1. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Attachments Workgroup

2. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Tasks for this week Complete gap analysis for remaining current types Evaluate if any of the current types are still needed? Identify other attachment types being requested in the industry, that are not already included in CCDA templates Collaborate with Regensteif on LOINC list for unstructured attachments Review/restructure solicited model (request at document level)

3. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. HL7 Jan. Meeting Summary Completed Gap analysis of AIS booklets to Consolidated CDA Templates and others  Ambulance data will be in ASC X12 837 – eliminating Ambulance AIS; EMS Run Trip Report will be an unstructured document  ASC X12 TG2 WG9 needs to review value set in 275 CAT02 Agreed that solicited requests will be LOINC codes at the document level only – nature of clinical reports Developed a format for a ‘Panel’ on the LOINC DB that will function as an external code set for unstructured and structured attachment documents – replaces PIUC  Update from DOD/VA their project to implement CDA Consolidated Guide Outreach to re-evaluate the need of current attachment types and for additional attachment type used today – WEDI survey results expected in March Developing list of requirements for a rewrite of the AIS Implementation Guide Information exchange with HL7 RM-ES project and relationship to ESMD initiative Developed a time line for 2012 – target September ballot for HL7

4. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Tasks for this week – Complete gap analysis for remaining current types  Clinical Rpts; OB Ultrasound – document level LOINC is in CCDA; add 100+ elements?, Cardio Echo Study – document level LOINC is in CCDA; add details?, EKG – not in Diagnostic Image Report table of CCDA; need to add to table X-rays – 8 specific types in AIS; each consists of 7 common detail elements  Medications, Dynamic value set; Details are matching; Does ‘Current’ = ‘Admission’ for Discharge Meds?  Lab Results, Dynamic value set  Rehab. Therapies 10 types; 24 common details in each type; need to verify date fields and if Treatment Plan = Plan of Care?  Ambulance – Data elements to be included in X12 837; need to create an unstructured document LOINC code for EMS Run Report

5. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Tasks for this week Identify if other attachment types being requested throughout the industry, that are not included in CCDA templates  Outreach via WEDI Survey and Winter Forum; Results due in March. Collaborate with Regensteif on LOINC list for unstructured attachments  We will create 3 classifications of LOINC codes in a Panel on Relma; Panel will need to be named in Regulation like an external code set Unstructured, Unstructured for HIPAA, (may have children LOINCs) Structured (details are defined in a quide) Review/restructure solicited model (request at document level)  Agreed to change requests to document level only for clinical attachments

6. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Tasks for this week – Evaluate: are the current types still needed? Evaluate: are any of the current types still needed?  Ambulance  Lab Results  Medications  Rehabilitative Services Alcohol-Substance Abuse, Cardiac, Medical Social Services Occupational Therapy, Physical Therapy, Psychiatric, Respiratory Therapy, Pulmonary Therapy, Skilled Nursing, Speech Therapy  Clinical Reports Cardiac Diagnostic Studies: Cardiac Echo Study, EKG Study Obstetrical Studies:OB Ultrasound Study Clinical Notes/Reports Physician Hospital Discharge Summary Operative Note Provider Unspecified History and Physical Note Radiology Studies (8 x-ray types) Members to respond asap, outreach via WEDI survey by March

7. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. 2012 timeline By end of Jan. meeting  Create list of data not in CDA Consolidate Templates  Consensus on solicited request - document level only  Defined format of LOINC DB for unstructured/structured attachments By March  Finalize list of Attachment needs Response on needs from gaps and current types Updated list of any new attachment types from outreach Begin writing guide, templates and LOINC descriptions By May meeting  Writing template requirements and Implementation Guide  Determine if out-of-cycle meeting is needed By September meeting  Prepared ballot

8. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Gap analysis: AIS vs. CDA Consolidated Templates and others Medications vs. CCDA Ambulance vs. EMS Patient Care Report, X12 837 and CCDA Clinical Reports (Diagnostic Studies) vs Diagnostic Image Reports in CCDA Clinical Reports (Care provider notes and chart sections) vs CCDA (attention on Notes: progress, procedure and consultation) Rehab therapies vs CCDA (attention on Notes: progress, procedure and consultation) Lab Studies vs CCDA (research with S&I LRI)

9. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. LOINC Codes for Unstructured? Regenstrief Database  Build list of attachment types for the unstructured documents to replace PIUC  Changes to existing HIPAA LOINC codes? Leave ALL (use for request)? Deprecate those NOT consistent with CCDA?

10. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Solicited request and response: what is the appropriate level? Document, section, element Difference in format impacts request and response: AIS use LOINC codes to identify the discrete elements that comprise a document and the documents CDA Templates use LOINC codes to identify documents and the sections that comprise the document 1) For the Request: Is it a requirement to request an element of a clinical document? Or the document? 2) For the Response: Can the payer accept the document level and parse for the components needed? Or is it the responsibility of the provider?

11. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Are these still the high priority attachment types? Original Attachment Types developed through industry participation  Ambulance  Lab Results  Medications  Rehabilitative Services Alcohol-Substance Abuse, Cardiac, Medical Social Services Occupational Therapy, Physical Therapy, Psychiatric, Respiratory Therapy, Pulmonary Therapy, Skilled Nursing, Speech Therapy  Clinical Reports Cardiac Diagnostic Studies: Cardiac Echo Study, EKG Study Obstetrical Studies:OB Ultrasound Study Clinical Notes/Reports Physician Hospital Discharge Summary Operative Note Provider Unspecified History and Physical Note Radiology Studies

12. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Do any of these take a higher priority? All are ‘unstructured’, but do we need to publish Periodontal and CPHS for codified guides? Additional Attachment Types that can be exchanged (with LOINC code identifier and using the unstructured model)  Periodontal  Newborn Screening  Pharmacy Prior Authorization  Home Health  Children’s Preventative Health Services  Consents  Durable Medical Equipment (DME)  Explanation of Benefits (EOB)  Letters/Reports  Skilled Nursing Facility (SNF)

13. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Will these guides (documents) satisfy current claim attachment needs? CDA Consolidation  History & Physical  Discharge Summary  Operative Report  Consultation Notes  Progress Notes  Procedure Note  Diagnostic Imaging Reports  CDA with Unstructured Body

14. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. What Guides need to be published? CDA Consolidated Template Guide only  Includes all Attachments needed (Rehab therapies, Ambulance)  Attachment Implementation Guide for definitions on request/response, solicited/unsolicited, structured/unstructured CDA Consolidated Template Guide Plus:  Attachment Implementation Guide for definitions on request/response, solicited/unsolicited, structured/unstructured  Attachments Template Guide for types not included in CDA Consolidated Templates ( types without clinical information, such as, consent forms, etc; and/or Rehab therapies, etc) Attachments only guides:  Clone or reference documents from the CDA Consolidated Template and add on the attachment documents.

15. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Should there be an Attachment Implementation Guide? If so, what will be the content? Discussions underway regarding role in development of operating rules for attachments. Attachments WG reviewing AIS’s and Implementation Guide for potential operating rules input Topics for operating rules could include:  Guidance for unsolicited attachments (e.g., business rules)  Guidance for solicited attachments (e.g., specific requests-LOINC modifiers)  Guidance on transport (e.g., NwHIN, Direct, Connect, NDM, FTP, CORE)  Definitions about metadata requirements (transport envelope) Include the Attachment control number  Payload file size  Number of attachment requests per claim?  Scope of Rules developed this year? Phases? Infrastructure/Content  Acknowledgments, error reporting  Requirements for Optional (that affirm you don’t have it as opposed to not sending just because)

16. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. ESMD transport neutral? Metadata content  Same in X12 275, CDA Header, IHE XDS  Attachment Control Number

17. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. 5.Would you be pursuing designation as an Operating Rule authoring entity? HL7 is not interested in being designated as the authoring entity, however we would partner with a named authoring entity to develop Operating Rules for Attachments

18. © 2008 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office. Other Questions?