1. Implementation Workgroup Udayan Mandavia, iPatientCare, Inc. With: Kedar Mehta and Arnaz Bharucha July 28, 2014 Constraining the CCDA User Experience Presentation

2. Background iPatientCare EHR is one of the three CMS designated Test EHRs Extent CCDA documents interoperable across systems today – Our Experience Challenges faced by us and Recommendations presented in the next few slides are based on our: – Field experience as the CMS designated Test EHR – Working with iPatientCare EHR provider users 2

3. Challenge: Missing Coded Values Some vendors do not send coded values

4. Challenge: Coded values are not proper Wrong Coding system. Eg. “SNOMED” as the coding system where RXNorm is sent in the code Coded values not sent in appropriate node

5. Challenge: Use of nullflavor for Codes ONC 2014 Edition Test data does not mandate LOINC Codes for Vital Observation Entry. Some EHRs send nullflavour in the code

6. Challenge: UCUM Codes not implemented Since MU does not validate the proper use of UCUM codes for unit of measurements, many vendors do not implement them. Valid UCUM Code is [in_i]

7. Challenge: Uncoded allergy reactions Not all vendors send allergy reactions in coded structure

8. Challenge: Improper Implementation of effectiveTime Some vendors do not send proper precision of effectiveTime in elements such as vitals. In this case the data gets imported in EMR as recorded at 12:00 midnight

9. Challenge: Incorrect application of Nullflavor Use of SNOMED Code “261665006” for “Unknown” instead of nullflavor Use of “UNK” where “NI” or “NA” should be used Which is the most appropriate method of documenting when the information is available in the system, but it is not to be sent in C-CDA Document Template?

10. Challenge: Frequently missing Elements Not all vendors send the following elements: – Medication route – doseQuantity – Author at element level

11. Challenge: Multiple coding Systems In Procedures, either SNOMED or CPT 4 or ICD-10-PCS codes are accepted. Most EHRs use only one coding system to document data. As EHRs, we have to use Crosswalks while importing discrete data in our systems when the coding system used by the other vendor is different.

12. Challenge: Multiple coding system for Problem List Providers have to document ICD codes for billing purposes and SNOMED codes for MU and C-CDA interoperability. This increases the overhead on the providers to document the problem list using two coding systems.

13. Recommendations Provide richer, more standardized samples in an online format EHR certification testing to include validation of codes and vocabulary Reducing the number of data elements that are optional Making available tools to ensure semantically robust document exchange in real-world and mechanism to monitor the same. 13