Date 15 Feb 2022

Item	Who	Notes	Action Items
Agenda Review
CDS Implementation Questions for partners 1. Does your software system have the ability to integrate with CDS Hooks services? 2. Does your software system have the ability to integrate with SMART-on-FHIR applications? 3. Does your software system have customization points for creating or modifying new or existing workflows? 4. Does your software system have customization points for user interfaces that can be displayed as part of existing workflows? 5. Would you be able to support one more partner call when they have potential implementation plans and questions so we can move forward with two pilots this year?		AllianceChicago Athena practice has some FHIR 2.0 but does not yet contain all SMART on FHIR. Release over the summer will have v4. Has been using a middleware tool for existing FHIR work. Montefiore - Not planning to move forward with pilot Not present El Rio - Opting not to pilot Status - Internal discussions. Using Epic, has SMART on FHIR 2.0 profile for integration points. Could be used as comparison for existing system - compare outcomes. Ohio Neither CHC is ready at this point, OPCA is waiting for answers to the technical questions. Fenway Will be switching to EPIC. Will be live in January 2023. Transition is starting now. Will not be ready to pilot until the switch is accomplished. Can Fenway implement as part of the launch.
Who has capacity and interest to participate in pilot?		AllianceChicago Montefiore El Rio Ohio Fenway
What questions do you have?		*Does NACHC have the specifications for the SMART on FHIR? Yes https://hl7.org/fhir/smart-app-launch/* Examples of SMART on FHIR applications: chronic pain questionnaire - for standards-based questionnaire-renderer https://github.com/cqframework/cds4cpm-mypain provider-facing Shared Decision Making with patient-facing SMART on FHIR applications https://github.com/cqframework/AHRQ-CDS-Connect-PAIN-MANAGEMENT-SUMMARY What is NACHC's timeline? CDC would like to see work begin ASAP. NACHC has requested funds for this. As part of the existing funding, NACHC is requiring an implementation plan to sketch out what steps would be required to move this to implementation - do you need permissions? what do you need to do to get the permission to implement? how many sites would you deploy at the inception? This plan is due by March *What is the goal of the project and what are the metrics are we trying to improve? What is the problem we are trying to solve?* We fund prevention and target populations at high risk for HIV, but we know that 7 our of ... people are living with HIV and do not know it. One theory is that if the clinical guidelines were properly implemented, and HIV screening became part of primary care for everyone, we would increase opportunities for ppl to know their status and have access to prevention - move towards universal testing, not just at "known high risk centers - in cities, HIV centers." This is a proof of concept - what would it take to improve HIV testing in the general population. Percentage of patients within recommended screening category are tested 13 - 24 should be tested at least once MSM tested once a year Risky behavior once every three months - sex w/out a condom, etc. The tool ends at identifying the risk category and triggers an order for someone who is overdue for one or at risk and in need of testing. El Rio already has a system that prompts for that, so what would be the improvement if universal screening is already in place? A: we could talk about it - could we look at the data and see if there are gaps? Automation of the orders could increase the number of patients screened. NACHC CDC also wants to know about qualitative improvements - how much staffing is needed, is this working, does it help? Is it same as UDS measure or another measure for indicator of success? A: there is a measure for each of the three categories - but you can also see all three in one bin so numerators are difference. Yes, these are different from UDS measures. 13 - 24 should be tested at least once MSM tested once a year Risky behavior once every three months - sex w/out a condom, etc. Timeline We hope to start prior to 31 Jul 2022 but new funding should be in place by 01 Aug 2022.	Partners can request technical assistance to guide through the process. NACHC could create 1 pager to provide to staff where this is being implemented - what the goal is, what we are doing, how we hope to improve. NACHC will create a dashboard from the UDS measure Documentation on the prompt and what the prompt looks like - staff already has good systems for identifying patients at risk, so letting them know the approach would be helpful so they don't get into alert overload - a flow diagram would help.
Main 2 Standards-based Approaches	Bryn Alphora	Two integration levels: Plug in screening algorithm. Content on which decision is made if the person should be referred to screening is already in your system. Mapping to your system for actual order. SMART on FHIR with deeper integration. This might be used if/when the information is not already being collected - a questionnaire re: risk would be pulled in and used by algorithm to determine if person should be screened. Screening algorithm can operate and figure out if it can provide a better answer than the questionnaire provides.

Next Steps		Partners need to complete an implementation plan so they have it on the backlog - getting permissions, getting on their IT department list, etc.

Background

https://github.com/cqframework/hiv-cds/blob/master/input/pagecontent/getting-started.md

### Overview

This implementation guide provides technical artifacts to aid in the implementation of appropriate HIV screening. The artifacts include data element definitions, data collection questionnaires, and logic for determining HIV risk and appropriate screening and follow-up.

The artifacts in this implementation guide consist of:

* **[Terminology](#terminology)**: FHIR [value sets](http://hl7.org/fhir/valueset.html) containing groups of standard codes used to represent concepts in the HIV screening artifacts

* **[Data Elements](#data-elements)**: FHIR [profiles](http://hl7.org/fhir/profiling.html) defining the data elements used in HIV screening artifacts

* **[Questionnaires](#questionnaires)**: FHIR [questionnaires](http://hl7.org/fhir/questionnaire.html) defining data to be collected

* **[Rules](#rules)**: FHIR [rules](https://hl7.org/fhir/clinicalreasoning-knowledge-artifact-representation.html#event-condition-action-rule) defining when activities should be recommended

### Minimal integration

A minimal integration approach would be to use the Risk Factors questionnaire to collect specific information related to assessing patient risk, enabling the decision support for risk factor determination to evaluate and recommend a screening test based on that risk. The Drug Abuse Screening Test (DAST-10) questionnaire could also be used as part of this integration.

### Implementation

The artifacts in this implementation guide can be used in the following ways:

* **[Reference](#reference)**: The artifacts can be used as a reference for implementing HIV screening within existing clinical system software capabilities.

* **[Ingestion](#ingestion)**: For systems that support import of clinical quality improvement artifacts, the artifacts can be used either directly, or through transformation to another format.

* **[Integration](#integration)**: The artifacts can be used by configuring existing systems to invoke applications and/or services that can use the technical artifacts in this implementation guide directly.

#### Reference

As a reference, the artifacts in this implementation guide can be used as a blueprint to implement HIV screening practices by configuring existing software capabilities based on the artifacts provided here. For example, the value sets and questionnaires provided here can be copied into existing customization editors such as a value set builder or form builder. In addition, the logic provided for determining screening appropriateness can be used as a reference to create equivalent logic in a clinical system's configurable rules engine.

#### Ingestion

For systems that support importing artifacts such as questionnaires and rules, the artifacts can be used either directly, if the clinical systems support import of [HL7 FHIR CPG-compliant](https://hl7.org/fhir/uv/cpg) artifacts, or they can be transformed into the format accepted by the clinical system. For example, many clinical systems support import of questionnaires and form definitions using system-specific formats.

#### Integration

Open source services and applications exist that are capable of rendering the technical artifacts in this implementation guide including questionnaire-rendering, decision support services, and with some additional development effort, custom SMART-on-FHIR applications. There are two main integration approaches:

* **[Services](#services)**: Integration via a service integration such as CDS Hooks

* **[Application](#application)**: Integration via a SMART-on-FHIR application

##### Services

Integration as a service is most commonly implemented via [HL7 CDS Hooks](https://cds-hooks.hl7.org), though for systems that do not support the CDS Hooks standard, service integration is still possible if the clinical system supports a decision support service integration. For more information on this approach, refer to the [Architecture](architecture.html) topic in this guide.

##### Application

There are existing open source [SMART-on-FHIR](https://www.hl7.org/fhir/smart-app-launch/) applications that support rendering questionnaires (both patient-facing and provider-facing), as well as more general provider-facing capabilities such as summary and management dashboards and shared decision making. This approach is the most flexible, but requires custom development, generally starting from one of the existing open source applications, such as:

* https://github.com/cqframework/AHRQ-CDS-Connect-PAIN-MANAGEMENT-SUMMARY

* https://github.com/cqframework/cds4cpm-mypain

* https://github.com/asbi-cds-tools/asbi-screening-app

* https://github.com/asbi-cds-tools/asbi-intervention-app

Here is the complete data dictionary in the FHIR IG: (these are the elements needed to execute the CDS)

https://build.fhir.org/ig/cqframework/hiv-cds/HIVDataElementsByActivity.html

As a reminder this is the ask for today:

Here is our ask – please keep in mind our flexibility with deadlines, and of course, this is just a first pass:

Review the IG and Github AKA links above– if you have challenges identifying the appropriate staff or do not have anyone on your organization well-versed on the topics, please let us know. Feedback is optional, we just want to make sure everyone is on the same page.

Provide an estimate of whether you could implement and plan a pilot before August – in other words, would you volunteer to be one of the first pilot sites.

Give an update on your own implementation guides - Now that you know a little more, and have some materials, what needs to change? How would a potential pilot look like? What staff would be needed? What additional funds would be needed?