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Our track will be operating around AEST (GMT +10); precise 'start' and 'finish' times TBC 

Submitting WG/Project/Implementer Group

Patient care WG

Justification and Objectives

This track aims to demonstrate the exchange of eye-related healthcare information between optometrists and ophthalmologists, as they collaborate in providing care for a patient. Relevant FHIR resources will be based largely on existing US CORE IG and resources and applying relevant ophthalmic extensions and profiles. This work will inform the development of a broader suite of projects and more comprehensive implementation guides, resources, extensions and profiles as needed to serve the interoperability requirements of the ophthalmic community. Some of this will be brought out in the 2 scenarios described below.

The overarching goal is to define and standardize the means through which all types of eye care and general medical providers can communicate between themselves for the betterment of the patient, as well as to and from the patients themselves. Decentralisation and remote monitoring of healthcare (and eye-care in particular) service provision is increasingly becoming necessary and feasible due to increasing disease burden, unsustainable demand, the chronic nature of diseases of eye diseases and our ageing population. Many common eye conditions can be effectively managed with low acuity monitoring. However, even scenarios requiring discrete episodes (eg cataract surgery) or urgent care still require standardized means of communications.

To handle the supply/demand mismatch, we are seeing increasing popularity of shared care models between ophthalmologists and optometrists (the 2 scenarios described below), as well as the emergence of high quality validated remote monitoring devices, that can either be utilized at home by the patient or in a primary care / pharmacy care setting. As ophthalmology as become a near imaging-dependent specialty, artificial intelligence automation has served to accelerate patient and provider acceptance of technology-driven management paradigm shifts. For example, the first FDA-approved autonomously diagnostic medical device was an algorithmic screening tool that automates the detection of referable diabetic retinopathy. In the aforementioned collaborative care models, both provider types often use the same few devices, and track the same clinical variables, yet lack a means of communicating them. Therefore, as the provider care system and management increasingly fragments, there is a greater need than ever to standardize and define data exchanges for the betterment of patient care continuity, data capture to fuel ongoing research and outcome monitoring.

Version of FHIR:

This track proposal will be based on FHIR Release 4.

Clinical input requested

Does your track have a need for input from the clinical community? If so, what are the needs?

There will be sufficient clinical stakeholders present No - there will be sufficient clinical presence

Related tracks

Coordinated care

Clinical reasoning

Cross Organization Application Access

FHIR Mapping Language Track


Proposed Track Lead

Ashley Kras, MD (ophth)

ashleylkras@gmail.com


Expected participants

Chandarshan Perera, MD (ophth)

Eddie Korot, MD (ophth)

Warren Oliver

Mike Mair, MD, (ophth)

Intermittent attendees:

Ted Leng, MD (ophth)

Mark Gilles, MD (ophth)

+/- others TBC

Scenarios: 

(FHIR v4 resources designated in bold)

Below are 2 detailed common clinical scenarios describing the collaborative care between optometrists and ophthalmologists +/- a surgical center. The overarching goal is to learn about the extent to which FHIR v4 can support these common scenarios involving highly structured data exchange between healthcare professionals, who share the responsibility of care for a single patient. 

In both scenarios #1 and #2 to follow, each encounter (Encounter) begin with engagement with either the receptionist or self check in, where the following takes place:

  1. reviews his insurance card, a commercial plan offered through his employer;
  2. provides Patient A with a routine oral health assessment questionnaire;
  3. updates the patient demographic (update Patient resource);
  4. updates insurance information (update Coverage);
  5. collects patient's co-pay.

Scenario #1: Collaborative cataract care: communication between ophthalmologist and optometrist 

Mr. ABC (patient) is a 69-year-old white male recently retired white-collar worker. He has recently noticed some changes to his vision, which are causing him symptoms such as blurring, particularly whilst driving at night. He decided to visit his local optometrist for a checkup. The following scenario #1 walks through the following steps: 

  1. His optometrist (Optom) encounter, during which the examination led to a presumptive diagnosis of bilateral visually significant cataracts (Condition, Observation)
  2. The subsequent referral to an ophthalmologist (Ophthal), for consideration of surgery (ServiceRequestReferral Note) and generates a ‘Referral request/note’ (Bundle.type=document) that includes FHIR coded information as well as the accompanying narrative (CCDA-on-FHIR Composition) describing the eye-related findings.
    1. (Encounter, planned).  Bundle.type=document is generated by Optom’s EHR system and is received by the Ophthal’s system.
  3. His Ophthal encounter, which encompassed assessments including history, clinical examination, ancillary testing (eg - biometry) as well as diagnostic ophthalmic imaging. This confirmed the diagnosis and completed the workup required to prepare Mr. ABC for surgery. 
    1. By the end of this encounter, Mr ABC had a risk assessment performed, consented to proceed with a cataract operation, discussed his refractive outcome goals and was booked for surgery
  4. Subsequently and prior to the procedure, the Ophthal selected the appropriate intraocular lens (IOL) implant, made a referral to the surgical centre with all relevant information. 
  5. Once a date is booked, the Ophthal, Optom and Mr. ABC receive notification and relevant data (IOL type, test results for reference is sent to the surgical centre prior to the date of surgery to ensure inventory is up to date and provide the Ophthal e-access to the data onsite (often a different location +/- different EHR). (Encounter, planned).  Bundle.type=document is generated by Ophthal’s EHR system and is received by the surgical center’s system.
  6. On the day of surgery, has access to the relevant data supplied and records encounter details (eg - operation report), which is then sent back to the Ophthal. Elements may also be sent to:
    1. Optom (eg - a high-level record of the encounter / letter from surgeon))
    2. Mr. ABC (eg - the type of IOL inserted, for personal record keeping)
  7. Following surgery, Mr. ABC is reviewed by the Ophthal on the following day.
  8. Thereafter, Mr. ABC returns to his Optom during which final follow-up observations are recorded (eg - subjective refraction) and receives a glasses prescription.
    1. The data from step #7 is then fed back to the Ophthal and relevant data may also be made available to Mr. ABD for record keeping.

There are many benefits for each party in such a system, should it be supported by interoperable eye care-specific resources and standards of healthcare information exchange. Some of these include:

Ophthal:

  • Receives follow up data to learn about Mr. ABC’s surgical outcome
  • Self-auditing becomes easier to assess outcome performance from aggregated data across the full journey of their patients
  • Peer benchmarking 
  • Minimize cognitive and practical energy applied to record keeping, sending, retrieving and chasing-up

Optom:

  • Increasing capacity to educate (Communication) patients in the preop and postop period & provide better service
  • Easier relationship building with partnering Ophthals
  • Standardized and automated auditing and aggregation (as above) to improve and/or change patient care paradigms
  • Minimize data harmonization efforts (as above)

Mr. ABC:

  • Receives relevant personal health data
  • Can integrate this into many emerging personal health record applications (eg - glasses prescription)
  • Minimize concerns and considerations about data harmonization efforts in a collaborative care model (as above)

Actors in scenario #1: patient (Mr. ABC),  2x practitioner (Optom, Ophthal), multiple devices, potentially multiple locations, and potentially 2x healthcare services

Success Criteria:

For Ophthal, Optom and surgical center EHRs to conduct trilateral information exchange; for each EHR

System able to capture relevant information during an encounter and generate a bundled (referral note) above and successfully POST to test server

System able to GET bundle above bundle from test server

Bonus point:

Patient app being able to GET a subset (eg IOL choice) of the referral bundle from test server

Scenario #2: Collaborative glaucoma care: communication between ophthalmologist and optometrist 

Mrs. XYZ (patient) is a 75-year-old Hispanic female with stable and controlled moderate primary open angle glaucoma (Condition) that requires regular monitoring. Mrs. XYZ’s glaucoma is cared for collaboratively by an Optom and Ophthal. The majority of encounters take place at the Optom, whilst she is stable, during which she undergoes a series of examinations (eg: visual acuity, intraocular pressure measurement (Observation)) and diagnostic tests (eg - visual fields, fundus photography, ocular coherence tomography) and a risk assessment is performed (RiskAssessment). As it is a chronic disease, optimal glaucoma management relies on capturing longitudinal and multimodal data points (examination, testing, imaging (ObservationImageStudyDiagnosticReport). Frequency of visits may vary (eg - from every 3-12 months, depending on a number of factors). Whenever certain parameter thresholds are reached that suggest worsening of disease (Condition), the patient will generally be referred (ServiceRequestReferral Note) to the Ophthal for evaluation and decisions about any new or changed management (eg - change in (Medication) or recommendation for surgical intervention (Procedure)). Therefore, it is essential that all of these monitoring records are routinely transferred to the ophthalmologist. The reasons for this are twofold; first, the Ophthal may be involved in reviewing some of the information collected during the Optom encounter, and second, if and when the time comes for referral, they will have the relevant information available. 

There are many benefits for each party in such a system, should it be supported by interoperable eye care-specific resources and standards of healthcare information exchange. Some of these include:

Ophthal:

  • Can be involved in remote monitoring of Mrs. XYZ’s care
  • Self-auditing becomes easier to assess outcome performance from aggregated data across the full journey of their patients
  • Peer benchmarking 
  • Minimize cognitive and practical energy applied to record keeping, sending, retrieving and chasing-up

Optom:

  • Increasing confidence to monitor Mrs. XYZ knowing that the Ophthal has access to her results and information 
  • Increased capacity to educate (Communication) patients about decisions and following Ophthal referral to provide a better service
  • Easier relationship building with partnering Ophthals
  • Standardized and automated auditing and aggregation (as above) to improve and/or change patient care paradigms
  • Minimize data harmonization efforts (as above)

Mr. ABC:

  • Receives relevant personal health data
  • Can integrate this into many emerging personal health record applications (eg - glaucoma medication adherence) and can leverage emerging devices (eg home Icare ® - home IOP monitoring device) to enrich the data available to practitioners between visits
  • Minimize concerns and considerations about data harmonization efforts in a collaborative care model (as above)

Actors in scenario #2: patient (Mrs. XYZ),  2x practitioners (Optom, Ophthal), multiple devices, potentially multiple locations, and potentially 2x healthcare services.

Success Criteria:

For Ophthal and Optom EHRs to conduct bilateral information exchange; for each EHR

System able to capture relevant information during an encounter and generate a bundled (referral note) above and successfully POST to test server

System able to GET bundle above bundle from test server

Bonus point:

Patient app being able to GET a subset of the referral bundle from test server (eg new medication (Medication) prescribed by the Ophthal added their medication list app)


Common ImageStudies for both scenarios:

(DICOM modality (0008,0060) attribute in bold):

-Optical Coherence Tomography (OCT)

-Ophthalmic Photography (OP)

-Ophthalmic Tomography (OPT)

-Ophthalmic Axial Measurements (OAM)

-Optical Surface Scan (OSS)

-Ophthalmic Visual Field (OPV)


TestScript(s)

Indicate any test scripts that will be used to help verify system behavior - to follow


INFO & Links for fellow participants

More background:

  • Link to main connectathon page - 2020-05 Connectathon 24
  • A Connectathon Information Session was held on Thursday, April 30th at 1:00 PM.
  • → zoom details will be ready on 13th 4pm ET
    • Webinars / tutorials - recorded
    • Thursday 9am ET intro to FHIR
    • Thursday 11am ET testing tools session

Overarching goal:

  • Create an IG based on above scenarios

To do prior (logistics):

  1. Sign up - https://www.hl7.org/events/fhir/connectathon/2020/05/
    1. Participants $150 non-members vs $100 members
    2. Observers free (not available for this virtual connectathon due to low cost)
    3. Must pay to access to webinar or zoom meetings
  2. Complete survey - https://www.surveymonkey.com/r/HNQ96MY
  3. Please join zulip chat channel - https://chat.fhir.org/#narrow/stream/237429-Ophthal_on_FHIR/topic/stream.20events

To do prior (tasks to optimize output):

  • Ensure test scripts ready
  • Get test data ready dummy patient / resources etc
  • Can use wild fhir test server through connectathon

Connectathon organization:

  • May 13-15; asynchronously coordinated, but official commencement is tentatively 4pmET = 6am AEST (will be recorded and each team can 'start' on day that most suits them)
  • Comms through zoom/zulip - connectathon to provide zoom channel
  • Webinar day 1 AM; aim for > daily check ins AM & PM
  • Only those who are registered can access zoom and connectathon webinars
  • Need to organize a few things prior (see above)

Lastly, to prepare....:

  • Finalize team and then coordinate best times based on TZs, and arrange session with someone via Aegis in advance (Sandy to coordinate w thanks)
  • Get organized re above and plan for Aegis session upcoming

Security and Privacy Considerations

Identify any expectations around security (e.g. will TLS, mutual-TLS, OAuth, etc. be required to participate - to follow

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