Meeting Minutes
S&I Framework
Query Health Initiative
Clinical Working Group
Meeting Date: 10/18/11-10/19/11
Meeting Title: Query Health Clinical WG – Face-to-Face (F2F) Session Days 1 & 2
Agenda/Objectives:
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Prioritization and Development of User Story
Develop and Refine Functional Requirements (Information Interchange, System &
Dataset)
Identification of Pre/Post Conditions, Issues and Obstacles
Develop Use Case Diagram. Base flow Activity & Sequence Diagrams
CIM Discussion
Action Items:
Description
Owner
Status
Due Date
Set up a sub-workgroup to develop the
definition and exclusions for the
numerators and denominators related to
the Expanded Analysis User Story.
Support
Team
In Progress
11/2/2011
Update Use Case Assumptions to reflect
working group suggestions.
Support
Team
In Progress
10/26/2011
Implementation planning for pilots should
consider include small 1-5 physician
practices to better understand workload
and system balancing.
Support
Team
Not Started
11/15/2011
Update Risk, Issues & Obstacles section
of the Use Case to include concerns
about potential issues with HIEs receiving
de-identified data.
Using the defined numerators and
denominators the Pilot sites will develop
the specific questions for the queries.
Follow up with Technical WG with
concerns and questions that came up
during the F2F Sessions.
Validate that the term “EHR or Health IT
System” is used consistently throughout
the Use Case
Doug
Martin
In Progress
11/26/2011
Doug
Martin &
Mike Buck
Not Started
11/15/2011
Support
Team
In Progress
10/16/2011
Support
Team
In Progress
10/26/2011
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Clinical Working Group
Day 1
Key Discussion Points: Use Case Diagram Discussion and Review
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The meeting kicked off with a detailed discussion regarding the Use Case Diagram
o Revisions were made to identify and add all roles and their corresponding to the
functions within the Use Case.
The working group members identified several Use Case assumptions & preconditions
throughout the course of the discussion
Time frame restrictions (related to Query Response, time outs, hang ups, etc.) came up
throughout the day 1 discussions.
o This concern will be passed along to the Technical Working Group for their
consideration. For example the group wants to understand how the framework
will handle limitations within the query itself.
The Clinical WG would also like to learn more about how the technical WG plans to
handle smaller organizations receiving queries that may not have enough memory to
handle the query request.
Results are “aggregated” and de-identified behind the firewall of the organization and
therefore are not pulled forward line level data. For example, results my come back by
insurance type or by provider, zip codes, age groups etc.
Key Discussion Points: Reference Implementations
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The WG members expressed their concerns around whether small practices / providers
are equipped to handle query requests. Since this is related to the technical framework
this concern will be passed along to the technical WG
Key Discussion Points: Overview of User Stories and Discussion on Expanded Analysis
of Diabetic Care in Outpatient setting
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The working group and support leads provided an overview of the 4 user stories:
o In-depth analysis of the Expanded Analysis of Diabetic Care in the outpatient
setting was chosen as it was the highest scoring User Story.
 The additional User Stories should be kept in mind when developing the
requirements so that they aren’t precluded from being potentially adopted
and leveraged
 The query will be limited to those patients who have Type I and Type II
Diabetes. Gestational Diabetes will not be included.
o The group reviewed reasons for why Expanded Analysis of Diabetic Care in
Outpatient setting was chosen
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List of Metrics were identified, reviewed and prioritized based on ease of
capturing data. All data elements to be captured for active patient data (i.e. alive
patients)
 Labs
 HbA1C > 9% (however, all other A1C metrics can be queried)
 LDL> 130 mm/hg (however, all other LDL metrics can be queried)
 Nephropathy i.e. Urine for Microalbumin <30
 Smoking Status
 The challenge with this metric is that each EHR will have a
different way to document the information. Could be a yes/no or
could be a scale from 1-5 etc.)
 While some community members disagreed keeping this measure
the group felt it was something they wanted to leave in since it
was so important.
 BMI
 BP (Systolic / Diastolic)
The group discussed benchmarking the results from the query; however, this
would be challenging as it would require identification of benchmarks for zip
code, age groups, race, ethnicity, provider groups etc. For this reason they
decided identifying benchmarks should be the responsibility of the Results
Receiver.
Key Discussion Points: Activity Diagram
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The steps within the Activity Diagram were revised in an interactive session with the working
group members.
o The working group members decided on a number of revisions which can be
seen in the most up to date diagram posted to the wiki.
o An additional assumption was added to the list
 Data loaded into the CIM model is de-identified data
o Risk/Issue: In certain scenarios identified clinical data might be required at the
intermediary level. Without this we might run into the issue of receiving multiple
query results from various EHR systems on the same patient. Without the identifiable
information this information wouldn’t be able to be merged, which would result in the
data being skewed.
 Doug Martin will revise this risk/issue so that it can be included within the
Risk, Issues & Obstacles section of the Use Case.
Resolution(s):
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The WG members made revisions to the diagrams and assumptions live. These updates
will be uploaded to the wiki for review.
Assumptions
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Query response times are dependent on the questions and priority.
Laboratory results have been sent to the EHR system and “Structured” data is
entered and available for the patient (i.e. problem lists, meds, allergies, etc).
o General health concepts (exercise, nutrition etc) are also important to the health
of the individual; however they are not being explicitly measured as part of the
query result
o The query syntax will be developed as part of the technical specification
Preconditions
o Patient clinical information/data is entered into the EHR during routine patient
care
o Provider/Provider Organizations subscribe to queries of interest
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Day 2
Key Discussion Points: Aggregator Discussion (Activity Diagram)
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The workgroup continued discussion and editing on the Activity Diagram and the
Aggregator Role from day 1
Boxes 11-15 seem to be more technical in nature and perhaps could be combined with
some of the other steps.
o Boxes 11-13 was replaced by “EHR System formats aggregated analysis results
into the query request result field”
 Left 14-15 as is into the role of the both Data source and Aggregator
shared role.
The activity diagram was updated to reflect that the data source can either be an
Electronic Health Record System or a Health IT System (i.e. registry, data warehouse).
Resolution(s):
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Group agreed on “EHR or Health IT System” to be the consistent term across the whole
use case in reference to the data source
o NOTE: This should be cross checked during the Use Case content reconciliation
to make sure terminology is consistent.
Key Discussion Points: Expanded Analysis User Story
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The group prioritized measures in relation to diabetes on ease of extracting them from
the EHR systems
o It was decided in day 1 that lab values are the easiest to document and extract
During the discussion, representatives from potential pilot sites for the Query Health
Initiative made sure to weigh in from their perspective what it would mean to their
organization in terms of implementation
Summing values such as the Hemoglobin A1c, LDL, BP, BMI could potentially allow
providers to see a percentage of high risk patients in their communities
“Structured Data”:
o It is important to prioritize what we think we can get in terms of structured data,
pilots, and then adding other items such as medication lists, etc.
o Smoking Cessation: There’s a difference between yes or no in terms of smoking
cessation – MU wants to know that the question is being asked but it doesn’t
require intricate details. We are just going to be asking if someone is a current
smoker or not (structured data value of either Yes or No)
 Emphasis is on childhood obesity; question for smoking has been asked
from 13 and above
o Discussed the potential to include documentation of Eye and Foot exams via
pulling Dx /CPT codes as it is not easy to pull via free text notes documentation.
However at this time decided to not include those as part of the queries.
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There are LOINC codes that are used some of the time that are used without having to
tailor to the particular value set vs. cross vendor you can use the LOINC codes more
often.
o Group was reminded that once the data elements are defined that should be
queried against, Harmonization to current standards will determine which of the
different LOINC codes will be used – This occurs after the Use Case is
developed
Defining the question (query - The ToC CIM should be foundational to the information
that we will be querying against ):
o Example questions:
 Based on the recognized quality measures, from a population health
management standpoint, what percent of patients are meeting these
goals?
 What is the distribution of HbA1C control by NYC neighborhoods for
patients seen within the last year?
o While starting out, it’s important to make the question simplistic enough so that
we can prove the mechanism.
o The group determined that they would define the denominator and numerator
options.
The pilot sites will be responsible for determining how they will use the denominators
and numerators to ask specific questions of interest.
Calculations:
o Numerator Fields: Patient Count, Risk Stratification Group
o Denominator Fields: Age, Zip Code, Gender, Race/Ethnicity, Last Seen, Alive
(y/n), Facility, provider, specialty etc.
o Risk stratification will be conducted in order to see the distribution of patients who
fall into any of the following categories: BMI > 25, LDL > 130, BP > 140/9, HgA1c
> 9, and smoker, ALSO could have Nephropathy (Microalbumin) > 30.
o If these scores are added together most they could have is 6 least is 1 then you
can choose where the point is where a patient is at high risk.
 The group suggested that the range could be from 0-6 if a patient didn’t
meet any of the metrics (i.e. total of 7); however, it was pointed out that in
order for a patient to be considered a diabetic, he/she must satisfy at
least one of the scores.
There may need to be some exclusion criteria if patients cannot be tested.
o A sub-workgroup will be set up to develop the definition and exclusions for the
numerators and denominators.
Resolution(s):
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Check to see if it is relevant to add a general assumption about general health concepts
(exercise, nutrition etc) and that they are also important to the health of the individual;
however they are not being explicitly measured as part of the query result.
Risk stratification will be conducted in order to see the distribution of patients who fall
into any of the following categories (or none):
o HgA1c > 9.0%
o Blood Pressure > 140/90
o LDL > 130 mm/hg
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Smoker
BMI > 25
Microalbumin > 30 micrograms/mg Creatinine
Key Discussion Points: Functional Requirements
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Information interchange requirements:
o No comments – all members present agreed with the format and descriptions
System Requirements:
o In order to complete the information interchange described within the Use Case
your system has to meet these requirements
o The concept of being able to “subscribe” to the queries will be brought back up to
the technical working group (Query metadata was added to address some of
these items)
o Asynchronous messages vs. synchronous messages: Do we need to account for
the fact that queries might not exist anymore?
 In this scenario, the requestor would stop working (inactive)
 A date could be set, after which the query result won’t be valid or
necessary anymore
 This topic will also be sent to the Technical WG for their consideration
There will be more Metadata in this section
o Metadata is really important in terms of a distributed system
o This becomes the dataset for analysis in this system
Query Metadata (Defining the Envelope) Discussion
o This part of the discussion focused on defining all of the Query Metadata terms
for developing the “envelope” that will be used to send the Query Syntax.
 NOTE: Look to Definition column of the Query Metadata table to see
details of this discussion.
o The query syntax won’t be defined as part of the use case but will be defined as
part of the technical WG efforts.
Structured Data Elements for Generic User Story
o General section – concept of diagnosis – we are only interested in this for
Diabetes. Type I and II you would use the ICD 9/10 codes for this diagnoses
Resolution(s):
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Group got verbal consensus on the Functional Requirements
Questions for technical working group:
o Clarify details around query subscription.
o Will a requestor be able to make edits as part of renewing a query or will they have
to create a brand new query?
 Add to assumptions:
o The query syntax will be developed as part of the technical specification
o Leverage output of LRI initiative
o Returned query values are aggregated
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All measures should be ideally documented of which selected measures will be
tracked
Query may consist of multiple results entries
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