1. Companion Guide to HL7 Consolidated CDA for Meaningful Use Stage 2

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

3. 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
(b)(7)
Transition of Care/ Referral Summary
Electronically create a transition of care/referral summary
Transition of Care
(b)(1)&(2)
Clinical Summary
Create a summary for a patient
(e)(2)
Ambulatory Summary or Inpatient Summary
Electronically view, download, and transmit an ambulatory summary or inpatient summary
View/Download/Transmit
(e)(1)
Summary Type
Criterion
Description
Main Idea(s):
INSERT HERE
Talking Points:

4. 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
(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):
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Talking Points:
NOTE: Data requirements marked with a double asterisk (**) also have a defined vocabulary which must be used

5. 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
Current some day smoker
Former smoker
Never smoker
Smoker, current status unknown
Unknown if ever smoked
Heavy tobacco smoker
Light tobacco smoker

6. 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):
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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

7. 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 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):
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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

8. 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):
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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.)

9. MU2 requirements in the context of C-CDA
Companion Guide

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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