SDS & Harmonization HeD Leadership Agenda

SDS & Harmonization HeD Leadership Agenda • Solution Plan Discussion • HeDStandards Selection Risks • Timeline review • Detailed Data Requirement Analysis • Follow-up on discussion with Dave Shields • IG Update • Conformance Verbs • Data Model Approach • Functional Interaction Types • Vocab & Codeset inclusion into HeD UC2 IG: update from HL7?

Discussion Points and Activities for Week of 5/20 • Solution Plan Discussion • Presentations on vMR and CCDA held last week • Decisions on Standards must be made ASAP • Specifically the selection of vMRvs CCDA/QRDA, • SOAP vs. REST • Meetings with EPIC and Partners Healthcare being held to help facilitate discussion

CDS Request Options Option #1: CDA/vMR Request Service: DSS Request Element Request Service: DSS Request Element Request Service: e.g., DSS Request Element Request Items Organizer/Container: CDA Based Container(CCDA, QRDA) Request Items Organizer/Container: vMR/GELLO Request Items Organizer/Container: CDA Based Container (CCDA, QRDA) Request Item Payload: vMR Clinical Statement Request Item Payload: vMR Clinical Statement Request Item Payload: CCDA Option #2: vMR/vMR Option #3: CDA/CCDA

CDS Request Options

CDS Response Options Option #1: HeD Schema/vMR Option #2: vMR/vMR Response Service: DSS Response Element Response Service: DSS Response Element Response Items Organizer/Container: HeD Schema Response Items Organizer/Container: vMR/GELLO Response Item Payload: VMR Proposal Response Item Payload: VMR Proposal

CDS Response Options

CDS Options Summary

Discussion Points and Activities for Week of 5/20 • HeD Standards Selection Risks • vMR vs. CCDA • SOAP vs. REST • Update from Pilots Call on SOAP/REST • Information on use of SOAP today?

2 of 12 Health eDecisions (HeD) Standards RiskvMR vs. C-CDA vs. QRDA • Background • vMR, C-CDA and QRDA could support the payload of the request for CDS guidance • C-CDA is in wide use today within EHRs and is cited in regulation, but there is currently no template specifically for CDS use, and existing templates may require population of data that is non-essential to a CDS guidance request • QRDA is used for quality reporting; it leverages the C-CDA construct, but may not be as strictly templated • vMRis used more heavily for clinical decision support and was the basis for the HeD UC1 solution, but there may be push back from EHR community if we require another format for export of data • The community is torn and is unsure which solution would be better for sending a request for CDS guidance to a CDS service • Risk • The HeD community is currently exploring the option of writing Implementation Guidance for both vMR and C-CDA and using pilots to determine which solution would be better for HeD. • Community time and support team resources would be spent developing implementation guidance that may never be used (depending on which standard is selected after pilots) • Ongoing and Planned Mitigation Actions • C-CDA and vMR overview presentations will be given to the community this week in order to give them a better idea of how it could be used to support a CDS Guidance Request • HeDLeadership is considering developing vMR as its primary implementation guidance, and developing C-CDA guidance only as time and resources allow • Another option that is being considered is the use of a C-CDA-to-vMR transform, which would allow EHRs to continue using C-CDA alone but still utilize vMR within the CDS Guidance Request 11

3 of 12 3 of 4 Health eDecisions (HeD) Standards RiskvMR vs. C-CDA (continued) • IG Options 12

4 of 12 4 of 4 Health eDecisions (HeD) Standards RiskSOAP vs. REST • Background • SOAP is widely used in the industry today; REST is considered to be the future standard for the industry • Risk • The HeD community would like to develop Implementation Guidance for both as different vendors may have a preference for one vs. the other • However, if the use of SOAP vs. REST varies from vendor to vendor, ultimately this would necessitate EHRs and/or CDS Service Suppliers to support both, which would be a burden on implementers • Ongoing and Planned Mitigation Actions • We are raising this risk to the HeD Pilot community to get there input on how much of a burden this would be, and if they would instead prefer either SOAP or REST (and which one) • Solution Options 13

HeD UC2Proposed Harmonization Timeline

HeD UC2Proposed Harmonization Timeline: Solution Plan Impact

Discussion Points and Activities for Week of 5/20 (Continued…) • Detailed Data Requirement Analysis • Review approach to complete document • Possible to block off 3-4 days to complete? • Should we be using the data elements from the schema instead of in conjunction with the elements from Use Case 2? • SDC team noticed that the Actions section had additional elements in the schema that weren’t in the Use Case

Update on Conversation with Dave ShieldsTransactional Layers Transport and Security • The response needs to include context elements (e.g., patient) that were not part of the HeD UC1 spec. • The request and response should have parallel approaches • The response wrapper would be in a class/complexType called CDSOutput • This type would incorporate appropriate pieces of the HeD schema (e.g., actionGroup, actionSentences, etc). • To not have a two-way dependency between vMRand HeDS (HeD schema from UC1), we will move the current CDSInput and CDSOutput types from the vMRnamespace into a new namespace • The cdsInput and CDSOutput will continue to be part of the vMRspecification and project Request Service: e.g., DSS Request Element Request Items Organizer/Container: e.g: VMR or CCDA Request Item Payload: e.g., VMR Clinical Statement Transport and Security Response Service: e.g., DSS Response Element • So the response will look like this: DSS Response Element Contains CDSOutput (new name space, new type that imports HeDS types) Contains vMR Clinical Statements (in vMR namespace; further CDSOutput will be designed so that clinical statements from other types can be incorporated (e.g., FHIR), but this is out of scope for HeD UC2) Response Items Organizer/Container: e.g., HeD Action Groups Element Response Item Payload: e.g., VMR Proposal

Discussion Points and Activities for Week of 5/20 (Continued…) • IG update • Have determined which sections will be populated internally, and which sections will be community homework. Have also drafted a timeline for completion of each section. • Internal team beginning to populate the Introduction section • Begin Implementation Approach Sections? • Pre Conditions • Constraints • Should Conformance Verbs include the full HL7 v3 list or to cut out the May/Need Not per ONC’s direction? • shall: an absolute requirement • shall not: an absolute prohibition against inclusion • should/should not: best practice or recommendation. There may be valid reasons to ignore an item, but the full implications must be understood and carefully weighed before choosing a different course • may/need not: truly optional; can be included or omitted as the author decides with no implications • Data Model Approach • Talking point at HL7 Patient Care/SD/CDS WG Joint session: the XML format of HeD schema/expression language is not as useful/valuable as a more generalizable model (e.g. UML) would be • What’s useful to an implementer? • What’s in our purview?

Discussion Points and Activities for Week of 5/20 (Continued…) • IG update (continued…) • Functional Interaction Types • How many should we focus on? • Drug Dosing Calculation • Immunization Forecasting • Disease Management • Quality Measure Evaluation • Transition of Care Support • Prediction Rule Evaluation – APACHE score, AHRQ Pneumonia Severity Index, etc. • Severity of Illness Assessment – Charlson index, etc. • Will these be included in the main IG document, or can they be submitted as examples (allowing them to come after the other materials) • Vocab & Codeset inclusion into HeD UC2 IG: update from HL7? • How will we leverage Vocab & Terminology WG/work • Scrum calls have been reinstated on Fridays from 3:30 – 4:00

Appendix

Use Case 2 – CDS Guidance Service Transactions CDS Guidance Requestor CDS Guidance Supplier 1. CDS Request (Clinical Data & Context) INSERT SELECTED STANDARDS HERE 2. CDS Response (Clinical Data, Supporting Evidence, Supporting Reference, Actions, Attribute-Value List, Response Metadata & Exceptions) INSERT SELECTED STANDARDS HERE

Use Case 2: CDS Guidance Service Transactions - Standards per Transaction

CDS Guidance Request Transaction: Service Standards Rationale

CDS Guidance Response Transaction: Service Standards Rationale

CDS Guidance Request Transaction: Organizer/Container Rationale

CDS Guidance Request Transaction: Organizer/Container Rationale (continued…)

CDS Guidance Response Transaction: Organizer/Container Rationale

CDS Guidance Response Transaction: Organizer/Container Rationale (continued…)

CDS Guidance Request Transaction: Item Payloads Rationale

CDS Guidance Request Transaction: Item Payloads Rationale (Continued…)

CDS Guidance Response Transaction: Item Payloads Rationale

CDS Guidance Response Transaction: Item Payloads Rationale (Continued…)

CDS Guidance Request Transaction: Transport Rationale

CDS Guidance Response Transaction: Transport Rationale

CDS Guidance Request Transaction: Authentication/Authorization Rationale

CDS Guidance Response Transaction: Authentication/Authorization Rationale

CDS Guidance Request Transaction: Encryption

CDS Guidance Response Transaction: Encryption

Solution Plan • View the different combination of standards, across the different buckets, and determine the viability of each implementation option • Decide which implementation option(s), and therefore combination of standards, is the best approach • Document reasons why certain implementation options were chosen or not chosen

Solution Plan Next Steps • Decide which implementation option(s), and therefore combination of standards, will be used as the approach in the IG and incorporated into the final design

Gap Mitigation Plan • Identify any gaps for all standards under consideration • Determine if the gap is for the request or response transaction, or both • Document recommendations on how to close the gap (i.e. modification to existing standard)

Gap Mitigation Plan Next Steps: • Pull out the standards which have gaps requiring modifications and document in the IG • Contact the SDO to initiate modification needed • Gaps that are related to a standard being utilized in a manner which it has not previously been designed for will be addressed and written into the IG

SDS & Harmonization HeD Leadership Agenda