1. HL7 C-CDA Survey and Implementation-A- Thon Final Report Summary Presentation to the HL7 Structured Documents Work Group on July 14, 2016

2. Background

3. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Project Focus and Delivery  Create a survey to assist HL7 in identifying C-CDA inconsistencies;  Plan, create and conduct two Implementation-A-Thons; and  Create and distribute a report reflecting the results of the survey and Implementation-A-Thons.

4. Approach

5. Ties to C-CDA R2.1 Companion Guide Project Review of:  2015 Certification Requirements  C-CDA R2.1 Standard  Incorporate review analysis in content surveys  Incorporate survey results in IAT Scenarios  Deliver IAT  Incorporate IAT findings in C-CDA R2.1 Companion Guide

6. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Surveys  Focused on identifying C-CDA R2.1 pain points  Focused on gauging respondent awareness and opinion of CDA-related resources  HL7 Education  Listservs  HL7 CDA Helpdesk  C-CDA R1.1 Companion Guide

7. Survey Respondents Survey #1 (n=68)Survey #2 (n=70)

8. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Surveys Finding #1 – Common Issues  Terminology - Inconsistent terminology usage, issues with value set accessibility and use of non-compliant vocabulary by implementers  Optionality - More than one way to do things and inconsistent implementations across vendors  Complexity - The C-CDA standard is difficult to understand and consume and is exacerbated by a lack of clearly documented examples

9. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Surveys Finding #2 – Support is greatest for CCD

10. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Surveys Finding #3 – IAT Interest

11. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Surveys Finding #4 – Awareness/Utilization of Resources is Low  Reasons for not taking advantage of education included cost concerns, a lack of awareness and uncertain value proposition.  Reasons included a lack of awareness of what it is as well as too much noise to signal ratio.  Reasons included a lack of awareness that it exists and not being aware of what kind of assistance could be provided.  The extra rationale, descriptions and comparison between document templates was useful, but many were not aware of its existence.

12. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Implementation-A-Thons  January 7-8, 2016  University of Central Florida, Executive Development Center in Orlando  April 14-15, 2016  DePaul University Student Center in Chicago

13. IAT #1 - Orlando Purpose:  Work through clinical scenarios to uncover issues with C-CDA 2.1 and/or Meaningful Use rules  Set a baseline IAT approach that could be evaluated and adjusted for IAT #2 if necessary Approach  “ Observe and Document”  Four Scenarios:  Common Clinical Data Set  C-CDA R2.1 Minimum Mandatory  C-CDA R2.1 Minimum Mandatory with Unknown Sections  C-CDA R2.1 Full

14. IAT #2 - Chicago Purpose:  Work through clinical scenarios to uncover issues with C-CDA 2.1 and/or Meaningful Use rules - with a focus on the Common Clinical Data Set  Continue to evaluate the baseline IAT format and review for suitability for future IATs Approach  “Observe and Document”  Patient information released in advance  Addition of homework scenarios  Slack usage

15. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. IAT Outcomes Four Categories of Issues Identified:  Terminology  Understanding  Interpretation  Specification Ambiguity

16. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. IAT Outcomes (cont.) Consensus Guidance:  All devices must be noted in the Medical Equipment section. In the circumstance where the procedure that implanted the device is known, the device information may also be noted in the Procedures section.  To meet certification requirements, the C-CDA recordtarget/Administrative Gender is the field used to record the Birth Sex and must be coded as follows: M (male), F (female) or a nullFlavor of 'UNK'.

17. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. IAT Outcomes (cont.) Suggested Items for Inclusion in the Companion Guide:  Approaches for documenting "No Known Allergies" - including differences between "No Known Allergies" and "No Information about Allergies"  Act.code differences between C-CDA R2.1 and C-CDA R1.1 in the "Discharge Medications" template and how to properly keep backwards compatibility.  Guidance regarding use of "entries required" section templates and if an "entries optional" template ID needs to be included as well.

18. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. IAT Outcomes (cont.) Suggested Items for Inclusion in the Companion Guide (cont.):  The Care Plan document template specifically precludes the inclusion of a "Plan of Treatment" section.  The difference between a "Health Concern" and a "Problem".  Approaches to recording a tapered dosage for medications.  How to document lab tests with results and lab tests without results  How to document current vs. historical smoking status

19. Lessons Learned

20. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. IAT Lessons Learned  The use of pre-event communication mechanisms such as conference calls and Slack channels with registered participants was very helpful.  For IATs, facility network security requirements should be explored well in advance of the event so that mitigation strategies (e.g. creating account credentials) can be explored.  The timing of IAT #1 conflicted with other events such as the IHE Connectathon which affected attendance. Timing of future events should be carefully considered to avoid participant conflicts.  The "Ask the ONC" portion of the IAT was well received. Any future IATs should have authoring stakeholders (ONC in this case as they authored the 2015 Certification Rules) present to respond to queries about the materials being tested.

21. Next Phase Recommendations

22. ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Project Team Recommendations 1.HL7 should focus on addressing issues identified in the survey 2.HL7 should consider continuing the use of IATs as a way to interact directly with the implementer community. 3.HL7 consider the suitability of IATs for other HL7 C-CDA standards

23. Questions?

24. Thank You!