C-CDA Implementation-a-Thon 3

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Return to C-CDA: Enhancing Implementation (ONC Grant Project) page.

Return to C-CDA 2.1 Companion Guide Project page.

September 15-16, 2016 Accenture Offices Arlington, Virginia


  • Joginder Madra (Facilitator)
  • Jean Duteau (Facilitator)
  • Dave Hamill (HL7)
  • Karen van Hentenryck (HL7)
  • Matt Rahn (ONC)
  • Nagesh Bashyam aka Dragon (ONC)
  • Dr. Julia Skapic (ONC)
  • George Cole (Allscripts)
  • Brett Marquard (River Rock)
  • Calvin Beebe (Mayo)
  • Ben Flessner (Epic)
  • Raychelle Fernandez and Ozlem Kurt (Dynamic Health IT)
  • Lisa Nelson (Life over Time Solutions)
  • Russ Leftwich, Craig Lee, Alok Saldanha (Intersystems)
  • Linda Michaelsen (Optum)
  • Gina Canonica, SuAnn Svaby, Jiong Mao (NexGen)
  • Marie Swall, Rene Kinsey (VA)
  • Kim Heermann-Do, Mark H (DOD)
  • John D'Amore (Diameter Health)
  • Andrew Statler, Gene Beyer, Deb Fang, Michelle Colahan, Haiwin Zhu, Jane Marlatt, Vinayat Kulkarni, Margot Jackson (Cerner)
  • Jeff Cutaio, Ed Donaldson, Matthew Lance (Greenway Health)


Thursday, September 15, 2016

  • 0900-0930 Introductions/Housekeeping
  • 0930-1200 Homework Scenarios 1 and 2
  • 1200-1300 Lunch
  • 1300-1400 Discussion
    • C-CDA Scorecard
    • Narrative Text
  • 1400-1430 Ask the ONC
  • 1430-1700 In-Session Scenario 1

Friday, September 16, 2016

  • 0900-1000 Homework Scenario 3
  • 1000-1200 Discussion
    • Section/Entry ID population
    • VSAC presentation (Rob McClure)
  • 1200-1300 Lunch
  • 1300-1330 Ask the ONC
  • 1330-1530 In-Session Scenario 2
  • 1530-1630 Discussion
    • Categorizing Results
    • Multiple Authors
  • 1630-1700 Wrap Up

Discussion Items

Item Notes
Introductions and Housekeeping
  • Dave Hamill welcomed the group
  • David Sulsana (Accenture) - welcomed the group and went over office logistics
Scenario 1 - Discharge Summary
  • Admission Medications vs. Discharge Medications
    • intended to differentiate between medications the patient is on upon admission to the hospital vs. medications administered upon discharge
  • EKG discussion
    • Procedures should only be used for "procedures" that change the state of the patient. Findings, reading, etc. should be captured as results or observations instead. These can be thought of tests that were ordered with results.
    • How these are represented in systems are often dependent on how a provider records the information in the system. A provider may differentiate between therapeutic and diagnostic procedures...but still view both as procedures.
    • For scenarios where information can be found in both the procedures and results section, Epic includes text in the procedure narrative that says "Results for this procedure are found in the results section"


  • All procedures go in the procedures section
  • All results go in the results section
  • Related results and procedures should be linked
Scenario 2 - CCD
  • In C-CDA 2.1, the Implants section is deprecated. Medical Equipment should be used instead.
  • Some vendors deal with historical devices - not as entries in the Medical Equipment section - but as items in an assessment or the like.
Scenario 3 - Referral Note
  • Authorship
    • Author at the section level is the person/system responsible to creating the information in the section FOR THIS DOCUMENT.
    • Providers may be more interested in who recorded the information on the patient's chart - i.e. the person who brought the information (via reconciliation) into their EHR has responsibility for the information...even if it was originally sourced elsewhere. The original information is not discarded (as per MU3).
    • In a perfect world, the person who originally recorded the information should follow the information as it is exchanged...even if it is in the context of a clinical document that is created or generated elsewhere.

Action: Calvin Beebe to carry forward the discussion with the Structured Documents work group.

  • Lab Results
    • Partial results (e.g. full panel is ordered but only 2/4 tests have results)
      • Different approaches:
        • do not handle
        • use result organizer (with status on the organizer)
        • keep in the plan of care/plan of treatment until all results ready

Action: The Companion Guide to document the different approaches but stay silent on the recommendation.

Scenario 4 - CCD

Care team presentation:

  • Does the lifetime care team belong in the header? Is it better to have a separate template for this?
  • It is believed most people would associate the care team with the service event or encompassing encounter. May also need to look at participant.
  • Some vendors use the care team composition for routing of information.
  • Perhaps put people involved in ongoing treatment in the plan of care or plan of treatment section.


  • Forward to the Learning Health workgroup for follow up and consider a new section template for care team members - including attribution, information routing, etc.
  • This should also be forward to the Examples Task Force for consideration.

Birth Sex and Gender Identity:

  • No issues with populating birth sex as per the HL7 C-CDA R2.1 Companion Guide
  • For full coverage, there may be four concepts:
    • administrative gender
    • birth sex
    • gender identity
    • sexual orientation
Discussion Items

C-CDA Scorecard for C-CDA 1.1 and 2.1:

  • Currently in beta
  • Provides an evaluation of pass/fail as pertains to certification requirements - i.e. does the document meet the requirements of transition of care v1 certification criteria
  • Provides an indication of adherence to best practice that is scored independently (letter grade)
  • Based on Path...but some terminology compliance is validated.
  • 100 is the maximum score
  • 55 rules are evaluated. Maximum score per rule is 1.
  • The score is total rule score/maximum score (e.g. 20 rule score / 55 total rules = 36%).
  • Discussion:
    • It would be helpful to understand what contributes to raising or lowering one's score...e.g. how are criteria weighted?
    • Bugs and suggestions for improvements should be sent to Dragon or Matt
    • Missing sections will result in the score being downgraded - even if the section is not required by the document template.
      • This may be a bug. Dragon will investigate further.
    • Marie Swall provided some advice - for vendors looking evaluate their document instances, only include one entry per per section so that one's score is more indicative of the instance's score as the scoring will cumulative deduct if an issue appears more than once and skew the scoring.
    • Customers may use the scorecard as a way to evaluate vendors and hold less than perfect scores against the vendor - even though deductions may not be indicative of true errors.
      • There will be a difference between vendor scores and implementation scores as an individual implementation may have been configured or used incorrectly.
      • The ONC should consider providing scorecard scenarios and/or changing the scoring criteria to reflect variance as a result of allowing any sort of scenario to be submitted. Or add a disclaimer to indicate how to interpret scorecard results.
    • Suggestion that certification rule failures are separated from best practice rule failures.
    • Add a scorecard channel to Slack?

Narrative Text:

  • Use of style code
    • If you do not understand style codes, ignore them
  • Linking to machine-processable data
    • text/reference is to the entirety of the text
    • codes should not be put in the human-readable narrative, unless they are important to the end user (e.g. ICD-9 codes)

VSAC Presentation (presentation by Rob McClure - File:VSAC-CCDAthon-2016.pdf):

  • Requires UMLS license.
  • Intended to be freely available once published.
  • Originally intended as an authoritative authoring and publishing tool.
  • Can be used for runtime access, but it is not really set up for heavy use - e.g. used by all providers in real-time during prime time hours. Real-time access should be considered a future use case.
  • Feature requests should be done via "help"

Intended Recipient and Direct:

  • Documents should be able to be sent to multiple intended recipients
  • This may or may not be related to the document's information recipient

Effective Time:

  • Should patients have an expectation that the timestamp in the clinical document that is reflective of when they they actually had the service?
    • Yes. If a patient does not, there may be an issue with a portal's implementation

Ask the ONC

Q: Is there a test in certification that validates the narrative text and machine-readable content is consistent? A: There is no check in the certification that does this.


  • VA and DOD are implementing a new viewer that combines the machine-readable content with the narrative block.
  • How should systems handle patient mismatches?
    • Perhaps systems should check for patient mismatches - i.e. on queries.
    • This could be handled via manual reconciliation (in push scenarios)

Q: Is it true that all validated, certified content will be made publicly available? A: Yes.

Q: Is there a decision on Birth Sex? A: Yes. Use the social history section as documented in the Companion Guide.

Q: There is a requirement to display just a section but along with the accompanying header. What needs to be supported? A: Matt will look into this and report back.

Q: Are the other Gold Standard C-CDA examples - e.g. Care Plan? A: Additional Gold Standard examples can be created.

Q: Health survey diagnosis section is split up into multiple concepts - e.g. health care condition, co-morbidity, etc. - where should ambulatory diagnosis be housed? A: Sueann to send an email to Matt and Matt will follow up.

Q: For the transmission to Public Health, with respect electronic case reporting how should information be structured? A: Send an email to Matt and Matt will follow up.

Q: Does the certification process take time zones into account? A: No. Not even in the visual validation component.

HL7 C-CDA R 2.1 Scorecard rules (Dragon)

  • What should the Scorecard do? Discussion:
    • Should the scoring disregard certification rules? When the scoring was developed, it was intended to highlight best practice by reflection "warnings" as well as "errors". If warnings are not part of the scoring, they may be disregarded by vendors. This function should not be confused with the validator.
    • Should note what the certification score reflects and what the letter grade represents (e.g. Best Practice Data).
    • Should show why an instance fails if it fails the certification test.
  • Scoring rules that need to be revised:
    • display names → should only be validated against one of the published descriptions if the code system is known
    • time → should allow for zero offset
    • sections with no information

Homework Scenarios

Pre-Published Patient Information

Pre-Published Practitioner Information

In-Session Scenarios - to be shared at the event