2022-10-21 Immunization Innovations Group Meeting notes

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. 

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. 

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.