caEHR Domain SME F2F Meeting #4

1. caEHR Domain SME F2F Meeting #4 Day 1 Las Vegas, NV April 22, 2010

2. Welcome • Introduction of New Members • Lisa Schick – caEHR Business Analyst • Agenda Review and Session Objectives • Agenda Review • <add> • Other changes? • Session Objectives • Referrals Working Session • Domain Analysis Model Review • Outcomes Working Session

3. Day 1 Agenda • Welcome and Introductions • Meeting Objectives • Agenda Review • Project Status <Marti Velezis> • Referrals Working Session <lunch> • Domain Analysis Model Review • Referrals Working Session continued • Wrap Up

4. NCI caEHRProject Updateas ofApril 21, 2010Marti Velezis Discipline Specific Lead – Analysis Team National Cancer Institute

5. Project Overview Development Methodology

6. NCI sSOA Development:Architecture for the Translational Medicine Continuum Consume/Contribute Validate Inform

7. sSOA Development Methodology Overall Scope and Vision Topic scope per release cycles Parallel focused service delivery teams supporting overall project goals Effectively breaking large complex interdependent project deliverables into focused service delivery Iterative and Incremental ensuring fail often, fail early, course corrections. Provides early progress against larger project goals Allows for stakeholder engagement early and often Supports ability to integrate 3rd party other agency involvement in services delivery Services Development Methodology

8. Project Overview Scope Development

9. The Big Picture: Under Development • The project’s scope is not well defined outside the initial business capabilities (in stakeholder priority order on the next page) • The project’s definition of caEHR is not well defined across stakeholders • Shell with Services to a full EHR Reference Implementation • Balancing the NCCCP Adapt/Adopt Scope with providing Healthcare-focused services • Over the next 30 – 45 days, we would like this to be clear to all stakeholders

10. Scheduling Billing Allergy list management Problem list management Generate Reports Clinical Decision Support Outcomes Management Business Capabilities • Patient Registration and record maintenance • Referrals and Consults • Clinical Documentation • Medication ordering • Medication list management • Treatment planning • Laboratory result management

11. caEHR Reality: Project is Highly Visible in the National Healthcare Landscape • Example: PODS Transition = EHR Lite • A patient creates a Microsoft’s HealthVaultrecord, outcomes data comes from Microsoft’s HealthVaultto PODS via Amalga and the patient's PHR is available to the physician as a EHR-lite

12. Referrals Working Session Christine Bester & Bill Dumais

13. Referrals • Iteration 1 Status Update • Use Case and Activity Diagram Review

14. Brain Teasers! • How many common four letter English words can you make from the letters EANM using all the letters in each word? • How many flowers do I have if all of them are roses except 2, all of them are tulips except 2, and all of them are daisies except 2? • Which three letter word can be attached to the beginning of the following words to give six other words ? • ROCK • POST • SPREAD • TIME • EVIL • CLOTHES

15. Lunch!

16. Domain Analysis Model Jean Duteau

17. Domain Analysis Review • Review of existing DAM • Treatment Plan • Activities • Orders • Imaging Results • Observations • Problems • Treatment Course/Cycle Attribute Discussion • Outcomes Model Discussion

18. Review of Existing DAM • Currently getting the existing DAM ready to publish – to draw a “line in the sand” and consider the DAM 90% complete. • Remaining 10% will come due to changes as use cases are further developed, service specifications are developed, and refined information models are created. • This review is not all of the DAM – just the more important pieces of the DAM. As always, the DAM is published and anyone can go review it. • http://www.ncientarch.info/ent-services/nci.enterprise.caehr.analysis.information/

19. Treatment Plan Model

20. Activity Definition • Any action that can, be defined, scheduled or performed. • For example, a surgical procedure, a laboratory test, or the administration of the drug. • Activities are generally part of a treatment plan, either through a cycle or a course of treatment. But there are activities that are part of a patient's care plan that are not part of a specific treatment plan. • We distinguish some broad categories of activities: • Activities you can order • Treatment Activities • Diagnostic Activities • Supply Activities • Administrative Activities

21. Activities You Can Order

22. Treatment Activities

23. Diagnostic Activities

24. “Administrative” Activities Definition: An activity that is not directly related to hypothesis evaluation or testing, but is typically essential to the efficient and/or effective coordination and provision of healthcare.

25. Order Pattern • We have come up with a pattern for orders. There is an overarching order that provides patient information, ordering provider information, and overall “meta-data” about the order. Then the order contains a bunch of things (called an order component) that are being ordered: • Lab tests • Substance Adminstrations • Images • Every order component can have a result returned for it and these results can be amalgamated into a report. The overall order may have a final report generated for it, but that is not necessary. • A Clinical Document (such as a History & Physical) can be considered a Order Report.

26. Orders Model

27. Imaging Orders

28. Observations • Anything that can be observed about a patient. Sources could be the patient, the healthcare provider (or other healthcare providers) or persons related to the patient • Divided into root level Clinical Observations and other observations that support them • Diagnostic Findings (high cholesterol) • Problem Observations (pregnant) • Allergy Observations (including intolerances, drug and non-drug, negation of allergies) • Family History Observations • Social History Observations • Lab Test Results • Image Studies • We believe that this segments the entire range of observations. Are there others?

29. Problems and their Observations HL7 uses the word “Problem” in their Clinical Documents. But they have changed to using the word “Concern” in the Patient Care domain, because it represents more things than just problems. “Pregnancy” might be a Health Concern but it might not be wise to call it a “Problem”. Problems have relationships to Observations that may support the problem or be the cause of it. Gastrointestinal Disorder might be the problem and it is supported by observations of abdominal pain, constipation, job stress, etc. Allergies are also considered problems that are supported by allergy observations.

30. Treatment Plan Components Need to identify attributes for TreatmentCourse and TreatmentCycle. Suggested Attributes: Sequence Number – tells us when, in the set of all courses/cycles that this course/cycle occurs Pause Quantity – tells us how long to wait before proceeding with this course/cycle, eg. Wait one week and then do this cycle. Description – a textual description of what the course/cycle is trying to achieve Repeat Number – how many times this course/cycle is to be done Effective Time – how long this course/cycle is to be done, eg. Do this twice for two weeks each with one week between. Others???

31. Outcomes • Outcome Definition: A measure of how a patient (or study subject) feels, functions, or survives. • An attributed change -- i.e. specifically linked to a particular recording source, e.g. patient, clinician, etc. –in a measured or recorded (i.e. recorded using a quantitative aspect (e.g. coded), semi-quantitative, semi-qualitative, or qualitative description or scale) of a patient health status compared between two or more points in time.  • Outcomes measurements are often -- but not always -- linked to/the result of one or more interventions (or non-interventions) that were made between those points in time.

32. Outcomes Model

33. Referrals Working Session Christine Bester & Bill Dumais

34. Referrals • Continued from earlier session

35. Wrap Up Day 1 • Agenda Changes or Additions for tomorrow • < > • Actions and/or Homework • Comments/Questions? • Dinner Plans!

36. caEHR Domain SME F2F Meeting #4 Day 2 Las Vegas, NV April 23, 2010

37. Day 2 Agenda • Brief Recap of Day 1 • Referrals Working Session continued • Outstanding Issues • Narratives • Referrals Data Review • Outcomes Management Working Session • NCI All Hands Meeting <lunch> • Outcomes Management Working Session • Introduction to External Data and Document Capture • Wrap Up

38. Recap Day One • Project Status Update • Referrals Use Case and Activity Diagram Walk Thru • Level 1 and Level 2 Diagrams • Domain Analysis Model • Review of Model • Treatment Course/Cycle Attribute Discussion • Outcomes Model Discussion

39. Referrals Working Session Christine Bester & Bill Dumais

40. Referrals • Narrative Homework • Referral Discussion Document

41. Lunch!

42. Brain Teasers Part Deux! Brain Bats… say what you see • sdraw • C    O    F    F    E    E • Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins Vitamins • H I J K L M N O

43. CLINICAL DOCUMENT EXCHANGE SCOPE DRAFT for Discussion

44. Documents Defined DRAFT for Discussion • HL7 Clinical Document Architecture (CDA) document characteristics: • Human Readable • Documents are used to communicate from human to human using common narrative formats (text, lists, tables, images, drawings etc.) and cross references to other material. • Persistent • Documents exist for long periods of time without change. •  Whole • The various parts of a document are an interrelated whole. • Information within a document may be related or relevant only within the context of situations described inside it. • Context • A structured document establishes the default context for its contents. • Manageable • A document may be authorized, ordered, created, stored and maintained, copied, destroyed, reviewed, released, replaced or updated, appended to, acknowledged, signed, approved and archived. • Stewardship - document is maintained by an organization (called the custodian) who is entrusted with its care • Potential for Authentication - document is an assemblage of information that may be legally authenticated

45. Document Formats DRAFT for Discussion • Electronic • E.g. HL7 CDA Discharge Summary • Transmitted electronically and incorporated into EHR or generated from EHR. • Paper Based • E.g. signed consent form • Incorporated into EHR through scanning and applying the context through indexing at the time of entry.

46. Documents Contain Data DRAFT for Discussion • Documents must be human readable; however, it is also anticipated that most electronic documents will also incorporate significant portions of discrete data that may be at different levels of encoding. • Example, a discharge summary may include textual information and a table of medications prescribed on discharge, but might also include a codified list of discrete medications. • Expectation of an EHR receiving a document that contains discrete data is that the discrete data, where appropriate, would be incorporated into the EHR's discrete data and displayed alongside discrete data received from other sources or input directly into the EHR. • For example, the EHR's Medication List would be updated based on medications entered by the EHR user, but also from medication information in discharge summaries, transfer of care documents, treatment plans, insurance providers or updates from a pharmacy system.

47. Documents Reference other Documents DRAFT for Discussion • Some documents may be amalgamations of other documents or information derived from other documents and sources. • Revisiting the characteristics of a document such as the potential for authentication and wholeness explain the importance of maintaining the concept of the document. • Example, a Consultation Report may incorporate results from diagnostic testing and reference reports received from specialists that were party to the consultation. • However, once the author (presumably the consulting provider) has amalgamated the materials into his report, included links to referenced and related documents and authenticated them as whole within the context provided; then the new document is formed. • The importance of maintaining the integrity of the document as a 'whole and authenticated' product is critical to the integrity of the EHR. • Whilst it is expected – and desired – for the receiving EHR to extract the discrete diagnostic data that was included in the report into the relevant sections of the EHR; it is equally critical for the document to continue to be preserved in its original form.

48. Sources of External Documents DRAFT for Discussion • Administrative systems such as Practice Management Systems (PMS) • Financial information systems • Other EHR systems • Personal Health Record Systems • Health Information Exchange Networks • Other caEHR systems • Hospital or acute care systems • Clinical Research systems • Others…

49. Document Types DRAFT for Discussion

50. Existing Standards DRAFT for Discussion