - the 3 services need to get agreement on what they'll

Col Baez will provide draft use cases with sample data that would be important to convey as part of a Dental Referral/Transition of Care scenario

Russ, Greg, Manisha, Jean, LCDR Bohman, CDR Stalling (BUMED), Joel Bales, Courtney Panaia-Rodi, Eric Kirnbauer, Carla Evans, Craig, Susan Langford, Robin Isgett, LT Col Kevin Parker, Dave DeRoode, Chris Johnson (BCBS)

Administrative items:

• The PSS was approved 10/8/19 by the US Realm Steering Committee. They requested a few clarifications to be added to the PSS language: that not only the CDA template will be created but also FHIR. Other committees that need to approve are the administrative steering division and the technical steering committee.
• Doodle poll to be sent out for future weekly meetings (changing to weekly vs biweekly). Last Wednesday meeting will be 10/16/19 (230-330pm ET). 

Review of Col Baez' use case document:

Russ introduced the document content to the group and noted that we should highlight where in each use case does the transfer of data occur. We then can identify where in the CCD that does or should be, discuss implications or details of that data, and comparison to the 1084 for sanity check on appropriateness of data sets. These use cases are also helpful for implementation example when it comes time to publish IG for ballot.

The group started looking at the requirements xls to start the ground work. Discussions include:

1) InformationRecipient: facility type code and facility type. it was noted from a federal rep that this information would be good to have, even if it's unavailable now. Need to determine if dental is included in Location identifiers: SDLOC and HSLOC in CDA.

2) ReceivedOrg: Russ stated that in CDA there is no designation for Organization address or phone. He will take this back to the HL7 community to see if we did want to include it, where could be stored.

3) LegalAuth, assigned entity, id: question if this is one person within the dental world? decided to parking lot this one. (there is some debate on how much we want to shift examples like this for implementors).

4) DocumentationOf. service event, performer: (the care team that directly aligns to the care plan of the given patient). Dental provider types ARE included in VSAC for provider identification in CCDA.

1. Check with HL7 community on where facility address and phone number (under receiving org) could exist (Russ)
2. Check to see how facility type code and code would be modeled IF separate from SDLOC and HSLOC (Russ)
3. Work on the list of facility types (Russ sent CDA list for reference) (Col Parker)
4. Doodle poll sent to email distro 10/9/19. Finalize new day/time on 10/16. (Manisha)

Greg, Jean, Russ, Manisha

CDR Stalling, Joel Bales, Carla Evans, Robin Isgett, Rebeka Fiehn, Michael Honeycutt, Kipp Clemmons (DSS), Lt Col Jeff Ford, Chris Brancato, Col Baez, LCDR Bohman, David DeRoode

1. Context around Encounter (single or multiple): discussion landed on a suite of procedures, by performers (multiple), care plans, etc. Confirmation that detail care plan to be built out in spec.
2. Purpose as defined in 1084. what information is or should this convey and how is it used by recipient of document?
3. Problems - what terminologies will be used to convey problems? ---did not finalize 
4. Procedures - discuss HL7 way of defining procedures (procedures vs. observations vs. acts) ---did not get to 

LT Col Parker, Joel, Greg, Russ, Jean, Michael Honeycutt, Brett, Kipp, LCDR Bohman, Julie Hawley (DentaQuest), Gyle Gales (HS), Toni, Will, Col Baez

NEW date/time series: Mondays 1-2pm ET

Agenda: detailing out how the summary will be exchanged:

1. What will likely happen in the Dental EHR before summary creation
   1. It was noted in most cases, claims data is the driver for referrals. If a dental profile is created for a patient, it doesn't mean the requirements to fulfill the claims request is met. 
2. What action will actually trigger the summary creation (and who takes this action)
3. How the summary will be transmitted to the desired recipient
   1. Dentrix follows a push/pull process for care summary reports.
   2. Query-based methods was also noted as a way to send.
4. What exactly the receiving organization will do with the summary upon receipt

Key Takeaway: if we dont know when a follow up visit may be, pushing this information to one's inbox creates noise unless it is directly related to the visit the provider is working on. Dentrix puts summaries in a holding pattern. Summary exchange for query would be a good use case where dental information is needed. It is also helpful for utilization and treatment needs. 

Right now, in many cases (including Army), this process is manual and in free-form note. The provider can add what they want and it is intended to be shared as a blob of context.

Bob Cox, Joel Bales, Kipp, Zabrina, Greg, Eric, Susan, Chris, Toni, Carla, Dave DeRoode, Michael Honeycutt, Karen Clark, Rebekah, Jeff Ford, Zack Church (HS), Col Baez

1. The group reviewed a Dental Summary use case diagram created by the team. 
2. The group prioritized the following domain areas:
   1. High Priority; Always needed - Advanced Directives, Alerts (Allergies), Medications, Plan of Care, Purpose (reason for referral), Social History
   2. Medium Priority; Include if Relevant - Immunizations, Problems, Vital Signs
   3. Low priority; Generally 'noise' - Family History, Functional Status, Medical Equipment, Results

Note: to discuss Procedures during Encounters discussion next week

Consider/brainstorm prioritization of Encounter sub-sections.

Greg Zeller, Manisha Khatta, Russ Ott, Eric Kirnbauer, LCDR Bohman, Karen Clark, Rebekah Fiehn, Carla Evans, Chris Brancato, CDR Steve Stallings, Dave, Zabrina Gonzaga, Mike Honeycutt, Kipp Clemmons, LCDR Kevin Parker, Susan Langford

The WG discussed the prioritization (always expected to be there, sometimes important, and usually not important; noise) of the following logical sub-sections of data for exchange:

1. Procedures - Medium priority
   1. a full list of a patient's procedures is unnecessary unless it is directly related to the referral.  
2. Encounters (Odontogram – General measurements) - High priority
   1. it was noted that not all data may be needed other than the last set of teeth status.
   2. it was mentioned that if those data elements are required, how does this impact practices that cant fulfill it? dental to non-dental exchange - a 'roadmap' of a patient's record could be something to consider, where we will always have a high level summary of what the patient is going through, but we may not have the full suite of measurements (BUT, would have the set of problems)

Clinical Notes: There are designated areas within the CCDA to include clinical notes, 1) there's a logical structure to anchor the clinical note and build it in as a sub-related structure, or 2) identify a dedicated section for a pile of notes with a framework (separate from discrete data elements). Russ suggested we discuss this in greater detail at another time.

PM: Greg, Manisha, Jean, Russ

DQ: Rebekah Fiehn, Eric Transby

Federal: CDR Stallings, LCDR Bohman

Lantana: Zabrina

DSS: Kipp Clemmons, Michael Honeycutt

Other: Rachel Foerster, Christol Green (anthem)

The WG continued down the list of Encounters, discussing prioritization of encompassing data elements:

1. Encounters (Oral Soft Tissue Exam) - Medium/High- If abnormal, then needed
   1. For this particular data set, it could be more of a status; an assessment that was performed at a single point in time, not current state. 
   2. Could the sub-data elements of lips, tongue, floor of mouth, etc, fall into a value set of abnormalities?
   3. IRT Base modeling- Would need to consider active/inactive, or active/resolved; how this data is packaged, and how is it received.
   4. Additional Concepts: identifiers that are loosely tied to the encounter info.

When considering specific dental measurements, it's important to identify the relationship between the measurements and how it is/can be exchanged. Can assessments be shown as Findings in the record? How important are TMJ Assessments when sharing a record for referral? These are the considerations to look into if we start modeling the data sets. 

Next Monday:

1. TMJ Exam
2. TMD History

Russ, Manisha, Greg, Col Baez, Bob Cox, Maj Turney, Bedo, Rebekah, Ubong (IPO I2TP support), Dave, Zabrina, Joel, Eric Tranby

The group started the discussion with procedures 

1. Procedures: within the dental space, there are many complex measurements, complications, and problems among teeth. There are various encounter subsets noted in the 1084 that together, represents what the current status of the patient is. Plan of care is definitely something to be separate from Encounter data subsets. 
2. TMJ Exam (Deviation upon opening, popping, clicking, crepitus, etc): condition standpoint
3. TMD History (history of trauma, popping, clicking, crepitus, limited opening, pain upon chewing, etc): standpoint of a patient; could have multiple encounter entries.

Next week:

1. Implantable devices
2. Occlusion exam

Greg, Russ, Manisha, Lt. Col Ford, Chris Brancato, LCDR Stallings, Carla Evans, Rebekah Fiehn, Zabrina, Joel Bales, Ubong, Dave DeRoode, Michael Honeycutt, Col Baez

1. Implantable Devices: High Priority (it is expected that this information would/should be in a record)
   1. this particular data set is sometimes viewed as a checklist, and helpful for future visits.
   2. the group discussed the differences and similarities of general implantable devices (like head and neck), vs. mouth/tooth implantable
2. Occlusion: Medium Priority 
   1. Data set that essentially tells the dentist/ortho a story
   2. Occlusal classifications are determined on an encounter basis and are visible observations by the dentist/ortho

The group talked a little bit about the format of a referral and consult note, Russ briefly showed what JLV looks like; a chart review platform that pulls from a CCD.      

Russ, Greg, Jean, Manisha, Besos, CDR Tearney, Col Baez, Eileen Ulick, Ubong, Chris Brancato, Dave DeRoode, Zabrina Gonzaga, Eric Kirnbauer, Rebekah Fiehn, Clara Ren, Carla Evans, Lt Col Parker, Acar

*Last meeting until Jan 2020*

Russ reviewed the homework assignment to the team. Team to complete homework by Jan 6th so we can review findings and present during next meeting Jan 6th.

The group prioritized content for a “Consult Note” response from a Dental Provider back to the original referring provider. This includes content that could be net new when the referral is sent back to the dentist who originally requested the referral. 

The group briefly looked at Consult Note subcategories in the CCDA to discuss which ones we think are relatable to a dental record. 

Greg, Russ, Jean, Manisha, Beto, CDR Stallings, Maj Tierney, Col Baez, Clara Ren, Eric Tranby, Eric Kirnbauer, Michael Honeycutt, Ubong, Dave DeRoode, Rachel Forester, Brian Flynn

Continue to prioritize Dental Consult Note data sets:

1. Odontogram- group decided that this is always needed; if the specialist performed any treatment, the receiving record would need to be updated to show this.
2. Periodontal- decided to include as always needed; It's not always expected as a receiving referral, but good to have.
3. Oral soft tissue, TMD, and TMJ were all noted as include in relevant (just as the outbound referral). 

Russ reviewed modeling approach and a few guidelines to follow during the process. 

WG discussed where the narrative content of a consult note would live (to include info such as reason for referral, summary of procedure/services, progress note, etc.), Russ suggested the Assessment and Plan section of the CCDA would be the best place. 

Col Baez and Russ to meet to review project updates.

Russ to receive OID by next week.

Review/add to modeling guiding principles.

Russ, Greg, Jean, Manisha

CDR Steve Stallings, LCDR Michael Bohman, Besos, Col William Baez, Chris Brancato, Zabrina Gonzaga, Dave DeRoode, Clara Ren, Eric Kirnbauer, Eric Transby, Ubong, Carla Evans, Kipp Clemmons, Rebekah Fiehn, Christopher Breeden (Epic)

Goal to complete draft of FHIR IG by FHIR Connectathon in May (draft to be completed April 15). To prepare for this, we need to build the logical subset for testing purposes during the connectathon. 

The WG discussed other items such as compatible data standards (Snodent), high priority data sets (Odontogram), and that simple display of the data is ideally what would be seen (not images, since it hasn't worked well within CDAs before).

Homework assignment request: 

1. what are the high level dental specific measures/findings that we need to convey to support a use case.
2. lower level data points to rebuild supporting Odontogram that one would want to share for the use case example.

Russ, Manisha, Greg

LTC Parker, Kipp Clemmons, Clara Ren, Christopher Breeden, Rebekah Fiehn, Zabrina, CDR Stallings, Rachel Foerster, Eric Kirnbauer, Michael Honeycutt, Dave DeRoode, Gary Guest, Col Baez, Eric Tranby, Joel Bales, Aishwarya Gandhe, Phil Accio (Cigna)

Discussion focusing mostly on the minimum data reqs related to displaying an Odontogram. The WG discussed the importance of the following data fields from ADA:

"Missing" - tracking this data is important because dentists would want to see if the odontogram data was actually missing vs incomplete/inaccurate.

"Caries" - discussion included the reported surface of caries (all enamel factors/sides), root involved, etc. Caries by tooth and the surface of tooth were noted to be critical points of data for Caries within an Odontogram.

Use cases for FHIR Connectathon - Col Baez, LTC Parker, and Greg offered to attend a separate working session for identifying detailed medical to dental and dental to dental use cases.

Jean, Greg, Manisha

CDR Steve Stallings, Rebekah Fiehn, Dave DeRoode, Zabrina Gonzaga, Carla Evans, Clara Ren, Rachel Foerster, Kipp Clemmons

Russ was unable to join. Greg, Zabrina, and Dave reviewed the FHIR Connectathon use cases that were compiled during an offline use case working session. The WG added more detail to one of the use cases; Dave to post on Confluence and share link. Next meeting Greg will talk through the next use case to gain additional feedback on that scenario.

Jean Narcisi, Greg Zeller, CDR Steve Stallings, Rebekah Fiehn, Dave DeRoode, Zabrina Gonzaga, Carla Evans, Clara Ren, Rachel Foerster, Kipp Clemmons, Eric Kirnbauer, Chris Breeden, Chris Brancato, Susan Langford, Michael Honeycutt, Ubong Ikpe, Sonya May, Beto (DSS)

• Allergies (AllergyIntolerance Resource):
  • Epic's Wisdom is part of the overall Epic stack and uses the same exchange
  • DSS (Beto) - we don't receive or exchange this data today - I'm not sure even hold it in our system, but it is something we've been wanting to use for a while
• Patient Education/Instruction (Communication Resource)
  • This is going to be unstructured content that will be conveyed in text
• Conditions (Problems such as Hypertension):
  • Generally captured as narrative text. The only data that's really captured in a codified manner today are the CDT procedure codes
• Coverage (Payer/Insurance):
  • This is generally captured as narrative text.
• Encounters (Referral Urgency)
  • This captures the "planned encounter" needed from the POV of the Medical Provider issuing the referral
  • Capturing the "priority" on the referral is important, at least in Oregon, as they need to report on timeliness of servicing referrals.
  • Oregon Health Plan Priority Categories (per Rebekah Fiehn):
    • Emergent - Enrollees are appointed for emergency concerns within 24 hours.
    • Urgent - Enrollees are appointed for urgent concerns one to two weeks, depending on the enrollee’s condition.
    • Routine - Enrollees are appointed within eight weeks. Pregnant enrollees are appointed within an average of two weeks.

Russ, Manisha, Greg, Col Baez, LCDR Stallings, Joel Bales, Rebekah Fiehn, Jean Narcisi, Sonya May, Zabrina, Chris Brancato, Dave DeRoode, Rachel Foerster, Kipp Clemmons, Michael Honeycutt, Chris Khanoyan

Zabrina and Dave walked through the first iteration of the FHIR use case narrative and data sets.

Risk Assessment discussion: potential to add null flavors for risk assessments not performed. The team viewed a document sent by CDR Stallings that included caries risk assessment details. 

Final Q to the group: what details of vital signs would a dentist want to see for outbound and receiving dental referral? BP, temperature, pulse, and perhaps respiration was noted.

Russ, Manisha, Greg, Jean, Zabrina, Dave, Michael Honeycutt, Chris Breeden, Joel, Kipp, Rebekah Fiehn, Matt Szczepankiewicz, Dan Rutz, Chris Khanoyan,  LCDR Bohman, Michelle Barry, Col Baez, Toni Magni, Ubong Ikpe, Carla Evans

Dave reviewed the reason for referral value set codes within the FHIR use cases. After walking through the content, the group agreed to package the details as is, post to confluence, and identify the value sets for specific data elements.

Mixed terminology communication discussion topic: e.g., relationship between code systems such as SNOMED and SNODENT. SNODENT is a subset of SNOMED and its codes are maintained by a small work group (ADA). 

Greg, Russ, Manisha, Zabrina, Dave, Jean, CDR Stalling, LTC Bohman, LTC Parker, Col Baez, Michael Honeycutt, Chris Breeden, Dan Rutz (Epic), Toni Magni, Chris B., Matt Szcz, Kipp Clemmons (DSS), Rebekah Fiehn, Carla Evans, Nancy Orvis, Joel Bales, Ubong, Eric Kirnbauer, Christopher Khanoyan

The group reviewed the value set list for reason for referral. Some edits were made to the current version. Vendors spoke to preparedness level of testing their system against the FHIR draft specifications, mentioning they will not be ready, but are interested in building such capabilities. 

The group decided it would be best to continue to prepare the specifications for the FHIR Connectathon, but will be shifting more robust testing for September 2020. This would mean that posting IG for ballot will extend to January 2021. The group will continue to work through incremental capabilities that are more attainable from a testing standpoint.