ToC+CIM+Vocab+WG+F2F+Meeting+Minutes+2011-06-14

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**CIM Vocab WG Breakout Session One**

 * Date:** 06-15-2011
 * Time:** 1:30-3:00pm EDT

**Attendance**
Allan Hobbs, Amy Knopp, Arien Malec, David Tao, Gordy Raup, Holly Miller, Mayuri Patel, Michael Fitzmaurice, Robert Hunter, Russell Leftwich, Sandra Raup, Steve Wagner, Susan Campbell, Susan Nedza, Thomas Kuhn, Tony Calice, Vassil Peytchev, Virginia Saba, Walter Suarez

Meeting Purpose & Objectives
The purpose of the session was to achieve consensus on the Core Data Elements.

Meeting Notes

 * Important Outcomes**
 * Consensus on Demographics achieved
 * Discussion on Active Medication List started


 * Introductory Comments**
 * The core data element groups that will always be captured in a transition of care are demographics, active problem list, active medications list, allergies and intolerances. Beyond the core group, which is captured in the EHR as discrete data, the sending clinician has the choice to send additional elements, but those elements are not required. To review the criteria for the data element classifications, see ToC Harmonized CIM.
 * For example, in a hospital discharge, a long hospitalization, or an ICU visit, the patient would have multiple vital signs taken. The primary physician clearly does not want all the data that might be generated because the significant data will get lost in the shuffle. It is also important to consider that the physician is legally liable for anything in the EHR database.
 * In this WG, we want to start with the Core Categories – see if we can look at mapping and drive the group to consensus.
 * We are looking at an Anticipated Transition of Care Model that is a “Push Model.” This is a “Push” that would not need patient consent under HIPAA.
 * Question: Why are we interested in a Clinical Information Model and what added value do we bring? In the beginning, we felt it was important to start with a clinically centered view of the world. Each piece of the model was clinically appropriate and significant
 * The vision is as follows. I am in my EHR system and send my patient to a specialist and receive back changes from the specialist. I can choose to upload discrete data, rather than change the whole record. If a patient has been found to have an allergy, it can be added as discrete data.
 * We should emphasize that there are newer models of care than the Clinical Information Model. In fact, the CIM model is part of the larger Health Information Model. That being said, we may identify other parts that are non-clinical that are critical.


 * Core Data Elements Discussion**
 * The objective is to include some data elements from Meaningful Use 1 and to satisfy EMPI Algorithms. We want to find a positive match.
 * As we go through the data elements we should ask the question: What do we really need this information for?


 * Demographics**
 * Patient Identifiers, or alternate identifiers, need to include these elements from the article Reconciling and Managing EMPIs by AHIMA
 * Is it ok to leave information with another family member? This brings up a legal issue; should we add a consent category? What about leaving a message with a non-family member? Issue to be placed in the "parking lot" for future discussion.
 * Existence of Advanced Directives only reflects whether the advanced directives have been discussed with this physician or not; it does not indicate what the advanced directives actually are; simply saying whether this happened or not, whether an advanced directive has been signed by the patient and lives somewhere in someone’s record.
 * There has to be a way to clearly manage which provider delivers which form of care at what part of the cycle. In the example of pediatrics and neonatal care, the primary care giver is involved in different parts of the care cycle. CF provides a great example as well of a situation where you may need extra coordination.
 * The general group seems to be ok with having multiple PCP and Designated Providers. We need to be mindful that the PCP may not be a doctor it could be an entity.There was also some general confusion around this field. We have been talking about who owns the patient vs. who owns the patient specific problem? If we think it’s really important to identify the locus of care, there are some patients that validly have more than one locus, but there is a small % of patients that basically have this need (1%).


 * Active Medication List**
 * There are certain instances when I have to tell you what happened or changed, rather than send a full list of medications; if a specialist is sending back a full list of medications, this could potentially be very confusing. Let’s take the example of a dermatologist, when all they change is “lotions and potions.” Is there any value of the dermatologist sending the full list? What about sending a partial list? On the other hand, a Cardiologist would require a fully reconciled list.
 * Maybe we need a rule that says, I am either sending a reconciled full list, or I am sending an update on what happened/what changed but it is not reconciled?
 * Do we need to consider a degree of reconciliation? What does it to mean to reconcile? Internally, you can reconcile data from different sources within the system. However, when you talk about reconciling external systems, you need another level of reconciliation.
 * One scenario is I have a list of medications that the patient came to me on; then I also create a list of what I did or changed. Then I look at my lists and send out a reconciled list. Ultimately, this is the full list the patient should reference. Reconciliation is in fact a menu list in Meaningful Use (MU) Stage 1; it has been suggested for a core part of MU 2.
 * What does the group want to see documented as part of the Active Medication List? This portion needs to be very clear. It is not a random list of medications, it is active medications. Certain EHR systems have excellent reconciliation, however certain ambulatory systems have less developed reconciliation, how do we bridge these gaps? Pick up at this point in the next session.

**CIM Vocab WG Breakout Session Two**

 * Date:** 06-15-2011
 * Time:** 8:30-12:00pm EDT

**Attendance**
Allan Hobbs, Amy Knopp, Arien Malec, David Tao, Gordy Raup, Holly Miller, Mayuri Patel, Michael Fitzmaurice, Robert Hunter, Russell Leftwich, Sandra Raup, Steve Wagner, Susan Campbell, Susan Nedza, Thomas Kuhn, Tony Calice, Vassil Peytchev, Virginia Saba, Walter Suarez.

Meeting Purpose & Objectives
The purpose of the session was to achieve consensus on the Core Data Elements.

Meeting Notes

 * Important Outcomes**
 * Consensus on Active Medication List achieved.
 * There is a need to make certain assumptions very clear, especially pertaining to reconciling medication lists due to legal ramifications that may come with taking responsibility of the lists.
 * The person taking responsibility for the medication list is the sender; the sender is initiating an anticipated ToC; he or she is telling the recipient, here is a list of all the medications this patient is taking; the sender is taking responsibility for the list of medications. **//The receiver needs to become a sender in order to assume responsibility for the medications list. A best practice would be to assume a sender is the responsible party for the medications list; at the time of sending the list, one must take responsibility for that list.//**
 * Reconciliation means that the provider, who upon completion of the care of the patient, sends an active medication list either, a) having reviewed the original active medication list relative to any new prescribed medications or changes to existing medications and reconciles the two or b) only makes additions to the active medication list. Essentially, what we are saying is the rendering physician takes legal responsibility of their domain, but if it’s not their purview they do not take legal responsibility. The group has been asked to provide examples.
 * Further thought is also warranted regarding “Who assigned the problem?” (This field is available in most systems). The group discussed whether we should only really care about the last person who touches the problem or whether we should also care about who initially found the problem. They did not come to consensus.
 * No Consensus Achieved on Problem List
 * Consensus Achieved on Intolerances including Allergies
 * The group achieved agreement on the importance of leveraging already existing metamodels to build the CIM.
 * The decision was made to build a small team that will take the UML FHIM and word document and take a pass at applying it to our work.


 * Detailed Meeting Minutes**

The group picked up the conversation at the **//Active Medication List//**.

 They kicked off the discussion with the following possible scenario: If I am a dermatologist, is it appropriate for me to send back the whole medication list and say that I reconciled it but in reality I only adjusted the “lotions and potions”, and did not touch any of the other medications?

 //**Question to the group:**// Meaningful Use says that the medication list should be reconciled in every ToC, but in scenarios like the one above, what is appropriate? //**Some important assumptions **// The expectation is that you, the new physician/specialist etc., receive the list of medications and once you send it back it is assumed that the list has been reconciled. However, if you reconcile the medication list, does it mean you are taking legal responsibility for the full list, including those medications that were simply left on the list? This conversation has highlighted the need to make operating assumptions clear:
 * If there are core elements in the medications list that need to be there, then the dermatologist would keep the previously recorded date of reconciliation that was documented by the referring physician. The dermatologist would want to update the medications that he or she is responsible for, and it is important to note that the medications have not been reconciled.


 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Overall, the person taking responsibility for the medication list is the sender; the sender is initiating an anticipated ToC; He or she is telling the recipient, here is a list of all the medications this patient is taking; The sender is taking responsibility for the list of medications; In the case of a specialist, this could be a sub-list; for a Primary Care Physician, it could be just a part of the list; in the case of medical home, it is probably the full list. **//The receiver needs to become a sender in order to assume responsibility for the medications list.//** **//A best practice would be to assume a sender is the responsible party for the medications list; at the time of sending the list, one must take responsibility for that list.//**
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Reconciliation means that the provider, who upon completion of the care of the patient, sends an active medication list either, a) having reviewed the original active medication list relative to any new prescribed medications or changes to existing medications and reconciles the two or b) only makes additions to the active medication list. Essentially, what we are saying is the rendering physician takes legal responsibility of their domain, but if it’s not their purview they do not take legal responsibility. The group has been asked to provide examples.

//**<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Some important considerations for designing the CIM **//
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">In the design of the model, the group wants to make sure that that all the necessary information that needs to be shared in a ToC is shared (namely a comprehensive medications list that can then be filtered). If the model is too constraining, the group may run the risk of having to start over any time new scenarios are developed. In addition, we need to make sure the points discussed are valuable to both clinicians and non-clinicians.
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">It is important to provide a clear definition of what it means for a medication to be active (half-life/Behavioral Health Medications etc.). The group needs to make a clear distinction between “Active” vs. Relevant and Pertinent.
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">There are different ways medications can be classified:
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Medications upon admission, during, and on discharge
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">As a vendor, you look at medications from the perspective of whether they are active, inactive, or on the discontinued list; the information is provided as data types so that all the information clinicians may need is available.
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Historical, active, and discontinued (In the core data elements we want to document the active medications. In C32 you can actually classify a medication as “Active”; there is a field designed to capture this information)

//<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> **Key take-aways from this portion of the discussion** //
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Active medication list: current scripts going forward
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> PRN Medication List
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Active Medications (held for period of time)
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Another need is medications the patient was exposed to that are still clinically relevant
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> There is a software need to just know the deltas to build systems that will do reconciliations
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Useful to know the history to know that certain things have failed (not necessarily pertinent to this list)

<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> __**Conclusion:**__ Ultimately, physicians will send the active medications and the delta.

//<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> **Active Problem List Considerations** //
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">The group faced similar challenges regarding reconciliation for the Problem list as were faced in the discussion of the Active Medication List.
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> It was decided that reconciliation needs to be in the scope in order to protect patients. The PCP, care team or care manager will primarily be managing the problem list, and therefore should be part of the model.
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> We need to indicate that that the problem list has been reconciled:
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Problem reconciled, yes or no?
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Need to show re-diagnosis in the event of a wrong diagnosis
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> It is also important to keep in mind recommendations on the Problem List from Meaningful Use (MU). MU states that we need to maintain a problem list of current and active diagnoses; it’s not just a problem list. 'Diagnoses' is the critical component of this statement.
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Further thought is also warranted regarding “Who assigned the problem?” (This field is available in most systems). The group discussed whether we should only really care about the last person who touches the problem or whether we should also care about who initially found the problem. //**They did not come to consensus.**// The need to include fields for the name of the rendering clinicians as well as the date of clinical recognition was discussed.
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> There are articles from IHIMA that discuss problem lists. We should consider using these as a reference and so that we are better informed.

//<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> **Intolerances including Allergies Considerations** //


 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Medication (ingredient or class code/text if available) that is attributed to an allergic reaction or intolerance, or drug code if attributed to ingredient or class if unavailable.
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> With “Medication” we are being highly inclusive: This needs to include medications, OTCs, biologicals, herbal supplements, vaccines (immunizations)
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">A key question warranting further discussion was whether we should also be considering the classification of the different types of allergens such as food allergens or whether they should be a separate data element. If so, the question was asked if we should call out types of food (shellfish, eggs, peanuts etc). Example: How do you classify an allergy to the flu vaccine, if it is really an allergy to eggs?
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> The way the intolerance and allergies were outlined in HITSP fits well with the way they should be presented to clinicians. We may want to consider adding “SEVERITY” to our criteria because it worked well in the other model.
 * <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">The group also needs to make sure they are aligned and harmonized on their reactions classifications with the FDA.

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