Canadian FHIR Baseline Profiles - Governance Stream Meeting - September 27th, 2-3pm EST

I don't think the US Core profiles have enough information to support full medication management *or* e-referrals. Such functionality would be layers on top of the US Core base standard. US Core would let you know what medications a patient was taking, but would not give sufficient support for ordering meds or dispensing them, and there's no support for tracking administrations at all. Support for discrete dosage is much less than what we have in most Canadian DIS systems. Similarly, US Core would allow you to see that a referral had happened, but wouldn't let you make one or manage one and, again, support for discrete data is low. It really is a "lowest common denominator" spec.

The benefit of supporting US Core isn't that systems are suddenly able to expose tons of new data elements. Rather, it's that clients can count on a consistent minimum set of data elements from pretty much everywhere. It also defines a basis for future growth. To the best of my knowledge, U.S. Core didn't require implementers to support a single new data element that they didn't already have to support in v2 or CDA. It simply expressed the minimum data set that the US government had defined through meaningful use and added in a few additional data elements that the implementers agreed they could all do and felt would be useful to share.

If almost all systems in Canada are already tracking gender identify information as patient demographics, then there's a good case for including it in the initial version of CA Core as mustSupport. If not, then the best it can be is optional, and it can only appear at all if the jurisidictions have consensus about what the codes should be. The 'core' spec reflects application capabilities, it doesn't drive new ones from a data perspective, only from an architecture perspective. It's the IGs that build on the 'core' spec that start to drive new capabilities. But you have to have the foundation in place first.

Folks,

I think we can agree that the US-core profiles have gone through an extensive vetting process with multiple use cases based on meaningful use criteria. So our current effort is to assess how well these profiles fit within the Canadian context. If there is concern that our use cases are too narrow, may be we can focus on key domain areas where Canadian jurisdictions and organizations have already made significant investments. How about looking at the three domains of medication management, patient summary and electronic referral? I hope we can all agree that the CA-core profiles should be able to cover the data elements for these three domains, which takes up a big chunk of the healthcare activities in Canada? By having three overlapping domains, jurisdictions/organizations can raise their hands to focus on one or more areas based on their resource availability, and have the confidence that areas not covered by them will be addressed by others. We still need to have a strong argument to justify the need for CA-core profiles, but now these can be described in ways that make sense to different stakeholder groups like improved medication safety, clinical documentation and continuity of care through more specific use cases that are relevant to specific audiences.

As for sex-gender, I think their rightful place is in demographics, not as observations that have to be collected during clinical encounters. This is no different than ethnicity-race that most agree (I hope) should be part of the demographics. Whether we want to or not, there is growing momentum to incorporate sex-gender info into electronic systems now. The ONC 2019 ISA reference edition has defined Sex at Birth, Sexual Orientation and Gender Identity as part of the required patient info for EHR certification (www.healthit.gov/isa/section-i-vocabularycode-setterminology-standards-and-implementation-specifications ). In Canada, there is already work done/underway at multiple levels. As examples: (1) Treasury Board has published a policy direction on collecting sex-gender data in federal agencies (www.canada.ca/en/treasury-board-secretariat/corporate/reports/summary-modernizing-info-sex-gender.html#h-6 ); (2) CIHI has published sex-gender as part of the socio-demographic stratifiers (www.cihi.ca/sites/default/files/document/defining-stratifiers-measuring-health-inequalities-2018-en-web.pdf ); (3) BC health ministry has done extensive work defining sex-gender info as an expanded set of demographics information; (4) Dr. Pinto at St. Michael Hospital is already collecting sex-gender data routinely at their clinics ( www.cmaj.ca/content/191/3/E63). By aligning the CA-core profile work with these initiatives, I think it will make a strong argument for jurisdictions/organizations to work on the core profiles since it has clear focus and tangible outcomes that are relevant to their communities.

Thanks - Francis

I'd be a strong supporter of this if we had a sense how to get it off the ground. Is this something Infoway would be willing to take the lead on forming?

My only caveat would be starting it at the level of a single province. It might be that one province would drive initial activity, but participation should be open to other jurisdictions and we should try to have at least 3-4 present for one of the different types. Otherwise it's going to be hard to get anyone else to play or feel in any way bound by the recommendations.

Hi all,

Don't want to interrupt the momentum of the great comments being posted in this thread, but just wanted to honor the routine process and post the meeting attendees and broad discussion points. Please continue to discuss in this thread following this post. Apologies for the light content below, had a number of IT issues on my end so had to get a little creative; please feel free to post your notes if they are more comprehensive.

Attendees

Michael Savage
Derek Ritz
Jorge Pichardo
Alex Goel
Andrea MacLean
Fariba Behzadi
Joel Francis
Philip Alcaidinho
Ron Parker
Russ Buchanan
Scott Prior
Shamil Nizamov
Smita Kachroo
Raman Dhanoa
Francis Lau
Finnie Flores

Discussion

• Contributions from the Community on the approach needed to have the Canadian Baseline Profiles endorsed at the national level – emphasis on concrete, actionable items the community can move forward

• Pitches / requests for support MUST start with the clinical context – any pitch to a group should focus on the fact that these core profiles can be built off of to better support the clinical workflows and use cases

• Need to get the focus beyond just profiling
o Need to wrap clinical use cases around the draft profiles
o E.g. “here’s how we will use this in a clinical workflow, and here’s how a vendor can test that it’s been implemented properly”

• Ultimately we need all key pillars of stakeholders (e.g., patients, vendors, clinicians, jurisdictional groups, etc.) aware and supportive of the work
o Need to start collecting a list of key stakeholders to pitch the work to

Hi all,

Just wanted to make a comment from a vendor perspective re: governance, the need to draft a business case for wide-spread adoption of FHIR standards, and the various stakeholder "pillars" we briefly started identifying on Friday's call. I think it's very important that we first look at the end-users who will be most impacted by this type of work and work our way backwards. It's almost as if we need a group of leadership hospitals, ambulatory centers, etc. across a single province (to start), who come together on a volunteer, non-compete basis and a governing/organizing body without legal insight (i.e Infoway, CIHI) overseeing it. This would be very similar to the formation of the Electronic Health Record Association (EHRA) here in the U.S which was established about 5-7 years before the first round of Meaningful Use was implemented. We can learn a lot from the M.U program, specifically that we can't shove this type of thing down the throats of hospitals, providers, etc., we need them at the table with us.

The EHRA brings together companies that develop, market, maintain and support EHRs and work in collaboration to help drive standards and push (sometimes push-back) future initiatives. The EHR Association is led by an Executive Committee and routinely provides testimony, comments, and education to legislators and policymakers, and have open, on-going, and collaborative dialogue with federal agencies and standards committees.

My apologies for coming at this from a different angle, but I think it's important to be considered as part of a future business case.

The base use-cases are support for SMART on FHIR, CDS Hooks, FHIRcast and similar technologies. (And each of those have a set of compelling use-cases.) These are also the profiles that Apple Health Records and CommonHealth (Android equivalent) would use to share information between patients and clinical systems.

The CA-core profiles are the baseline from which more use-case-specific profiles can then grow. In the U.S. there are a wide variety of use-case-specific profiles that build on and tighten US Core for use in solving specific problems and sometimes even driving new behavior. However the foundational profiles need to be generic in order to be a suitable base for the key infrastructure technologies which themselves have to support a wide range of use-cases. (SMART and CDS Hooks are relevant for care delivery, research, public health, patient engagement, insurance and numerous other areas.) The base profiles are an 'enabling' layer that is necessary in order to be able to build additional capabilities.