20220509 Q4 PHWG WGM Minutes

AIRA

• SISC Small groups- Small groups that come together for 4 weeks to address a particular need and generate guidance (Tell Marie)
  • IG Gap Identification- June
    • Gaps identified will determine path forward
    • Based on implementation or what SHOULD be implemented today, not necessarily aspirational. Formalization of what’s already reality
    • Need more IIS participation
    • Out of Scope- moving 2.8 or FHIR, incompatible, breaking, new changes
    • Could come up with recommendation on what to do with 2.8 guide.
    • What group is doing this work? SISC is a small group just identifying the gaps. CDC is leading the discussion. Get the full list and decide an appropriate path forward.
    • At that time, will discuss publishing.
    • in scope: 
      • SISC guidance
      • Gaps identified by NIST
      • Latest guidance from HL7
      • Measurement and improvement
      • ONC EHR requirements
      • Frequently asked questions
      • Actual practice by most/all
      • updated code sets
      • IZ gateway uber guidance 
  • SOGI- July August
    • Adopt work already done on interim guidance on how to use OBX segments. Want to make sure that guidance is in alignment with how its being proposed broadly
    • Guidance would detail how it would be implemented
    • Have a few IISs interested, but no jurisdictions are confirming requirements
    • PID-8 Administrative Sex
      • largely leaving this field alone
      • original definition for hospital admin purposes
      • exceptions would be US passports now have x, Candidate for adding to PID-8
      • Gender Identity
      • Sexual Orientation
      • Sex at birth/birth sex
    • Moving rapidly in V2 management and lab
    • Short term solution involves 2 OBX segments and LOINC
    • Long term solution includes 3 new HL7 segments & Vocabulary from USCDI
    • After that will be error codes (ERR-5) and Immunization DS
      • Error codes- hoping to take to connectathon in the fall.
      • Imm DS- not sure of next steps. Will need to address special conditions. Expect a connectathon at some point. Want to create a mechanism to be generalized. May want to engage Helios (Steve Hill- Cerner, Michelle Barber- Oregon)
      • Needing more IIS participation
• PID-3.1 Patient Id Length.
  • In base standard its listed as only 15 characters and this causes problems as systems are starting to use longer ids. HL7 v2 length values are considered non-binding. NIST will be removing checks for length of PID-3.1
  • IIS and EHRs should accept longer IDs

CDC

• Using NIST IGAMT to digitize the 2.8 guide
• Starting QA testing on IG
• Will send IG to SISC at AIRA for review
• Then will be publishing guide in IGAMT. It will include additional conformance that didn’t exist previously
• Will then be entering in local igs into IGMAT to compare against the national IG.
• Once SISC has identified the IG gaps, will determine best path forward
• Some jurisdictions have their own IGs, some registry vendors have their own IGs, where other registries have none. Trying to get everyone on the same page and goal to align with national. AIRA has asked for IIS to documented their interface specs, particularly to document the differences. Guidance given to IIS is to minimize those differences.
• Just documenting WHY they had differences nationally was a great exercise to highlight those difference and most decided that they would rather just fix the issues the document the difference.

NIST

• See comments from CDC and AIRA
• Working to improve tools to be able to computerize as many of the requirements as they can to support the differential profiles at the local level and to build the conformance tools
• Also looking summary reports on differentials, not just 1 guide against the national guide but for all the local guides against the national. The report may also include details provided on WHY certain differences are present, if entered.
• Similar work is underway on lab guides
• Vital records & syndromic were put into the older IGAMT version. Nothing on eCR.

• Will review here to get some thoughts down, then will take to the Friday call. Then will bring to the workgroup for disposition.
• FHIR -36061- We need to indicate the associated request related to an Immunization
  • Already done this in R5, created .baseOn element that allows references to most of the suggested resources minus ServiceRequest. There is a separate discussion regarding how to place an order for an immunization to take place. Recommendation has been to use MedicationRequest rather than ServiceRequest, but we need to resolve the that before we update the .basedOn element.
  • Need to resolve this. Could be a duplicate or possibly pser. With mod.
  • Immunization is the resource for tracking the event, but MedicationRequest is the resource to place the order
  • In the EHR, if someone asked for the order, which would it be? Not sure this is done today. Amit to check. PH doesn’t normally get these.
• FHIR-36060- How to indicate Supporting Information for an Immunization
  • Suggested to created a new element (supportingInfo) of type Reference (Any) with a 0..* cardinality.
  • In R5, there is already a reason element (codable reference) that can point to condition or diagnosticReport.
  • The main difference between proposal and what’s already in R5 is that the proposal suggested a Reference (Any) as opposed to specifying specific references.
  • Is it better to have a completely open reference or to define and then extend? It better to provide more guidance to implementers rather than less.
  • What is in R5 covers the two examples suggested (preg and rabies).
• FHIR-36059- we need to indicate the code of a procedure related to an immunization
  • Similar to FHIR- 33120- general extension to capture procedure codes
  • Believe this is a duplicate
  • Is this attempting to push the use of this resource towards supporting billing? Might be better to point from immunization to procedure.
  • Leaning towards extension because its believed that this isn’t really common
• FHIR-34301- Immunization.recorded is ambiguous
  • Date the occurrence of the imm was first captured in the record, potentially significantly after the occurrence of the event.
  • Captured in which record since so many systems record the record?
  • Who records? The person who gave the dose? This may have come from V2 RXA-22 (System Entry Date/Time) which is optional in the Imm IG. We don’t currently use it in HL7 V2 VXU in the US. Australia uses date of administration. primary.Source can be used to determine whether this record is the primary source of truth record rather than a secondary reported record. True= primary
  • Could remove it, or convert to extension if we cant give people good guidance, and based on 80/20 rule.
• FHIR-32773 Allow Patient, RelatedPerson in Immunization.performer/actor
  • Performer back bone element includes a function and actor.
    • Actor can link to practitioner and practitionerRole, and Organization
  • Use case attempting to be addressed is self-administered vaccinations
  • Include ability to document related persons everywhere to could document provider unless specifically prohibited.
  • Don’t really support this at all in the US.
  • If we include that in the resource, we could also extend away in the IG.
  • Grahame expressed the as a general rule of thumb we should include other types of care givers (like patient or related person) unless there is a reason that they should not be allowed across jurisdictions. As well, it is always possibly to constrain away reference types in an IG is the specific use case should be allow that person in the element.

• REMINDER- no Q1 and Q3 scheduled for Tuesday, Hosted by FHIR-I in Q2. Q4 meets to discuss eCR and MedMorph