Attendance

2022 May WGM Patient Care Attendance - Patient Care

Quarter - Time Zones Conversions

Agenda

Minutes

Tuesday Q1

Updates on CIMI efforts
skin & wound - Nathan to investigate publication tooling issue.
podiatry - specializes skin & wound, by EHR. has not gone to ballot.
vitals (1541) https://build.fhir.org/ig/HL7/cimi-vital-signs/: aiming for stu publication
pain (1585 - on hold)
COVID 19 FHIR IG (1620) https://build.fhir.org/ig/HL7/fhir-COVID19Library-ig/index.html: voted to publish; to FMG next for informative publication

Model questions
Allergy discussion from January
    reaction should be an independent resource
    or an observation profile 
      It's a description of symptom; conclusion of cause is a different
      Need to be able to call it a reaction without calling it AE/AI
      include onset & exposure
      There is a difference between association & determination of AI. This is usually not noticed but may be.  Nursing process, e.g.: rxn 1st, 'allergy' later
Solutions 
    Rxn resource?
    Add AE to codeable Ref?
    Add response to Medication Admin?
    Observation as partOf Med Admin?
    Detected Issue?
        * Add to ClinOnFHIR workflow. Define use cases, test in tool. Laura to schedule. Tue 5 pm ET standing call.

Tuesday Q2

Hugh: Vulcan progressing well, planning to invest more in AE
page https://confluence.hl7.org/display/VA/Catalog+of+AE+Gaps

Jean: publication for http://hl7.org/fhir/us/icsr-ae-reporting
    some extensions in R4 IG, changes mostly already made to R5

Remaining Jira
Status        FHIR-36009, FHIR-34200
Code        FHIR-34318, FHIR-26436
Observation    FHIR-34316

Discussion of Code, role in respective use cases
Two-use-case situation continues to require extensive discussion, even when no action items result. Action item: try modifying language to clarify boundaries up front.
> 9.9: The resource does not represent the event, but the characterization or interpretation of an event.
> The first-class data is (typically) included by reference, not recorded in the AE resource, which represents judgment process metadata (that this is an AE, why this is an AE, etc.).
> Proposal to expand AE.code to codeableReference & use it to point to whatever the thing is that is judged to be adverse. All of those things (care provision acts, disorders, contributing factors) already have homes in the resource, but this would specify the one of concern.

Jean to draft answer to FHIR-26436
PC to schedule time on FHIR call (5pm ET Th) to address; BRR to be invited

Tuesday Q3

Tuesday Q4

Agenda 

CDA Gender Harmony plan

"Consent to Treat" codes

Floyd: use of Procedure for breast feeding measure 

CCDA-FHIR Questions/Proposals 

1. RecordedDate
   1. FC Allergy & Condition: Leave recorded date unmapped because it's not always author date
   2. Do not conditionally populate effectiveTime
2. Recorder
   1. FC Allergy & Condition: Use Provenance.agent(s) for CDA author; use "ProvenanceAuthor" if possible
      1. include Recorder? deduplicate?
   2. CF Allergy & Condition:
      1. Put all authors in Provenance
      2. if there is one ProvAuthor, or one latest ProvAuthor
         1. Put latest CDA ProvAuthor in FHIR Condition recorder
      3. Otherwise,
         1. if there is one Author, or one latest Author
            1. Put latest CDA Author in FHIR Condition recorder
         2. Otherwise,
            1. don't

Discussion: 

CDA Gender Harmony plan

• Rob Hausam
• Informative document is done
• How to do this going forward in CCDA – Gay will work with Lloyd
• Should this be done during existing SD calls or use additional call
  • Additional work for this is done for V2
  • V2 management group – Craig did work off line
  • Lorraine made request to be included in the loop

"Consent to Treat" codes - Corey Spears

• PACIO Project working on the ADI IG
• Specifically addressing Healthcare Agent
• 
• Here is my Agent
• Need to add what actions the HC Agent can take
• Not talking about the procedure itself but metadata about the procedure
• Codes https://build.fhir.org/ig/HL7/fhir-pacio-adi/CodeSystem-PADIHCADecisionsCS.html
• Mohammed – there is FHIR resources encapusulating more than just the code. The action is a codeableConcept. Suggest changing this in the Core Consent to a CodeableReference
• Clarification of the requirement – patient is identifying individuals and specific procedures the agent can perform. Would like to identify a class of procedure and not individual procedures. Concent.provision.action – change to codeableReference
• Rob M. what is consent for? The thing? When the patient exactly specifies what the proxy should be able to do.
• Lorraine –
• John M - Seems we are speaking to a "actor.role" and that "role" is mapped to a set of activities.
• Floyd - What is the reason we can’t use the same consent for advance directive for the patient and use something like the requester to be patient or RelatedPerson - perhaps with an AuthorizedRelatedPerson profile? I.e., HealthcareAgent
• Maria Moen – consent to allow someone to speak for you.
• John Moehrke – nesting of provision allows you to do the same thing. The element to use is provision.provision. This element is used for the specific “procedure”
• Jay – Cory’s question is about re-use of the existing vocab
• Floyd – a certain person can decide
• Emma – what are your functional use cases?
• Corey – trying to identified the agent and the powers they need to perform
• Lisa Nelson – have seen use case where the parent wants to prevent the children from removing them from their home.
• Daver – agreement with Lisa there need to be a grouper
• Maria – national jurisdictional definition. Saw an opportunity for an individual to expand on the basic jurisdictions. Majority of the forms are free text.
• Davera – suggesting a grouper to be able to enumerate the coded concept.
• John – thinks this has been done.
• Jay – the need to predict what people would select.
• Corey – there are particular areas of the procedure that aligned with MOLST. The point is to try to make this computable.
• John – the datatype provides the free text possibility
• Jay- did the environmental screen
• Corey – This part of the IG is specifically for health care agents and what they can do.
• Mohammed – suggestion to cover the delegation in the core
• Maria - It makes sense to match procedures authorized by the patient to the services delivered when we are talking about Portable Medical Orders. Not sure that level of specificity exists in the current forms that are patient-authored.  I could be wrong and the forms are very diverse by jurisdiction.
• Ross - Agree re leveraging CDS in situations where directives are known, but have to remember that in many (if not all) jurisdictions written advanced directives can be overruled with verbal direction by patients or by delegates
• Paul - Do you need separate codes for request and reject? Does request=permit and reject=deny?
• Mohammed – suggest bringing this to the Consent working session with CBCP
• John – the current consent model has been almost 100% based on privacy consent. This is why the push back on using the action element.
• Corey – Will be following up with John and Mohammed

Use of Procedure (Floyd)

• Floyd – Measure trying to identify that a new born in a hospital received only breast milk and nothing else. Ask if for baby to receive exclusive breast milk. Can provide nutritional intake for the product. What will be used to “administer” the breast milk.
• Becky Gradl – Nutrition Intake and Nutrition Product (pulled into R4B). NutritionProduct is in R4B.
• Yanyan – SNOMED code can be used. Have procedure codes.
• Jay – the neonatal registry had a similar
• Peter Jordan – provided the following 1163377005 Breast milk feeding management (Procedure); parent 440626008 Procedure related to breastfeeding; 1145307003 Exclusively breastfed (finding)
• Yanyan – looked at all feeding.
• Rob – look for it as a finding which will be an observation. Suspect that the mother is breastfeeding
• Peter Jenning - https://ecqi.healthit.gov/ecqm/eh/2023/cms009v11
• Yanyan - this information is documented in the intake form. Would like ecqm to review the documentation – if so, the computer looks for any other dietary information.
• Paul Denning - PCNewborn."Single Live Term Newborn Encounter Ends During Measurement Period" QualifyingEncounter

with ["Substance, Administered": "Breast Milk"] BreastMilkFeeding

such that Global."NormalizeInterval" ( BreastMilkFeeding.relevantDatetime, BreastMilkFeeding.relevantPeriod ) starts during QualifyingEncounter.relevantPeriod

without ["Substance, Administered": "Dietary Intake Other than Breast Milk"] OtherFeeding

such that Global."NormalizeInterval" ( OtherFeeding.relevantDatetime, OtherFeeding.relevantPeriod ) starts during

• 
• Becky - would be nice if there was a nutritional administration resource. 
• Floyd - Intended to be used only for inpatient. 
• Becky - would doing this as attestation work for now. 
• Rob - could use a hack and treat is as a medication administration
• Stephen - How does FHIR deal with [fluid] Intake/Output charting? Would be nice to have intake and output. 
• Becky - NutritionIntake included fluid, but again it is in R5

Provenance mapping

Provenance Domain

Jay - advertising for this discussion during SDWG Q2 quarter tomorrow. 

Tuesday Q5 - PACIO - Birds of a feather

Presentation by Dave Hill on PACIO project progresses since the January 2022 WGM

Presentation (zip file) is here:

• • 2022-05-10 PACIO Birds of a Feather v3.pptx.zip

Wednesday Q4 

CDeX Update - Eric Haas

• Added guide with draft content for Digital signature
• Direct Query Vs Task based approach
• 
• 
• 
• 
• 

Next steps - Ballot reconciliation

Meetings are on Wednesdays. 

Drivers for the new draft is legislations. 

New will be claims authorization attachments

Will get an X12 request and will send a FHIR response

X12 277 and 278 - SMEs are in the PIE WG

Discussion: 

Isaac - Attachment rules - does Da Vinci have 3 burden reduction?

Eric - received this question as ballot comments. Need to get and provide clarity on this. 

Isaac - there need to be four IGs to be supported by implementers.

Eric - lots of uncertainty in the attachment space

International Patient Access (IPA) (spec) (Isaac V.)

Discussion:

• Likelihood that servers will re-use its capability across countries
• Need to get time schedule with PCWG
• Hoping to get 5-10 min time slots weekly
• Seeing nice engagement and support
• Themes within the ballot feedback
• Trying to accurately reflect current state credibility of countries that are using and adopting FHIR. 
• Inconsistencies - generally countries and jusridiction don't define patient access profiles. Most countries will define national base profiles. 
• Grahame - the must support focus is if this populated "behaviour". was not intended to require server support. For example patient identifier is must support. doesn't mean the server have to populate. Its about pulling apart the must support for patient safety purpose. 
• John - guide in Vulcan based on IPS - how stable is IPS. Rob will give an update. 
• Eric - if the must support is all client based that's good.
• Grahame - the server side must support is much looser. The IG have to address the Must Support. IPA is a different IG.
• Isaac - client must support is like clinical guidance; server side must support gives guidance to developers as a table of elements that are identified as more important that others. should be used with national level guidance. 
• Grahame - patient.active - must support it if you need to get the record. 
• Rob - sounds like thare are different Must Support for client and servers.
• Eric - capability statements are different. 
• Isaac - engaging international FHIR community have been slight. Need to do outreach and education. Will focus this summer on improving the IG, getting thru the ballot. As a patient crosses border IPS shares the data between providers. For IPA, patients can access their data in what ever country they're in. 
• John M - this client focused mustSupport is yet-another example of why mustSupport does not work as a Boolean.   That said, the client "safety" items don't seem appropriate to be communicated in a profile, but would be better expressed as shall/should/may language on the client actor.
  
• Rob - IPA is closer aligned with US core. IPS is about a summary of relevant clinical data that is about crossing boundaries. Question with IPA is access to patient's data or patient access to data? IPA is a natural means of getting the data to create the summary.
• 
• January ballot
  • Ballot Dashboard
  • Scheduling for block-vote-2 (details on vote)
  • Recurring PC timeslot for upcoming votes?
  • Next PC call May 23, 2022 - ACTION: Emma will add to PCWG agenda. 
• Argonaut sprint this summer
• Netherlands feedback about Must support

International Patient Summary (IPS)

Discussion:

• STU period is expiring in a few days. Need to get an STU extension. Very close to publishing and will get it out in the next 1-2 months. 
• Have a number of pull requests getting ready to merge. Few publication cleanup. 
• Have a longstanding set of link errors that show in the build but are not treated as errors. Can get around this by using manually generated text. Would like to see it fixed. John is working on this. 
• Have gone through fairly good analysis for must support with a few countries - Canada, New Zealand. Most of the concerns have come up from the server side of things. 
• Terminology updates - lots have happened in that space. SNOMED international has started offering a free set to terminology that is becoming available - out currently as a beta release. Will be available at the end of the year. Will have a full SNOMED international edition release. Can take the same definition for SNOMED non-member countries and expand it and get it dynamically updated. For publication will need to revise the valueset definition to accommodate this. 
• Stephen - SNOMED edition for IPS - does the beta version include all the IPS concepts that has been defined. 
• https://www.snomed.org/snomed-ct/Other-SNOMED-products/international-patient-summary-terminology
• To extend the STU - use a publication request in Confluence. Publication request created
• Motion: Jean Duteau moved to accept the IPS STU Extension Request as reviewed; Rob Hausam Second
• Vote: 0 Against; 0 Abstain; 22 For
• Georgio - CDA IPS IG will expire in Oct. Plan on doing an STU ballot in Jan. Need to do an STU Extension. Will join a PC call to get extension reviewed and discussed. 

Thursday Q1

Care Plan updates

MCC

Pharmacist Care Plan - Shelly Spiro

IG - Pharmacist Services and Summaries - FHIR (PhCP):http://hl7.org/fhir/us/phcp/STU1/index.html

Nutritional Quality Measures - Preview (Becky Gradl)

• Invitation from Dave Hill for Becky to present to PACIO

POLST - Diana Wright

POLST CDA IG Project page - POLST CDA IG

Project is a model of use - take a paper POLST form and make it into a CDA document. Its a clinician authored clinical form. 

The language is very form specific. 

National POLST would like to pilot it. 

LOINC Process - can go to ballot with temporary but should not publish with temporary codes.

National POLST  - POLST is not an accronym, its a term. 

PaCP - CDA IG - Natasha 

Personal Advanced Care Plan (PACP)

PACP dashboard: https://jira.hl7.org/secure/Dashboard.jspa?selectPageId=15201

Ballot in May 2022

PACP GitHub: https://github.com/HL7/CDA-pacp

PACIO

• Have been looking at what the Gravity project has done
• 

ADI

• 
• PACIO ADI: http://build.fhir.org/ig/HL7/pacio-adi/
• 
• 

Reassessment Time Point

SPLASH

PACIO HIMSS Interoperability Showcase

Harmonization

Thursday Q2

Joint meeting - PC hosting SDWG

Topics:

• Cont. provenance mapping topic (if needed)

• How to represent change patterns of a condition - Tracking Improving, stable, deteriorating patient conditions  
  • FHIR-36197 - Representing improving | deteriorating patient responses in R4/R5 Condition resource TRIAGED
    • 2022-05-12 Changing condition trends-info exchange requirements and options.pptx
• Discussion:

  • stephen presents deck with overview of the different options and overview of elements that match, challenges

  • time dimension

  • evidence dimension

  • intervention (assessment of what? patient, disorder, intervention?)

  • mikeP: does stable mean unchanged or not dying. We have more than 3 values.

    • condition specific, context specific? what are reason for not choosing Observation: because objective?

  • Suggestion for post co-ordination using condition

  • May have implementation difficulty with the captured data
  • Question about referencing the prior capture of this information. ClinicalImpression has previous that allows this.
  • Tom: it's part of the condition, logically. Jay: or of snapshot.
  • how do EHRs do this. as part of condition?. in flowsheet?
  • Why are we going over this on the SD call? to avoid surprises.
  • SD is pretty busy; will let PC design in FHIR first & then look at translating.

Provenance: as per yesterday. FHIR/CDA Translation team to bring SD very concrete, specific questions, not design artifacts to approve.

Thursday Q3

Learning Health System

Topics:

Virtuous Cycle Project - registries + quality improvement

Thursday Q4

Joint meeting with Learning Health System

Topics:

Patient-Centered Care Team