Attendee



Orders & Observations

Vancouver Working Group Meeting

September 2008

Meeting Minutes

Table of Contents

Attendees 3

Monday Q3 – OO – V2.7 6

Monday Q4 – OO/Pt Care/CDS 6

Tuesday Q1 – OO/Rx/Lab – Dynamic Model 7

Tuesday Q2 – OO 7

Tuesday Q3 – OO/Patient Safety 8

Wednesday Q1 – OO/Devices/II 9

Wednesday Q2 – OO – BTO 9

Wednesday Q3 – OO/Lab – Composite Order 9

Wednesday Q4 – OO 9

Thursday Q1 – OO/CG 11

Thursday Q2 – OO/Lab 12

Thursday Q3/Q4 – Clinical Statement 13

Friday Q1 – OO 16

Attendees

Attendee |Company/E-Mail |Mon AM |Mon PM |Tue AM |Tue PM |Wed AM |Wed PM |Thu AM |Thu PM |Fri

AM | |Rita Altamore |Rita.altamore@doh. | |√ | | | | | | | | |Madhu Bannur |Madhu.bannur@maximus.bc.ca | | | | | |√ | | | | |Phil Barr |Phil.barr@ | | |√ | | | | | | | |Calvin Beebe |cbeebe@mayo.edu | | | | | | | |√ | | |Fred Behlen |fbehlen@ | | | | |√ | | | | | | |Bmm15@ | |√ | | | | | | | | |Deborah Belcher |Deborah.belcher@ | |√ | | | | | | | | |Anita Benson |anita@ | | | |√ | | | | | | |Louise Brown |Louise.brown@ | | |√ | | |√ |√ |√ | | |Hans Buitendijk |Hans.buitendijk@ | |√ |√ | |√ |√ |√ |√ |√ | |Jim Campbell |campbell@unmc.edu | |√ | | | | | | | | |Jim Case |Jtcase@ucdavis.edu | |√ | |√ |√ |√ |√ |√ |√ | |Howard Clark |hclark@ | | | | |√ | | | | | |Lee Coller |Lee.coller@ | | |√ | | | | | | | |Kathleen Connor |kathleen.connor@ | | | | | | | | |√ | |Todd Cooper |t.cooper@ | | | | |√ | | |√ | | |Gary Cruickshank |g.cruickshank@sympatico.ca | | |√ | | | | | | | |Laurecia Dailey-Evans |Laurecia.dailey-evans@ | | | | | | |√ | | | |Dick Donker |Dick.donker@ | | | | |√ | | | | | |Robert Dunlop |Robert.dunlop@ | |√ | | | | | | | | |Jean Duteau |Jean.duteau@ | |√ | | | | | | | | |Dav A. Eide |Eide.d@ | | | | |√ | | | | | |Isobel Frean |freani@bu. | | | | | | | |√ | | |Marguerite Galloway |Galloway@ | | | | | | | |√ | | |Christof Gessner |gessner@mxdx.de | | | | |√ | | |√ | | |William Goossen |Williamtfgoossen@ | | | | | | | |√ | | |W Gregory |Gregory@ | | | |√ | | | | | | |Graham Grieve |grahame@.au | | |√ | | | | | | | |Rick Haddorff |Haddorff.richard@mayo.edu | | | | | | |√ | | | |Nick Halsey |Nick.halsey@cmca.puropa.cv | | | |√ | | | | | | |Dick Harding |dickh@.au | | |√ | |√ | | |√ | | |Ken Harvey |k.harvey@ | |√ |√ | | | | | | | |John Hatem |John.hatem@ | | |√ | | | | |√ | | |Rob Hausam |Robert.hausam@ | | | |√ | |√ |√ | | | |Rusty Henry |Rhenry@ | |√ |√ |√ |√ |√ | |√ | | |Joyce Hernandez |Joyce.hernandez@ | | | | | | |√ | | | |Stan Huff |Stan.huff@ | | | | | | |√ | | | |Nathan Hulse |Nathan.hulse@ | |√ | | | | | | | | |Julie James |Julie.james@bluewaveinformatics.co.uk | | | |√ | | | | | | |Marta Jaremek |Mart.jaremek@ | | |√ | | | |√ | | | |Amy Knopp |Knopp.amy@mayo.edu | | | | | | | |√ | | |Helmut König |Helmut.Koenig@ | | | | |√ | | |√ | | |John Koisch |John.koisch@ | | |√ | | | | | | | |Indira Konduri |Indira.konduri@fda. | | | |√ | | | | | | |Alexander Kraus |Alexander.kraus@ | | |√ | | | | | | | |Austin Kreisler |Austin.kreisler@duz1@ | | | |√ |√ |√ |√ |√ | | |Thomson Kuhn |tkuhn@ | |√ | | | | | | | | |Ben Kupronts |Bbk3@ | | |√ | | | | | | | |Ed Larsen |e.larsen@ | |√ | | | | | | | | |Joann Larson |Joann.larson@ | |√ | | | | |√ | |√ | |Dragana Lojpur |Dlojpur@infoway.ca | |√ | | | | | |√ | | |Patrick Loyd |Patrick.loyd@ | |√ |√ |√ |√ |√ | |√ | | |François Macary |Francois.macary@gmail.fr | | | | | |√ | | | | |Joginder Mada |Joginder.madra@ | | | | | | | |√ | | |?? |Marti610@ | |√ | | | | | | | | |David Markwell |david@clininfo.co.uk | | | | | | | |√ | | |Michael Martin |mmarti5@clemson.edu | |√ | | | | | | | | |Ken McCaslin |Kenneth.h.mccaslin@ | | | |√ | | |√ | | | |Clem McDonald |Clem.mcdonald@mail. | | | | | | |√ | | | |Rob McClure |rmcclure@ | | | | | | | |√ | | |Charlie Mead |Charlie.mead@ | | |√ | | | | | | | |Gary Meyer |Gary.h.meyer@ | | |√ | |√ | | | | | |Michael Miller |Michael.miller@ | | | | | | |√ | | | |Suzanne Nagami |Suzanne.nagami@ | | | | | | |√ |√ |√ | |Tom Oniki |Tom.oniki@ | | | | | | | |√ | | |Rom Pereira |Rom.pereira@maximus.bc.ca | | | | | |√ | | | | |Andrew Perry |Andrew@clininfo.co.uk | |√ | | | | | |√ | | |Vassil Peytchev |vassil@ | |√ | | | | | | | | |Yvonne Pijnacker Hordijk |Yvonne.pijnackerhordijk@tno.nl | |√ | | | | | | | | |Lisa Pinto |Lisa.pinto@ | | | | | | | |√ | | |Philip Pochon |Phil.pochon@ | | | | | | |√ | | | |Ali Rashidee |arashidee@ | | | |√ | | | | | | |Rich Rogers |rrogers@us. | | |√ | | | | | | | |Dave Rowed |drowed@.au | |√ | | | | | | | | |Eleanor Royle |Eleanor.royle@.cw | | | | | | | |√ | | |Steve Sagoid |Steve.sagodi@ | | | | | | | |√ | | |Gunther Schadow |Schadow@regenstrief.iupui.edu | | | | |√ | | | |√ | |Amnon Shabo |shabo@il. | | | | | | |√ | | | |Ioana Singureanu |Ioana.Singureanu@ | | | | | | | | |√ | |Rik Smithies |Rik@nprogram.co.uk | | | | | | | |√ | | |Tim Snyder |tim@ | | |√ | | | | | | | |Harry Solomon |Harry.Solomon@med. | | | | |√ | | | | | |Lise Stevens |stevensl@cber. | | | |√ | | | | | | |Michael Tan |tan@nictiz.nl | | |√ | | | | |√ | | |Greg Thomas |Greg.j.thomas@ | |√ |√ | |√ |√ | | | | |Sue Thompson |sthompson@ | | | | | | | |√ | | |Klaus Veil |Chair@.au | | | | | | | | |√ | |Cindy Vinion |cvinion@ | | | | | |√ | |√ | | |Geraldine Wade |gmwade@ | | | | | | | |√ | | |Grant Wood |Grant.wood@ | | | | | | |√ | | | |

Communication with declared O&O participants can be done through ord@lists.. You can sign up through the HL7 website, . List servers for focused aspects of the O&O domain are: bloodbank@lists., pharmacy@lists., microbiology@lists., lapauto@lists., and dicom@lists..

Monday Q3 – OO – V2.7

Reviewed V2.7 ballot feedback per attached spreadsheet.

[pic]

Motion to defer all A-T items to editors. Patrick, Jim Against: 0, Abstain: 1; In Favor: 6

Monday Q4 – OO/Pt Care/CDS

• We completed the ballot reconciliation of the January 2008 Common Observation Model. The reconciliation spreadsheet is attached and will be uploaded to the ballot site.

[pic]

• Additionally we discussed some of the Order Set ballot reconciliation items. CDS is reconciling them separately.

o The major concern raised is the use of the mood that is not Definition to communicate the statement of Goals and documentation of certain data when the Order Set is actually ordered.

o The confusion that this is causing is that, e.g., a Goal that is communicated in Event mood does not state that it is supposed to be collected.

o When an Order Set is communicated it is only intended to state a proposed set of orders and data to be collected when that order set is actually instantiated for a particular patient (and leave it up to the order management system how is does that, including duplicate avoidance, etc.)

o The problem is that the RIM does not appear to be clear enough on how to communicate as part of a definition the intended mood when it is actually ordered.

o Patient Care has a similar issue when it defines care plans.

o To date Patient Care has not resolved this either, other then it uses the text attribute to indicate that this is supposed to be stated (e.g., Goal) or collected (e.g., Assessment data).

o We did not reach a consensus on a resolution. Given the state of the ballot, the couple of negatives on this topic do not have to be resolved for the document to move forward. This is seen by some as a major problem.

Tuesday Q1 – OO/Rx/Lab – Dynamic Model

• John Koisch provided an overview of the direction ARB is heading to establish a Behavioral Model within which the dynamic modeling needs are being addressed.

• Behavioral Model maps to RIM. Some potential to use similar tooling, maybe, to model.

• In the Behavioral model the Exchange and Interaction concepts are “new”, but maps to what we have – Interaction to Transaction and Exchange to Interaction.

• Existing work needs to fit in to this. Particularly Implementation Guide (bottom of the stack) being dependent on the level above.

• How can we create examples? Current examples may be bound by old methods, so would not be able to take as-is, but have to progress work.

• Tool – Eclipse based tool, services focused. Business Process Model Notification another.

• Patrick, Austin, Luise, Dick will work with John, Graham, and Charlie to create an actual example based on the OO/Rx/Lab knowledge we have and the approach and modeling technique that the ARB has started to put in place. A full example would be ideal, but objective is to review progress on what worked and what did not.

• Not yet clear what level specifications will be balloted at different levels depending on the level that the industry/business case needs.

Tuesday Q2 – OO

• We reviewed and updated a number of project definitions in Project Insight.

• During the discussion the question was raised how the different projects and models tie together in a larger picture.

• The following is a cleaned-up version of the flip chart that we started to look at:

[pic]

• From that there are potential models/projects that do not yet exist (e.g., Clinical Event, Composite Clinical Event), and those where we may need to rename the projects as they are effectively more focusing on specialized templates to be used within a more general model (e.g., Common Observation Request and Blood Order are two templates to be used within the Composite Order Model to enable sending a composite order).

• The latter is particularly interesting as it may indicate that the Composite Order Model may be “enough” to enable messages, assuming that the various templates are in place, while the templates are usable across Documents, Messages, and Service.

• More discussion required to flesh this out.

Tuesday Q3 – OO/Patient Safety

• We reviewed the take on of the clinical statement model to support the Patient Safety needs for ICSR R3.

o Mead needs to work with the newly formed Clinical Statement Workgroup to reconcile changes to this portion of the model. 

o There were substantial comments about modeling derivation (Is ICSR intended to be directly derivable/mapped back to Clinical Statement?), compatibility with Clinical Statement as a core structure, participations (seemed to be issues with where/how the participations were placed in the choice box), Actions Taken (need to look at GIN), etc. – This is the primary area of concern for next release of modeling structures prior to submission to formal ballot

o Further follow-up is required to identify other areas for reconciliation.

Wednesday Q1 – OO/Devices/II

• We reviewed the diagram initiated during Tuesday Q2 and found general consensus (no vote) that this direction makes sense.

Wednesday Q2 – OO – BTO

• We reconciled the September ballot materials. The reconciliation spreadsheet is attached with the dispositions.

o Motion to accept A-T to be addressed by the editors.

▪ Against: 0; Abstain: 0; In favor: 9

o [pic]

o Motion to move forward toward DSTU. Patrick, Greg

▪ Against: 0; Abstain: 0; In Favor: 9

Wednesday Q3 – OO/Lab – Composite Order

Reviewed the Composite Order attribute level descriptions, made updates using Lab as much as possible as the starting point. During the review, the following additional notes were made.

• Need to determine defaults for context control until general approach is updated. Applies to all classes.

• Do we need sequence number in the receiver participation? Why there but not on verifier? Agreed to remove it from receiver.

• We need to change the Referrer participation from R_AssignedEntity to R_AssignedPerson to enable only persons and organizations as referrer. Note that to communicate the referrer as an organization the scoping entity is the organization and the entity is blank.

• Change of DataEnterer from ENT to TRANS needs to be done in the Pattern as well.

• Left of at Consultant.

Wednesday Q4 – OO

• We reviewed the state of implementation guides based on V2 Orders and Observation topics, whether done through OO or not:

o ELINCS

▪ Done

▪ Includes upgrades

o HITSP

▪ Done

▪ No upgrades within scope

o Orders

▪ Ken withdrew as project lead

▪ CDC’s champion is not available as stakeholder

▪ Needs to be closed.

o Implantable Devices

▪ Need to get status

▪ Started with OO, but is now part of Devices

o Clinical Genomics

▪ Working on V2 implementation guide

▪ HITSP concerned with duplicate documentation.

o PHER Electronic Laboratory Reporting to Public Health

• Objective is to keep the duplication across implementation guides to a minimum and find a construct that new topics can be easy extensions and updates to existing implementation guides.

• We would like to use the HITSP guide as the core to extend Implantable Devices and Clinical Genomics, while keeping ELINCS on a separate track with intent to move over to HITSP when ELINCS participants’ applications are ready. When the HITSP guide goes to V2.7 this merge should occur.

• All IG projects are closed.

• We need to be co-sponsor of V2 Chapter 4/7 based implementation guides to ensure we close the loop to any standards updates. Also allows updates to the base implementation guide to be addressed in the process where needed.

• Need to work with IHE to figure out who has what implementation guide in the OO space so we can determine what we should start.

o Francois will be able to provide a list of IHE profiles that are based on chapter 4 and 7.

Thursday Q1 – OO/CG

• V2 Implementation Guide project

o Goals

1. Consistency between implementation guidance

2. Ability to quickly respond to prototype progress

3. Extend into global?

• Initially US and then later global

4. There are multiple genomics models to support in parallel

5. Other??

o Approaches

1. Separate guides on independent tracks

• Independent ballot cycle with a lot of duplication

• Not seen as desirable

2. One guide with appropriate extensions (chapter/addendum)

• A single ballot cycle that would create too many dependencies

3. Hybrid: separate drafts with one normative

• Normative ballot cycle remains intertwined while the draft/prototype

4. CG guide(s) references to the common sections

• Enables independent ballot cycle while reducing redundant efforts.

• Need to keep up with version changes on the base

o Consider micro to follow a similar path

o Motion: Development of V2 implementation guides through the CG WG follow a process whereby independent implementation guides be developed for CG topics. When those guides follow the then current HL7 Interoperable Result IG, (for the US Realm) are already published that these CG implementation guides explicitily reference materials that are to be used as-is. Phil, Clem

▪ Concern that this is not collaborative between CG and OO.

• Add: In collaboration with OO to address most appropriate use of V2 (particularly chapters 4 and 7) in the CG space and facilitate any enhancements necessary to the base V2 standard.

o Friendly amendment accepted. Understanding that materials are shared between the CG and OO serve lists.

Updated Motion: Development of V2 implementation guides through the CG WG follow a process whereby independent implementation guides be developed for CG topics. When these guides follow the then current HL7 Interoperable Result IG, (for the US Realm) that these CG implementation guides explicitly reference materials that are to be used as-is. CG will collaborate with OO to address most appropriate use of V2 (particularly chapters 4 and 7) in the CG space and facilitate any enhancements necessary to the base V2 standard. Phil, Clem

Conditional vote pending feedback in joint session between CG and OO with Molly present to ratify. If she does not have a problem, this will be accepted.

Against: 0; Abstain: 4, In Favor: 15.

• V2 topics

o It is acceptable that CG and LOINC work out panels definitions that maintain structure that are external to the V2 message but are used to interpret the results coming across. That is not counter to the standard.

o Amnon has a concern with current OBR/OBX organization in DNA Marker, Coverage Panel, etc. space. Need to provide the alternative to determine whether it can be.

▪ This message though is only stating what is done, not what is intended to be done.

• Specimen Material & Anatomic Location

o Work in progress on specimen type that is richer and more appropriate for CG.

o It is no problem to use that instead of Table 487.

o At some point we could consider dropping maintenance of Table 487.

Thursday Q2 – OO/Lab

• Logistics

o Will start with joint conference calls and meetings and then determine in January how to overall move with WG structure.

o Conference Calls

▪ Suggestion is 1-2 ED/ST every Thursday, starting Oct 1. Austin will invoke a “doodle.ch” to validate.

o WGM sessions

▪ See proposed agenda attached indicating joint sessions.

• Composite Order

o See updates in Visio model.

o The structure allows for the three specimen/container/order constructs in V2. Lab needs to provide language how to achieve each in V3.

o Context Control Code for Destination and Product2 needs to be added to the pattern.

o Need to harmonize the substitution approach that Rx uses vs. Composite Order

o Need to harmonize the consumable2 with Rx.

o The DirectTarget on Medication is too generic to understand its purpose. We either need the clarification or remove it.

o CallBackContact.time should be looked to determine whether it should be GTS to enable multiple time intervals to be specified. That’s a RIM problem requiring a harmonization request.

[pic][pic]

Thursday Q3/Q4 – Clinical Statement

This is the last time the Clinical Statement minutes will appear in the OO minutes.

o Agenda

• New Workgroup Status

▪ Co-chair elected (3) – will ask through Clinical Statement list, one of the three expected to be minute taker

▪ Modeling Facilitator, Vocab Facilitator, Project Facilitator

▪ Pt Care and OO will not meet Thursday Q3/Q4, Struc Doc and PHER will split with co-chair present.

▪ Conference calls as needed with 2 week notice.

▪ Need a decision making document review, particularly quorum. See document attached which will be voted on during the first conference call after the September 2008 WGM.

• Mission/Charter

▪ Revisit in January 2009 based on draft from a couple of folks (Hans, Todd, Isobel, Calvin, Patrick, Rik)

• Project Statement

▪ Current statement:

• The Clinical Statement project intends to provide a pattern that can be used by various domains in some form of specialization and constrained, that enables consistency across domains in the area of clinical statements.

While we want to ensure that clinical statements involving such information as Pharmacy, Laboratory, and Allergies, the objective is not to express the very detailed operational modeling that is required to support these domain's specific message requirements. Rather it is more focused on the general clinical statement aspects when used as context in other messages or 'summary' documentation. As this is a fine line, and consistency is required, the primary TCs participating in this effort, and their associated SIGs, are constantly balancing the need for general patterns and highly specialized/constraint models.

▪ Will close current project.

▪ Need relationship with other WGs better defined.

▪ New project definition needed at least to formally incorporate most current model into the DSTU or Normative

▪ CDA Release 3 is planning to go to normative with most current Clin Statement that is in place Sept 2009.

▪ Motion to go into Normative ballot round with May 2009 ballot cycle. Dave, William.

• Rx still needs to submit change requests did not include yet.

• Model needs to be updated.

• Against: 0; Abstain: 7; In Favor: 20

▪ New Project Statement

• Name: Clinical Statement Pattern goes Normative

• Description: The objective of the “Clinical Statement goes Normative” project is to move the current Clinical Statement DSTU to a Normative state including any change requests submitted through the January 2009 WGM. This will enable:

o CDA Release 3 to take the most current Clinical Statement into their normative cycle with a high degree of stability

o Other workgroups to reference, harmonize, and synchronize with a normative pattern in those clinical areas as agreed to between the Clinical Statement workgroup and those workgroups.

• Objectives: Provide a Clinical Statement model that can be used by other domains to establish a common and consistent model to express clinical statement data regardless of the domain or communication method.

• Deliverables:

o Clinical Statement Pattern including attribute level descriptions.

o Guidelines on how to use the pattern in the respective domains. (if time permits)

o Current set of CMETs (no additional)

• Dependencies: Submission of change requests in a timely fashion by affected workgroups.

• Supporting WGs: Clinical Statement, Pt Care, OO, Struc Doc, PHER, Rx

• Approach:

o Ensure we understand exactly what the format of the Clinical Statement should be to be normative and adjust the model accordingly using change request process.

o All workgroups will be invited and urged to submit any change requests through the Clinical Statement wiki page. Conference calls and the January 2009 WGM will be used to reconcile and dispose of those requests. Any change requests after the Clinical Statement meeting in January 2009 (Thursday Q3/Q4) will be considered out-of-scope.

• Move: Patrick, William. Against: 0; Abstain: 4; In Favor: 20.

• Quorum

▪ Motion to consider quorum 1 co-chair + 4 people present. Patrick, Andrew.

• Against: 0; Abstain: 3; In Favor: 24

• Process on how to manage conformance, extensions and documentation thereof

▪ Postponed to Q4

• Harmonize Medication/Prescription and address Canadian Medication Information

▪ Rx has not passed normative yet.

▪ How far do we want to be able to go that the Med DMIM can be unrolled from the Clinical Statement?

• While financial is clear, within clinical still some questions.

• Clin Statement unrolled should mostly cover Med DMIM but is not possible to completely cover. It depends on the knowledge in play, e.g., reference knowledge (not) vs. patient instance (yes). So case-by-case.

o In patient record?

o Same across jurisdictions?

o Etc.

• Workgroup should be active in resolving where there are questions.

▪ Need to continue to harmonize Rx and OO and Lab vs. Clin Statement.

• Attribute Level Descriptions (30 minutes timeboxed)

▪ From the properties in Visio we need to get the following before we can go normative:

• Description Must

• Rationale Maybe

• Implementation Notes Maybe

• Design Comments Maybe

• Issues Maybe

• History Maybe

• Mapping (within HL7) Maybe

• Business Name Maybe

▪ Patrick following up with Publishing to enable automatic pulling from RIM where these should not change.

▪ Austin can help with Public Health related definitions. Andrew and Patrick can jump in as well. Rik will help pull together.

▪ Getting schemas out of HL7 is quite difficult. We may be achieve this better by changing our bi-directional relationship to a pair of one way relationships.

• CMETs

▪ Patrick and Charlie to assess current state on what is needed to get CMETs in sync with most current pattern

• Clin Statement + Clin Genomics

▪ Not discussed.

Friday Q1 – OO

• We continued ballot reconciliation until we were below quorum.

• The spreadsheet attached to the Monday Q3 section reflects all reconciliations through Friday Q1.[pic][pic][pic][pic][pic][pic]

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RIM

“Non-Clinical” Pattern

Care Record

Model

CP Request/Promise Template

CP Query Template

Allergy & Intolerance Template

Care Plan Template

Assessment Scale Template

Etc.

Care Provision DMIM

Services

Documents

Messages

Composite

Clinical Event

Model

Clinical Event Pattern

Common Obsv Event Template

Lab Result Template

Rx Administration Template

Blood Donation Template

Blood Transfusion Template

Assessment Template

Etc.

Common Obsv Request Template

Lab Order Template

Rx Prescription Template

DI Order Template

Blood Order Template

Infusion Order Template

Etc.

Composite

Order

Model

Orders & Request Pattern

Clinical Statement Pattern

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