HL7 Clinical Quality Information September 2017 San Diego WGM Minutes

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HL7 Clinical Quality Information September 2017 San Diego WGM Minutes

Time: Monday Q3
Facilitator / Floyd Eisenberg / Scribe / Patty Craig
Attendee / Name / Affiliation
Attendance sheet for this meeting is at the beginning of this document.
Quorum Requirements Met: Yes

Agenda Topics

  • Business Meeting
  • Agenda Review
  • Behavioral Health group introduces themselves (added to agenda)
  • QI Core (added to agenda)
  • New Project Scope statements

Supporting Documents – CQI HL7 Wiki agenda

Minutes/Conclusions Reached:

Business Session

  • Introductions
  • Agenda Review Planning and Update – updated Wiki agenda as appropriate
  • Behavioral Health group introduced themselves
  • Behavioral Health AMIA workgroup wants to become involved in HIT standards development work based on the research they have been doing within AMIA.
  • Current EHR workflows, in general, do not support behavioral health
  • Wants to work on content and computation that is adequate for behavioral health
  • SNOMED and LOINC needs work
  • DSM 5 is used by behavioral health professionals to derive the diagnosis code, which is then billed using ICD-10. However, DSM 5 is not fully aligned with HL7 data models
  • Their goals are:
  • Prioritize projects for developing standards for:

Capturing signs, symptoms, exposures, disorders, and history of BH conditions

Diagnosis are based on signs and symptoms; however, behavioral health models are theoretical based. There are 12 common models.

Psychosocial assessments and assessment procedures

Psychosocial interventions

  • Establish relationship with other HL7 WGs doing similar work
  • By the end of the WGM, it was decided that this group would become an Interest Group underneath CQI until they are ready to become a Workgroup
  • CQI co-chairs created a link for the CQI Wiki to the new Interest Group and they have begun creating their Wiki page:
  • QI Core
  • Will discuss in Mon Q4
  • New proposals
  • Will discuss in Mon Q4

CQI was invited to attend the Mega Report-out
Time: Monday Q3
  • See sponsoring Workgroup meeting minutes for more information.

Time: Monday Q4
Facilitator / KP Sethi / Scribe / Patty Craig
Attendee / Name / Affiliation
Attendance sheet for this meeting is at the beginning of this document.
Quorum Requirements Met: Yes

Agenda Topics

  • QI Core update
  • New Proposals
  • QRDA Cat I R5 Ballot Reconciliation

Supporting Documents –

  • QRDA Cat I R5 Ballot Reconciliation spreadsheet at end of WGM:

Minutes/Conclusions Reached:

  • QI Core update (Floyd)
  • Floyd is working on cross-walking QDM 5.3 to QI Core
  • Identifying mismatches between QDM and FHIR, either QDM or FHIR needs to be modified – the preference is to enhance FHIR, working with FHIR on these issues.
  • In some cases, the issue is that QDM needs to be more specific – working with QDM workgroup on these issues.
  • CQI discussed specific issues
  • Additional discussion will occur either Wed Q1 and/or Wed Q4 with CDS and CIMI
  • QRDA Cat I R5 Ballot Reconciliation
  • Received around 100 comments
  • Not a lot of comments would require a substantial change
  • Block #1
  • The following items have been found Persuasive or Persuasive with Mod

Items #64, #66, #70, #71, #72, #73, #74, #75, #76, #77

Floyd Eisenberg moved to approve these dispositions as stated and Michael Holck seconded

No future discussion

Opposed: 0; abstentions: 2; approved: 14

Approved

  • Block #2
  • The following items have been found Persuasive or Persuasive with Mod

Item #21

Floyd Eisenberg moved to approve these dispositions as stated and David Sundaram-Stukel seconded

No future discussion

Opposed: 0; abstentions: 2; approved: 14

Approved

Time: Tuesday Q1
Facilitator / KP Sethi / Scribe / Patty Craig
Attendee / Name / Affiliation
Attendance sheet for this meeting is at the beginning of this document.
Quorum Requirements Met: Yes

Agenda Topics

  • QRDA Cat I R5 Ballot Reconciliation

Supporting Documents –

  • QRDA Cat I R5 Ballot Reconciliation spreadsheet at end of WGM:

Minutes/Conclusions Reached

  • QRDA Cat I R5 Ballot Reconciliation
  • Block #1
  • The following items have been found Persuasive or Persuasive with Mod

Items #79 through #99, #101, and #102

  • Item #100 is on hold to receive more information from The Joint Commission

Floyd Eisenberg moved to approve these dispositions as stated and Michael Holck seconded

No future discussion

Opposed: 0; abstentions: 0; approved: 15

Approved

  • Block #2
  • The following items have been found Persuasive or Persuasive with Mod

Items #5, #9, #10, #20

  • The following item has been found as Not Persuasive

Item #43 – the submitter will be directed to review the CMS Measure Blueprint for how terminologies are used within quality measures

Floyd Eisenberg moved to approve these dispositions as stated and Anne Marie Smith seconded

No future discussion

Opposed: 0; abstentions: 0; approved: 16

Approved

Time: Tuesday Q2 (Hosted CDS and FHIR-I)
Facilitator / Floyd Eisenberg / Scribe / Patty Craig
Attendee / Name / Affiliation
Attendance sheet for this meeting is at the beginning of this document.
Quorum Requirements Met: Yes

Agenda Topics

  • Updated/new PSS for CQF on FHIR and CDS Hooks
  • CDS Hooks informal comments review
  • Infobutton in CDS Hooks

Supporting Documents – None

Minutes/Conclusions Reached:

  • Clinical Decision Support Big Picture Implementation Guide PSS
  • Robert Jenders presented the updated PSS for the project.
  • PSS Scope: Clinical decision support (CDS) is increasingly viewed as a vital health information technology for supporting and maintaining good health outcomes. However, a proliferation of health information technology standards related to clinical decision support, including those that address knowledge representation and access, have increased confusion and uncertainty in the industry regarding the implementation of CDS. This implementation guide will demonstrate how standards in this space, with a focus on HL7 standards, can be brought together and used to implement an overall CDS strategy, including cases of specific kinds of CDS, e.g., alerts/reminders, order sets and the like. This PSS is identical to the one for this project approved in 2014 but with the timeline extended in order to accommodate limited resources to complete the project.
  • Arden Syntax workgroup is the primary sponsor and has already approved the updated PSS. They will be providing the majority of the work effort.
  • CQI and CDS voted to approve the updated PSS and agree to be co-sponsors:

Robert Jenders moved to approve the PSS and Howard Strasberg seconded

No future discussion

Opposed: 0; abstentions: 2; approved: 38

Approved

  • CDS Hooks informal commentsreview
  • The copyright issues with “CDS Hooks” and some tooling discussion delayed the HL7 Informative ballot for the next version. Plan is to ballot a formal STU ballot in Jan 2018.
  • Given the HL7 ballot cannot go forward, CDS requested a review for informal comments. The comments will be used to update the document prior to the STU ballot.
  • The combined workgroups discussed comments that exist within GitHub for the document. For each comment, GitHub was updated with the discussion during this quarter.
  • Given this isn’t an actual HL7 ballot, voting is not being performed.
  • Items discussed: #52, #80, #82, #89, #92, #93
  • Infobutton in CDS Hooks
  • Discussion will occur in a future quarter
  • Updated/new PSS for CQF on FHIR and CDS Hooks
  • Discussion will occur in a future quarter

CQI joined EHR Workgroup
Time: Tuesday Q2
  • See EHR Workgroup meeting minutes for more information.

CQI joined CDS and FHIR-I Workgroups
Time: Tuesday Q3
  • Agenda:
  • ITS Work Group will be conducting vMR XML specification ballot reconciliation at the top of the quarter (ITS is the owning WG).
  • CDS Hooks informal comments review
  • Future of QICore / modeling activities and vendor support for required FHIR profiles
  • Infobutton in CDS Hooks
  • Updated/new PSS for CQF on FHIR and CDS Hooks
  • See CDS meeting minutes for more information.

Time: Tuesday Q4
Facilitator / Yan Heras / Scribe / Patty Craig
Attendee / Name / Affiliation
Attendance sheet for this meeting is at the beginning of this document.
Quorum Requirements Met: Yes

Agenda Topics

  • QRDA Cat I R5 Ballot Reconciliation

Supporting Documents -

  • QRDA Cat I R5 Ballot Reconciliation spreadsheet at end of WGM:

Minutes/Conclusions Reached:

  • QRDA Cat I R5 Ballot Reconciliation
  • Block #1
  • The following items have been found Not Related – the VA/DOD have specific requirements that need to be evaluated across all CQI standards / IGs – including QDM/QI Core, HQMF, QRDA Category I. There may also be update requirements for CQL.

Items #23 through #41

KP Sethi moved to approve these dispositions as stated and Michael Holck seconded

No future discussion

Opposed: 0; abstentions: 0; approved: 12

Approved

  • Block #2
  • The following items have been found Not Persuasive

Item #100

  • The following items have been found Not Related

Item #103 – Per Thom, this comment was intended for a different ballot

  • The following items have been found Persuasive or Persuasive with Mod

Item #11,#56, #59, #60

KP Sethi moved to approve these dispositions as stated David Sundaram-Stukel seconded

No future discussion

Opposed: 0; abstentions: 1; approved: 12

Approved

  • Block #3
  • The following items have been found Not Persuasive or Not Persuasive with Mod

Item #48 and #49

KP Sethi moved to approve these dispositions as stated and Michael Holck seconded

No future discussion

Opposed: 0; abstentions: 0; approved: 13

Approved

Time: Wednesday Q1 (Hosted CDS and CIMI)
Facilitator / Floyd Eisenberg / Scribe / Patty Craig
Attendee / Name / Affiliation
Attendance sheet for this meeting is at the beginning of this document.
Quorum Requirements Met: Yes

Agenda Topics

  • CDS KNART project
  • Demo of authoring process for the VA KNART Project
  • Public Health FHIR Case Reporting PSS - consider co-sponsorship
  • Future of QI Core/modeling activities
  • Other topics as proposed

Supporting Documents -

  • FHIR Public Health Electronic Case Reporting (eCR) discussion
  • eCR and FHIR for CDS-CQI-CIMI v4
  • KNART discussion
  • KNARTAuthoring presentation - Wed Q1
  • HL7 KNART Q1
  • QI Core to FHIR discussion
  • QDM to QI Core Issues - September HL7 San Diego

Minutes/Conclusions Reached:

  • FHIR Public Health Electronic Case Reporting (eCR)
  • Reporting, investigation, and management – electronic transmission of clinical data from Electronic Health Records to Public Health
  • Build off the C-CDA STU Public Health Case Report standards to support a number of activities related to electronic case reporting (eCR) through appropriate FHIR representations
  • Activities:
  • Reporting to public health
  • Bi-directional information exchange between public health and EHRs
  • Triggering decision support – automated initiation of an initial report in EHR based on public health specifications and logic
  • Discussion
  • CIMI
  • developing the logical models from which FHIR models will be created
  • has a real interest in working with the project, may have bandwidth issues
  • The project is trying to use the data that is available instead of creating a lot of new data; however, they will need “travel history”

Walter Suarez moved that the three represented workgroups (CQI, CDS, CIMI) will co-sponsor with occasional updates and Lorraine Constable seconded

No future discussion

Opposed: 0; abstentions: 0; approved: 51

Approved

  • Knowledge Artifact (KNART)
  • Project was funded in part by VA Knowledge Bases Systems’ Knowledge Artifact research contract
  • PSS 1336 co-sponsored by CDS, CQI, and CIMI
  • There is a larger project working to stress test the project
  • Work occurred from May – Sept 2017
  • Clinical Use Cases
  • Exposing clinical intent to establish or monitor appropriate use of KNARTs
  • Expressing a KNART at clinical, logical, and implementation levels
  • Composing a KNART from other KNARTs to support reuse and support of more complex clinical requirements
  • Orchestrating behavior of KNARTs to enable an optimal or mandated workflow
  • Chaining artifact behavior using data created and/or retrieved by one or more artifacts.
  • Identifying (and resolving) “conflicts” between KNARTs
  • CRM is the natural evolution of the KNART specification but in a FHIR-specific way that prevents the immediate use of clinical knowledge artifacts in non-FHIR environments
  • Recommendation #1:
  • New PSS to evolve and develop a KNART conceptual model that anchors implementation level knowledge artifact representations
  • Map, translation between implementations
  • Common bridge to FHIR
  • Elements to support source referencing and possible reverse translation
  • Incorporating FHIR innovations
  • Develop a compounding and referencing mechanism
  • Develop a composite packaging method
  • Enhance metadata
  • Recommendation #2:
  • An additional STU period for the HeD KNART specification and a PSS to maintain that specification
  • Resolving and responding to the existing STU comments
  • Updating the physical specification to include enhancements from innovations in the FHIR Clinical Reasoning
  • Include the ability to dynamically bind to an expression language
  • Bring the specification up to date with the current versions of related specifications.
  • Develop physical representations of the features defined by the c conceptual model, including composites.
  • Composite Knowledge Artifact Conceptual Model PSS (PID tbd)
  • The existing Knowledge Artifact (KNART) Specification (STU 1.3) defines specifications for Documentation Templates, Event Condition Action definitions, Order Sets as independent artifacts. Including consult requests, there is a need to create composite artifacts comprised of Documentation Templates, potentially multiple Order Sets and Rules.
  • Additionally, the current specification is a mix of logical and physical representations. One of the conclusions of the Composite KNART investigative project was to create a conceptual model that can bridge physical representations, which currently include the Health eDecisions (HeD) xml and FHIR Clinical Reasoning module. The conceptual model will include:
  • Support for composite / compound knowledge artifacts
  • Mapping to FHIR Clinical Reasoning to ensure consistent semantics across physical representations
  • Re-align KNART with the FHIR community effort
  • Additional lifecycle support for Authoring, Governance, etc.
  • Project Need:
  • Singleton KNARTs provide a structured means to represent clinical knowledge, guidelines, and protocols to support the provision of CDS to the point of care. Care provision requires that stand-alone knowledge artifacts such as order sets and consult referrals be related and managed in sets to support clinical workflows. This implies that KNARTs may be develo0ped in sets that share common packaging and metadata.
  • Separation of the physical implementation from the conceptual specification will allow the conceptual model to support mapping between different physical representations including the HeD and FHIR Clinical Reasoning formats, as well as providing a means to document the relationship with external, non HL7 knowledge artifacts.
  • CDS Knowledge Artifact Specification DSTU Update 4 PSS (PID 931)
  • Revised scope to cover a recommended update to the CDS Knowledge Artifact (KNART) STU Release 1.3. The composite KNART investigative project made the following recommendations for the next release of the Health eDecisions (HeD) knowledge:
  • Scope will cover updates to the HeD physical specification
  • Add support for alternate expression languages
  • Update to support functionality that has been added to the Clinical Reasoning model
  • Add support for composite knowledge artifacts, and any additional functionality identified in the conceptual model
  • Bring up to date with current versions of CQL and ELM
  • Address submitted change requests to the current specification and identified technical corrections
  • Consider the addition of support for post coordinated concept expressions
  • It is expected that an STU Update will be produced, but if the scale of changes warrant based on the STU update guidelines, an STU ballot may be conducted.
  • Project scope:
  • Ongoing work to implement HeD knowledge artifacts, including updates to the specification to support requirements such as composites that combine Documentation Templates and Order Sets in support of consultation requests. Separation of the physical implementation form the conceptual specification will allow the conceptual model to support mapping between different physical representations including the HeD and FHIR Clinical Reasoning formats.
  • Discussions:
  • Backward compatibility is not a concern based on the current implementation level. The VA is the largest implementer and they are asking for the update.
  • Request: By the end of the project, be able to create a CIMI logical model and will generate the physical model.
  • Both PSS’ will be updated based on the discussion and brought back for voting by CQI, CDS, and CIMI at a later time.

Lorraine Constable motioned to request a 2nd extension to the existing STU for KNART and Bryn Rhodes seconded

No future discussion

Opposed: 0; abstentions: 0; approved: 51

Approved

  • KNART demo was provided
  • US FHIR Core Updates PSS (PID 1265)
  • Original US FHIR Core publication profiled several key resources to meet the requirements of the ONC 2015 Common Clinical Data Set (CCDS). Since HL7 published US FHIR Core in March 2017, additional pilots within Argonaut and FHIR implementation community identified additional key resources.
  • This project will develop new US FHIR Core profile for:
  • DocumentReference
  • Encounter
  • PractitionerRole
  • Each of these resources have been piloted through the Argonaut Data Access and Provider Directory initiatives.
  • Development of formal HL7 profiles will be done in collaboration with the appropriate work groups. It is expected the base DocumentReference will be consistent with XDS.b requirements and this new profile will not introduce any contradictory guidance.
  • Vocabulary omissions or errors in previously developed will be considered. Efforts to align with C-CDS on FHIR value sets is considered in scope if participants are available to identify gaps and recommend resolutions.
  • ** CQI, CDS, CIMI needs to look at what is in QI Core to see what needs to be brought into US Core. Requests need to be added to the FHIR Tracker quickly so they can be included as part of this project.
  • Discussion
  • CQI and CDS desire that QI Core is brought into US Core

Bryn Rhode motioned that CQI and CDS is a co-sponsor of the PSS, CIMI is an interested party of the PSS, and we want periodic updates and Julia Skapik seconded