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Facilitator:

Austin Kreisler


Date:


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Agenda:


10:00am ET

  1. Call to order 
    1. Call for Attendance


  2. Business Updates (10 min)
    1. Additions/modifications to the agenda
    2. Approve minutes from 2020-08-20 Agenda and Minutes

    3. HL7
  3. External Updates - ONC and others
  4. Project Updates
    1.  

  5. Additional Items
    1. Extensions
    2. Individual as Custodian

    3. David Riddle - CDA to FHIR mapping questions
    4. Sept. WGM Agenda Review
  6. STU Comments
    1. Nick Radov(Expand C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm to find Nick's issues)
      1. HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm
      2.  Click here to expand...

        STU

        Last Updated

        Commenter

        Issue

        1945

         

        Encounter Diagnosis (V3)
        [act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.80:2015-08-01 (open)]

        This template wraps relevant problems or diagnoses at the close of a visit or that need to be followed after the visit. If the encounter is associated with a Hospital Discharge, the Hospital Discharge Diagnosis must be used. This entry requires at least one Problem Observation entry.
        1885

         

        @sueann svabySHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Social History Type urn:oid:2.16.840.1.113883.3.88.12.80.60 DYNAMIC (CONF:1198-8558).
        a. If @codeSystem is not LOINC, then this code SHALL contain at least one [1..*] translation, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-32951).
        1873

         

        Encounter Diagnosis (V3)
        [act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.80:2015-08-01 (open)]

        The template is missing a binding for statusCode.

        Figure 144 shows a statusCode of "active". This provides the wrong guidance.
        1859

         

        Please REMOVE/DEPRECATE this commentIn the errata release from June 2019,Figure 162 is wrong and needs to be updated to use the correct Code System OID for CVX 2.16.840.1.113762.1.4.1010.6. It currently shows as 2.16.840.1.113762.12.292

         

        Care Plan (V2)
        [ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.1.15:2015-08-01 (open)]

        The CDA Care Plan represents an instance of this dynamic Care Plan at a point in time. The CDA document itself is NOT dynamic.
        Key differentiators between a Care Plan CDA and CCD (another “snapshot in time” document): There are 2 required sections:
        o Health Concerns o Interventions
        There are 2 optional sections:
        o Goals o Outcomes

        • Provides the ability to identify patient and provider priorities with each act • Provides a header participant to indicate occurrences of Care Plan review A care plan document can include entry references from the information in these sections to the information (entries) in other sections.
        Please see Volume 1 of this guide to view a Care Plan Relationship diagram and story board.
        1802

         

        Smoking Status - Meaningful Use (V2) (urn:hl7ii:2.16.840.1.113883.10.20.22.4.78:2014-06-09)

        . This value SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Smoking Status urn:oid:2.16.840.1.113883.11.20.9.38 DYNAMIC (CONF:1098-14817).

        1800 

        1801

         

        We have trouble adding new Social History Observations when the US Gov't identifies the observation using LOINC. We really should be using LOINC in the code ("the question").

        I recommend creating a Grouping Value Set that combines the original set of concepts using SNOMEDCT (Social History Type (SNOMEDCT)) and then agree to put all new/additional social history observation codes in the Social History Type (LOINC) value set. Use the existing OID for the new Grouping VS and make two new value sets for the parts of the grouping VS.
        1798

         

        On page 392, Section 3.61.1, the last three sentences of the text read as follows:

        "Procedure act is for procedures that alter the physical condition of a patient (e.g., splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (e.g., EEG). Act is for all other types of procedures (e.g., dressing change)."

        This is different from the wording on page 390, Section 3.61 Procedures Section (entries optional) (V2). Updated language is in the proposed section below.
        1793

        3.41 Immunization Medication Information (V2) includes SHALL have a manufactureMaterial where this code MAY contain zero or more [0..*] translation, which MAY be selected from ValueSet Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.8 DYNAMIC (CONF:1098-31543).

         

        3.41 Immunization Medication Information (V2) includes SHALL have a manufactureMaterial where this code MAY contain zero or more [0..*] translation, which MAY be selected from ValueSet Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.8 DYNAMIC (CONF:1098-31543).

         

        We have seen real-world implementation defects where planned future encounters appear in the Encounters section rather than the Plan of Treatment section where they should be. I think some developers are just querying their database encounter tables for all encounters for a particular patient and sticking everything in the Encounters section regardless of whether they are past or future. Let's introduce a new conformance rule to ensure each Encounter activity ends before the document header effectiveTime.

         

        In section 3.81 Procedure Activity Procedure (V2) the Procedure.code (CONF:1098-7656) doesn't mention HCPCS as a possible code system. I think that code system should be explicitly listed because it is in common use in the US realm along with CPT-4. There are many procedures which are in HCPCS but not in CPT-4.

        This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19207).

         

        Section 3.23, page 483:

        Table 272: EncounterTypeCode
        Value Set: EncounterTypeCode urn:oid:2.16.840.1.113883.3.88.12.80.32
        This value set includes only the codes of the Current Procedure and Terminology designated for Evaluation and Management (99200 – 99607) (subscription to AMA Required
        Value Set Source: http://www.amacodingonline.com/

         

        <!-- ************************ ENCOUNTERS *********************** -->
        <component>
        <section>
        <!-- *** Encounters section (entries required) (V3) *** -->
        <templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
        <templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>

        I think there is a problem with the sample CCD file C-CDA_R2-1_CCD.xml included in this package.

        1381

         

        doseQuanity/@unit and administrationUnitCode/@code are a confusing set of elements, but I will do my best pulling from the base definitions:
        1370

         

        In the Comment Activity template (2.16.840.1.113883.10.20.22.4.64):

        5. SHALL contain exactly one [1..1] text (CONF:81-9430).
        a. This text SHALL contain exactly one [1..1] reference (CONF:81-15967).
    2. Matt Szczepankiewicz (expand HL7 CDA® R2 Implementation Guide: C-CDA Templates for Clinical Notes Companion Guide, Release 2 STU - US Realm )
      1.   

         Click here to expand...

        STU

        Last Update

        Commenter

        Comment

         

        The Provenance entry in the Appendix C is inconsistent with the author entry in the C-CDAr2.1 IG in terms of allowable values and it is misleading.

         

        For the UDI information, can we get clarification on whether it is possible to send other information when we do not have the DI information?

         

        Appendix B UDI
        1.1 UDI Organizer 

        Figure 1: Unique Device Identifier (UDI) Organizer Template ID root is incorrect

         

        (Vocab issue)
        Table 9 of the Companion Guide recommends the LOINC codes 11502-2 for Laboratory Narrative notes and 11526-1 for Pathology Narrative notes. However, these codes aren't actually included in the Note Types value set (urn:oid:2.16.840.1.113883.11.20.9.68) as required by the Notes Section and Note Activity templates in Appendix A. Likewise, although no specific LOINC code is recommended for Imaging Narrative notes, the value set doesn't include any codes from the value set recommended for imaging notes in Table 8 (urn:oid:1.3.6.1.4.1.12009.10.2.5).

         

        The following unimplemented constraints use the expression "not(.)" throughout the main Companion Guide schematron file:

        CONF:3250-16902
        CONF:3250-16912
        CONF:3250-16914
        CONF:4435-133
        CONF:3250-16942

        Typically unimplemented constraints use a dummy expression like "not(tested)" that always returns false (since the current element doesn't have a child named "tested"), but in this case, we're asserting that the current node is null, which returns false, makes the assertion fail, and triggers a false positive schematron error.
        2006

         

        In Appendix C:

        vi. This representedOrganization SHOULD contain at least one [1..*] telecom (CONF:4440-12).
        2009

         

        The Provenance - Author Participation template has a strange-seeming inconsistency between the requirements around the assignedAuthor/id and the assignedAuthor/representedOrganization/id:
        2014

         

        The Note Types Value Set (urn:oid:2.16.840.1.113883.11.20.9.68) version 20191017 is missing three note types specific in USCDI v1:
        2015

         

        The value Set binding for the Note Types value set in the Notes Section template does not include a binding strength.
      2.  

11:00am ET

  1. Value Set Updates
  2. Value Set STU Comments
    1. #nnnn
  3. Adjournment

Notes/Minutes:

  1. Call to order: 9:05am

  2. Business Updates (10 min)
    1. Additions/modifications to the agenda - David Riddle - CDA to FHIR questions
    2. Approve minutes from

      2020-08-20 Agenda and Minutes
       - Approved by general consent

    3. HL7
  3. External Updates - ONC and others
    1. Accepting submissions for new USCDI data elements - must be received by Oct 9 - https://www.healthit.gov/isa/ONDEC
  4. Project Updates
    1.  none

  5. Additional Items
    1. Extension for Additional Identifiers - Lisa R. Nelson
      1. Presentation - describing problem and solution
      2. Proposed extension adds time and code elements (maps to FHIR identifier's period and type). No clear location for FHIR's use field, but this is not required in FHIR.
      3. Benjamin Flessner - clarify - will this go on every ID or only roles? Austin Kreisler - can only apply to roles. So things like ClinicalDocument/id, Section/id, Observation/id, etc.
      4. Discussion about meaning of alternate identifier when found with normal id elements.
      5. Wordsmithing
    2. Individual as Custodian - Lisa R. Nelson

      1. Want to enable patient to be custodian of their own information.
      2. Austin Kreisler - would have to be a new release of CDA to add a choice; otherwise (if extension) it would have to be safe to ignore.
        1. Also difficulties - may not even be able to publish a new V3 standard.
        2. Lisa R. Nelson thinks Lantana is working on something to do this
      3. May explore alternative options - Lisa and Austin to discuss offline
    3. David Riddle - CDA to FHIR mapping questions
      1. Result Performer: 
        1. Result Observation - FHIR lists performer = CDA participant[@typeCode=PRF]
        2. C-CDA doesn't list anything about the performer element, though C-CDA examples task force has written examples
      2. Immunization Status:
        1. "not given" immunizations are communicated with statusCode=completed + negationInd=true. But FHIR mapping for status doesn't mention negationInd.
        2. Lisa R. Nelson - many FHIR resources have different status fields, named differently, with different meanings
    4. Sept. WGM Agenda Review
      1. Agenda looks good; haven't heard from HQ how virtual space has been allocated
      2. Sean McIlvenna - Add FHIR tracker items to agenda
      3. Matthew Rahn - Discuss submissions for new USCDI data elements - must be received by Oct 9 - https://www.healthit.gov/isa/ONDEC
  6. STU Comments
    1. Nick Radov - not present
    2. Matt Szczepankiewicz (expand HL7 CDA® R2 Implementation Guide: C-CDA Templates for Clinical Notes Companion Guide, Release 2 STU - US Realm )
      1.   Discussed issues:

         Click here to expand...

        STU

        Commenter

        Comment

        Discussion / Resolution
        The following unimplemented constraints use the expression "not(.)" throughout the main Companion Guide schematron file:

        CONF:3250-16902
        CONF:3250-16912
        CONF:3250-16914
        CONF:4435-133
        CONF:3250-16942

        Typically unimplemented constraints use a dummy expression like "not(tested)" that always returns false (since the current element doesn't have a child named "tested"), but in this case, we're asserting that the current node is null, which returns false, makes the assertion fail, and triggers a false positive schematron error.

        Matt provided example schematron rules for resolution.

        Matt S / Benjamin - 19/0/0

        The Provenance entry in the Appendix C is inconsistent with the author entry in the C-CDAr2.1 IG in terms of allowable values and it is misleading.

        Wants to add clarity

        Need Brett's input

Adjournment - 11:55

 


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