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HL7 Clinical Quality Information January 2018, New Orleans, LA, USAWGM Minutes

Attendance: Note – The attendance log presented addresses attendance at sessions during which CQI met as the host. For attendance at any quarters during which CQI was hosted by other Workgroups, please see the minutes and schedule of those other workgroups. Note also, the planned Tuesday Q4 and Thursday Q1 sessions were cancelled during the WG meeting.

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Name Company Email Q1Q2

Q3Q4 Q1

Q2 Q4 Q1

Q2

Abdulmausk Shaker HI3 Solutions [email protected] Alex Liu EPIC [email protected] Amnon Shabo (Shvo) Philips [email protected] Andrew Gordon Wolterskluwer [email protected] x Andrew Simms Cognitive Medical

[email protected] x

Angela Flanagan Lantana [email protected] x x x x x x XAnn Phillips NCQA [email protected] Anne Marie Smith NCQA [email protected] x x x x x x XAruind Jagnathar Lantana Consulting Group [email protected] Athla Farkas Canada Health Infoway [email protected] X XAvinash Shanbhag ONC [email protected] Bar Van Den Heurth Philips [email protected] X X x x xBecky Kuhl Lantana Consulting Group Brian Alper EBSCO [email protected] X xBrett Marquard River Rock [email protected] xBruce Bray University of Utah [email protected] X X

Bryn Rhodes Database Consulting Group [email protected] x x x X X x

Byounct-Kee Yi Samsung Med Center [email protected] xCarsten Quinlan Epic [email protected] x x x x x x xChris Hills IPO [email protected] xChris Melo Philips [email protected] Chris Peck Cognitive Medical

[email protected]

Christian Knapp Furone [email protected] Claude Nanjo Cognitive Medical [email protected]

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mailto:[email protected]








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SystemsClaudia Hall Mathematica [email protected] Craig Parker Intermountain Healthcare [email protected] Crystal Kallen Lantana Consulting Group [email protected] Dan Morford BZ/VA [email protected] xDaryl Chertroff HLN Consulting [email protected] x XDave Carson VHA [email protected] X David Parker Defined IT / DoD / VA [email protected] xDavid Sundaram-Stukel Epic [email protected] x

X x

X

Dennis Patterson Cerner [email protected] Dennis Polling Philips [email protected] Doug Martin Regenstrief [email protected] Egge Clive Ahdis-HL7 Switzerland Clive.egge@alonich x

Emory FryCognitive Medical Systems [email protected]

Eric Larson CDC / AIRA [email protected] Eric Nystrom Lantana Consulting Group Floyd Eisenberg iParsimony [email protected] x x x x x x XFrancis Macary PHAST [email protected] Gay Dolin IMO [email protected] Genny Luensman CDC / NIOSH [email protected] x XGreg Linden Linden Tech Advisors [email protected] xGuilherme Del Flol University of Utah [email protected] x XHanhong Lu Epic [email protected] XHans Buitendyk Cerner [email protected] xHoward Strasberg Wolterskluwer [email protected] x x xIL Koh Kim KNU Korea [email protected] Isaac Vetter EPIC [email protected] Isabel Gibaud HL7-France [email protected] xJacee Robison 3M [email protected] xJack Wallace GTRI [email protected] xJames Agnerus UHN james@[email protected] Jamie Lehner PCPI [email protected]

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mailto:Clive.egge@alonich





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Jamie Parker ESAC [email protected] xJames Agnean Smile CDR [email protected] xJared Nichols Wolterskluwer [email protected] Jeff Danford Allscripts [email protected]

Jerry Goodnough Cognitive Medical Systems [email protected] x x

Jennifer Brush ESAC [email protected] Jessica Strzesak RSNA [email protected] Jim Harrison CAP/UVA [email protected] xJoe Quinn Optum [email protected] John Loonsk CGI EBD / APITC john.loonsk@????.com Joshua Mandel Childrens Harvard [email protected]

Julia Skapik Cognitive Medical Systems [email protected] x

x x x x

X

Julie Scherer Motive Medical Intelligence [email protected] X

x

Juliet Rubini Mathematica [email protected] x x x X x XKanwarpreet (KP) Sethi Lantana Consulting Group [email protected] x X X x X

Kathy Pickering Cerner [email protected] xKatiya Shell ESAC [email protected] xKen Kawamoto Utah [email protected] x x x XKevin Olbrich McKesson [email protected] x xKen Rubin VA [email protected] Kent Lemoine CDC [email protected] xKevin Rose Pionetechs [email protected] Kevin Shekleton Cerner [email protected] Klingler Andreas Siemans Health [email protected] Leon Rozenglit Prometheus Research [email protected] Linda Michaelsen Optum [email protected] x Lindsy Hoggle AND [email protected] Lisa Anderson The Joint Commission [email protected] x x x x x

Lorraine Constable Cognitive Medical Systems [email protected]

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0 0 0 0 0 0 0 0Mon Tue Wed

Lou Bedor [email protected] Mags IPO [email protected] Maiko Minami HLN Consulting [email protected] Malcolm Pradhan Alcidion [email protected] x X x xManisha Khatta DOD / VA IPO [email protected] x Mark Kramer MITRE [email protected] Mark Meadows GA Department

Community [email protected]

xx

Martin Modera ACS [email protected] xMasski Hirai HL7 Japan [email protected] XMatthew Dugal Dynamic Health IT [email protected] x X xMatt Rahn ONC [email protected] xMathew Tiller ESAC [email protected] May Terry Flatiron Health [email protected] X xMichael Donnelly Epic [email protected] Michael Holck ESAC [email protected] Michael Van Der Zel UMCG [email protected] xMike Tushan Lantana Consulting Group [email protected] x Muhammad Asim Philips [email protected] Nancy McQuillen Health Catalyst [email protected] X Nancy Orvis DoD Va IPO [email protected] xNick Rador Optum [email protected] Noam Arzt HLN Consulting [email protected]

Ostem Kurt Dynamic Health IT [email protected] Xx

Pamela Mahan-Rudolph Memorial Hermann [email protected]

g Patrick Langford Intermountain Healthcare [email protected] Patty Craig The Joint Commission [email protected] Paul Denning MITRE [email protected] x x x x Peter Haug Intermountain Healthcare [email protected] X x xPhil Langthorne Prometheus Research,

[email protected] x

Piper Ranallo MDH/Six Aims [email protected] x 4 | P a g e













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Raj Mehra Cerner [email protected] x

Rebecca Baker ACC – American College of Cardiology [email protected] x

xRhonda Schwarz ESAC [email protected] x x Richard Esmond PenRad [email protected] Richard Ettema AEGIS.net, Inc [email protected] Rob McClure MD Partners [email protected] Rob Samples ESAC [email protected] Robert Jenders UCLA [email protected] x x XRobert Lario VA / U of Utah [email protected] Robonette Renner NMDD - NCI [email protected] Ron Ross Clinical Architecture [email protected] xRussell Ott DoD VA IPO [email protected] xSadamn Takasaka HL7 Japan [email protected] Sagy Mints Allscripts [email protected] X X XSananda McGarvey Northrop Grumman [email protected] xSean Murz VHA [email protected] xSerafina Versaggi BookZurman [email protected] Shah Mur VHA [email protected] X xShelly Spiro Phit Collaborative [email protected] Srinath Remak CDC/CSELS/OK [email protected] x x xStan Huff Intermountain Healthcare [email protected] x Stan Rankins Telligen [email protected] Steve Bratt MITRE [email protected] XSteve Hufnagel CIMI [email protected] XSusan Matney Intermountain Healthcare [email protected] x Sweta Ladwa ESAC [email protected] Sylvia Thun HLA DE [email protected] xTaima Gomez ACOG [email protected] Tar Younktm UC Davis [email protected] Tessa van Stigh NICTIZ [email protected] Thomson Kuhn ACP [email protected] x x XTony Laurie NHS [email protected] x

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Vaspaan Patel NCQA [email protected] Walter G. Suarez Kaiser Permanente [email protected] x x x x xWes Rishel [email protected] Yan Heras Optimum eHealth [email protected] Yukimoni Konishi HL7 Japan [email protected] Yunwzi Wang IMO [email protected] xZachary May ESAC [email protected]

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Time: Monday Q1Facilitator Floyd Scribe KP

Attendee Name AffiliationAttendance sheet for this meeting is at the beginning of this document.

Quorum Requirements Met: Yes

Agenda Topics Welcome CQI BUSINESS MEETING

Topics

Review January Meeting Schedule

Known PSSs and NIBs for May Ballot, if any

Known FHIR activities for May Ballot

GOM and Decision Making Practices Review/Update

Business Session Review of Agenda for the Week

Minutes/Conclusions Reached:

Business Session

Introductions

Agenda was reviewed:We will want to talk about what topics we have to talk with OO during our joint meeting in Q3. We might have a problem attending the Q3 mega workgroup report out due to a shortage of chairs. Floyd talked about the IP issue between Boston children’s hospital and HL7, and the problems it has caused for NIBs going to ballot. No changes to agenda currently.

PSSs and NIBs for May Ballot:CQL based HQMF may need to go for a May ballot to represent new changes like ratios. There are 2 comments out there. Sounds like we may not need a ballot. Might do a STU update. We’ll have to make the decision as a group.

Known FHIR activities for May:Would be nice to get all CQI FHIR resources up to maturity 4.

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Julia Skapik spoke about a registry project that uses FHIR to share data. There will be time left at the end of this session if folks want to hear about it. Julia will introduce this topic at the end of this session.

Decision Making Practices Review:There is a default DMP. We can review and accept or change if we need to re: Quorum requirements. Default DMP was reviewed. Our Quorum requirements: 2 co-chairs and 3 WG members with none from a single org. Folks felt the default Quorum requirements were a low bar.

Walter made the motion that we continue our current Quorum requirements of 2 chairs and 3 additional WG members from at least 2 different organizations. Anne Smith seconded. Motion passed with 14 affirmative, 0 against, 0 abstain.

Walter made the motion to accept the Electronic voting requirements as is from the default DMP. Anne Seconded. Motion passed with 15 approved, 0 against, 0 abstain.

Walter read through the current Quorum requirements in the CQI DMP.

Julia presented on CIIC (Clinical Information Interoperability Council): Julia presented on the January 2018 meeting of the CIIC. Refer to Julia’s meeting notes/outcomes and slides for additional projects.

Walter presented on the Da Vinci Project:

Project about creating better mechanisms for payer and providers to exchange data. Refer to slides from Walter. Point of Care Partners.

Time: Monday Q2Facilitator Walter Scribe Floyd



Agenda Topics And Minutes

Composite Measure discussion for CQL-based HQMF IG

Stan Rankins (Telligen – CMS Measure Authoring Tool) joined by freeconferencecall.com to

participate in the discussion about CQL-based HQMF issues regarding composite measures. The

slide deck will be uploaded to the CQI document site. The discussion is based on input from

Telligen, Mathematica and National Committee for Quality Assurance (NCQA) to address composite

measures.

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Example component measures:

Screening for breast cancer –

Screening for colorectal cancer – same issue

Pneumococcal vaccination – same issue

All-or-none: Simplest case: Patient-based, proportion scoring composite measure – All

preventive services met

All or nothing – the patient must meet all criteria – in the denominator if they are

in the denominator of any of the composite measures, they are in the numerator

only if they meet the numerator criteria for all component measures.

Example – a patient is in 4 of 5 component measures – thus, the patient does not

meet numerator criteria for one of the component measures and therefore, that

patient fails the numerator. Hence, this “All or none” example might not be the

best approach unless all component measures have the same denominator, or if

all patients meet all component measure denominators. If all or nothing is

chosen, the denominators should incorporate potential exclusions. In this case

men would not meet the breast cancer screening denominator and therefore,

would fail all-or-none criteria for the preventive screening composite.

Opportunity scoring: Second case: Patient-based, proportion scoring composite measure

– Who had all preventive services met for whom the patient meets denominator criteria

Denominator is opportunities to provide preventive service and numerator is

those services completed if there was an opportunity

Component-level Linear Combination – percentage of patients who received preventive

services

Calculate each of the component measure scores and average the total scores

Patients are still in the denominators only for those for which they are

eligible

Weighted Component measures – Each component measure is given a weight to

calculate the average.

Patient-level Linear Combination: percentage of completed preventive services. Gives

Eligible Clinicians (EC) partial credit for meeting the criteria for some, but not all

components of the measure

Might be handled as a continuous variable measure where the measure

observation is a numerator score divided by a denominator score (numerator

score is 1 for every numerator and denominator score is 1 for every denominator)

– the result is the average of the population.

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Clarify in the IG that the patient-level uses linear combination and Weighted combination is used

only for component level measures.

Further discussion about types of composites and what can be included:

All examples are about proportion measures. Bryn asked the group for examples of composites of

continuous variable measures, composites of ratio measures, or composite of mixed measure type

(e.g., a proportion and a continuous variable measure). There are no current such use cases

presented by the group present.

Proposal – Ratio and CV composites are allowed, but all component measures must be of the

same type

Proposal – All components of a measure are required to have the same subject type (i.e., patient-

based or encounter-based or procedure-based. (i.e., not to combine encounter-based and

procedure-based and patient-based). E.g., composite for multiple screenings for a single patient

over time. Need further examples to determine if a composite may have a mix of subject types.

Proposal: Human readable should be included for all component measures to prevent having to

reference components to read the measure.

Next Steps:

Enhance examples

Plan to enter comments on the CQL-based HQMF STU site and subsequently vote on

planned changes to the CQL-based HQMF.

Will the discussion need to address how to apply the result reporting to the QRDA. The issue

would only impact QRDA Category III – it is not communicating patient data, only the score.

Will need to enter comments on the QRDA Category III STU site to accommodate that

discussion.

Stan Rankin provided an overview of reporting a continuous variable in QRDA

Category III (each measure component e.g., measure population, measure

observation, etc. is reported.

The same examples need to be entered into FHIR tracker for the Clinical Reasoning FHIR

component to address measure and measure report in FHIR.

Bryn has worked up the CQL example of the continuous variable – Stan will evaluate if it

works in the MAT

No changes are needed in Harmonization – the same terms we now have will work

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The functionality for CQL-based HQMF may be substantive and therefore may need to be

balloted (instead of an Update). Timing for such a ballot will be discussed this week during

the WG meeting. If the changes are to be present in the CMS Measure Authoring Tool

(MAT) in September, the ballot would need to occur in May 2018.

QI Core Ballot Reconciliation

Discussed Comment 41 – Genny Leunsmann was present (requested in person

resolution). The addition of occupational data was deemed significant and important by

measure developers in the room and is also significant for clinical decision support. The

WG agreed that moving forward will depend on how occupational data (ODH) is

finalized in the FHIR STU 4 ballot in May. Genny agreed the WG could vote on such a

disposition later this week without her present. No vote was taken this session.

Business SessionNA

Time: Monday Q3 – Hosted by OOFacilitator N/A Scribe N/A


Quorum Requirements Met: OO Hosting

Agenda:Discussed options for when it is appropriate to use DiagnosticReport Vs Observation. The work will require a lot of communication among OO, CIMI, PC, etc. to assure ambiguity is resolved.Need to focus on data capture with the end in mind, meaning that the groups should meet together.OO and CQI co-chairs will work together to help resolve challenges. Need to address USCore as well.

Address OO FHIR resources used by CQI


See OO meeting minutes for more information.

Time: Monday Q4

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Facilitator KP Scribe Walter



Agenda Topics

QRDA Data Sharing User Guide

QI Core - QDM Alignment

HSPC, CIIC and Cancer Registry Interoperability Initiative Update (Richard)


QRDA Data Sharing User Guide

o User Guide redline document and comments from the ballot were reviewed

o There was one set of comments from TJC that need to be verified as to appropriate

resolution

o Need to double-check about the publication process, once the reconciled resolutions are

accepted

o Recommendation is to put publish this as a final white paper

o Motion by Floyd: that the WG give until Feb 9 to the two commenters to respond,

following which we will vote on publication on Feb 17, pending verification of

publication procedures with HL7

o Richard second -

o 11 approvals; 2 abstentions

QI Core - QDM Alignment

o Brief orientation of the QI Core Ballot

QI Core Profiles, can take any one of those, and go to the Mapping of its data

between QI Core and QDM

In some cases then looking at the mapping, there are one-to-many relationships

(from QDM to QI Core); there are also issues when there is a 1:1 relationship,

where QI Core includes more than one interpretation or option. There is specific

metadata in QI Core that expands and is different from the data being noted in

the QDM

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The group reviewed various examples where there are issues with the mapping,

including procedure, order; procedure, recommended; medication, discharge

Need feedback on all of these items

o Action:

To utilize the excel file with all the QDM Attributes and QI Core Metadata,

prioritize into 1) Major Issue with Mapping; 2) Minor Issue with Mapping; and

3) No Issue with Mapping – do you agree with mapping?

Floyd will generate the Excel file and send it to the WG

Since we plan to go back to ballot in September with QI Core (not in May), there

would be less urgency; however, some decisions will need to be made by May,

so it gets reviewed by the Methods Control;

Will split it into topics, deal with them during conference calls, asking people to

review the ‘topics for the call’.

HSPC, CIIC and Cancer Registry Interoperability Initiative Update (Richard)

o Part of CIMI – 2 projects working on Breast Cancer and Lung Cancer

o Need to develop a clinician-driven app to facilitate the transition from spreadsheet-based

artifacts to workflow process, and facilitate clinicians to comment on them

o Richard presented an app developed to fulfill this issue

o Trying to capture the clinical aspects of the model, not the modeling aspects of the

model, to facilitate clinicians’ review and input

o At this point is a prototype for use by CIMI and anyone trying to map data models to

FHIR resources, including, for example, CQLMore on this will be provided at an upcoming call in about 1 month.

Business SessionNA

Time: Tuesday Q1 Facilitator Walter Scribe Floyd



Agenda Topics

DoD presentation of use cases - potential gap in quality standards

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QI Core

Add PPS review of CIC Common Clinical Registry Framework presented to DESD January 29

DESD follow up

SSSupporting Documents - None


DoD presenters were unable to attend. Agenda updated to address QI Core ballot reconciliation this quarter Since DoD presenters are not available, will cancel Q4 session

Discussed DESD Discussion from January 29: TSC recommends preserving 4 domains. DESD will be called “Clinical” domain Workgroups in the domain would remain the same with possible addition of CDS and Clinical

Statement and Orders & Observations. Announced that CQI is among healthy workgroups that have been healthy for the past 3 WG

meetingsCIC Common Clinical Registry Framework PSS Review for consideration as co-sponsor

The PSS plans to update the Common Clinical Registry Framework DAM as an informative ballot with common data elements. Discussion confirmed the need to align the registry work with what is needed for clinical care documentation and measurement, and coordination of all data across registries.

Motion to approve CQI as co-sponsor – KP, Second – Thom Kuhn; 0 opposed, 0 abstain, 16 approve

QI Core Ballot Reconciliation: Comments 8, 30, 34 See Reconciliation Spreadsheet. Motion to approve all three resolutions (all persuasive with mod) – KP Sethi, Second, Thom Kuhn.

0 Opposed, 2 Abstain, 9 Approve

Business Session:

NA

Time: Tuesday Q2 (Hosted CDS and FHIR-I)Facilitator KP Scribe Floyd



Agenda Topics (Kevin Shekleton):

Connect-a-thon updates

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CDS Hooks 1.0 specification GitHub comments review

Infobutton on CDS Hooks - Connect-a-Thon recap

Opioid on CDS Hooks - Connect-a-Thon demo and updates (Ken Kawamoto, University of Utah)

CDS Hooks Boston Children's IP issue update and May 2018 ballot approach -- submit NIB or wait

until IP issues resolved? If submit NIB, pull before ballot announcement if IP issue not resolved?)

Supporting Documents – Link to presentation: https://docs.google.com/presentation/d/14zzZJBCZ-NCG701MTzeAJX5NUB7yOmi8jZ3sCtyrTRw/edit?usp=sharing Also uploaded to CQI WG document site (http://www.hl7.org/Special/committees/cqi/docs.cfm?)


Connect-a-thon UpdatesKevin Shekleton ---- Note CDS Hooks 1.0 release is a specification that is not a formal HL7 ballotted item.

Connectathon Summary

42 CDS Hooks participants – a new record (EHRs, CDS Service Providers, Healthcare Organizations (Cerner, Epic, Allscripts, McKesson, eClinicalWorks – several new participants, University of Utah, etc.)

Excellent 1.0 feedback – several issues logged & changes made Resulted in several changes and issues logged

Excellent security implementation feedback Big focus was to implement the security model

Lots of disparate use cases (Infobutton, opioids, genetics, etc.) There was a common thread (CDS Hooks) but with different content-related use cases

(challenge is that the spread was wide, benefit is that the focus was not a single thing). Ken Kawamoto presented the scenario addressing the opioid CDS service at

University of Utah to calculate morphine milligram equivalents (MMEs) based on medication order data. The pilot addressed free text prescriptions (1 in 5 prescriptions at the pilot hospital) – these free text prescriptions were parsed to provide structured data for MME calculation on 80% of free text prescription

Infobutton CDS Service – Dan Adams discussed the ability to connect with EHR vendors using Patient View hook and provide Infobutton service with information from UpToDate and guidelines.

Medication-Prescribe hook in Cerner – when user is in process of prescribing a medication, the CDS hook receives the medication to be prescribed – calls CDS service

Argonaut security assessment summary Argonaut funded a 3rd party security review and assessment since October 2017 – performed

by Dixie Baker, PhD (also assessing SMART on FHIR) – Majority of changes are just documentation improvements:

Articulate risks and potential threats so that implementers understand them and can make their own choices based on their tolerance of risk (e.g., how long the CDS Hook is allowed to search for the element)

Strengthen conformance verbiage where appropriate (MUST, SHOULD, MAY, etc.) Document each request/response field with REQUIRED or OPTIONAL

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http://www.hl7.org/Special/committees/cqi/docs.cfm

https://docs.google.com/presentation/d/14zzZJBCZ-NCG701MTzeAJX5NUB7yOmi8jZ3sCtyrTRw/edit?usp=sharing

https://docs.google.com/presentation/d/14zzZJBCZ-NCG701MTzeAJX5NUB7yOmi8jZ3sCtyrTRw/edit?usp=sharing


Add new Subject parameter to fhirAuthorization (see slides)Specification changes

JWT signatures, JWT public key – summary From implementer feedback (post Sept 2017 Connectathon) and the Argonaut

security review, it is clear this is an issue to tackle for 1.0 Plan is to align strategy with that of the SMART Backend Services, which also

leverages signed JSON web tokens. Initially intended to be addressed post 1.0, the reality is that all implementers

need a solution today SMART’s use of OpenID Connect already requires JWTs and JWKs SMART Backend services leverage signed JWTs too and we want to align our

strategy Adopting two existing IETF standards allows us to leverage existing OSS

libraries and work JSON Web Signature (rfc7515) JSON Web Key (rfc7517)

Notable additional changes Hooks define their own context – code and examples are more important than

specification doc :P. Context is now an object, the contents of which defined by each hook. E.g., medication prescribed – context is medication that is prescribed – context will change depending upon the hook. Context field is documented as a JSON object. However, in the sandbox, it was coded as a JSON array. Therefore, all implementations showed as an array. Therefore, the sandbox was fixed to allow context to be an object.

Move patient_id and encounter_id to context. A CDS service may not be invoked to a single patient, but to a patient list (i.e., without specific patient context). Patient and encounter are hook-specific. Patient and encounter were moved to context objects.

Clarify prefetch tokens – ability to prefetch FHIR data – commonly invoked when chart is opened. CDS service may ask for full patient resource.

Proposed (a) hooks indicate which first-level fields can be prefetch tokens, (b) Prefetch tokens have a defined naming convention

{{user}} {{context.patientId}} [[context.encounterId}}

CDS Hooks 1.0 release plan Finalize security assessment (early February) HL7 Jan 2018 WGM Feedback (‘informal ballot’ – NOW) Wrap-up remaining 1.0 milestoned issuesPost 1.0 feedback & plans – release late Q1 2018

Release Plans Still ongoing – working on checkpoints

CDS hooks logo was created by the project – resolved yesterday 29 January Boston Children’s and HL7 need a joint copyright – template in place (similar to

SMART) – in progress – SMART specification indicates an open license allowing sharing and adapting but must attribute the original work. CDS Hooks is expected to be handled in a similar way.

Process and tooling – issues managed in Github – FHIR uses a different tool set and process – tooling changes in FHIR in Github – working on alignment

Decision Process Regarding May 2018 HL7 Ballot Process

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February 25 is the deadline for submitting the NIB – will need to determine if the likelihood is sufficiently likely to move ahead.

Most likely the IP issues will be resolved. Will need to check in closer Discussion about using apps with CDS Hooks – might certification of apps assure consistent use.

Need to assure patient safety. How to deal with a service provider that is hacked? Future Post CDS Hooks Feedback and Open Discussion

Clinical Reasoning Track allows multiple rules and determine scope, creating a specific workflow based on the patient – how to handle a back-end event – rather than stringing CDS Hooks. Consider a scenario based on events – e.g., EHR identifies a cohort of individuals and runs the CDS on the cohort. From a care management perspective – may want to ask specific questions about a patient (Care management workflow). The local organization needs to determine to whom (or what role) the notifications go. Current cards are prescriptive about the actor. Care management includes multiple individuals and roles. And there may be different tasks based on the role (which may be organizational specific). May need to align the discussion with composite measure considerations.

Business Session NA

CQI joined EHR Workgroup (UsabilityTime: Tuesday Q2

Agenda includedo Usability Project Update per EHR online agenda

See EHR Workgroup meeting minutes for more information.

CQI joined CDS and FHIR-I WorkgroupsTime: Tuesday Q3

Agenda includedo Clinical Reasoning and QICore ballot reconciliation; CQL STU comments reconciliation

o Future of QICore/modeling activities and vendor support for required FHIR profiles

Discussion about Immunization Forecast FHIR Ballot comment questions regarding CDS Hooks Decision to take CQL to STU 3 ballot in May 2018 Discuss QI Core – plan to ballot based on FHIR STU 4 in September – QI Core is aligned with

QDM – the plan is that the mapping of QDM to QI Core profiles will allow running measures in FHIR servers. Requested feedback from implementers present in the room. There was limited response in the room. The answer will depend on what vendor clients request. The categories of information provides good coverage but concept boundaries are difficult to map. Concept boundary (e.g., negation rationale for reason). The approach taken was to map the QDM attributes to the FHIR metadata – and to the extent possible QI Core uses US Core. Feedback on the QDM to QI Core mapping will be very valuable to assure appropriate mapping.

See CDS meeting minutes for more information.

Time: Tuesday Q4 - The Tuesday Q4 session was cancelled due to insufficient attendance for the planned discussionsFacilitator Floyd Scribe KP

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Quorum Requirements Met: Cancelled

Agenda Topics

Follow up discussion of DoD requirements and standards requirements – Presentation did not

occur in Q1 due to presenter issues

Project Planning – moved to Wednesday Q2

Supporting Documents -


Session cancelled

Time: Wednesday Q1 (CQI Hosted CDS and CIMI)Facilitator Walter Scribe Floyd



Agenda Topics

CDS KNART project

eLTSS Project (electronic long-term services and analysis) and FHIR Resources

Future of QICore/modeling activities and intersection with CIMI - relationship to FHIR profiles


Minutes/Conclusions Reached: .CDS KNART Project Update – Jerry Goodnough

Slide deck uploaded to the CQI document site (http://www.hl7.org/Special/committees/cqi/docs.cfm?) See slide deck for details of presentation Clinical Decision Support Knowledge Artifact Specification Release I Listserve [email protected] Conceptual model – extract concepts from existing physical representations

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Review and align with AP14KP Extend to cover concepts identified from clinical use cases and whitepaper delivered last

cycle – Address metadata around context and governance 34 STU comments in queue Plan to create an STU update release in May with a full ballot in September 2018 Discussion –

- Is the project in CQL – loosening specification to allow expression language to be open (but CQL is what is being used for the examples)

eLTSS – seeking feedback – Primary WG is CBCP Slide deck uploaded to CQI document site:

http://www.hl7.org/Special/committees/cqi/docs.cfm? ONC – CMS project launched in 2014 as a joint project between CMS and ONC Driven by requirements of the CMS Testing Experience and Functional Tools (TEFT)

in Medicaid community-based long term services and supports (LTSS) Planning and Demonstration Grant Program

Scope – o (1) identify standardized components or data elements needed for the

electronic creation, sharing and exchange of person-centered service plans, o (2) Field testing/piloting these data elements within participating

organizations (pilots) respective systems (paper based and electronic) – not all clinically-based – includes lifestyle and life event content.

Workflowo Starts at assessment level at the HCBS settingo Person-level plan is generated at the HCBS setting and shared with other

settings – payer and other accountable systems, beneficiary and caregivers, and care team (institutional or otherwise)

o Vision – standardize at data element level so it can be shared across different systems – wearables, transport, housing mobile health, and clinical and non-clinical IT systems

Planso Published data set Sept 2017-September 2018 – led by Georgia Department of

Community Health HITo Standard testing – Feb 2018-June 2018 – Pilots with AGILE development and

SPRINT testing – call for participation Nov 2017 to Feb 2018 – first tests to be scheduled Feb and March – pilots will inform eLTSS HL7 Artifacts

Further details of the workflow presented – see slide deckso Pre-screening – financial eligibility – functional evaluation – etc.o FHIR resource structure – Episode of Care Resource

Waiver intake status Clinical impression – data on methodology and results of functional

assessment Care plan – add goals and specify actions that will occur with

respective goals LTSS Service plan

Long term services and supports Natural supports Beneficiary Steps or Actions

Risk determination – has risk been considered as potentially a calculation based on existing data using expression language (e.g., CQL) to determine the risk – No – the main effort has been to establish a vocabulary about types of risk. The narrative contextual

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description is needed as well as codified, machine-processible content. The narrative will be captured by the care manager.

Also considering how to evaluate the data capture with needs for measurement.

ONC scope is at the care plan level – CMS is working on coordinating with measures

Functional Assessment work is to standardize the assessment Discussion – assure these requirements and details are captured in the FHIR Tracker

to allow the primary resource owner to coordinate the resource requirements Discussion – FHIR connectathons are good opportunities to test and show the

elements in the requirements Contacts – Bonnie Young – [email protected], Irina Connelly

[email protected] Evelyn Gallego [email protected] Future of QI Core / CIMI Modeling Activites

o QI Core addresses the physical model, QUICK is an extract considered as a logical model. The requirements from the CMS Quality Data Model (QDM) and virtual medical record (vMR) used for CMS were merged into QI Core that includes the combined requirements (QI DAM). It is the basis of the QI Core profiles which is the “source of truth” maintaining the resources and mapping QDM to QI Core to suggest how the requirements might be expressed in FHIR. QUICK is the extraction of the logical model from a set of profile to consider the extension as a first-class element – one-to-one mappable and usable with tooling. One approach CIMI is working on is to create FHIR profiles from CIMI elements. Could the same tooling that creates QUICK from QI Core be used to provide a logical view for CIMI to allow it to run FHIR. QI Core is expressed as FHIR profiles – to the extent possible, US Core is represented in QI Core – derived from US Core where there is a profile in US Core (or FHIR Core) as the base – and extend from that. The process addresses feasibility since it is based on the based US Core and FHIR core.

o CIMI similarly starts with the foundation of US Core and then extends as needed. CIMI would similarly work with QI Core. In some areas, CIMI will go deeper (e.g., representing Blood Pressure (BP), glucose finding, etc.) – i.e., use US Core / QI Core (the best defined starting point) and then make further special constraints. And that the result will be used for CDS, measurement, public health reporting, registries or other areas.

o Q4 Tuesday CDS discussed similar issues (see CDS minutes from Tuesday Q4)o Question – how do all models stay synchronized (QI Core – CIMI archetypes – US

Core)? o Proposal – use SMART on FHIR applications and pilot definition of archetypes,

develop FHIR-generated profiles, generate logical view using QUICK tooling and determine if the process is not overly complex – show concrete details The simplicity of a logical model is very helpful – and CQL can reference the

logical model to write expressions in CDS or eCQMs – a logical view of new profiles from CIMI might be tested – perhaps focused packages for specific use cases rather than an uber-model for all uses. Focus the model only on the set of data elements for the use case.

Archetype can be confusing – it is a FHIR format to express a detailed clinical model (DCM) – not in the sense of an English meaning “pattern” – here we are talking about the DCM and not a “pattern” archetype.

Next steps would be to create a document describing the discussion – will discuss how to proceed.

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Time: Wednesday Q2 (Hosted CDS)Facilitator KP Scribe Walter



Agenda Topics

Drug-drug interaction knowledge modeling with CDS and Pharmacy

Slides presented by Richard Boyle, University of Pittsburgh

Core concepts:

Potential drug-drug interaction: exposure happened but clinical effect not

meaningful at low doses

Alerts – good but have to avoid over-alerting

Need to address this issue

Ongoing efforts to improve PDDI Decision Support

Concept is to improve the knowledge base representation for PDDI alert

specificity

Three approaches (see slides)

What information should be present in a PDDI Alert?

Drugs involved, seriousness, clinical consequences, mechanism of the

interaction, contextual information, recommended actions, evidence supporting

this

PDDI Minimum Information Task Force

Formed within W3C Life Sciences and Health Task Group

Has developed formal definitions for 10 minimum information items, defined

uses cases and user scenarios for information model, agreed on scope of

knowledge representation (relationship b/w core information items, value sets,

and a CDC rule language)

Presented more detailed information about the 10 definitions

At the end, contextual information/modifying factors look very much like a clinical

algorithm that can be expressed in a decision tree mode

Step 1 – Develop Value Sets

Step 2: Write modular rules for each branch point

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Problem Statement: Creation and maintenance of contextualized PDDDI decision support

generally requires considerable time and energy – higly trained domain experts

After all of that work there is still no standard EHR context for CDS service – need to

ensure consistency

Goals of the HL7 CDS WG PSS

Contextualized potential drug-drug interaction clinical decision support

Develop an Implementation Guide to show how to achieve consistency across

various DDIs

Knowledge representation mechanisms for the drug interaction logic

A key will be to prioritize how many of these algorithms will need to be developed

At the end, the main product will be a Knowledge Representation, the COnextual

Modifying Factors, and representing them in the implementation Guide that will show

how to achieve the goal of highly effective and sharable CDS rules for PDDIs by

combining:

Tagged narrative (the definition from the PDDI minimum information model)

Clinical algorithms using FHIR resources/profiles and CDS Hoods triggers

Action: PSS will not go for May but for September; PSS will be distributed to CQI for

review/action, as well as to Pharmacy for review/action

CQL-based HQMF Potential Ballot STU 2.2 ballot May 2018

During this week CQI had lengthy discussion about Composite Measures, with some

recommendations to move forward with modifications/updates that will affect CQL-

based HQMF.

Given this, the proposal is to move the development of a May ballot to address the

changes needed to support composite measures

Bryn reviewed the Composite Measures presentation discussed earlier in the week at the

CQI WG session

Action:

There will need to be an updated PSS. Deadline for PSSs is Feb 11; CQI will

present the updated PSS to CDS later this week for action

NIBs are due February 25

Cross Paradigm Story Board

Lisa Nelson presented an update of this project

CQI is an interested party

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Story Board objective was larger than the FHIR versioning issue; the Story Board artifact

will describe a patient-centered situation that includes relevant challenges from the payer

perspective

How: Approve the premise for the Story (layer 1); Establish the story as a narrative

description (Layer 2); Establish the story as a time-line (Layer 3); Add clinical details

(data) where needed (Layer 4)

Project Plan

NIB due February 25 (complete NIB, any other steps in Attachments WG?)

Initial content deadline: March 11 (help create clinical details, help create C-

CDA entries)

Final content: later in 2018

Planned outcomes:

Balloted storyboard

Expandable and reusable story & repeatable story creation process

Rich and reusable synthetic data

Progress – for standards development and adoption in areas aligned with the

objectives set for the story

No actions needed at this point

May Meeting Planning (postponed until Q4)

Other topics as proposed: None


Minutes/Conclusions Reached: .

CQI sent representatives to (OO Hosting)Time: Wednesday Q2

Agenda includedo Joint with PC, CDS, RCRIM, OO, FHIR

o Proposed Topics:

BiologicProduct plus other OO resources of interest

Trackers for ownership of Supply

Plan Definition, Order Set

See OO Workgroup meeting minutes for more information.

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CQI joined CDS and CIMITime: Wednesday Q4

Agenda includedo CIMI for Quality

o QI Core Ballot Reconciliation

o Scheduling discussion for the HL7 WGM in Cologne in May

See CDS meeting minutes for more information.

Time: Thursday Q1 Facilitator KP Scribe Floyd


Quorum Requirements Met: Cancelled (notification sent to WG on Tuesday 1/30)

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