SIGN IN AT 2019 May WGM - Patient Care Attendance

Agenda

Minutes

Mon Q1

• approve minutes from 2019 Jan WGM - Patient Care Agenda and Minutes  Emma/Michael
• review agenda for the week
  • Mon Q3 - moving topic to Q2 - not on SD schedule
  • Tues Q1 - Jay is checking with CIMI. We may need to cancel if nothing from CIMI
  • Tues Q2 - SOA - Room is Suite 728
  • Tues Q3 - V2 topics removed quarter - this is old.
  • Tues Q4 - Trackers from Floyd for discussion. Some are resolved. Others are not owned by PC. Is it for discussion
  • Wed Q1 - Cancelling. Not enough trackers for this quarter
  • Wed Q2 - with PA
  • Wed Q2 - blood thing removed. Not on OO schedule
  • Wed Q3 - CIC - removed. No invitation
  • Thurs Q3 - at risk of getting cancelled - May not have enough trackers

• Quality criteria for V2 and V2 IGs
  • HL7 Version 2 Implementation Guide Quality Metrics (PC doesn't have any v2 IGs)
  • Health Level Seven (HL7) Version 2 (V2) Standard Quality Criteria
  • V2 Ballot Comments
    • NEG (chapter 11)
      • Comment on sections 11.3:  Insufficient information: If the messages will be deprecated, there is specific language to be used. These messages were valid in 2.8.2,: if they are being deprecated in 2.9, the appropriate notification must be added to each message.
        • Craig / Nick:   7 in favor / 0 against / 0 abstain (persuasive with mod)  Reasonable to add standard deprecation language.  Amit Popat  What was the reason why this was deprecated?  We could add a redirection to whatever chapter it was replaced with.  
      • Same comment on 11.8
        •  Amit Popat Craig Newman  What does it mean that the segment WILL be deprecated?  Is it deprecated in this version?  If it will be deprecated in a future version, why mention that in this version? 
    • A-T
      • Craig/Emma:  block vote on all affirmative typos – 6 in favor / 0 against /1 abstain 

    • A-C (chapter 11 section 07.01) – Remove comment - does it need to be addressed?

      • Craig/Sabrina  – 7 in favor / 0 against /0 abstain (persuasive with mod) Remove the comment.  Leave the RXA segment to be allowed to repeat for backwards compatibility, but we will add a note after the message definition indicating that it is only technically allowed to repeat.  If multiple RXA segments need to be sent in a message, then a repetition of the MEDICATION_ADMINISTRATION_DETAIL should be used.   Amit Popat can work with Craig Newman on the exact wording.

    • A-Q (chapter 12 section 03.01) – ROL is indicated as deprecated- should it have been replaced here with PRT?

      • Chapter 11 has ROL deprecated, but Chapter 12 has both ROL and PRT. 
      • Craig / Nick  :  7 in favor / 0 against / 0 abstain Refer to InM.
    • No Vote classification (chapter 11 section 06.01) – This notation is not standard - fix per style guide - ROL should be marked as deprecated and the PRT segment should be a separate row
      • Craig / Nick:  6 in favor / 0 against / 1 abstain Persuasive - use the standard style guide methodology

Mon Q2

IPS update  - Rob Hausam

• Status Update (SDWG is co-sponsor, PC is primary sponsor)
• Five IPS project products
  •  CDA version of IPS 
  • FHIR version of IPS
    • Recent work to do further updates. Planning on going to ballot in Sept.
    • SDWG has some IPS work - wondering if should be moved to PC - will re-assign to Patient Care
  • Two CEN standards - have been published
  • One SNOMED International - global Free Set (GPS) available Sept 1, 2019- free of monetary cost for use of the concept identifiers. Will increase all the free sets in one package including DICOM, IHE, etc.
    • How will it be available? Can the concept relationships be used?
    • IPS set available in SNOMED ref set.
• IPS alignment with Argonaut
  • Discussions about aligning with Argonaut
  • Need to determine changes needed in IPS to better align
  • Intent is not for IPS to become realm specific.
  • Terminology is not expected to fully align
  • IPS Ballot/update strategy - limit scope of ballot to only the changes since January
• Further IPS dev
• Identify new or missing use cases and content
• Encourage implementations - getting interest from folks around the world
• Structural Vs Vocab differences
• Goal is to maintain structural alignment as close as possible
• Terminology alignment - expect to not be aligned because of "International aspect"
  • Currently IPS does not include chapter with terminology differences, is there a way to tell differences?
  • There have been a white paper. Rob can share it.
  • Can a US core profile that inherit from the base FHIR and IPS and make the tooling show the difference?
    • Not automatic. Need a tool to do this. Further discussion needed
• Planning FHIR dev days in June in WA

Provenance - Brett Marguard (on Phone), Ken Lord

Provenance - US Core/Argonaut

• Basic Data Provenance. Project kicked off in Jan
• Reviewed Selected Scenarios - functional scenarios
• Time line - use cases defined by this WGM. Plan is to go to ballot this fall. 

Scenario 1 - "Fax"

• Receipt of a transmission from another site (e.g. DIRECT, patient provided upload). Not "imported" yet
• What information do the clinician need?

Scenario 2 : HIE redistribution

• HIE acting as a clearing house
• DOD and Va have a common viewer. displays sources in the viewer
• Met with the users. Most users just need to know how to go find the data.
• They care a little about who send it but mostly care where the data came from.
• Chain of custody vs some sort of clinical authorship. E.g. got seen at Kaiser.
• Plan is to stay away from organizational rules as to how they propagate the chain of custody.
• Per users, authorship was cared about and custodianship was an after thought. They cared which organization provided the info more than the author that created.
• Suggestion made to take into consideration encounter specific scenario

Scenario 3 - HIE Transformation

• Taking data in and re-aggregating it -
• Aggregation is important to V3→FHIR convertions. Can have data from several different HL7 messages. Need to reflect the path the data went thru in the final results that shows the record from multiple sources.

Scenario 4 - Clinical information Reconciliation and Incorporate

• What changes in the context.
• HIEs aggregation has been with no human intervention.
• IHE RECON profile - key was the data was the outcome of reconciliation and the sources. Need to be able to trace it back. Not purely algorithmic.

Have been aggressively trying to figure out what is the bear minimum.

• Bare Minimum -
  • Pick one
    • Organization
    • Author
    • time stamp

For Scenarios 1-4

• Is Organization at document level suppicient or need more granular level
• Is Author at document - level sufficient
• Is author a structure Vs a concept

Out of scope

• Full chain of custody
• Provenance of how information is created, managed within an EHR
• Organizational polocies on which individual authors to include
• Blockchain
• Assigning a level of trust to the person/system assigning the provenance
• Additional metadata elements to support data reconciliation

1. Suggestion for discussion with HL7 security WG. Meeting with Security Q4 Tues

Clinical notes update - Brett Marguard (on phone)

• Composition not heavily implemented
• Part of Argonaut. Consolidating ballot comments into R4

Clinical Status - Act Status, Clinical Status, Verification Status - Lisa Nelson

Status Alignment

• C-CDA 
  • Concern act statusCode (state model - behavior inside the system to know if this is active or has been completed)
  • Problem Observation 'Act status" statusCode = completed (the observation has been made)
  • Problem Status (clinical status of the problem observation Condition.ClinicalStatus
• US Core Condition
  • Condition.VerficationStatus - unconfirmed | provisitional| etc
• Note: Many FHIR resources have a status element and no clinicalStatus element
• Suggestion for Observation certainty status
• Need to get this straightened out.
• No clear picture as to what we're doing with status on the FHIR side
• Condition did away with "status"
• Fundamental problem that needs to be solved.
• Need a state model that both sides will understand.
• Need to think of "business" status spot - for claims and coverage.
• Need to adopt and align ActStatus and Adopt a common state model that will work across technologies
• The problem is the difference between clinical state and machine state. the two are not the same thing. How is your database handling when something
• FHIR-I q4 today is discussing consistency topic - consistency across FHIR. Michelle will bring topic up there.
  
  • Follow-up from Michelle - 

  • "We touched briefly on the topic of record status in FHIR-I workflow (Mon Q4).  The initial response was that FHIR would like to know a specific use case before considering the addition of a record status.  CDA alignment wasn’t a compelling argument since not everything in CDA is actually used.  Concern status wasn’t a compelling argument either since that can be solved either by using the List (and the Condition’s inclusion in the List represents the provider’s active concern) or else Condition.category = problem-list-item (since concerns are generally managed via the problem list). If you have other use cases that explain why we need a record status, then that would help further the discussion."

Mon Q3

• Mega Report Out
  • Report out provided by: 
    • EHR WG
    • CIC
    • BR&R
    • PCWG
    • LHS WG

Mon Q4a

Mon Q4b

• Main topic is International Patient Summary:
  • Data-set: ( 1 CDA (balloted and approved) and 1 FHIR ( has passed, but reballot in September). Today we will discuss what we bring to ballot.
  • Is the IPS CDA maintained with the feedback from the FHIR ballot? Actually the focus is on the FHIR publication.
  • Argonaut is based on FHIR release 2 and working on an upgrade to release 4. Trying to get harmonized with the IPS. There is a document available with the differences from Michele Mottini.
  • Big issue to be solved is with slizing.
  • Also looking for solution to facilitate the local adoption for example terminology.
  • Christoff Gessner asks what is the normative material? Can this be found in Github?
  • This is dependant on what you are seeking and would like to contribute. This could be the IG. Giorgio explains that the material is in Github and the publication also produces a package with which you can facilitate.
  • Medication Statement is used to declare that (certain) medication is not used. There is a comment, that currently the medication reference is too heavy to use for just one code. The commenter would like just to mention one code. A suggestion was raised to put the medication in codable concept. This leads to an error in the build of the publication. Argonaut does not have this issue, because they do not register not used medication.
  • Alexander Henket states that in Netherlands they rule out the codable concept and can only use the medication reference, because for IT systems it is more difficult if there are 2 options.
  • Rob Hausam wants to know what to do correctly and what we could do temporarily?
  • What is the onsetDatetime for no known allergy in AllergyIntolerance? This onsetDatetime is now required. Question whether this should be conditional?
  • Alexander mentions that 2 slices in medication statement have the same name.
  • These are slicing issues which tooling should fix. ( Grahame).
  • General topic on IPS versus Argonaut. How do we manage alignment when we do not want to be realm specific. Look at the whitepaper comparison between Argonaut and IPS from Michel Mottoni. This document can be found here:
  • Part of the difference is because of the different purpose of Argonaut and IPS.
  • IPS ( in FHIR) is now considered also to be REST based, where you can retrieve seperate resources itself, for example immunizations.
  • Oyvind Aassve mentions that Norway is building the National Infrastructure on this principal which approach the IPS as much as possible. However you still can deliver the resources in a bundle.
  • Argonaut has a longer list of "must support " items.
  • IPS is explicit on statements on negation.
  • In the REST architecture of Argonaut the asssumption is, that no information will be returned if the data is absent, i.e. there are no allergies.
  • Stephen Kay expresses his worry how to solve the differences between IPS and Argonaut, because they have 2 different purposes. Who is going to use the IPS?

Tues Q1

Tues Q2

Tues Q3

R5 Ballot Timeline proposed

• Will be seeking formal feedback on schedule by Sept.
• January cycle to review normative content readiness –May not be a formal ballot
• May cycle – 1st normative ballot, main STU ballot
• Sept. cycle – 2nd normative ballot (if/where needed)
• ~Dec. – Publish R5

IG Tooling

• Moving to a single ‘template’ for HL7 Int’l-published FHIR IGs
• Template will be developed over next 2 months –Seeking feedback on how to improve FHIR IG appearance/utility
• Use of template will be optional for Sept. cycle –Likely mandatory for cycles thereafter
• Will also be a template to use as a base for non-HL7 work

 IG Capacity

• Several stakeholders have indicated that the demand for FHIR IG development is likely to increase ‘significantly’ in coming years
• We need to increase number of people with the skills to
  • –Facilitate/develop/manage IGs
  • –Review and compare IGs
  • –Assist with selecting/developing terminology
• Will be putting together a training/mentoring process to build HL7 capacity in this space

Questions:

1. For those work groups planning to take resources normative in R5, working back from the timelines indicated, what do you need to do to ensure all resources are at FMM 5+ maturity prior to the January cycle review?
   1. Gather feedback informally (e.g. asking at WGM) and if unconfirmed, then ask Grahame for help soliciting feedback from the community.
2. Do you need any assistance identifying/getting implementation to meet the implementer requirements?  Are there any terminology actions you need to take that might involve proposals to external terminology agencies (through the HTA) or going through the HL7 terminology harmonization process (and if so, how soon can you initiate those processes)?
   1. Going to FMM =3 will require using external code systems, where available.
3. What are your FMM targets for your remaining resources?  Below.
4. What do you need to do to hit those targets?  How will you get there?  How will you know you're on track?
   1. RIM mappings - Jean, Netherlands (Alexander), Structured Documents, AMS
   2. http://build.fhir.org/qa
5. Is there anyone from your work group who would be good candidates to build skills in IG development and/or IG review?
   1. No volunteers today
6. If you're planning to bring forward IGs for ballot, how will you ensure the implementability of those IGs prior to ballot?
   1. None identified yet.  Will raise on Patient Care co-chair lunch Thurs.
   2. Past examples included:
      1. Profile on Observation for patient preferences
      2. Profile on Task or VerificationResult for care plan reviews
      3. Profile on AdverseEvent for clinical trials vs clinical care
   3. If a profile is needed on a FMM=3 or above, then the resource work group that owns the resource would need to approve the profile

FMM Resource Proposals

AllergyIntolerance 3 → Normative

• Germany - Stefan
• Netherlands - Alexander Henket - STU3 

Condition 3 → Normative

• Germany
• Netherlands

Procedure 3 → Normative

• Germany
• Netherlands

CareTeam 2 → Normative

• Netherlands

FamilyMemberHistory 2 → 3
CarePlan 2 → 3
Goal 2 → 3
Communication 2 → 3
CommunicationRequest 2 → 3
AdverseEvent 0 → 1?
ClinicalImpression 0 → 1
Linkage 0 → 1
Flag 1 → 3

Resolved:  

• GF#11332 - Acknowledge Advance Directives as type of Care Plan - 2016-09 core #490 (2016-Sept Core)

Tues Q4a

• Negation -
  Jay will take time this summer to wrap this up. Anybody want to get involved contact Jay Lyle
• Gender harmonization - Rob Hausam
  
  • Pub Health needed another code for when the person is not male nor female. Clinical connotations.
  • Context Definitions - started to describe.
  • Have initiated the PSS.
  • Goal of the project is to have wide review of the concepts
  • PC should have a stake in this.
  • Other stake holders are PA, PH (one of the main driver for collecting the data)
  • Added a number of international affiliates (Germany, Canada, Australia, etc)
  • Have identified the primary types (context of use) 
  • Goal is to prove that the landscape have been covered. For e.g. how does US censor do this, how does organizations do this? Ways of covering sex identity or gender identity. Do this pointing to lots of examples.
  • Intent is to do an informative ballot. 
  • Questions/Comments:
    • Is intent to be international? Yes
    • Is the intent to push this into regulatory work? No but is totally possible. Will be terrible to have a definition and not be able to use it. Agreement. Can use it within context of the standard.
    • Ask is for PC preliminary approve the PSS. Need to get this done by end of month. Vocab is primary sponsor. PC as co-sponsor with the request for formal content review. PSS have to be at PMO by May 24, 2019. Vocab will be meeting Wed Q4 this week to finalize the PSS. Request PC attendance.
    • Next PC co-chair call is May 27, 2019

GF#17946- Closed the QDM

Opiate care plan CDS - no further updates provided.

Discussion about 20658 – Managing inter-related procedures using Event resource 

Discussion about 20527 - Request for Principal Procedure (to Structured Documents) for the reason for the admission.

• The principal procedure on the claim is coded after the fact. principal procedure may not be the reason for admission. Could be admitted for another reason and have a procedure done. 
• Trying to find the procedure they came in for and track the outcomes from that. 
• Attempting to use a sequence of code that should be modeled. Will need additional data fields and appropriate data models. Problem ishere is not a willingness to apply the model to the data use. 
• Seems to be encounter specific 
• Suggestion to look at reason for admission and determine the procedure codes from the reason. 
• Suggestion to change it from "principal" procedure to "planned" procedure. 

CIMI update

• Have completed the wound assessment modeling
  • Have re-modeled body location. 
  • Made extension to fully extend body location. Used extension in condition. Complex extensions  that have extensions on extensions. 
  • Suggestion for PC to review this work. 
• Is about going to pilot with breast cancer related data elements. 
• Completing curation all qualifiers for Vital signs. 
• New PSS for pain assessment - data from nursing. include all the pain qualifiers.
• All value sets are available in VSAC
• From CIMI logical models have tooling to convert into FHIR resources. 
• Trying to get the documentation in Confluence. 

Tues Q4b - PC Declined

Wed Q2

• GF#11173 CarePlan needs support for reviews -
• GF#20650 CareTeam.participant.timing - replace timing with data type period (Zulip follow-up)

Wed Q3

Wed Q4 

• GF#20676 Update AdverseEvent introduction – resolved
• GF#22108 AdverseEvent is missing status - logged, but not resolved
• GF#22107 AdverseEvent.suspectEntity.causality -- cardinality of 0..1 – logged, but not resolved
• GF#22106 AdverseEvent.supportingInfo.item -- clarify definition – resolved 

Thurs Q1

• PC Care Plan DAM 2.0 - Following overview provided

• Care Team DAM - Update provided by Russ Leftwich
  • FHIR Enhancement Project (LHS) - Update provided by Claude Nanjo
• Patient Care Care Plan DAM 2.0 Project 
  • SDoH - George Dixon - Overview provided
  • 
  • Interactive Lesson in SDoH - Activity demonstrated. 
• Gravity Project -  Overview provided by Lisa Nelson 
• CCDA - Care Team entries -  Overview presented by Emma Jones
• 
• NCPDP/HL7 Pharmacist Care Plan -  Update provided by Zabrina Gonzaga 
• 

• Nutrition - Update provided by Becky Gradl 
• FHIR Workflow
  
  • FHIR Connectathon - Care Planning and Management Track Update provided by Dave Carlson and Jeff Danford (Update) 
    • IHE Dynamic Care Planning Profile - Update provided by Emma Jones

Discussion: 

• Care Plan Review
  • Application/computed review needed so not to increase burden on providers
  • User actions and context - should be a procedure
  • This topic need awareness
    • Can have multiple care plans across multiple of care providers. Need to figure this problem out. Should include the patient and caregivers. 
    • Care plan is not a document -it's a dynamic representation of what is going on. Longitudinal record.
    • Adding in care team with who sees what and when. 
    • Measurements and Decision Support can be very granular.
    • Need to take a step back and let AI determine that something happened.
    • Need to be careful not to put requirements on providers and add additional burden. Looking for a solution. 
    • Use case of how this is wrong is the handling of the problem list and medication list. It's a mess. Best way to make things worse is to throw something at it.
    • Have been looking at use cases for Care Plan Review POC
    • Agreement it's a mess. Care plan fragments exists in many places. Care plan as a document has been constraining us. Need to start thinking of Care Plan as a dynamic data set. This will need to provide views of limited access and limited provisions to change things. 
    • Currently, the problem is nobody updates the historical data. 
    • Another problem is looking at things on the screen and not knowing the provenance.
    • Care coordination is always implied.
• Quarter Adjourned - will continue same quarter next WGM

Thurs Q2

• New project from ONC on FHIR Update. This has just been kicked off. CCDA templates using FHIR SD templates. Migrate with the purpose to use the publication utilities from FHIR. The product will still be CCDA using a document structure.
• Collaborative template review
• Companion guide on CCDA for ballot in juli.
• Stewardship of clinical content: Templates that have been reviewed by PCWG are problems, allergies. The team looked at the consistency of clinical status.
• Clinical status:
• Condition status 14874 has been resolved for clinical status. Other status are also related like verification status, Concern status, Need alignment.
• Some status are not represented in CDA.
• In the RIM the act status is a machine status.
• Health Concern can group certain problems: the resource that will be used is Linkage. It does not have a status, only a Boolean. There has been no feedback and the maturity level is still 0. Name change considered from linkage to concern. Which additional fields are necessary? Which codes are necessary for status ?
• Calvin has doubts about the implementation of health concern's.
• Will there be support from stakeholders? EHR would. George Dixon: need go to back to the functional workflow.
• Lisa suggests to see if linkage/concerns is pilotable.
• Is there any guidance in FHIR in the naming of status in FHIR. Yes, just look at the resource.
• Care team: DAM defining concepts in many projects. Try to identify gaps and align the resources for the care teams. This is done in LHS.       Will be taken up in the companion implementation guide and go to ballot in July.
• Negation: this project has not be funded and therefore Jay has wrapped up this project. What is the standpoint of FHIR on negation. There is no generic strategy. This is an issue which has to be dealt within each resource.
• CDA management group: IG quality. Topic is the quality criteria for CDA IG's. There has been comments, which SD is dealing with. Need a month or 2 to finalize the dispositions. The group sponsoring the IG is responsible for the quality.
• Next WGM SD will only send representatives.

Thurs Lunch  - Admin Quarter

Thurs Q3 - Cancelled

Thurs Q4 - LHS Quarter. See LHS for meeting notes.