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Date: 2019-09-16

Quarter: Q3


Agenda Topics

  • Agenda
    • Quarter to discuss FHIR IGs → Wed Q2
    • Reps to other WGs
    • Assign Roles for Quarters
    • If we have new attendees, review
      • Overview of Pharmacy material - V2, V3, FHIR
      • Overview of Template work
    • Hot Topics
    • Prep for Joint FHIR meeting

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • Quarter to discuss FHIR IGs → Wed Q2
  • Reps to other WGs
    • Monday Q4 - FHIR Workflow - Scott will attend
    • Tuesday Q2 - O&O - Jean
    • Tuesday Q4 - EHR - Podiatry FP project - no rep
    • Tuesday Q4 - PH - check with John if we need to attend
    • Wednesday Q3 - SDWG - CDA Medication Activity entry to FHIR MedicationRequest - topic to be discussed in SDWG - Scott and others to attend
    • Thursday Q1 - PC - Scott will attend
  • Assign Roles for Quarters - see updated agenda
  • Review of material
    • Overview of Pharmacy material - V2, V3, FHIR
    • Overview of Template work
  • Move approval of minutes to Wednesday

Date: 2019-09-16

Quarter: Q4


Agenda Topics

  • Joint Meeting with BR&R

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • Review of resources
  • Discussion of RegulatedAuthorization
    • FMG asked for this to be generalized to apply to other things that get authorized for example, authorization of procedures, protocols
      • suggest that this be reviewed with Patient Care to determine if there is a use case
      • suggest that this be reviewed by NIH with respect to IRB
      • Need clear definitions and scope of the regulator
  • FDA has been providing use cases for PQ-CMC for these resources
  • Still need look at attributes and determine if part of the 80% rule and if it should be an extension
    • make decisions once have use cases and work through a series of examples
  • Project status
    • Project can be closed
      • Hugh - Smita - motion to close project - 16-0-0
  • Propose to FMG that it would be good to have R4.5 build that we can point implementers to
    • want to ballot PQ-CMC Iguide - need to point to the resources that are in the current build
    • Question for Lloyd - dependency between quality specification through FHIR going to ballot in January that will use resources in the CI build and not it R4
  • Joint meeting - no joint meeting for Sydney
  • Requirement for Ingredient
    • additional measure of what is content % left in drug after it is made
    • could use ingredient.role for every step and a number on each for each strength - no need to add anything to model to meet this use case doing it this way
      • some people felt that this is complicated - prefer to use content% in strength
        • makes it less clear for implementers
        • prefer to use an extension
    • further discussion once the requirement is fully scoped out
    • 2 options for now - use the role or add an extension
    • discussion of the use of the name "strength" - 

Date: 2019-09-17

Quarter: Q1


Agenda Topics

  • Standardized medication profile project
  • Formulary Ballot Reconciliation

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • Standardized medication profile project
    • Jean Duteau provided an overview of the project, meetings, background and contributions from both NCPDP and HL7 Pharmacy. 
    • Elements indicated by the Impact Act
    • Initial focus on Post Acute Care - see the Brief Description section PDF document created by RTI for CMS, for exclusions. One interpretation is that the focus includes every setting but the acute care hospital.  
    • What is the relationship to the Medication List we see in the Argonaut project?  This includes more information than what is in the Medication List found in the Argonaut project. 
    • Reviewed draft mapping - see document. Std Med Profile TG - draft mapping was the title of the document. 
      • In the mapping document, FHIR GAPs were found related to either attributes or potentially new resources
    • Accessing minutes from HL7 or from NCPDP
    • Discussion about how Medication Statement is impacted by this work - JD stated this will result in a Pharmacy WG discussion to revisit the Medication Statement resource.  
    • White paper will be written by staff at NCPDP
  • Forumlary Ballot Reconciliation
    • Tracker Items - PDEex Formulary Ballot 
    • Motion to accept 34 issues that are resolved per Jean Duteau, seconded by Shelly   For: 6 Against: 0 Abstain: 5
    • Remaining 15 issues will be discussed and the results of that discussion will be communicated to Pharmacy via conference call. 

Date: 2019-09-17

Quarter: Q2


Agenda Topics

  • Joint Meeting with FHIR-I

addded

  • VA project introduction
  • FHIR tracker items

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • Plans for Pharmacy resources (From Jan 2019 email between Melva and Graham)
    • Move Medication to maturity level 5 and plan for normative in next ballot cycle
    • Move MedicationAdministration to maturity level 3
    • Move MedicationDispense to maturity level 4
    • Move MedicationRequest to maturity level 5 and plan for normative in next ballot cycle
    • Move MedicationStatement MedicationUsage to maturity level 4
      • what is preventing us from moving this to level 5 is lack of info on the number of production implementations
    • Move MedicationKnowledge to maturity level 1
      • this presumes FMG approval of this resource


  • R5 timeline
    • Ballot for comment R5 in May 2020 - concern if there would be sufficient attendance in Sydney for reconciliation
    • Normative in Sept 2020
    • extra Normative, if needed, in December 2020
    • Publish 2021 Q1 
      • Pharmacy okay with this plan
    • any concerns if the was pushed back further?
      • no specific concerns from Pharmacy
  • Pharmacy needs assistance: which resources are used in which Profiles, Implementations, etc
    • no clean mechanism
    • post question to Zulip
    • could look at resources used in the Connectathon
      • not currently tracked
  • Attendance plans for Sydney
    • will meet
    • Maybe not John.  Melva, Jean, and Scott are attending
  • Structural changes
    • MedicationUsage
  • any projects/profiles/IG
    • Medication List IG
    • MAR IG - proposed by Graham, need more requirements
      • we don't have many groups using MedicationAdministration
  • impact from Accelerator projects
    • Yes.  for example, DaVinci - generally their use of our resources are reasonable 
    • New projects are okay so far.  the list is getting long.  
      • Gravity
      • CARIN
      • Argonaut
      • CodeX
    • new projects are pretty good about seeing similarities with other projects
  • new IG tooling
    • getting the various formats merged to define a commonformat
    • also the tooling to support the common format


VA Project introduction

  • Added to agenda, main discussion is Wed Q2
  • new pharmacy system in VA: AMPL GUI.  after some development, was informed that must use FHIR
  • This is a preliminary discussion, no decisions


FHIR Trackers

  • 22148 MedicationDispense.performer.actor - should allow HealthcareService and CareTeam?
    • should add CareTeam to MedicationDispense.performer.function
      • side discussion:  FHIR Workflow is looking at "patterns" ... an attempt make attributes like "participant" more consistent between resources.  Really a discussion for another time
    • should add "counselor" as an MedicationDispense.performer.function
    • will not add HealthCareService to MedicationDispense.performer.function.  not in 80%. if needed, can be added by implementation
    • vote will be considered in Q3

Date: 2019-09-17

Quarter: Q3


Agenda Topics

  • FHIR Tracker items 
  • Grahame G issues
    • US Core - Grahame G, raised questions about what is the current status of Pharmacy's opinion on the US Core implementation of Medication Request.
    • Participation patterns and lack of consistency issues

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • FHIR Tracker items 
    • Tracker #23561 -  See gForge for resolution.  Motion by Grahame, seconded by Daniel.  Motion passed 5-0-3
  • Grahame G issues
    • US Core
      • Grahame asked if Pharmacy had seen the Medication List work from US Core and did we have any issues with their decisions.  John H explained the history of the US Core work: originally started by using only Medication Statement to represent the items on the Medication List, and after many, many discussions and a few changes to Medication Request, they decided in the most current FHIR 4.0 release to move from Medication Statement to Medication Request.  Pharmacy's position all along was that they felt there were use cases where some of the items on the Medication List can be represented as Medication Statements and some of the items on the list can be represented as Medication Requests.  The majority of the input from Argonaut members Epic and Cerner was they could represent all of their requirements by using the single Medication Request resource.  
      • The types of data that would be represented on a Medication List for US Core are: 
        • Medication orders prescribed by authorized clinicians
        • Medication orders prescribed external to the system that was generating the list
        • Over the Counter medications, where typically no order is generated
        • Patient reported medications that they state they are taking
      • John H reported that Pharmacy is continuing to review use of Medication Statement and Medication Request  and will have discussions about how to document these requirements in a Medication List Implementation Guide.  This project is in it's very, very early phase.  Our initial thoughts are that this IG will address many different types of Medication Lists, in addition to the list that US Core has specified. 
        • Grahame provided information that we should investigate about how IG's can be referenced from within the specification, and provided information that made it clear that IG's may or may not include profiles; may be very explicit or less so depending on the nature of the IG.  This comment also included a suggestion that we may want to review our Scope section to see if this could be improved to help implementers determine which resource to use for a specific use case. 
    • Participations
      • Grahame reviewed the patterns and lack of consistency that was found in the participations across all resources. The review was not solely based on Pharmacy resources, but did look at all resources. 
      • Pharmacy specific issues were raised about the types of References we use in MedicationRequest.requestor  and MedicationRequest.recorder  - why are their differences?  Can our documentation be improved to clear up any issues related to why the patient is present in one case and not in another.  One suggestion was to look at the Scope section of our resources and update that part of the specification.  
      • Grahame  also pointed out some issues related to how we currently use basedOn in several of our resources, and our consistency (or lack of consistency) 

Date: 2019-09-17

Quarter: Q4


Agenda Topics

  • FHIR Tracker items

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • Basis of strength - tracker item:  # 23733
    • Julie James present for discussion - see tracker item for resolution and information on how RxNorm and SNOMED CT represents these concepts. 
    • Motion: Julie James/Tim  Vote: 5-0-0
  • We discussed other trackers, but had no votes. 

Date: 2019-09-18

Quarter: Q1


Agenda Topics

  • Catalogue Project
  • Medication List IG Project

 Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

Catalogue Project - Francois reporting

  • Purpose: exposes definition/descriptions of healthcare items (services, products, devices, knowledge artifacts) for practitioners and/or patients to select
  • currently no approved by FMG
    • group addressing FMG issues - see document 
  • Has addressed and tested (connectathon) for several items.  Next up is Pharmacy 
  • structure
    • Catalog is a profile on Composition
      • CatalogEntry (issue: 
        • metadata
        • reference to MedicationKnowledge (| PlanDefinition | Practitioner | ... )
          • (there is an issue with adding new referenced resources, currently have to re-publish CatalogEntry.  MnM is working on the )
  • discussion of relation to formulary
  • asks
  • Pharmacy
    • issues will create tracker items for our concerns
      • estimatedDuration should be moved out of the metadata and into the referenced resource (or somewhere else)
      • Composition vs List
      • need to discuss further on an upcoming call
    • review/comment on the document (pending link from Francios)
  • Material for Catalogue Project

Best Practices on Medication Lists for different use cases

  • see 2019-08-19 minutes for background
  • Not all lists have the same requirements
    • Australia's medication list is from the patient's perspective (this is what I take)
    • a collection of meds from an institution, meds known from outside the institution, 
    • there is a 3rd party app that uses bundle to contain dispense and statement
  • This has only been a discussion, to develop/publish a best practice guideline, we need a PSS

more things to consider

  • need guidance on how to represent/differentiate between entries where
    • a medication a patient is taking based upon the recommendation of a prescriber (or someone else)
    • a medication a patient is taking because they decided to
  • also consider prior discussion on Medication Profile from the wiki
  • CDA documents to communicate medication lists
  • Germany also has a medication list given to patient to describe how to take medication (for links see comment section on this page: Contexts)
  • a prescription
  • a prescription from an another/external system
  • how to represent OTCs that are prescribed
    • MedicationUsage when the patient just buys it, if it is document in the system
    • MedicationRequest when a "prescription" exists - electronic of otherwise
    • MedicationUsage 

Next steps


Date: 2019-09-18

Quarter: Q2


Agenda Topics

  • VA discussion (Jay Lyle)
  • Medication List IG Project
  • Other FHIR IGs for consideration

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • VA Discussion
    • At the VA, VISTA is used for entering orders
      • using FHIR for a new GUI application - Argonaut/DSTU 2
      • trying to map fields to a read only application in Phase 1
      • Looking at data flow - 
    • Some issues:
      • There is a distinction between the order placed by the clinician and the order processed by the pharmacy. They have different identifiers and different properties.
      • There are distinctions between inpatient IV, inpatient ‘unit dose,’ and outpatient orders
      • There are distinctions between pending and final orders
      • Sometimes renewals have new identifiers and sometimes they don’t
      • We capture an ordered med and a dispensed med. DSTU2 handles that nicely, but not R4.
        • this was removed after DSTU2 - because it wasn't part of the 80%
    • Some questions for an agenda:
      • I think we have at least 5 and possibly 7 cases. Should they be supported by different profiles? Or should a single profile support all cases, letting application logic manage differences?
      • Should the different files be treated as states, with the original order # used as an immutable id? Or should I be able to make distinct queries for the clinical order and the pharmacy order?
      • What are the assumptions around the term “dispense”? I always thought that was a physical transfer of medication, but I seem to be mistaken.
    • Suggest that Jay provide more detail for review by pharmacy
    • Also Pharmacy could review the final profile
    • Suggest that an IG be created
  • Medication List IG Project
    • Treatment Identifier - want to link prescriptions, dispense, administrations
      • GForge tracker was resolved
      • May need basedOn - in MedDispense, MedAdministration and MedUsage
  • Review FHIR IGs


Date: 2019-09-18

Quarter: Q3


Agenda Topics

  • Joint Meeting with CDS - CDS hosting
  • Rep to Structured Documents 

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • Rep to Structured Documents Meeting - John's notes
    • Outcome of the meeting - there was agreement by both Pharmacy and Structured Documents that the use of CDA for collecting (Prefetch) data that could be used in the Opiod use case described by Matt Lord would not be successful.  There may be other  use cases where this approach would work, but we did not discuss those use cases.  The challenges with using CDA is that several attributes don't exist in CDA; some attributes may be in free text (not structured); CDA does not represent a Medication Prescription in their current materials. 

Date: 2019-09-18

Quarter: Q4

Agenda Topics

Report on FHIR IG Training

Approval of January 2019 WGM Minutes

Project Management

  • Schedule for Conference calls
  • DMP - 2018
  • M&C - 2018
  • SWOT - 2018
  • Reaffirmation/Withdrawal of 5 year items
  • Forward Planning
  • Project Review
    • Motion to extend 1239 to 31 Dec 2021 - Scott - Ronan - Carried 5-0-0
    • Motion to close 856 (3 year plan) - Carried 5-0-0
    • Motion to extend Pharmacy Domain Model (3 year plan) - extend date to 31 Dec 2020 - Carried 5-0-0
  • Action Item list review
  • Addition of another chair
    • discussion of adding co-chair from the perspective of succession planning
  • Should we move templates to CDA R2.1
    • Discuss with IPS to see if they plan to move to R2.1
  • Publication Request - approval

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

Report on FHIR IG Training - Melva reported on the FHIR IG

Review of Wed Q3 sessions

  • mapping of MedRequest to Medication Activity - review of issues
    • there is no representation of a prescription in CDA
    • issues with textual information vs coded data
  • Joint with CDS
    • review of MedicationKnowledge and IDMP resources

Approval of January 2019 WGM Minutes

  • Motion by John Hatem- seconded by Daniel Zhang to approve the minutes - 4-0-0

Project Management

Action Items

Date: 2019-09-19

Quarter: Q1


Agenda Topics

  • Meet todayQ4
  • Formulary Ballot Reconciliation
  • FHIR QA
  • Conditional Dosing examples

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • Meet today Q4
    • will not meet today in Q4
  • Formulary Ballot Reconciliation
    • Discussion of ballot reconciliation
    • Motion to rescind previous ballot reconciliation vote on the tracker items - Melva - Tim - 9-0-0
    • Block Vote #1 - Motion to accept ballot reconciliation disposition for Block Vote #1 Melva - Dave 9-0-0
    • Will join on teleconference on September 30th
  • FHIR QA
  • Conditional Dosing examples
  • Melva Petersto let HQ know that we will not meeting today in Q4

Date: 2019-09-19

Quarter: Q2


Agenda Topics

  • FHIR Tracke
  • Matt Lord - Medication List  questions 

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • Scott R provided an overview of Pharmacy resources for Matt Lord and other attendees
    • covered all resources and also the future conditional extension
  • Vince M raised a new potential medication list  use case.  Australia has a requirement when the physician is prescribing and is provided a list of medications that are found on a PDMP like repository.  

Date: 2019-09-19

Quarter: Q3


Agenda Topics

  • Nutrition - use of resources

Supporting Documents

Atlanta Working Group Meeting Agenda

Minutes/Conclusions Reached

  • Becky G reviewed Nutrition requirements and after much discussion it was determined that Nutrition Intake should be a separate resource from the existing Pharmacy resources.  It is very similar to Medication Administration resource, but does have many distinct differences.  A few of the differences are related to need to represent place holders for Protein, Fat and Carbohydrate measures in addition to the ingredients.
    • Nutrition Intake resource will support both measures of food intake and also be capable of measuring the fluid intake of food products e.g. tube feeding, coffee
  • Another notable need is the Nutrition Product - similar to Medication.  The Nutrition Product will include greater detail than what is found in the Pharmacy's Medication resource.   
  • Another need by Nutrition is a method to represent a Menu and the capability to represent the individual item(s) on that menu.  And Pharmacy does not have a corresponding resource to address this need.