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Orders & Observations
San Antonio Working Group Meeting
January 2008
Meeting Minutes
Table of Contents
ATTENDEES...............................................................................................................................................................3
MONDAY Q1, TUESDAY Q3, FRIDAY Q1 – OO – V3 BALLOT RECONCILIATION................................10
MONDAY, Q2 – OO/PT CARE/PHER/PT SAFETY/RX.....................................................................................11
EXPOSURE REPORT...................................................................................................................................................11SUBSTANCE ADMINISTRATION.................................................................................................................................11IMMUNIZATION.........................................................................................................................................................12
MONDAY Q3 – V2.7 PROPOSALS........................................................................................................................13
SPECIMEN SHIPMENT................................................................................................................................................13PROPOSAL 492 - MAKE OBX-8 CWE.....................................................................................................................13PROPOSAL NN - PHARMACY ORDER TYPE..............................................................................................................13
MONDAY Q3 – OO/PT CARE/CDS.......................................................................................................................14
ORDER SET BALLOT RECONCILIATION....................................................................................................................14
TUESDAY Q1 – OO/RX/LAB..................................................................................................................................15
TUESDAY Q2 – OO/RX/LAB – DYNAMIC MODEL..........................................................................................17
TUESDAY Q3 – OO/PT SAFETY/BTO/PHER/RX..............................................................................................18
IMMUNIZATION.........................................................................................................................................................18
WEDNESDAY Q1 – IMPLEMENTATION GUIDE.............................................................................................20
WEDNESDAY Q2.....................................................................................................................................................21
THURSDAY Q1 – GENOMICS...............................................................................................................................22
PEDIGREE.................................................................................................................................................................22GENOTYPE................................................................................................................................................................22
THURSDAY Q3/Q4 - CLINICAL STATEMENT.................................................................................................23
CHANGE REQUEST....................................................................................................................................................23OVERALL DIRECTION INCLUDING:............................................................................................................................23
Topics/Common fragments - Larry McKnight.....................................................................................................23T3F related discussion on content of Clinical Statement material......................................................................24CEN 13606 harmonisation - Charlie McCay......................................................................................................24
DUPLICATED TARGETOF/SOURCEOF RELATIONSHIPS - KEITH................................................................................24BALLOT RECONCILIATION........................................................................................................................................24
Friday Q1 – V3 Ballot Reconciliation.........................................................................................................................25
Attendees
Attendee Company/E-Mail Mon
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Mon
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Tue AM
Tue PM
Wed
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Wed
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Thu AM
Thu PM
Fri
Rett Addy Rett.addy@accenx.comFarhan Ahmad farhan@epicsystems.com √ √Rita Altamore Rita.altamore@doh.wa.gov √Kay Avant avantk@uthscsa.edu √Fred Behlen fbehlen@laitek.com √Chad Bennett cbennett@ifmc.org √Bernd Blobel √Scott Bolte Scott.bolte@ge.com √Keith Boone Keith.boone@ge.com √Bill Braithwaite bill@braithwaite.com √ √Louise Brown Louise.brown@gpinformatics.c
om√
Sabine Brosch Sabine.brosch@emea.europa.eu
√
Hans Buitendijk Hans.buitendijk@siemens.com √ √ √ √ √ √ √ √Jim Case Jtcase@ucdavis.edu √ √Howard Clark How_clark@nema.org √Lee Coller Lee.coller@oracle.com √Todd Cooper t.cooper@ieee.org √ √Garry Cruickshank
g.cruickshank@sympatico.ca √ √
Karen Cuthbert Karen.cuthbert@bms.com √Pat Distler Pat.distler@iccbba.org √ √Richard Dixon-Hughes
Richard@dhx.com.au √
Bob Dolin Robert.h.dolin@kp.org √Dick Donker Dick.donker@philips.com √Gina Dube Gina_dube@firstdatabank.com √Robert Dunlop Robert.dunlop@infermed.com √Jean-Henri Duteau jhad@shaw.ca √ √Kristi Eckerson Kee8@cdc.gov √ √Anita Feeley anita@blackstonebay.com √Jamie Ferguson Jamie.ferguson@kp.org √Jim Foss jimfoss@stellarsystems.com √Woordrow Gandy wgandy@tsystem.com √Laura Gibson Laura.gibson@wolterskluwer.co
m√
Hugh Glover Hugh_glover@bluewaveinformatics.co.uk
√
Peter Goldschmidt
pgg@has.com √
William Goossen Williamtfgoossen@cs.com √ √Grahame Grieve graheme@ketral.com.au √Rick Haddorff Haddorff.richard@may.edu √Rob Hallowell Robert.hallowell@siemens.com √Peter Haug Peter.haug@imail.org √Dick Harding Dickh@bigpond.net.au √ √Anja van Haren a.v.haren@cbg-meb.nl √
Attendee Company/E-Mail Mon
AM
Mon
PM
Tue AM
Tue PM
Wed
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Wed
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Thu AM
Thu PM
Fri
John Hatem John.hatem@oracle.com √ √ √Peter Haug Peter.haug@intermountainmail
.org√
Rob Hausam Robert.hausam@theradoc.com √Peter Hendler peter@javamedical.com √Rusty Henry rhenry@cerner.com √ √ √ √ √ √ √Yan Heras Yan.heras@ihc.com √Julie James Julie_james@bluewaveinformati
cs.co.uk√
Marta Jaremek Mart.jaremek@siemens.com √ √Gaby Jewell gjewell@cerner.com √Dave Johnson David.johnson@guidant.com √Mike Jolley mjolley@uhin.com √Tom de Jong Hl7@tdejong.demon.nl √ √Reina Kalish Reina_kalish@baxter.com √Dan Kempf dkempf@epicsystems.com √ √Jürgen Kerstna jkerstna@sjm.com √Gert Koelewijn koelewijn@nictiz.nl √Astrid Koenders a.koenders@mca.nl √ √ √ √ √ √ √Helmut König Helmut.Koenig@siemens.com √Austin Kreisler Austin.kreisler@duz1@cdc.gov √ √ √ √ √ √John Kufuor-Boakye
kufuor@telusplanet.net √ √
Joann Larson Joann.larson@kp.org √ √Ed Larsen e.larsen@ic.netcom.com √ √Kip LeCrone klecorne@e-mds.com √Carolyn Logan Carolyn.b.logan@questdiagnos
tics.com√ √
Patrick Loyd Patrick.loyd@gpinformatics.com
√ √ √ √ √ √ √
Cecil Lynch clynch@ontoreason.com √David Markwell david@clininfo.co.uk √Susan Matney Susan.matney@siemens.com √Koichiro Matsumoto
Koichiro_matsumoto@mb1.nkc.co.jp
√
Ken McCaslin Kenneth.h.mccaslin@questdiagnostics.com
√ √
Barbara McKinnon Bm.n15e@comcast.net √Larry McKnight Lawrence.mcknight@siemens.c
om√
Tim McNeil tmcneil@rxhub.net √Mukesh Mehta Mukesh.mehta@thomson.com √Gary Meyer Gary.h.meyer@cardinalnodt.co
m√ √
Linda Mook mook@nictiz.nl √Matthew Moores Matthew.moores@oracle.com √Suzanne Nagami Suzanne.e.nagami@kp.org √ √ √ √Elise Neill Elise_neill@allscripts.org √Masaharu Obayashi
obayashi@kthree.co.jp √
Frank Oemig Frank.oemig@afga.com √ √Tom Oniki Tom.onik@intermountain.mail. √
Attendee Company/E-Mail Mon
AM
Mon
PM
Tue AM
Tue PM
Wed
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Wed
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Thu AM
Thu PM
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orgMadeline Palla mpalla@ahi.org √Andrew Perry Andrew@clinical-info.co.uk √ √Vassil Peytchev vassl@epicsystems.com √Yvonne Pijnacker Hordijk
Yvonne.pijnackerhordijk@tno.nl √
Philip Pochon Phil.pochon@covance.com √Andrea Poteat Andrea_poteat@baxter.com √Doug Pratt Doug.pratt@siemens.com √Ali Rashidee arashidee@quantros.com √Melvin Reynolds melinvr@ams-consulting.co.uk √ √John Roberts John.a.roberts@state.tn.us √Scott Robertson Scott.m.robertson@kp.org √Craig Robinson Craig.robinson@siemens.com √June Rosploch June.rosploch@kp.org √Carlo Roxas Carlo.m.roxas@kp.org √Dan Russler Dan.russler@oracle.com √Tod Ryal tryal@cerner.com √ √Rob Savage savagrb@dhfs.state.wi.us √Gunther Schadow Schadow@regenstrief.iupui.ed
u√ √ √ √
Paul Schluter Paul.schluter@med.ge.com √Peter Schwarz Schwarz@amaden.ibm.com √Amnon Shabo shabo@il.ibm.com √Rik Smithies Rik@nprogram.co.uk √Harry Solomon Harry.Solomon@med.ge.com √Nicholas Steblay Nicholas.stabley@guidant.com √Steve Steindel Sns6c@cdc.gov √Lise Stevens stevensl@cber.fda.gov √Walter Sujansky wsujanksy@sujansky.com √Heather Sutcliffe Heather_sutcliffe@hc.sc.gc.ca √Michael Tan tan@nictiz.nl √ √ √Greg Thomas Greg.j.thomas@kp.org √ √ √ √ √ √ √ √ √Ian Townend Ian.townend@nhs.net √Daniel Vreem dvreeman@regenstrief.org √Perry Vonk Perry.vonk@health.goo.sk.ca √Steve Wagner Steve.wagner@va.gov √Scott Whyte Scott.whyte@chw.edu √Grant Wood Grant.wood@intermountainmai
l.org√
Ning Zhuo Ning.zhuo@ihc.com √
Communication with declared O&O participants can be done through ord@lists.hl7.org. You can sign up through the HL7 website, www.hl7.org. List servers for focused aspects of the O&O domain are: bloodbank@lists.hl7.org, pharmacy@lists.hl7.org, microbiology@lists.hl7.org, lapauto@lists.hl7.org, and dicom@lists.hl7.org.
Monday Q1/Q2 – OO – ELINCS Implementation GuideAttached are the slides we stepped through to review key issues raised during the ELINCS IG guide ballot process.
Monday Q3 – OO – Clinical Decision Support
Decision support TC presentation by Robert Dunlop and BarbaraMcKinnon. Topics: Virtual Medical Record (vMR) and GELLO.
Project 1: vMR
vMR is a term which people came to know over the past decade and they try to find it but do not find it posted storyboards to list and got feedback imortant secondary output would be to standardize CDS specific data as well as the vMR content (because
they specify output). Discussed with many committees, including
o Clinical genomicso ARB
While many interesting discussions have happened, the group is currently not quite clear view as for who to use for the modeling
It was suggested that Orders&Obs and Patient Care should be the partners to work with. The Clinical Statement group was also discussed, and it was understood that the vMR is related to the clinical statement. However, detail technical discussion and understanding should be sought in the committee first and then any new requirements for changes moved to the clinical statement group as concrete proposals if that would be necessary.
o patient care had "asked" for a get together with the co-chairs on the modeling
Timeline:
2008Q2 Gap analysis 2009 Q1 issue CDS recommendation on a vMR model 2009 Q2 test recommendation with @neurIST and Cocoon/RIGHT projects in Europe 2009 late: issue implementation guide.
Questions:
how to model pro/con argumentation structures from recommendation. Some questions exist on the idea of a "state file", a record of all data and decisions that the clinical decision
support (CDS) system would consider for its recommendations. This is more than just an audit log:o this would contain data which the CDS system had been requesting of users (via forms)o also contains the state of the guideline
challenges are how to update interpretations on data where the changing body of knowledge yields more information.
The first question was most concrete and taken up. Pro/con argument structures would be modeled with ActRelationships for which new ActRelationship type codes would likely need to be proposed. Thestructure would have (for example)
SubstanceAdministrationmoodCode = RECOMMENDATION- Participation typeCode = CONSUMABLE - Role..Entity code = "HMG CoA Reductase Inhibitor"
- ActRelationship typeCode = REASON - Observation moodCode = EVENT code = medical problem value = "Hyperlipidemia"- ActRelationship typeCode = PRO-ARGUMENT - Observation moodCode = GOAL (?) code = life span ???? value = extended ????- ActRelationship typeCode = CONTRA-ARGUMENT - Observation moodCode = RISK code = medical problem value = "Rhabdomyolysis" - ... potential links to literature evidence, and personal genomics data....
For pro-argument we have considered the objective (final and continuing) act relationships but determined they would be for different purposes. The DSTC representatives were very familiar with the constructs in the RIM. So a preliminary agreement on the above model was easy to achieve.
Project 2: GELLO
moving GELLO forward passed in 2005 has not been widely implemented some companies IBM, MedReach, others have worked with it some problems had been found in the GELLO syntax seeking to revise and submit for DSTU ballot would often be implemented by mapping, e.g., to SQL important that it's aligned to the HL7 v3 RIM
2007-2008 Q1 worked on the issues and solutions
issues encountered hl7's TC position maintaining alignment with OCL
2008 Q3 ballot
Questions:
can operations be specified within HL7 retain operations in Syntax?
store operations in separate reference library?
moving towards reconciliation with OCL
Proposed that much of that OCL discussion should be had with the INM committee (especially Grahame Grieve) so that O&O may just need to be updated every once in a while without this being the place for deep discussions about the technical details.
Tuesday Q1/Q2 – OO/Rx/Lab – Dynamic Model
Should we do anything here?If so, how do we proceed?
Goals Overall Model Synchronize Guidelines
Activities in Progress:1. MnM and SOA is getting together.2. ARB has Dynamic Model on the plate3. We may be premature
Agenda:1. What are we trying to achieve with a Dynamic Model2. Need to capture what we have done to date.3. Define what we expect from ARB/MnM.4. Guidelines
What are we trying to achieve with Dynamic Model? Get to a framework to determine what data is sent when, and who is responsible for what. Establish interaction patterns to enable that framework to be constructed
o Canada created pan-Canadian patterns that the jurisdictions can then be tailor to their needs.o A profile contains Identification, Transactions Supported, Interactions Supported, and Story Board in
table form.o A couple hundred profiles.o Described from the perspective of one role, rather then a pair, e.g., a Patient Health Condition
Repository vs a Lab system. Almost application roles, but not quite at same level of granularity. Canada has no immediate need to be at same level of granularity, but everybody expressed a
desire to be at the same level.o At Jurisdictional project level is where further details is worked.o While there was no specific pattern definition, could be re-engineered.o Louise Brown willing to volunteer to create a set of patterns. Would be a subset of what HL7 may
be interested in. Create guidelines on how to drill down from high-level to detail and/or how to build patterns
together.o Canada did not drill down.o Add optional behaviors to Canadian model to further validate how it ties together.o Eliminating optionality along the way.o Lab’s approach/focus on building blocks very similar.
Should we have a One Role, or Multi-Role interaction perspective?o One Role was easier to communicate with, e.g., EHR provide, what their responsibilities are.o Multi-Role establishes the full pattern. Deriving a set of patterns from the building blocks available
now would show this aspect.o
What are we looking at ARB/MnM for:
How to document patterns? How to document building blocks? What tooling? How do we get the (business) transaction concept demonstrated by Canada into HL7 approach? Should it? Should we restrict V3 trigger events to real-world events, since interactions could handle this?
o Initial response is not. SOA is thinking of using CDL tooling, but has not been engaged with our discussions. Ask ARB to
coordinate across groups to ensure everybody is involved. What artifact to use to document requirements and link HL7 stakeholder requirements to what we do?
Guidelines Focus on building blocks and general patterns. ??Do we need to allow for multiple levels of transactions or are then storyboards enough?? Canadian transaction appears to have 1 V2 trigger event but can have multiple V3 trigger events. Customers do not see interactions, rather then transactions.
V3 Ballot Reconciliation
Order Pattern & Composite OrderMotion: All A-Ts dealt with by editor as appropriate. Patrick, Craig.Against: 0; Abstain: 1; In Favor: 18
Observation RequestMotion: All A-Ts dealt with by editor as appropriate. Patrick, Greg.Against: 0; Abstain: 1; In Favor: 5
Tuesday Q3 – OO/Rx/Pt Safety/PHER
Agenda: BTO SPL Immunization
o Overviewo Rel with Med Modelo Ballot Reconciliation (Partial)
BTO Diana could not be here. Ballot reconciliation starting tomorrow, but not enough authors/domain experts available to complete. Question out as to what we want to do next. If we want to move faster, then need volunteers. Storyboards being filled out
SPL Patrick provided overview of SPL. Currently Release 4 ballot All regulated products are now in scope, not just medication. That creates harmonization challenges with
medications to keep synced, as well as that Medication is also considered for removal.o While there are no attribute differences, there are domain differences.o ISCR dealt with product generically already. o Needs further discussion.
After ballot opened, already started making updates to address key issues. Concern with ActDefinition (top right) that code is CWE bound to ActCode. Does not follow HL7
practice. Agreed to change. MarketingAct and Highlight not modeled correctly. Will be fixed. Intent to deprecate use of lot number. Question is that a lot number is an identifier of an instance vs. an
attribute/reference of another. Could also look at it as a production cycle that generated this, in which case a lot number is an identifier of an act. For now we will keep this as a known topic where there are two ways to solve the problem, both valid with pros/cons.
Another challenge with the II data type for ProductInstance id. Need to confirm whether we need the root to make it unique.
Member on ProductInstance and DeviceInstance is not sibling focuses. Concerned that kinds and instances are mixed. Change DeviceInstance ID to mandatory.
Immunization Annotation Indicator: discussion on whether a code is needed. Consider using Annotation Put class code into Annotation (CMET). Gunther, Patrick. Subtype of Act. Against: 0; Abstain: 0; In
Favor: 40
Tuesday Q4 – OO – V2.7 Proposals
See document attached for cumulative set of proposals reviewed. During the San Antonio session we reviewed Proposals 505 onwards.
Wednesday Q1 – OO – Implantable Devices
Progressing with nomenclature development Expect in May to have final approval from HRS and then move into ballot IEE Initial focus V2 message Start after May with IHE to develop V2 profile. In parallel re-start V3
Problem with null flavor on observation value OBX.5
Wednesday Q2 – OO – BTOMotion: Patrick/Greg – All A-Ts will be addressed by the editor as appropriate, and brought back to committee if in doubt. Against: 0; Abstain: 0; In Favor: 5
II
Work in progress Discussion document in discussion. CDA – IG for conversion of DICOM SR to CDA documentation on way to working group 6. High
probability for comment (DICOM) and ballot (HL7) next.
Next topics: Alignment of Order accession numbers and patient identifiers between DICOM and HL7. Mostly addition
of fields in DICOM to harmonization.
Observation Request Walkthrough for Radiology Why is interpretationCode in Observation Request Performer – Not obvious from the model that it is the requested performer. Consultant – Not obvious from the model that it is the requested consultant. Location – Not obvious from the model that it is the requested location or the performed location. methodCode – Question whether it covers approach site (use case from Japan) Not likely able to get interventional Radiology, which would need a separate RMIM for Procedure Request
(with all the necessary substance administration, etc. topics). However, how do we cover requested use of contrast? May not need that much detail to require all the
additions. Will ask ACR/NEMA to come up with the messiest example or two to see whether it indeed holds, but
initial take is that Obsv Request for diagnostic radiology should work.
Thursday Q1 – OO – Clinical Genomics
Clinical Genomic Overview Variation data in ballot Expression data in the future. When we have more experience with topics, will re-create the DMIM and replace the DSTU. Will need
phenotypes, but may not need proteomics. RCRIM using Clin Genomics as well, so after topics and RCRIM stabilize. Should consider that family history should be a separate model Phenotype expected to be available as CMET as well as part of overall model. Locus and Loci intended to be deprecated. Family history .
Version 2.7o Coding system references are not standard, e.g., SNOMED. Not structural, o Need to ensure that V2 approach considers V2.5.1 (in light of HITSP/CCHIT direction) and V2.7
proposals. Clin Genomics + Clin Statement + Lab
Too early to incorporate materials now. Wait for September Ballot Cycle materials before discussion should start.
Would be helpful if in May ballot cycle we would have at least bare-bones CMET with a choice box that can be extended later. Otherwise Lab is moving from Committee to Membership. This approach can be applied to RCRIM as well.
Differential Diagnosis Specimen Derivation
Thursday Q3/Q4 – OO/Pt Care/Struc Doc/PHER
o Where are we?o What’s Next?o Change Requestso Clinical Statement CMETso Topic Model Approach
What’s next:o Incorporation of Clin Statements into CDA (2010)o Harmonize Clin Statement and Medication/Prescriptiono Clin Statement + Clin Genomicso Next ballot round not expected earlier then 1 year from last round (after Sept 2008 WGM).o Process on how to manage extensions/documentation thereof/etc.
Change RequestCR-71Motion to accept as proposed. Austin, William. Against: 0; Abstain: 9; In Favor: 20.
CR-72 - Withdrawn
CR -73Motion to accept. Austin, Dick. Against: 0; Abstain: 10; In Favor: 19
CR-74Concern with extensions and need use cases when to use what.As part of DSTU process further learn how to delineate.Motion to accept with use documentation to be provided. Austin, Dave. Against: 0; Abstain: 11: In Favor: 17
CR-75Motion to accept. Austin, Patrick. Against: 0; Abstain: 16; In Favor: 13
CR-76Withdraw substitution of R_Subject from ProviderOrPatientOrRelated. Keep PatientOrRelatedOrSpecimen.
Motion to swap. Austin, Patrick. Suggestion to go to the additive option requiring an inner choice box. Easier to describe what’s Public Health. Concern that other committees will not be considered conformant once in place.
Against: 3; Abstain: 14; In Favor: 11
CR-77 see wiki
CR-78 see wiki
Model Topics Keep it in sync
o Manualo Automated – If committees add RMIM content then automatic added to Clin Statement. Can’t quite
take on everything though. Patient Care uses Care Statement that is constrained from Clin Statement. IHE has an implementation of care record as well with three parties implementing. Keep DSTU as is to facilitate development streams without constant change. Challenge how we can reduce effort. Do we really need to be perfect to be the same? Apply and learn? Recreate chart. How do we provide guidance to somebody who wants to use Clin Statement and then communicate, e.g., a
Micro correctly and synchronous with the Lab’s suggestion on how to send Micro.
Motion: When using CS and the topic at hand already exist in a CS-harmonized domain, then they should implement it according to that domain. This statement should appear in CS and referenced by every committee’s ballot that uses CS. Bob, William. Once adopted, should be moved towards ARB to further endorse and consider as part of the “checklist” project. Against: 1; Abstain: 5; In Favor: 16.
Clin Statement CMETs CMETs are out-of-sync with balloted materials. CMET should be in sync with what we have. Patrick to work with Charlie (Rik to contact) to update with target for May. Related note that we don’t have CMET descriptions that go down to the attribute level.
o Keith will attempt to get both care record and CS statements of truth to then see how much can be copied automatically.
1 Conference Call end of January and then as-needed.
V2.7 Friday
Table 0070 in OBR-15. Move to add table reference into the attribute table both in chapter 4 (4.5.3) and 7 (7.41.). Bill, Greg. Against: 0, Abstain: 0; In Favor: 6.
Motion to change 7.4.3.4 from CWE to CNE (HL7 Defined). Greg, Bill. Against: 0; Abstain: 1; In Favor: 4
Prefer that EVN is removed from others rather then adding it to QBP-Q11. Chapter 5 should have final decision. OO is flexible to add it in if requested. Frank, Bernd. Against: 0; Abstain: 1; In Favor: 4
Change in 0487 AUTOC, DRN, GRAFT ATTE Environmental, Attest AUTOA Environmental, Autoclave Ampule Remove 2 of 3 drains and keep one. GRAFTS Graft Site
Motion: Greg, Bill. Against: 0; Abstain: 0; In Favor: 5
Agreed to fix NP, NOSE, PAROT, THORA, UMBL to avoid duplicate codes for 0550. Frank, Bernd. Against: 0; Abstain: 0; In Favor: 5
Motion to deprecate Waveform sections 7.14 – 7.17. Frank, Bernd. Against: 0; Abstain: 0; In Favor: 5.
Motion to request ARB what to do in V2.x when an attribute is deprecated, while the table is still in use by other fields and where the table continues to evolve over time. How do we “freeze” the content for that field at time of deprecation OR accept that new values could be used. Needs to be addressed across the standard. This is also applicable to data types, data lengths, and message structures. Motion. Frank, Greg. Against: 0; Abstain: 0; In Favor: 5.
Section Comment Status
4.13.14: vinserted [{NTE}] after RXE to be in sync with 4.13.64.13.6 is the master message definition. It seems that the change hasn't been applied to all occurrences.
EDITORIAL FIX.
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