PCC Minutes - November 7th-8th
On Wenesday, we reviewed agenda, and reordered some items to allow for participation in ITI and PCC activities.
We pretty much followed the agenda thereafter. What follows are notes on the different discussion topics, ordered by profile proposal.
We needed to move the vote up an hour on Thursday to address issues of people having to leave early.
See the spreadsheet for voting results, and roster for vote.
Planning will schedule followup call to discuss how to deal with report from TC.
(TC Cochair discussion post-meeting, agenda is posted, and working day was clearly identified, need to not try to rearrange voting schedule on short notice in future).
Focused Care Management
Focused Care Management was reviewed. Key talking points:
- Support for an Alternate Care Provider to Review and Add Information
- Needs also to address issues in Quality, Aggregated Care Data vs. Individual. Many quality measures are really dealling with care of patients with Chronic conditions.
- Profile appears to be a Framework for support of CDM/Public Health Registries
- Need to address support for Immunization and Cancer Registry Data
- Req't from Canada to support V3, but in US, installed base is V2.x
Standards:
- HL7 V2.X - NAACCR, CDC 2.3.1 Registry
- HL7 V3 Immunization
- HSSP
- QRDA
Need to support identification of data elements (quality, numerator and demonitor commponents)
Need a way to define the data set, query for that data, accept unsolicited data updates, and support decision support with same.
Patient Care Workflow
Key Concept is Medical Home, somebody knows and manages "EVERYTHING" about the patient. Documents or metadata needs to be communicated to more than one provider.
Embed in CDA Header key data, e.g., identify medical home for patient. This could be communciations address.
Possible use of NAV and PWP was discussed.
Need to support ad-hoc, provider to provider communcation. Need to be able to identify provider, and technology resources used to communicate.
There is a triple, Patient, Provider, and Organization through which they have relationship.
Key elements that identify patient are MRN and Organization. Key elements that identify target for communication are either provider/organization, or in context of a patient, role, patient, organization.
Need some sort of telecom address to handle this.
Thought: ######@ihe.net
Discussion with ITI resulted in loud NO! General discussion: Sounds simple, but when you dig into it, it isn't. Issues not explained. Need to follow up.
Mention of ISO Registry standard, may need to look into this.
Resolved to treat this as a white paper topic. Thom can probably gather a number of contributors, Lori may have interest and may be able to contribute as well.
RFD/QED Discussion
related proposal - Clinical research data capture
related proposal - Drug Safety content
RFD has changed, Form Filler now sends "Chunk of XML Context" (Blob) to forms manager to support FM selection of form to fill. Needs to have a content profile.
Concern raised that "Chunk of XML Context" will result in to many content profiles. Authors seemed to think it needed only a few, PCC consensus was that it needed many.
e.g.)
- Investigation of New drug - 1 per "drug profile"
- Pharmaco-vigillance - many, depending upon type of AE
- Disease Registry - Many, depending upon disease
- Biosurveillance - Several, may depend on type of event.
- Disease management, one of each disease being managed.
After two days of discussion, end result is that we are looking at different levels of interoperability.
- With "a few" content profiles, EMR can fill in some, but not all fields on a form. Will still require copy and paste, even for data that the EMR might be able to obtain for prepopulation. For Clinical Trials, this is "Good enough", and much better than what they have.
- A concern was raised that profile does not meet all its intended use cases, and that "Good enough" for clinical trials is not good enough for other purposes, that it would be hard to sell this profile in spaces where the end-user knows that the EMR knows the data, and integration profile makes it look as if the EMR is unaware.
Resolved that we will pursue enhancement of RFD in subsequent year to support better "form filling". Proposal to incorporate a new actor, called the form populator, that would be able to be grouped with FF or FM. Form populator could communicate with "Analyzer" (decision support) to determine what might be needed. Could then communicate (QED) with EMR to obtain data, then populate form. Would sit between FF and FM in updated profile.
Will consider CDASH content profile for current RFD, and possibly ICSR, but are concerned that data elements for ICSR could be more detailed.
Decision Support / Focused Care Management Redux
+------------+
| Content |
| Definer |
+------------+ Care
| | +----------+ Data +-----------+
| +---------| Support |------>| Analyzer |
| | Requestor|<------| |
| +----------+ Care +-----------+
| Plan
| +----------+ +-----------+
+-------------| Data | | Data |
|Repository|-------| Consumer |
+----------+ +-----------+
Virtual Medical Record
One idea discussed in HL7 Decision Support TC is that of Virtual Medical Record, assumed to have a canonical form in HL7 V3 RIM. VMR's have been defined for care specific use cases in the area of Cardiology and Breast Cancer. PCC TF is effectively a VMR with query support provided through QED.
Need a way to define data elements in the VMR May need to bridge between standards, e.g. VMR for CDASH, and HL7 V3-RIM
How is the defintion of a set of data elements defined and exchanged.
Little work seen on HL7 site in recent years on this topic.
ASTM E1384 is a definition of content of an EMR, E1633 is vocabulary for that. Basis for ADA 100 definition of dental EMR. May be usefull resource.
Bridging between Standards
+------+ +------+ |NEMSIS| |HL7 V2| | |----| or V3| +------+ +------+ +------+ +------+ |CDISC | |HL7 V2| | |----| or V3| +------+ +------+
Both need a "Bridge", HL7/RCRIM has one that is a work in progress. Could use a gateway between these.
CDASH is a tightly defined set of data elements that could be mapped to PCC-TF.
Family History Exchange
Content profile, request for FH for Son goes to father's PHR. Father's PHR returns submission set containing: Consent to use information to son, and Son's family history (so that all PHI exchanged now "belongs" to son).
Key Data elements: Problems -- Inherited Diseases Race and Ethnicity? Age at Onset/Diagnosis Age at Death Cause of Death Social Issues: Alchohol, Drug Abuse -- CONSENT! Exposures Relation to Patient Psychiatric Issues -- CONSENT!
Most of this content is already in the TF, this would be a content profile explaining how to exchange this content in a document.
Critical Results
Another form of Provider - Provider Communication
Key Distinction: Critical Result, vs. Important Result. Vocabulary: Urgent, Emergent, Not Urgent Where we fail is "Not Urgent"
Precondition: In an order, include communication addresses for distribution of critical results.
Need to support legal record of attempted contact and success or failure. Q to ITI: Could Audit log be used for this. A: No.
PWP and ECON might be useful. ECON would be translated as list of Emergency Contacts wher the types of information returned could be providers who need to recieve Urgent/Emergent/Non-Urgent results.
Have more than one provider to recieve a critical result is useful.
Note: Level of urgency, could potentially influense repsonse of registry for ECON query.
Concern about how the registry would be updated, why is this not included in ADT feed, which has provider relationships already?
PIX/PDQ/PWP/ECON, all mentioned for this. Add to ITI discussion topic.
(After ITI Discussion: Consensus reached that trying to do a profile that has dependencies on incomplete ITI profile would not work, need to deal with this as a white paper: How to use ITI profiles to support this capability. Draft Paul Nagy, Kevin O'Donnell to help with this paper in PCC.
Prehospital Care Report
+---------+
| CAD | (Dispatch)
+---------+
|
| NEMSIS Data/911
|
+---------+
| Onboard |
| Patient |
| Care |
|Reporting|
| System |
+---------+
|
| CDA Document
|
+---------+
| Hospital|
| EDIS |
+---------+
Randy Price from Loyola Emergency Medical Services System joined us and gave us a view of the First Responder world for the use case of the crash victim, and how information is exchanged.
Basic Data flows are shown above, with notes that several variations in how call information is provided.
Key notes: 1. Patient data is not typically provided en-route, because PHI over radio would violate privacy. 2. For unconcious victim, identifying the patient often occurs last if at all before arrival, because focus is on extrication, treatment, et cetera. 3. Notes may be written on nearest paper, article of clothing, et cetera, due to rush and flurry. 4. If there is time (rare when patient is unconcious), some data entry to on-board system might occur. 5. After patient is ID'd in hostital, EMS may actually get ID from EDIS/Reg system. 6. Run report written after the fact, copy turned in to ER staff.
Clay Mann presented some information about NEMSIS.
- Systems are Certified, Gold (all 433 elements), or Silver (83 required national registry elements). Standard is available on their web site.
Key standards: NEMSIS core 83 elements, HL7 ASIG, NHTSA.
Action Items: Remove ECON discussion from profile proposal, focus on Prehospital care report.
Nursing Discussion
Discussion regarding CCC and Omaha profiles. Agreed that decision should be made by professional discipline. Referred to Nursing Subcommittee. Nursing Subcommittee is new this year and is planned to be publicized within the next month.
Want to continue work from last year, deal with internal transfers of care, addressing care for important, otherwise unpaid for items:
- Surgical Infections (Important from Quality perspective)
- UTI
- Catheter, Primary Bloodstream infections
- Central Line
Standards: HL7, HAI, QRDA, CDC Definitions, Joint Commission Work
Key areas for recruiting participation: ICU, Dialysis, Oncology, Med/Surg
Focus on Core Measures
SIP Protocols
What is the document? Will need to develop Nursing summary document. Need to focus on improving Interoperability, e.g., ward/floor transfers from departmental (med/surge, ICU).
Long term goal: need to address interoperability for multiple steps of nursing process.
Antepartum Record
Little discussion. Know what we need to do, do it. Need to review SCOG work and ensure harmonization with ACOG data in APS and this year's profile, also reach out to Royal College of Obstetrics.
Attendees
| First Name | Last name | Affiliation | Nov 7th | Nov 8th |
|---|---|---|---|---|
| Keith | Boone | GE Healthcare | X | X |
| Larry | McKnight, MD | Siemens | X | X |
| Alean | Kirnak | Software Partners | X | X |
| Anna | Orlova | PHSDC | X | X |
| Anne | Diamond | ACOG | X | X |
| Clay | Mann | NEMSIS | P | P |
| Don | Jorgensen | Inpriva | X | X |
| Gail | Arnett | HIMSS Staff | X | X |
| George | Cole | Allscripts | X | X |
| Jan | Meyers | HCA Healthcare | X | X |
| Jason | Colquitt | Greenway MT | X | X |
| Landen | Bain | CDISC | X | X |
| LaVerne | Palmer | HIMSS Staff | X | X |
| Lori | Reed-Fourquet | E-Healthsign | X | X |
| Marcia | Veenstra | Eclypsis | P | P |
| Mick | Jolley | UHIN | P | P |
| Randy | Price | Loyola Emergency Medicine | X | |
| Richard | Kasama, MD | ACP representative | P | P |
| Sandy | Thames | CPH - CDC | P | P |
| Thom | Kuhn | ACP Staff | X | X |
| Todd | Rothenhaus, MD | Boston Univ School of Medicine | X | X |
| Tone | Sutherland | DigiChart | X | X |
| Virginia | Saba | CCC | P | P |
| Wendy | Scharber | CDC | P | P |