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HL7 Clinical Quality Information May 2017 Madrid, Spain WGM Minutes Attendance:

Mon Tue Wed

Name Company Email Q3 Q4 Q1Q2 Q1

Floyd Eisenberg IParsimony [email protected] X X XWalter Suarez Kaiser Permanente [email protected] X X XBryn Rhodes Database Consulting Group [email protected] X XChris Melo Phillips [email protected] XKen Kawamoto Univ of Utah [email protected] X XLisa Anderson (Phone) Joint Commission [email protected] X X X XPatty Craig (Phone) Joint Commission [email protected] X X xStan Rankins (Phone) Telligen [email protected] X X xDavid Hamill HL7 [email protected] XWayne Kubik HL7 [email protected] XAnne Smith NCQA [email protected] X XMichael Brody TCS mbrody@tcssystemts XAustin Kreisler Leidos [email protected] Claude Nanjo Cognitive Medical Systems [email protected] xGalen Mulrooney VA [email protected] XMarten Smits Furore [email protected] xMuhammed Asim Phillips Muhammad.asim.philips.com XRichard Esmond Pen Rad [email protected] XRobert Jenders UCLA [email protected] xManuel Suarez Taboada Bahia Software [email protected] XPatrick Lloyd Cognitive Medical [email protected] XLorraine constable Cognitive Medical [email protected] XTessa vanStijn NICTIZ [email protected] XRachel Richesson XCharles Parisot GE Healthcare [email protected] xSteve Hufnagel CIMI [email protected] XStan Huff Intermountain Health [email protected] XSusan Matney Intermountain Health [email protected] XBar van den Hensel Phillips Healthcare [email protected] XRobert Wade [email protected] x

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mailto:[email protected]



























HL7 Clinical Quality Information May 2017 Madrid, Spain WGM Minutes

TUESDAY ATTENDACE SIGN-UP SHEETS:

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The following is how to document votes – this includes when to bold and use italics.

CQL-based HQMF ballot reconciliation Total comments received: 66 Negative: 45 Affirmative: 21

o A-C: o A-S: 7o A-Q: 5o A-T: x5

Blank: 4

o Block Vote #1 - Item Numbers: Item #2 – Persuasive with Mod (will add documentation to explain how to

use the MeasureDescription section)

Bryn Rhodes moved to approve this disposition and Walter Suarez secondedAdditional Discussion:* Need to refer to the MAT team to ensure they can implement as specified* Added language to disposition: “In addition, we will remove the constraint that prevents inclusion of multiple measure descriptions.”Opposed: 0; abstentions: 0; approved: 15Approved

o Block Vote #2 - Item Numbers: Item #9, #10, #11, #12, #13, #14, #15, #16 – Persuasive as long as the

update isn’t a change to the change log (can’t change history).

KP Sethi moved to approve these dispositions and Juliet Rubini secondedNo future discussionOpposed: 0; abstentions: 0; approved: 11Approved

Revised ballot process PSSo Discussion occurred related to Lloyd’s request for DESD to ballot this PSSo CQI is supportive of an online process that eliminates the Excel spreadsheets;

however, concern was raised related to membership’s ability to review the requirements and uncertainty related to the exact deliverables of the project.

Walter Suarez moved to support the PSS along with the below comments which CQI requests DESD to forward and Anne Marie Smith secondedNo future discussionOpposed: 0; abstentions: 0; approved: 10Approved

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Time: Monday Q3Facilitator Floyd Scribe Walter

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

Quorum Requirements Met: Yes

Minutes/Conclusions Reached:

Agenda Topics Welcome Testing of Remote Access

The test was completed successful. Easy to start the system, good volume levels both outbound (us being heard by remote users) as well as inbound (we hearings everyone from the phone)

Video/web screen seen and refresh appropriately by remote users

We will make sure to have the system accessible for Q3 and Q4. It will also be available for Q1 and Q2 in case anyone is joining

Review of Monday Q1 and Q2 Good communication between various WGs at the multi-

WG Q2 meeting Common theme: consistency across WGs on clinical

information models – ensure CIMI work is cross-communicated

Business Session Review of Agenda for the Week

Agenda was reviewed Added discussion of creation of a CDA product family with

SCWG on Tuesday, Q1 Focused discussion on Clinical Reasoning, Status Update

on Alignment project, and review of key issues will be coordinated for Tuesday Q2

Also, CQL comment resolution will be part of Q2 Tuesday Q3 will focus on review of use cases, including

appropriate ordering, PHER immunization, infobutton Move HQMF Terminology Section to Monday Q3

HQMF Terminology Section

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There is a new API that allows to specify value sets ID, versions, and the system and versions of every code system involved in that value set.

This is sufficient for the expansion made to HQMF Are we OK with only the ELM (sharable version of the logic for the

measure) containing the information about the value sets (and how do we modify ELM to do that) or specify this on the HQMF

Preference would be in botho All this value set information should be both on HQMF and on

the ELM There was general consensus that info should be in both What Bryn suggested to do was to extend the schema extension to

support this additional info, as well as having the value set support multiple version references

Make the schema extension part of the CQL-based HQMF IG Bryn will take this to the group that is developing the document and

pursue the inclusion of the value set referencing approach into the final version of the CQL-based HQMF

Another topic brought up was the concept of Direct Referenced Code (DRC) and plans; comments from CMS included:

Need for an electronic file of OID and DRCs Some place to download all DRCs in a single measure, as group of

measures, or all measures A need for a centralized place to download DRCs seems to be clear

Supporting Documents – CQI HL7 Wiki agenda http://wiki.hl7.org/index.php?title=Clinical_Quality_Information_WG_May_2017_Madrid,_Spain

Time: Monday Q4Facilitator Walter Suarez Scribe Floyd Eisenberg



Agenda Topics STU Comment Review Request for participation in Podiatry PSS New PSS considerations

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http://wiki.hl7.org/index.php?title=Clinical_Quality_Information_WG_May_2017_Madrid,_Spain

http://wiki.hl7.org/index.php?title=Clinical_Quality_Information_WG_May_2017_Madrid,_Spain


Minutes/Conclusions Reached: STU Comment Review

o QRDA Category I STU 3o QRDA Category I STU 3.1o QRDA Category I STU 4o QDM-Based HQMF Comment #

1271 – Not a standards question. Disposition Consider- No action required Moved to approve – Floyd Eisenberg, Second – Patty Craig

Vote: Opposed = 0, Abstain = 0, Approved = 4 Michael Brody (Podiatry WG) presented information about a new PSS creating a

Podiatry version of the EHR Functional Model. o Podiatry requires some additional requirements not currently in the EHR

Functional Profile. One example is dispensed medications. Podiatrists dispense medications for fungal foot infections and other medications, including pharmaceutical samples. They are also expanding the functional model to address devices used and documented by Podiatrists that are not in the EHRFM. An additional item is the documentation of advanced wound care products such as grafts (biologic products – don’t fit well into device, medication, etc. – getting help from CIMI on modeling). The group also works with a QRDA for reporting of clinical quality measures and is working with CIMI on data modeling. The group is looking for support from other workgroups, including

PQRS 126 and 127 (neurological evaluation of diabetes, and evaluation of footwear of diabetics, respectively) – neither is an eCQM (they are only paper-based).

o Podiatry wants to create eCQMs and also create QRDAs for outcomes of treatment for heel pain and pediatric flatfoot for data to be used in the Podiatric Registry. Example items – pain scale 1-10, co-morbidities, patient demographics, patient treatments. There are currently 4 measures under consideration and there is a desire for 4 additional measures for use under MIPs.

o Podiatry meetings are 1 PM ET on Thursdays – generally information is sent to the WG ahead of the meeting and changes are sent post-meeting each week. The WG is going through the EHRFM for the first time and will do another review subsequently. Hopefully a comment-only ballot will occur in May 2017 (Cologne, Germany).

o The WG reviewed the PSS provided by the Podiatry Workgroup. Motion to add CQI as an Interested Party – Motion – Floyd Eisenberg; Second – Stan Rankins

Opposed = 0, Abstentions = 0, Approved = 5 Other PSS’

o QRDA Category I STU 5 – PSS is up to date and can be used without modification

o Clinical Reasoning FHIR 3 – PSS is up to date and can be used without modification

o QRDA Category III STU 2 – PSS approved May 19 2016 (project 896) includes a re-ballot September 2018 – can re-ballot a year earlier with existing PSS – will confirm with Dave Hamill.

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o The update planned for CQL-based HQMF to accommodate the QDM templates for QDM version 5.3 (for use with CQL) and also composite measure details – also does not require a new PSS.

o Request for consideration of KNART to be discussed on Wednesday Q1.o Should we consider a cross-WG PSS to address data validation and feasibility for

multiple purposes? For individual eCQMs, the sites must address workflow to assure accurate

capture of data. The organizations follow up with providers to capture information in the right fields to improve performance.

The all-workgroup meeting this morning discussed issues addressed in a Lantana report regarding the ability to validate data in EHRs for quality reporting (http://library.ahima.org/doc?oid=300255#.WRCSdYWcFZV) – the article was published in 2014.

The workgroup raised concerns that the scope is too broad and the real input required includes providers, EHR vendors, measure developers.

No action taken at this time – for further discussion after consideration.Business Session No additional business items.

Time: Tuesday Q1 (Hosted Structured Documents)Facilitator Floyd Eisenberg Scribe Walter Suarez



Agenda Topics QRDA Category I STU 5 (Planned for September ballot) - Direct Referenced Codes and

removal of value set OIDs Structured Documents invited CDS and many other Work Group representatives on

creation of a CDA product family. Interested individuals are welcome to join. Other topics TBD

Supporting Documents - None


Topic 1 - QRDA Category I STU 5 (Planned for September ballot) - Direct Referenced Codes and removal of value set OIDs

Quality data logic when trying to state a measure it becomes difficult. So, the plan has been to move to Clinical Quality Language. So use CQL for the logic, HQMF for the

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http://library.ahima.org/doc?oid=300255#.WRCSdYWcFZV


data model. We now have CQL-based HQMF, currently under final review. This allows to be more explicit about certain elements.

QDM-based HQMF – has mappings to QDM CQL-based HQMF – has mappings to CQL logic. It also has Volume 3 for cross-

referencing QDM elements Is that OK with SDWG?

The other issue: to make sure that when we provide value set on the terminology section of HQMF, that the reference values of the value set are provided.

Any issues for SDWG? Bottom line: value sets are still usable, but we are providing a shell to support any value

sets

Without having VSAC do the heavy lifting and having all value sets OIDs loaded, it will be a lot more cumbersome and risk loss of synchronization

Emphasis is on the need for an electronic file of OID and DRCs; a central place to download all DRCs contained in a single measure

Topic 2 - Structured Documents invited CDS and many other Work Group representatives on creation of a CDA product family. Interested individuals are welcome to join.

SD put out a ballot on this. It widens the vocabularies available. 240 comments; working on it this week; will move it to normative ballot This will help resolve the issue of negation for supply and encounter. Is this being

updated?o If they were in the RIM, they will all be here.o Value and Action negation on Observations was also separated

Since QRDA uses ActNegation – would we need to update QRDA, or can we leave it as-it?

o We are fine were we are – leaving it as-iso C-CDA is still on top of CDA 2.0. If and when C-CDA ever moves, then there

will be a need to update this as wello ActNegation is OK so long it is consistently used, and not being seen as a one-off

The other big thing is the approval of the CDA Management Groupo Product Line Architecture group has been asked to establish a formal family of

CDA productso Similar to FHIR Management Groupo Is you are planning to update a CDA implementation guide, you would work with

the CDA Management Groupo This will have an impact CQIo There is a meeting Q3 today to discuss the mission and charter of this groupo CQI will not be able to attend, due to current agenda commitments

QRDA Cat 1 is moving to STU 5 – do we need to wait for the new Management Group? No. Anything underway already will not be subject to the new management group

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The big purpose of this new group is to apply consistently the same quality criteria for IGs

Business Session: We discussed the need to have this meeting between SD and CQI

every Tuesday Q1 at HL7 WGMs. Decision was NOT to hold this as a standing meeting, but rather call for it only when needed.

Time: Tuesday Q2 (Hosted CDS and FHIR-I)Facilitator Floyd Eisenberg Scribe Walter Suarez



Agenda Topics Clinical Reasoning and CDS Hooks Status update on alignment and review of key issues including data models CQL STU Comments (if time allows)

Supporting Documents –

https://speakerdeck.com/kpshek/pss-1234-update-clinical-reasoning-and-cds-hooks-unification


A presentation on the PSS 1234 – Clinical Reasoning and CDS Hooks Unification was provided by Kevin Shekleton, Cerner, and member of CDS (see Supporting Documents).

A few key slides are included next.

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Will there be documentation about the use of the hooks, so that there can be analysis about the value, benefits, issues, challenges, etc? This analytic functionality is not at the moment in track to be part of version 1.0.

CDS Hooks will be able to use external sources. There will be multiple sources of the guidelines that can be converted into CDS rules and CDS Hooks.

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Next steps: For CDS Hooks – resolved all the initial issues of the project; working

on a 1.0 release for later this year – to be balloted in September There is a Google group, a chat, other services Everyone is invited to the project From HL7 perspective – PSS 1234 is Clinical Reasoning – now with

expanded scope to include CDS Hooks. Clinical Reasoning if part of Core FHIR Specs. CDS Hooks will have a separate NIB based on PSS 1234 that establishes the context for CDS Hooks

Need to review the PSS to make sure there is no need to change the scope.

Business Session No other business was discussed

CQI joined EHR WorkgroupTime: Tuesday Q2

Meeting did not take place

CQI joined CDS and FHIR-I WorkgroupsTime: Tuesday Q3

Agenda included:

o Clinical Reasoning and CDS Hookso Review of key use cases (Guideline appropriate ordering, InfoButton and PHER Immunization

data sharing - PHER WG key stakeholders will join remotely at 2:45 pm Madrid time / 8:45 am US Eastern Time for discussion of immunization CDS IG

o Healthcare Standards Integration WG invited CDS and many other Work Group representatives on review of these projects: FHIR for Device Data Reporting FHIR Document Sharing Guideline Appropriate Ordering Profile IHE - Lab profile to US realm lab guides harmonization Structured Data Capture (SDC) FHIR Profile International Patient Summary Template.

o Other topics TBD

See CDS meeting minutes for more information.

NO CQI MEETINGCQI members joined CDS WorkgroupTime: Tuesday Q4

Agenda included:o NOTE - CDS is meeting Q4 on Tuesday - their agenda is (listed meeting room is for CDS):

AHRQ Patient-Centered Outcomes Research (PCOR) CDS Learning Network: proposal for a Standards and Implementation Work Group coordinated with HL7 CDS Work Group

Ballot and standard review/planning Planning for next WGM

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Healthcare Standards Integration Work Group: reps invited for review of these projects: FHIR for Device Data Reporting FHIR Document Sharing Guideline Appropriate Ordering Profile IHE - Lab profile to US realm lab guides harmonization Structured Data Capture (SDC) FHIR Profile International Patient Summary Template

See CDS for meeting minutes It was noted during this meeting that QI CORE will be expiring in September, 2017. CQI

will discuss this point.

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



Agenda Topics Review new CIMI models Review “PSS Lite” for Knowledge Artifact Specification (KNART) – L. Constable, C.

Nanjo Discuss alignment with QDM, QI core Resources and Extensions HQMF Terminology Section – managing value sets and direct referenced codes Other topics as proposed

Supporting Documents -

Minutes/Conclusions Reached: CIMI Model

o 55 comments, 14 negative – first for comment ballot for CIMI – resolution in progress. The comments adjudication will begin Q1 and Q2 on Thursday at this WG meeting.

o Claude Nanjo provided a general, high level overview of the CIMI structure/content:

Defining detailed clinical models with constraints – main one is CIMI skin and wound assessment (with Patient Care). Tooling discussed yesterday (Q3).o 3 layers of reference model

Core layer – set of primitive types, most adapted from Open Air (parts modified) – every class derives from locatable association class and is associated with data value

More complex data types – text to represent coded fields – identifier, Boolean values and a number/integer values – aligned with FHIR – cannot do a ratio of integers, must interpret as an integer

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Aligned with ISO 13606 – semantics loosened for a broad set of use cases. ISO 13606 is focused on the clinical record.

Role – actor – party relationship (participation – parties can be related to a party relationship)

Compositions – content which can have sections that can have other sections or content – composite or simple entries

Clinical layer – ballot includes multiple inheritance which needs to be modified in ballot reconciliation. The clinical layer is a base clinical statement about the patient – provides the formal context – Topic and Context.

Topic (e.g., clinical finding) Context (e.g., presence or absence, performed, not performed,

attribution) Number of attributes to capture attribution (who captured, signed,

verified, record status, etc.) Foundation of clinical statement model –

Finding (e.g., measurements, statement of conditions), - Finding context (unlike mood codes, these are

classes) – context brings attributes that are relevant Absent (absolutely certain to be absent) Known or suspected present (with context

codes to differentiate)- Acts (e.g., clinical activity),

Act context Proposed – proposed against Promise of performance Planned Performed – Not performed –

Performed but not completed- Events (e.g., impact on clinical care but not clinical

events, e.g., car accident) Ballot material has a zip file with an html, navigable view

of the CIMI model and classes – Available at models.opencimi.org – must sign a license agreement and then can navigate to ballot information – open for comment on that site.

CIMI and Federal Health Information Model (FHIM) should align at the top level to provide a high-level view of how all fits in with other standards, including FHIR.

“PSS Lite” for Knowledge Artifact Specification (KNART) – L. Constable, C. Nanjo Investigative PSS – need for competent knowledge artifacts – define

comment elements and how to harmonize and de-duplicate elements (particularly across order sets and in the presence of co-morbidities), how knowledge artifacts relate to others, versioning a lifecycle management. Seeking sponsorship by CDS and co-sponsorship by CIMI and CQI.

Discussion – how will the resolution of issues identified occur. KNART is a conceptual specification – it is also the basis for resource descriptions in

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the Clinical Reasoning module of FHIR. Would it make more sense to define the resolution in Clinical Reasoning. Clinical Reasoning addressed some of the issues (e.g., composite) and trying to update the initial Knowledge Artifact may require more effort than using the Clinical Reasoning FHIR component. KNART is based on vMR.

The main question (in addition to resources to manage the projects) is the value in maintaining two parallel standards intended for the same purpose. Each requires some work:

The KNART update would require Motion to approve to include an investigative item to consider

whether we move from the current KNART specification to the Clinical Knowledge FHIR presentation – for Sponsorship by CDS, CQI co-sponsor, CIMI co-sponsor – the room has a quorum for all 3 Workgroups

Motion by Floyd Eisenberg Second by Richard Esmond Discussion – questioned if there are sufficient resources

and the answer was that the resources exist. This is an investigative project – a PSS lite. Another question addressed the rapid timing listed in the PSS lite – the project is time limited to 1 year and the requirements for PSS lite includes a maximum of 2 WG cycles.

Opposed = 0; Abstain = 0; Approve = 24 (21 present in the room and 3 remote access, not including the chair)

Alignment with QI Core, US Core and CIMI – US Core requires further constraints – e.g., a medication request needs dosing information to specify the logic in calculating morphine milligram equivalents. The question is whether QI Core should focus on narrow and deep profiles based on specific use cases or a broader approach. The question is where the expertise lies for the deep details needed. CDS WG (and CQI) do not necessarily include the clinical subject matter experts to collaborate on the detailed requirements. FHIM has similar content needs. QI core expires in September 2017. CQL expires in 11 days – applying the changes to CQL and QI Core – to be published soon but QI Core content will be fairly broad. There is also an effort to map QDM into QI Core (QDM is a US-based CMS conceptual data model).

HQMF Terminology section discussion was deferred due to time constraints.

CQI joined CDSTime: Wednesday Q2

Agenda included

o September WG Meeting Planningo PSS Review for September WG Meetingo Tentative: Janek Metsalik to present on Estonian CDS interoperability plan


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Resources and Notes:

o Connectathon summary from Bryn – https://docs.google.com/presentation/d/1u-v-Bk0a9qsiRnE6j-9vSaYMgK0ZJ9iz2SHR-5c0eMs/edit?usp=sharing

o Update on meeting needs with CDS

http://wiki.hl7.org/index.php?title=CDS_WG_Agenda_2017-09

o Additional updates on CQI Meetings: CQI WG by itself Monday Q3 and Q4 Agreement that there is no need to have a standing meeting with

SDWG on Tuesday Q1 CQI will reserve Tuesday Q1 (for itself or meeting with SD, if needed) Agreement to have CQI, CDS and FHIR meet on Tuesday (instead of

Thursday) Tuesday Q2 – CQI host CDS and FHIR Tuesday Q3 – CDS host CQI and FHIR

CQI will reserve Tuesday Q4 for itself or meeting with others (PC, others)

Wednesday Q1: Agreement to have CQI host CDS and CIMI Wednesday Q2: Agreement to host CDS Wednesday Q3: Meeting with CDS, FHIR-I, OO on FHIR Resources

with joint interest, such as Plan Definition, Activity Definition, Activity Group, etc.

Wednesday Q4: Meeting with CDS and CIMI, hosted by CDS. Thursday Q1: CQI Wrap-up of week and plans for future WGs Thursday Q2: Open Thursday Q3: Open Thursday Q4: Open

CQI joined Learning Health Systems Work GroupTime: Wednesday Q2

Did not join this meeting See Learning Health Systems Workgroup meeting minutes for more information.

CQI joined PC, CDS, RCRIM, OO, and FHIRTime: Wednesday Q3

Agenda includedo Joint meeting with FHIR-I, CDS, CQI, OO Topic: FHIR resources with joint interest, such as

Plan Definition, Activity Definition, Activity Group, ProcedureRequest, Condition, Observation

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http://wiki.hl7.org/index.php?title=CDS_WG_Agenda_2017-09

https://docs.google.com/presentation/d/1u-v-Bk0a9qsiRnE6j-9vSaYMgK0ZJ9iz2SHR-5c0eMs/edit?usp=sharing

https://docs.google.com/presentation/d/1u-v-Bk0a9qsiRnE6j-9vSaYMgK0ZJ9iz2SHR-5c0eMs/edit?usp=sharing


o GF#12966 ProcedureRequest - add DosageInstructions or Quantity ReferralRequest / ProcedureRequest boundaries

See PC meeting minutes for more information.

CQI joined CDS and CIMITime: Wednesday Q4

Agenda includedo Discuss use of Organization Resource for plan, disease management program participationo Tentative CIMI for Quality


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