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Introduction

The 2020 September HL7 Workgroup Meeting will be held as a virtual event.

To accommodate participants from different time zones, this Clinician-on-FHIR event will be spread over a number of days commencing Tuesday September 22 through to Friday September 25, from 4:00 or 5:00 pm US Eastern time.

Tracks Schedule

Four tracks have been planned

  1. Immunization status track: to test the use of Condition vs. Clinical Impression - Rob Hausam/Stephen Chu
  2. Care coordination track - Emma Jones
  3. Multiple procedures track - Mike Padula?
  4. Complex condition track: to test use of Condition + observations vs Condition profile that includes structure to represent signs and symptoms (Logica COVID-19 IG concepts) - Jay Lyle/Stephen Chu

The activities for these tracks are scheduled as follows:

  1. Define scenarios- pre-work to have content on confluence (weeks before.... our Tuesday meeting work, plus offline)
  2. Overview meeting for all tracks (each track gets 15 minutes to review what it will be working on) - 4 6 -7:30 PM ET Thursday Tuesday
  3. Launch meeting for each track (hour?)- determine who will be working on what, split up the load for offline work - coordinate work.... (1 hour meetings...5 6-7 pm ET Wednesday and 5 6-7 pm ET Thursday.... or anytime agreed to by the track participants)
    1. Wednesday 5 PM ET: Immunization status track: condition vs. clinical impression
    2. Care coordination track - Emma Jones
    3. multiple procedures track - Mike Padula?
    4. Thursday 5 6 PM ET:  Complex condition track: condition vs observations (Logica COVID-19 IG concepts) 
  4. Offline work - track team members work on their own on assignments....
  5. Track specific review/completion meeting (? time allowed) (4 pm ET Friday)
    1. 4:00-4:30 PM ET Friday:  Immunization track: condition vs. clinical impression
    2. Care coordination - Emma Jones
    3. multiple procedures - Mike Padula
    4. 4:30-5:00 PM ET Friday Complex condition track: condition vs observations (Logica COVID-19 IG concepts)
  6. Synchronous report out/discussion (each track gets 20 min, plus discussion) (5-6:30 PM ET Friday)


Alternative Schedule for week of September 14-18

(Monday = PCWG Co-Chair call)

Day/TimeActivity

Tues 5- 6:30 ET-Overview of all tracks 1.5 hours (15 min each)

Wed 5 -6:30 ETLaunch meetings for each track (30 min meetings each)

Thurs 5 - 6:30 ETWork day - could have individual calls set up for each topic...

Fri 5-6:30 ET

Synchronous report outs for all tracks/discussion (1.5 hours, 30 minutes for each topic)



Track Information

Track 1 Care Coordination

Track lead: 

Emma Jones

Details of this track are included in the following confluence page:

Track 1 Care Coordination

Track 2 Multiple Procedures

Track lead: 

Mike Padula

Background and Objectives:  

Aim to capture details around related and unrelated surgeries (procedure) that are performed by more than one surgeon on a patient within a single anesthesia timeframe and single visit to the operating room. 

Scenarios/Storyboard:

4 month-old ex-23 week gestation male infant with severe bronchopulmonary dysplasia (BPD), chronic respiratory failure (ventilator-dependent), gastroesophageal reflux (GER), subglottic stenosis has multiple surgeries performed while under general anesthesia. Procedures include (1) tracheotomy, (2a) Nissen fundoplication, (2b) gastrostomy tube (g-tube) placement, (3) circumcision, (4) bilateral hernia repair. The otolaryngologist performs the tracheostomy (+/- bronchoscopy) while the general surgeon performs the remaining procedure, some of which are related, some are not. 

Questions to address:

How are these procedures recorded using existing resources? 

Under a single anesthesia encounter? 

How should this be represented for the Procedure Progress Status?

Candidate Resources:

Patient 

Practitioner(s) - general (pediatric) surgeon, otolaryngologist, anesthesiologist, neonatologist (or PICU attending)

Procedure(s) - gastrostomy tube placement, Nissen (gastric) fundoplication, circumcision, bilateral herniorrhaphy

Procedure.performer  - general (pediatric) surgeon, otolaryngologist (is anesthesia considered part of this procedure or is it distinct?)

Procedure.category - surgical procedure

Procedure.code - many... https://www.hl7.org/fhir/valueset-procedure-code.html

Procedure.partOf   - for components of a procedure (med adminstration, IV placement. etc...)

Procedure Progress Status Codes

Code

Display

Definition

in-operating-room

In Operating Room

A patient is in the Operating Room.

prepared

Prepared

The patient is prepared for a procedure.

anesthesia-induced

Anesthesia Induced

The patient is under anesthesia.

open-incision

Open Incision

The patient has open incision(s).

closed-incision

Closed Incision

The patient has incision(s) closed.

in-recovery-room

In Recovery Room

The patient is in the recovery room.


Condition

(may use CareTeam for providers)

(may consider Encounter for grouping procedures/anesthesia)


Track 3 Complex condition track: to test use of Condition + observations vs Condition profile

Track lead: 

Stephen Chu / Rob Hausam / Jay Lyle

Background and Objectives:

For complex condition such as CoVID19, there is a need to represent and share extensive amount of information to help clinical decision making about how best to manage patients with such condition. In addition the diagnostic label of the condition, information including presence and/or absence of certain presenting features will need to be capture. The question of whether the FHIR Condition resource should be extended or profiled to accommodate such requirement has been raised.

The purpose of this track is to test whether the presence and/or absence of presenting features (e.g. signs, symptoms) should be represented in FHIR Observation resource and referenced by the Condition resource; or from information management perspective, extending the FHIR Condition resource is a better option.


SARS-CoV-2 Disease (aka SARS-CoV-2 Infection; COVID19 Disease)

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Disease/Infection (SNOMED CT code/ID: 840539006) is a multi-system syndromic disease caused by SARAS-CoV-2 infection). 

Patients with SARS-CoV-2 disease can present with variety of clinical characteristics, which include:

Signs and Symptoms:

fever, chills, muscle ache, fatigue

runny nose, dry cough, pneumonia, hypoxaemia or hypoxaemia without respiratory distress (silent hypoxaemia), acute pulmonary oedema, acute respiratory distress, respiratory failure

hyposmia or anosmia (loss of smell)

ageusia (loss of taste)

GI symptoms such as: nausea, vomiting, abdominal pain, diarrhoea

Hyper-inflammatory responses:

cytokine storm/over-reacting immunologic responses causing: endotheliitis, activation of coagulation pathways with potential development of disseminated intravascular coagulation (DIC) and deregulated inflammatory cell infiltration 

atypical Kawasaki disease like symptoms

Organ injuries:

pulmonary fibrosis

cardiac injury

stroke

renal failure

The CDC COVID19 PUI (person under investigation) questionnaire requires the capture of presence or absence of some of the presenting characteristics.

Note - patients can present for care with any permutations of possible clinical characteristics/presentations listed above. As new knowledge emerge about the SARS-CoV-2 disease, this list of clinical characteristics/presentations will be expanded.

The question of how best to model SARS-CoV-2 disease and the presence and absence of certain presenting characteristics is particularly challenging and requires careful consideration and evaluation.


Goals of the storyboards: 

  1. Test the COVID 19 IG profiles against a
    1. realistic presentation of a patient to either the clinic, ED or hospital admit scenario
      1. presentation with COVID 19 S/S, 
      2. presentation asympotmatic but with known contact with someone testing positive for COVID 19
      3. come in with some of COVID 19 S/S and ADDITIONAL S/S not on the the current COVID 19 list or S/S,
      4. come in with non COVID 19 S/S, gets tested and is positive for COVID 19. 
  2. Test the IG use of condition and observation for the published COVID 19 S/S 
     (https://covid-19-ig.logicahealth.org/)
  3. Test the use of negation in the COVID 19 IG

Scenarios/Storyboard:

Storyboard 1 -  * Patient Presenting at COVID Clinic /Drive Thru clinic/testing center*

Scenario - A 38-year old Caucasian male returned from a business trip in Asia last week. Over the past 24 hours, he had developed fever, rigors, myalgias, fatigue, nausea, loose bowel, upper respiratory symptoms such as runny nose, cough. He has no vomiting, no shortness of breath, no abdominal pain, no sore throat, no loss of smell or taste. He is a non-smoker, mildly overweight, has no chronic conditions. He initially planned to ride it out, but is feeling increasingly short of breath and fatigued. He presents himself to a COVID19 clinic for assessment and testing.

Storyboard 2 - Patient Presenting at ED -

Scenario - A 62-yo female patient, ex-smoker (stopped 5 years ago) with medical history of ischaemic heart disease and COPD was taken to the ED by ambulance with flu like symptoms, increasing shortness of breath and hypoxaemia. Patient had no recent travel and no known contact to confirmed or suspected COVID positive persons.

On examination, patient was febrile (Temp 40C/104F), HR 107/min, BP 158/87, RR 32/min, SpO2 88% on 2L/O2. Spot BSL 200 mg/dL (11.1 mmol/L). Patient complained of tightness of chest, cough with yellowish sputum, headache, nausea, generalised ache, chills. Patient denied loss of taste and smell, and digestive symtpoms. Moderate wheezing sound on auscultation on both sides, there were also bilateral basal crackles.

White blood cell (WBC) count was 12.49 x 1012/liter, whereas lymphocyte count decreased to 0.4 x 109/liter and the differential to 5%. Chest CT showed bilateral ground‐glass opacities in the upper and middle lobes with a rounded morphology. Naso-pharyngeal swabs were taken for RT-PCR test.

The patient's condition soon deteriorated with SpO2 dropping significantly despite oxygen therapy. Patient was intubated, ventilated and transferred to ICU within an hour of arrival at ED.

Storyboard 3 - Patient Admitted to Hospital -

Scenario - A 37 yo male patient diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spent 2 weeks in ICU and is discharged to a respiratory ward for continuous management.

COVID19 complications experienced by this patient included:

CT scans of the lungs showed interstitial abnormality in both lower lobes and rapidly progression to fibrosis.

Patient also complaint of chest pain. EKG showed ST-segment elevation on. His cardiac biomarkers were elevated (troponin T >10ng/mL, NT-proBNP [N-terminal pro-BNP] >21 000 pg/mL). An echocardiogram noted left ventricular dysfunction (ejection fraction 27%, left ventricular end diastolic diameter 5.8 cm) 

Storyboard 4 - Asymptomatic/pre-symptomatic persons and person with non-specific symptoms tested for COVID19 -

An 11 yo male child complained of sore throat and runny nose. The child's mother call the family Primary Care Provider (PCP) to seek medical advice.  The PCP recommended that the family of 4 to be screened for COVID19 at the family's local COVID19 drive through test clinic. Nasal pharyngeal swabs were taken from all 4 for RT-PCR test. The clinic nurse also took health history of each member and completed the CDC COVID19 PUI form. 

Father: age 41, reported no COVID19 symptoms, has medical history of asthma, medication: a corticosteroid and a long-acting beta2 agonist (Seretide MDI 125/25 – 2 puffs twice daily). RT-PCR test result: negative

Mother: age 42, reported no COVID19 symptoms, no history of chronic condition, RT-PCR test result: positive

Child 1: eleven years old, complained of sore throat and runny nose when woke up in the morning, no other complaints, two episode of acute otitis media in the past 3 years with no recent recurrence. RT-PCR test result: negative

Child 2: nine years old, no COVID19 symptoms, no history of chronic illness. RT-PCR test result: negative

Family was notified of the test results and advised to self isolate at home, each in a separate room at home.

Candidate FHIR Resources:

Condition - data elements:

Condition.clinicalStatus

Condition.verificationStatus

Condition.category

Condition.severity

Condition.code

Condition.bodySite

Condition.subject

Condition.encounter

Condition.onset

Condition.abatement

Condition.recordedDate

Condition.recorder

Condition.asserter

Condition.evidence

.evidence.code

.evidence.detail

Condition.note

Observation


Other Useful Materials

COVID19 FHIR Implementation Guide:

https://covid-19-ig.logicahealth.org/

Additional resource for list of associated S/S

https://confluence.ihtsdotools.org/display/DOCCV19/2.3+Clinical+Assessment


Track 4 Condition vs. Clinical Impression:  Using Immunization Status as a test case

Note - this track will not be tested at the September 2020 Clinician-on-FHIR event. But the contents will be developed in preparation for future event (possibly January 2021?)

Track lead: 

Rob Hausam/Stephen Chu/Mike Padula (will be adding more content here)

Background and Objectives:

CoVID19 and a number of other communicable diseases raise the question of how best to model and represent and share data/information about a person's immunization status. This goes beyond a simple capturing and sharing of laboratory data which include the presence or absence of neutralising antibodies to the infective agents. It also include vaccinations given and as well as clinical evaluation of all relevant information to determine the immunization status of an individual.

The objective of this track is to test the adequacy and suitability of FHIR Condition or ClinicalImpression resources in modelling and sharing immunization information about an individual.

Scenarios/Storyboard:


Candidate Resources:

Other Information of Interest

Additional Topic of Interest:  Representing complex condition - Wound Podiatry Group, COVID 19.





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