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Craig Newman, Noam Arzt, Kevin Snow, Assiatou Diallo, Mike Berry, Grey Faulkenberry, Chris Sorenson, Danny Wise

Discussion items

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Status updates on potential FHIR projects

  • Inventory Management: Got a response from Jose on FHIR chat. 
  • FDA is looking to get a bulk query extract for all medicaid/medicare patients current/historical. That can be a very large number. Initial guide has a flat-file to pass in and another for passing out. Similar to CVRS, custom, with duplicate patient information. Kevin presented to FDA the idea to follow a standard. They were open to the idea. Next step: reach out to a group to orientate them. Helios pilot? Kevin will connect with Craig to see the right place for them to engage. 
Future of Immunization Standards

Additional updates to The Future of Immunization Interoperability Standards in the Focus Area Status language. 

Development and support of standards is a long process, and the maturity model can provide a structure to better understand this. 

FHIR R5 comments

FHIR-39016 - Getting issue details... STATUS Craig is going to reach out to FHIR-I, perhaps through Zulip, to see what the definition of recorded. See

FHIR-39015 - Getting issue details... STATUS Need more information from the original commenter. 

Converting ImmunizationRecommendation to ImmunizationRequest

At the HL7 WGM, talked to Clinical Decision Support WG who had concerns about ImmunizationRecommendation as a resource. We have an old JIRA ticket saying that this resource should be standard, not specific. Now they are suggesting to change recommendation to make it more inline with MedicationRequest. How to better to support the workflow, from making recommendation to actually giving a vaccine. Either radically overhaul ImmunizationRecommendation or replace with ImmunizationRequest. Would be much more like a MedicationRequest or ServiceRequest. Original concern we had was that this would be too formal, recommendation is just a proposal, CDS not Clinical Decision Making. But MedicationRequest has an intent element that qualifies it. ImmunizationRequest with the intent is "proposal" and not something that needs to be acted upon. Then it could be change the intent. The downside is that the ImmunizationRequest is only for one thing. That would be two separate immunization requests. 

Question: What's the benefit of having ImmunizationRequest and MedicationRequest separate? When you act on ImmunizationRequest then you create a MedicationAdministration. It's a bit of duplication. The reason for a dedicated one is because the outcome of the evaluation isn't always give a dose, it can also be that the patient is complete, or the patient is contraindication and shouldn't give something. If we wanted to use MedicationAdministration then we'd have to be able to support that. Worried that Pharmacy would push back on because it would complicate their resource. 

The workflow would be the system would recommend a vaccination to be given an ImmmunizationRequest, then if they want to give it then they would create a MedicationAdministration. Would they update ImmunizationRequest to indicate that it was inappropriate request? They probably wouldn't update the recommendation directly. 

MedicationRequest probably covers enough of what we want to create an ImmunizationRequest. Worried about putting these out in MedicationRequest. ImmunizationRecommend is purpose build for immunization CDS and includes all the vaccine groups in the single resource. A dozen or more requests, some which say not to give then, and others in the future. Immunization recommendation in multiple groups but those three recommendations are met by one combination vaccine. There is not a one-to-one match. 

If they are going to force us to go to ImmunizationRequest then why have two different ones. Would like to keep ImmunizationRecommendation. There's not an action associated with it yet, not even a proposed one. A medical student can see the immunization recommendation and then put in a medication request for the proper vaccines. Then that medication administered can then request. 

Grey: Recommendations are important to providers for reasons other than taking specific action, such as planning purposes. If a provider knows they are due for four vaccines in this window, then the patient can be scheduled for that window. But don't want any of this to show up on the order queue. These are potentially long term, things due in the next year. 

Request Orchestration can bundle things together, but it's an overkill. Doesn't look like a good direction. Would have concerns if we moved this direction. 

Smart Health LinksIs really aggressively moving forward. Not a lot of us are not participating on that call. Should also bring this up on Public Health Call. 
FHIR Work 
  • Based on discussions at WGM
    • What is the appropriate FMM for Immunization?
      • See FHIR-I Thursday Q1 notes
      • What are the boundaries for the use of the Immunization Resource?
        • Individual patient care (including as a prelude to forecasting)
        • Public health planning (vaccination clinics, outreach, ect)
        • Quality metrics
        • Others?
          • Craig will ask the question on zulip
      • Are we confident that the resources is well suited to all of these uses?
      • Are we potentially prepared to move to Normative with R6?
    • Changes to ImmunizationRecommendation and ImmunizationEvaluation
      • Discussed with CDS/CQI Wednesday Q4
      • FHIR-14855 - Getting issue details... STATUS
      • Suggest that the ImmunizationRecommendation resource be changed to ImmunizationRequest and aligned with the Request pattern, and specifically that it represent a request to immunize for a single immunization. Forecasting would then be supported with a RequestOrchestration consisting of multiple ImmunizationRequest resources,
      • Be potentially aiming to get this in R5 (deadline in late Feb 2023)
      • Craig will reach out to set up more time with the CDS group to continue discussions
Inventory Management
  • Integration between VAMS and IIS
    • The goal is to sync up inventory levels in VAMS and IIS so that the IIS can be a single source of truth
    • Inventory is managed in the registry
      • Are there other FHIR based solution for managing inventories?
      • Some jurisdictions don't order through the IIS
  • Can this be done with FHIR?
    • Query for Organization resources?
    • What are the potentially relevant resources?
  • A high level use case description (and diagram of data flow) would be helpful
    • Kevin will work on this
  • May need operations to update the inventory (increment, decrement)
  • Need to consider how to make the solution generic enough to include other systems like EHRs
  • Separate from the ordering of vaccine (it's likely a pre-condition that vaccine product is available and documented somewhere)

Action items