I like the drawing, and the implication that "Problem List Items" is a subset of "Health Concerns." That seems to align with what I'm hearing from the practicing community.
(One tweak: An Encounter Diagnosis may become a Problem list item, but it need not. It may persist as an Encounter Diagnosis, though it does not thereby persist as an active concern.)
I have more of a problem with the creeping assumption of disjointness that keeps popping up like a weed. We just pulled it up there in paragraph one, and even as we affectionately regard that nice Venn-like picture, we read "I don't think Problem List Item would also be a Health Concern usually . . ." Meaning, I hope, we may or may not tag the Condition resource with the health-concern code, as defined in US Core.
It seems like every time we use the term "health concern," we now have to stipulate "I'm talking about the care domain, so I mean the overarching thing," or, "I'm talking about the technical design, so I mean the disjoint thing." Until we fix the US Core term.
Julia's note that the "concern" can be a facet of the problem, maybe not a different thing at all, is an important nuance to capture. I'm not sure how it changes the problem I'm seeing.
From: Julia Skapik NACHC <JSKAPIK@nachc.com>
Sent: Friday, March 15, 2024 1:39 PM
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Subject: RE: HEALTH CONCERN note from 3/13/2024 PC call on MCC
Lisa,
I love the diagram and content. I would suggest we remove or modify the language on differentiating between problem list items and health concern items. From my standpoint it’s an ontology thing:
Health Concerns List:
Problem List
Additional Health Concerns
I want to point out that metadata should link related problem list and health concerns items. Example from my clinic (not supported by EHR):
Problem List: Uncontrolled DM2
Health Concern: Foot pain
Ideally in my mind the two could be merged into the management of a shared condition. Many of my patients do not internalize about a1c goals but they do seek symptom control.
I would like to see in the record:
Diabetes and Foot Pain Care Plan
Clinical Goal: a1c below 7.0
Patient Goal: “To keep my foot pain from impacting my work and activity”
Thanks,
Julia
From: Lisa Nelson <lnelson@mydirectives.com>
Sent: Friday, March 15, 2024 1:29 PM
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Cc: 'Jones, Emma' <emma.jones@veradigm.com>; 'Stephen Chu' <chuscmi88@gmail.com>; 'Laura Heermann' <laura.heermann@gmail.com>; Hoang, Catherine <Catherine.Hoang2@va.gov>; Miller, Holly <Holly.Miller@va.gov>; Lorraine Richardson <lorraine.richardson@jpsys.com>; 'Floyd Eisenberg' <feisenberg@iparsimony.com>; 'Evelyn Gallego' <evelyn.gallego@emiadvisors.net>
Subject: RE: HEALTH CONCERN note from 3/13/2024 PC call on MCC
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+1 Julia, and your comment caused me to draw this illustration.
What I’m specifically focusing on is the working hypothesis that we agree an “problem” that is both a Problem-List-Item and a Health-Concern, is a single Condition (id=23456) with two category codes.
Since we all agree that more clarity would be helpful, I’d like to continue this conversation at this practical level to see if we are all in agreement or not.
Regards,
Lisa
Lisa R. Nelson, MS, MBA | SVP Enterprise Integrations
MyDirectives
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From: Julia Skapik NACHC <JSKAPIK@nachc.com>
Sent: Friday, March 15, 2024 11:14 AM
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Cc: 'Jones, Emma' <emma.jones@veradigm.com>; 'Stephen Chu' <chuscmi88@gmail.com>; 'Laura Heermann' <laura.heermann@gmail.com>; Hoang, Catherine <Catherine.Hoang2@va.gov>; Miller, Holly <Holly.Miller@va.gov>; Lorraine Richardson <lorraine.richardson@jpsys.com>; 'Floyd Eisenberg' <feisenberg@iparsimony.com>; 'Evelyn Gallego' <evelyn.gallego@emiadvisors.net>
Subject: RE: HEALTH CONCERN note from 3/13/2024 PC call on MCC
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The Problem List is a subset of Health Concerns. I agree that more language in multiple places would be helpful especially in USCDI to explain how it interacts with care plan. I have commented repeatedly to ONC also about my concerns of putting terminology bindings on “goals” given the value of a patient’s specific words in sharing their priorities and sought outcomes.
Thanks,
Julia
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Subject: RE: HEALTH CONCERN note from 3/13/2024 PC call on MCC
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Gay,
Are the two “lists” over lapping? Or are they independent? For example would the Health Concerns list duplicate items from the Problem List (and then some) or would it only include issues that are “in addition to” Problem List items, but never duplicate them?
Lisa R. Nelson, MS, MBA | SVP Enterprise Integrations
MyDirectives
M: (401) 219-1165
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Subject: RE: HEALTH CONCERN note from 3/13/2024 PC call on MCC
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For Domain level guidance, it sounds like "health concern" is a well-understood term, and any analysis artifact should be able to use it without distraction (option a). Any confusion introduced by US Core terminology might be managed with a footnote (+option b).
For a FHIR IG, it may be appropriate to use the Resource name. Or at the very least, provide clear boundaries between the domain and design diagrams, ideally with instructions on how the design supports the domain (e.g., "health concern => Condition").
I don't think annotating the Category binding will help people looking at the diagram, but it could introduce serious problems with semantic consistency. I'd prefer to change US Core, if possible (and footnote the diagram, too).
Anyone opposed to (or in favor of) a Jira on US Core like this?
Category code "health-concern" takes a commonly understood term and introduces a specific local constraint ("outside the provider’s problem list"). This is confusing and potentially dangerous. Either change the term to something matching the definition (e.g., "extra-problem-list-concern") or change the definition to match the existing term (one option: USCDI I/II "Health related matter that is of interest, importance, or worry to someone who may be the patient, patient’s family or patient’s health care provider.")
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Subject: RE: HEALTH CONCERN note from 3/13/2024 PC call on MCC
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Hi all,
I agree with Gay. We have hashed and rehashed “Health Concern”. Everyone knows it and is using it. I would be very hesitant to change it now. Thanks…Susan
Susan Matney, RNC-OB, PhD, FAAN, FACMI, FAMIA, FHIMSS, FHL7, AL2
Founder | CEO
Wise Owl Originals LLC
Consultant Informaticist
1148 Alice Lane
Farmington, UT 84025
+1 (801) 680-2161
From: Gay Dolin <gdolin@namasteinformatics.com>
Sent: Thursday, March 14, 2024 9:13 AM
To: Jay Lyle <jay.lyle@jpsys.com>
Cc: Jones, Emma <emma.jones@veradigm.com>; Stephen Chu <chuscmi88@gmail.com>; Laura Heermann <laura.heermann@gmail.com>; Hoang, Catherine <Catherine.Hoang2@va.gov>; Miller, Holly <Holly.Miller@va.gov>; Lorraine Richardson <lorraine.richardson@jpsys.com>; Floyd Eisenberg <feisenberg@iparsimony.com>; susana.matney@gmail.com; Julia Skapik <JSKAPIK@nachc.com>; Evelyn Gallego <evelyn.gallego@emiadvisors.net>; Lisa Nelson <lnelson@advaultinc.com>
Subject: Re: HEALTH CONCERN note from 3/13/2024 PC call on MCC
+Julia, Floyd, Evelyn, Lisa and Susan Matney
Hi Folks,
To be honest, I believe it would be a very bad decision to remove/ignore the term 'Health Concern' that has been used in Care Plans at least since the 1980's. What value would that be to the industry and the already complex challenges of getting people to finally , maybe start to actually implement and use standardized Care Plan modules and Apps? It would cause cascading , unnecessary confusion.
There is nothing wrong with the term Health Concern, nothing derogatory or less meaningful than condition, or problem or the less than perfectly accurate concept of "Hasn't risen to the level of being added to the problem list".
We use US Core because that is what is being implemented in the industry, that will also facilitate someone actually implementing FHIR Care Plan, in particular MCC
US Core Condition, has a category of Condition or Health Concern, with Health Concern having a brief (perhaps not quite accurate) "definition" of "Additional health concerns from other stakeholders which are outside the provider's problem list."
Emma demo'd yesterday that "anything" can be added to the problem list, with filtering as a feature to allow provider preferred views, likely institutional implementations determine what should and should not be added, and design their filters.
C-CDA has had a Health Concerns Section and Health Concerns Act since 2011 or so with better and broader definitions.
And perhaps in US Core 8.0 (next January) we can encourage a shortened definition of what currently is in C-CDA with "alignment" as a driving factor that everyone agrees on.
In the meantime, we need to continue to allow the term "Health Concern" to be used in the MCC Care Plan. It does not have to be used by implementations, but is available to be used and we will offer examples in text and clarify in the edited diagrams how industry HAS USED this term, especially in the context of Care Plan.
We can expose the MCC understanding definition of Health Concern (category) in the "Short" field at Category, that would display here:
Side note: The value of "Category" in FHIR is a tangential topic. But over time it has moved from what has been a theoretical thing to something that implementers care a lot about and have adjusted their systems to allow queries on it. At least that's what we hear in the US Core discussions
Regards,
Gay
On Wed, Mar 13, 2024 at 3:22 PM Jay Lyle <jay.lyle@jpsys.com> wrote:
I thought I heard Emma object that "health concern" could be taken to mean the US Core category term, defined as "outside the provider’s problem list". Whereas Care plans address what we have called "Condition (Problem)" - aka "A [thing] that has risen to a level of concern."
Three solutions to this problem would be
a) ignore it. We use overdetermined terms all the time.
b) add a footnote where that term is used in the IG to clarify its meaning. Or a glossary.
c) change it to Condition.
But there were some other points raised that I'm not sure I followed.
I think I also heard a suggestion for a Jira to re-define something - the definition of the 'health-concern' category code within the IG? If I heard right, that's a kluge. The best solution to the confusion caused by the US Core term would be a Jira to change the US Core code to 'ancillary-concern' or 'patient-concern' or some other appropriately specific term. Not to make a code mean different things in different profiles.
Jay Lyle, Contract Support (JP Systems)
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Knowledge Based Systems, Terminology Standards
Clinical Informatics & Data Management Office (CIDMO) 105CIDM
Office of Health Informatics, Veterans Health Administration
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Gay Dolin MSN RN FAMIA
Namaste Informatics
US Realm Program Manager
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Fostering Harmony in Interoperability