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Introduction

After considerable deliberations over several conference calls, it is decided that:

  • The Clinician-on-FHIR event will be held on the Friday during the week of HL7 WGM
  • There will be colleagues who will be committed to the Saturday and Sunday FHIR technical connectathon event prior to the HL7 WGM week.
  • These colleagues will make their own decision based on availability and other constraints whether or not to attend the Clinician-on-FHIR event as well
    • There will be de-briefing at the post January 2019 WGM CoF conference calls on the technical connectathon event so that colleagues who cannot attend the event will benefit from experiences of colleagues who do attend
  • This confluence page is set up to document information relevant to the Clinician-on-FHIR event at the San Antonio WGM

Helpful Links

The ConnMan Instance for the last WGM in Baltimore:  http://conman.fhir.org/connectathon.html?event=baltimore2018

The ConnMan Instance for this WGM:  http://conman.fhir.org/connectathon.html?event=sanant2019

David will not be present at the event but is accessible via the FHIR Chat tool. https://chat.fhir.org/#narrow/stream/179230-Clinicians-on.20FHIR

http://build.fhir.org/

Tracks

Patient-centered care team/Care Plan track

Track GoTOMeeting - https://app.gotomeeting.com/?meetingId=834436293&sessionTrackingId=c2a6048f-a2a1-6c1a-0f12-031da4a874ec

Track leads:

    • Emma Jones, George Dixon, Russ Leftwich

Objective:

    • To validate the FHIR CareTeam resources through clinical workflow steps, for example:
      • Creating CareTeam
      • Update CareTeam
      • Validating Care team resource

Suggested use cases:

Use Case 1 (Example):

    • Medication management planning results as a medication management plan
    • Care team members as individual (pharmacist) and organization (pharmacy) specific to a plan
    • Care settings: in-hospital and community (they have different workflows and different care team members, authorisation processes, etc

Use Case 2 (SDoH):

    • SDoH (George Dixon)

      Presentation: 

      Discussion:  Clinicians on FHIR’s best option for Care Plan 2.0 DAM is to draft an SDH white Paper.

      Summary:

      • Care Plan 2.0 DAM SDH Value Sets optional to define
      • SDH Reference Value Set to identify SDH Categories needed (add)
      • Questionnaire Response Resource reference to define SDH Category (add)
      • Condition, support for “concerns” that are not yet problems (?)
      • Support CDA Assessment Scale Supporting Observation, use for SDH  

      Factors:

      • Multiple groups focused on determining SDH value sets.
        • SIREN – Project to define:  transportation, food security, and housing stability and quality
        • ISA – Interoperability Standards Advisory (ONC) added Social, Psychological, and Behavioral standards.
        • HL7 Pharmacy Workgroup (NPRM) will be initiating a workgroup to identify SDH Value Sets
        • Existing SNOMED Coding identifying SDH exists, supports mining patients with existing SDH documented.
        • SDH potential information exceeds identified value set scope planned.
        • HL7 Care Plan 2.0 Model may or may not want to expand the value sets under consideration by other groups.
        • Patient documentation of SDH can be spread across care providers and workflows and should not, need not be the venue of one care provider type. This diverse data collection is realistic and reduces provider burden if the application is able to pull SDH together into a consolidated view.
        • Evaluation of FHIR /CDA Resources
          • After review and experimenting with logical models there are three existing FHIR resources suited to SDH.
          • Charting (Data Collection) for patient SDH, Conditions (Problems), and New Assessment Values
            • Condition (problems)
              • These can be mined by patient for existing SDH and charting for newly identified issues
              • There is an identified issue with condition that it does not adequately cover “Concerns” patient issues that are a risk but not achieved the state of being an active problem for the patient.
          • Charting SDH for patient
            • Observation Resource
              • This was deemed not optimal. The value in an observation loses context.
            • Questionnaire Response Resource
              • The question answer format provides context of the information collected.
              • Supports related (person) values
              • Supports patient data entry
              • Supporting Manual and Automated Care Plan Creation
                • Care Plan Resource currently supports query ability
                • Identified need for questionnaire response to support a reference mechanism to identify Q&A as SDH. This allows questionnaires to be constructed to support SDH information outside of groups determining specific value sets
                  • Identification of SDH specific reference standard for categories (E.g. Housing, Transport, Social Support).
                  • A questionnaire reference mechanism has benefits beyond SDH use
      • Workflow –  FHIR CARE PLAN – Queries for existing charted SDH either problems or charting Question / Response and returns suggested Care Plan issues problems/concerns that the user can incorporate into a plan of care.
        • Note – the focus of this solution is Care Plan oriented. There is no identified mechanism to identify SDH and list within an SDH specific section.
        • CCDA Support for SDH
          • Assessment Scale Supporting Observation
            • Assessment Scale Supporting Observation may need to support SDH category reference values
            • Assessment Scale Supporting Observation may need IG support for use beyond current section limits.

      Care Plan Resource

      Questionnaire Response Resource

      • 9.9.5 Search Parameters
      • Potentially use Item -> Modifier Extension

               Use Case 3 (Emma): 

  • Care planning and coordination - Care Team Management
  • FHIR Connecthathon 19 track info
  • Use Case Scenario - this use case focus is on the care team members, their roles and the care plan elements they are assigned to or responsible for. 

    Member NameRoleRelationship to Betsy (FHIR resource)Responsibility (relationship to the care plan activities)Comment
    BetsyPatientPatient


    DaughterrelatedPerson
    Betsy Lives with

    SonrelatedPerson
    Lives in another city
    Debra SmithCare CoordinatorPractitioner
    Rose Valley Primary Care
    Dr. John CarlsonPrimary Care ProviderPractitioner
    Rose Valley Primary Care
    Maria Gonzalez, RDNutritionistPractitioner
    Rose Valley Primary Care
    Dr. Vince JonesNephrologistPractitioner
    Nephrology Clinic
    Sarah KingCare CoordinatorPractitioner
    Nephrology Clinic
    Multidisciplinary Care Team
    CareTeam
    Nephrology Clinic
    Meals-on-Wheel (To Be added to the LHS use case)
    Organization
    Community Services
    Home health ServicesHome health aid service (SNOMED 385781007) Organization
    Home health agency

    Report Out
    Discussion Topics

    • Relationship between Care Teams - Super care team inherits from the sub care teams
    • Care team can play a role on other care teams
    • Big care team has the smaller care team as participants
    • Permissions should be separate 
    • OAuth scopes what is allowed to be accessed
    • Business permissions based on role
    • Skills on relatedPerson - not what they're doing but what they are capable of doing
    • Analytics may be needed on skills leads to the best outcomes
    • Skills is needed to be able to anticipate care needs - e.g. neonates discharged home on tube feedings, etc. 
    • ACTION: Need to add a procedure category for care team - will add a tracker for this. 

Emergency Care Track

Track leads:

    • Jim McClay

Emergency Care Track has an interest in the Clinical Impression Track for this event and will join and support that track in January 2019.  

Objective:

    • Continue work on Questionnaire and Questionnaire Response 

Suggested use cases:

ED screening tests - (Laura to get the list of next ones to address here)

Clinical Impression Track

Track leads:

    • Rob Hausam ( supported by Stephen Chu)

Objective:

    • Testing the clinical impression resource for fitness for purpose in clinical assessment and care plan use
    • Clarify the relationship between assessment, clinical impression, condition and clinical reasoning

Suggested use cases:

Use case 1

Scenario to include clinical workflow of patient assessment and clinical reasoning leading to establishment of clinical impression and its use in clinical management of the patient.  

Summary:

A 15 yo Aboriginal male patient from Central-West Queensland, Australia presents to his General Practitioner/Primary Care Provider (GP/PCP) with complaints of severe sore throat which started 3 days ago; and followed by fever, chills, cough, nausea and anorexia.

    • Patient has history of frequent recurring pharyngitis, last episode approximately 7 months ago
    • Onset of complaints: sore throat with odynophagia started 3 days ago, which is followed by low grade fever, chills, nausea and anorexia, non-productive cough, swelling and erythematous tonsillopharynx with exudation but no uvula deviation. Patient also complains of feeling of secretions coming out from back of throat
    • Patient denies any known exposure to arthropods (dengue fever and other arthropods carried infections exposure)
    • clinical reasoning: (1) acute bacterial or viral pharyngitis, (2) to rule out Group A beta-hemolytic streptococcal pharyngitis (patient is in population group at risk of rheumatic fever)
      • Clinical impression at first visit = acute pharyngitis; 
      • Treatment plan: (1) FBE/CBC and Group A beta-hemolytic streptococcal rapid antigen detection test (RADT); (2) oral paracetamol for pain and fever, (3) antiseptic gargle and lozenges, (4) schedule follow-up 24-48 hours after lab results available)
      • to rule out Group A beta hemolytic streptococcal pharyngitis
    • Follow-up visit (24 hours after lab results sent to GP): Group A beta-hemolytic streptococcal rapid antigen detection test (RADT) = confirms Group A haemolytic streptococcal pharyngitis
      • Clinical impression at follow up visit: Group A beta-hemolytic streptococcal pharyngitis
      • Treatment plan: (1) oral penicillin (PenV or Amoxicillin) for 10 days; (2) continue supportive therapy (analgesics, gargles and lozenges

Acute Pharyngitis clinical scenario details:

History

The ClinicalImpression resource has a precursor - ClinicalAssessment. Over the course of the resource development, there were numerous debates on "clinical assessment" as a process versus the tools used in the process. At certain point in time, it was decided to change the resource to ClinicalImpression to avoid the confusion. 

However, the issue of whether ClinicalImpression includes the assessment process + the clinical judgement that represents the outcome of the process still persists

Discussions on Clinical Assessment and other related topics can be accessed on these wiki pages:

Medication

Track leads:

    • Melva Peters
    • John Hatem

Objective:

    • Test, explore, evaluate existing Pharmacy FHIR resources:  MedicationRequest, MedicationDispense, MedicationAdministration, MedicationStatement, Medication
    • Provide update on new MedicationKnowledge resource - what it is and why one would use it

         Suggested use cases:
  • The order, dispense, administer and record medication usage processes will be reviewed with attention to key data elements within each resource and secondarily a review of the Medication resource use will be examined in each of the named processes. 
  • The MedicationKnowledge resource will be examined when it is used in support of pharmacy formularies, where each drug on the formulary is represented by on MedicationKnowledge item. 

Pediatric - Essential Information for Children with Special Health Care Needs Track

Track leads:

    • Mike Padula
    • Gay Dolin

Objective:

    • To test Care Plan resources including contingency plans and negation.

Suggested use cases:

Track - Infant with OTC deficiency

                 1 month old male infant with a metabolic disorder, ornithine transcarbamylase (OTC) deficiency, with a Care Plan that was developed by his metabolic specialist in coordination with his prImary pediatrician, who presents with lethargy and decreased intake to a Emergency Department. (Weight - 4.5 kg)

      • Scenario 1   (Mike) - Create (Contingency) Care Plan:
        • Document Care Team - Specialist and Pediatrician
        • Document care plan provided by the Metabolic specialist using CarePlan

      • Scenario 2 (Gay) - Utilize the Care Plan in the Emergency Department Setting
        • Triage patient and Review Care Plan using Observation +/- Clinical Impression
          • Document patient pr document lethargy, sunken fontanelle (thus no increased ICP)
          • Document weight of 4.5 kg
          • Document VS: Temp 36.3 C, HR 145, RR 32, BP 65/40
          • Add ED Physician to Care Team?
        • Contact metabolic specialist

      • Scenario 3 (Zabrina)- Make NPO, Place IV, Begin IVF
        • Make NPO using Service Request (please provide feedback if other suggestions) Nil by mouth (regime/therapy) SCTID: 182923009
        • Place Peripheral IV using Procedure
        • Begin IVF at 1.5x maintenance (Dextrose 10% with 0.45 Normal Saline (1000 ML Glucose 100 MG/ML / Sodium Chloride 4.5 MG/ML Injection [RxCUI = 244098]) at 27mL/hr) using Medication.request

      • Scenario 4 (Mike) - Risks and contraindications : 
          • Indicate patient at risk for Hyperammonemia, Seizures, Cerebral Edema, Coma using Risk Assessment
          • THAM (tris-hydroxymethyl aminomethane [RxCUI = 1311534]) using Medication.request with negation
                and
          • steroids 
            • Use NDRF or just make a statement with SNOMED-CT  Glucorticoid (SCTID: 419933005)
            • Alternative is to state not to use the following RxNorm (Hydrocortisone [RxCUI = 5492] and Dexamethasone [RxCUI = 3264] and methylPREDNISolone [RxCUI = 6902] and prednisoLONE [RxCUI = 8638])  unless directed by 
            • Question: Can we construct a statement that addresses avoiding all glucocorticoids? class: Glucocorticoids / id: H02AB / class type: ATC1-4 

      • Scenario 5 - Order Labs
        • Order labs: Ammonia, Venous Blood Gas, Comprehensive Metabolic Panel, CBC/differential, PT, PTT, LFTs, Plasma Amino acids using Procedure

Use case 2 - Newborn at risk for neonatal abstinence syndrome 

(going to put this on hold and focus on the OTC track...will aim to try this between now and the next WGM)

                Newborn female infant born at 37 weeks gestation to a 27yo Gravida 1 Para 1001 mother with a medical history significant for Hepatitis C and intravenous drug use managed with opioid agonist medication‐assisted treatment (methadone) during pregnancy, admitted to the nursery for further evaluation and management. 


      • Scenario 1 - Care Plan for Opiate Exposed Newborn
      • Add Condition: Perinatal Exposure to Hepatitis C (SNOMED Expression: Exposure to Hepatitis C virus (event) SCTID: 444563003 AND Perinatal period (qualifier value) SCTID: 371578004)
        • Condition.code 444563003:371578004)
      • Document Care Plan:
        • Order Neonatal Abstinence Scoring (Finnegan Scoring) for minimum of 5 days (Assessment using assessment scale (procedure) SCTID: 445536008)  
          • Notify prescribing clinician if 3 consecutive scores are >=24
          • Note: Terminology gap - no concepts for Finnegan Scoring in LOINC or SNOMED-CT
        • Order breast feeding PO ad lib
        • (Could add: Billrubin check, bathing infant, routine measurements and VS, social work consult, if time permitting)
        • Order Hep B vaccination prior to discharge
          • Adminster/document Hep B vaccination, if time permits
        • Needs follow up with PMD for Hep C Ab testing at 18 months of age. 

Useful resources

    • Care Plan including negation
    • Care Team
    • Observation





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