Companion Guide to HL7 Consolidated CDA for Meaningful Use Stage 2

Background Information Meaningful Use Stage 2 & HL7 Consolidated CDA (C-CDA) Background Information

2014 Ed. CEHRT Criteria Requiring C-CDA 2014 Edition Certification Program for Health Information Technology (2014 Ed. CEHRT) criteria specifies the use of HL7 Consolidated CDA to capture data requirements in a summary type Export Summary Electronically create a set of export summaries for all patients in EHR technology Data Portability 170.314(b)(7) Transition of Care/ Referral Summary Electronically create a transition of care/referral summary Transition of Care 170.314(b)(1)&(2) Clinical Summary Create a summary for a patient 170.314(e)(2) Ambulatory Summary or Inpatient Summary Electronically view, download, and transmit an ambulatory summary or inpatient summary View/Download/Transmit 170.314(e)(1) Summary Type Criterion Description Main Idea(s): INSERT HERE Talking Points:

2014 Ed. CEHRT Data Requirements Example: Transition of Care Criterion Transition of Care/ Referral Summary Electronically create a transition of care/referral summary Transition of Care 170.314(b)(1)&(2) Summary Type Criterion Description Patient name Sex Date of birth Race ** Ethnicity ** Preferred language Care team member(s) Allergies ** Medications ** Care plan Problems ** Laboratory test(s) ** Laboratory value(s)/result(s) ** Procedures ** Smoking status ** Vital signs Common MU2 Data Set Provider Name & Office Contact Information (Ambulatory Only) Reason for Referral (Ambulatory Only) Encounter Diagnoses ** Cognitive Status Functional Status Discharge Instructions (Inpatient Only) Immunizations ** Objective-Specific Data Requirements Main Idea(s): INSERT HERE Talking Points: NOTE: Data requirements marked with a double asterisk (**) also have a defined vocabulary which must be used

2014 Ed. CEHRT Vocabulary Requirements Standardized vocabularies promote the use of common definitions when sharing information across diverse clinical environments. Vocabularies are used to assign a unique value to a clinical concept Vocabulary standards required by 2014 Ed. CEHRT include: LOINC for laboratory test(s) and results data requirements RxNorm for Medications and Medication Allergies data requirements HL7 CVX for Immunization data requirement In some instances, specific values from a vocabulary are required SNOMED CT values for the Smoking Status data requirement must be one of the following: Clinical Concept SNOMED-CT Code Current every day smoker 449868002 Current some day smoker 428041000124106 Former smoker 8517006 Never smoker 266919005 Smoker, current status unknown 77176002 Unknown if ever smoked 266927001 Heavy tobacco smoker 428071000124103 Light tobacco smoker 428061000124105

Clinical Document Architecture (CDA) and Templates Clinical Document Architecture (CDA) is the base standard for building electronic clinical documents for exchange Templates are reusable and interchangeable “building blocks” that can build a variety of clinical documents Templates apply CDA for a specific concept, such as a diagnosis or hospital discharge summary Main Idea(s): INSERT HERE Talking Points: Speaker Notes: Tag Line #1: none right now Tag Line #2: Templates constrain, or limit, CDA to convey clinical content for a particular use, such as a medication or procedure Templates are reusable and interchangeable so a variety of clinical documents may be built for specific uses from the same standard Tag Line #3: Consolidated CDA contains many templates that may be used in variety of ways, including the MU2 summary types To help simplify implementations, commonly used templates were harmonized into a single implementation guide – Consolidated CDA

Continuity 0f Care Document (CCD) History & Physical (H&P) What’s in the C-CDA IG? HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, Release 1.1 - US Realm Document Templates: 9 Continuity of Care Document (CCD) Consultation Note Diagnostic Imaging Report (DIR) Discharge Summary History and Physical (H&P) Operative Note Procedure Note Progress Note Unstructured Document Section Templates: 60 Entry Templates: 82 Document Template Section Template(s) Continuity 0f Care Document (CCD) Allergies Medications Problem List Procedures Results Advance Directives Encounters Family History Functional Status Immunizations Medical Equipment Payers Plan of Care Section templates in YELLOW demonstrate CDA’s interoperability and reusability. History & Physical (H&P) Allergies Medications Problem List Procedures Results Family History Immunizations Assessments Assessment and Plan Plan of Care Social History Vital Signs History of Present Illness Chief Complaint Reason for Visit Review of Systems Physical Exam General Status Main Idea(s): INSERT HERE Talking Points: C-CDA R2 Release 1.1 (US Realm) – July 2012 harmonizes templates at multiple levels: documents (9), sections (60) and entries (82) 2 of 9 document templates shown here as examples Section templates highlighted in yellow indicate specific templates reused by multiple document templates

How does C-CDA meet 2014 Ed. CEHRT requirements? Templates are used to specify the ‘packaging’ for those clinical concepts 2014 Ed. CEHRT data requirements can be captured through C-CDA templates Sets of CDA templates are arranged to create a purpose-specific clinical document CDA standardizes the expression of clinical concepts which can be used/re-used MU2 Main Idea(s): INSERT HERE Talking Points: CDA is the standard framework, or container, for clinical data elements NOT a clinical document itself Numerous individual data elements can be assembled for numerous clinical documentation purposes – provides flexibility, reuse IGs and templates guide how individual data elements are arranged for creation of a unique clinical document (e.g. CCD vs. Discharge Summary vs. Health & Physical, etc.)

MU2 requirements in the context of C-CDA Companion Guide

Why a “Companion Guide?” Consolidated CDA (C-CDA) Implementation Guide (IG) not enough for implementers Call for public collection of implementation guidance, sample clinically-valid documents and testing procedures 2014 Edition CEHRT requirements (for Meaningful Use Stage 2) do not provide technical guidance for implementations using the C-CDA IG No practical roadmap for using the C-CDA IG for implementations to meet the needs of clinicians and achieve Meaningful Use

Bridges the gap between MU2 requirements and C-CDA sections & entries C-CDA observations acts documents data elements MU2 care team members value sets vocabularies smoking status laboratory tests header elements medications care plan conformance statements

Purpose of the Companion Guide Supplements the C-CDA IG to provide additional context to assist implementers and connect them to tools and resources Provides technical guidance for representing the 2014 Ed. CEHRT data requirements using the C-CDA IG Includes clinically-valid examples of C-CDA components necessary to meet 2014 Ed. CEHRT requirements Recommends an approach to implementations using the C- CDA IG to meet the needs of clinicians and achieve Meaningful Use

Overview of Companion Guide Package Contents of the Companion Guide Package: Companion Guide Requirements-mapping spreadsheet XML sample files Examples of recommended C-CDA templates for 2014 Ed. CEHRT data requirements A complete sample CCD meeting 2014 Ed. CEHRT requirements

What you will find in the Companion Guide Section Title Description 1 Introduction Overview of Companion Guide development and TOC Initiative 2 Understanding the C-CDA Navigating the C-CDA IG, migration considerations (MU1 to MU2), implementation considerations for MU2 data requirements 3 Implementing MU Requirements All representations of data requirements in C-CDA, best practices guidance (XML examples available separately) 4 C-CDA Document Alignment Aligning MU2 requirements to the structured documents available in the C-CDA IG 5 Initiative Recommended Approach Specific approach for implementing a CCD to meet MU2 requirements and needs of clinicians 6 Tools & Resources Additional C-CDA and MU2 educational materials and tools  to assist implementers Appendix A Clinical Best Practices Considerations for clinicians, implications of Direct Appendix B C-CDA Document Requirements Lists requirements for each of the eight structured documents in the C-CDA IG Appendix C Moving from HITSP C32 to CCD 1.1 Specific guidance for migrating from MU1 to MU2

What you will find in the Requirements-Mapping Spreadsheet List of all MU2 data requirements Mappings of MU2 data requirements to C-CDA Breakdown of requirements by summary type

What you will find in the XML Sample Files Annotated examples of recommended C-CDA sections including entries for MU2 data requirements to demonstrate how MU2 data requirements are represented CCD XML example to show how MU2 requirements can be met

Where can I find it? The Companion Guide to Consolidated CDA for Meaningful Use Stage 2 is available at the following address: http://wiki.siframework.org/Companion+Guide+to+ Consolidated+CDA+for+MU2 Also available through the Standards and Interoperability Framework Repository: http://siframework.org/