C-CDA Implementation-a-Thon 4

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

January 12-13, 2017 Trinity University San Antonio, Texas

Attendees

• Joginder Madra (Facilitator)
• Jean Duteau (Facilitator)
• Dave Hamill (HL7)
• Dan Chaput, Annette DeVito Dabbs and Nagesh Bashyam aka Dragon(ONC)
• George Cole, Jon Anderson and Jennifer Grater (Allscripts)
• Brett Marquard (River Rock)
• Calvin Beebe (Mayo)
• Ed Donaldson (Greenway Health)
• Ben Flessner (Epic)
• Raychelle Fernandez and Ozlem Kurt (Dynamic Health IT)
• Lisa Nelson (Life over Time Solutions)
• Russ Leftwich and Alok Saldanha (Intersystems)
• Linda Michaelsen (Optum)
• Jiong Mao (NexGen)
• Joe Lamy (Aegis)
• Gay Dolin (IMO)

Agenda

Thursday, January 12, 2017

• 0900-0930 Introductions/Housekeeping
• 0930-1200 Scenario 1 ("Everything and the Kitchen Sink")
• 1200-1300 Lunch
• 1300-1400 Discussion
• 1400-1430 Ask the ONC
• 1430-1700 Scenario 2 (Care Plan)

Friday, January 13, 2017

• 0900-1100 Scenario 3
• 1100-1200 VSAC presentation (Rob McClure)
• 1200-1300 Lunch
• 1300-1330 Ask the ONC
• 1330-1600 Discussion
• 1600-1630 Wrap Up

Proposed Discussion Items

• Complex medication SIG
• Partial refills for Medication - e.g. 90 capsules, but insurance only covers 30 days supply...refills = 1.5)
• Combination codes/code translation (Ben)
• Date usage in conjunction with Problem, Medication, Allergy, etc.
• Care Plan certification test data from 170.315_b9_CP_Amb and _Inp
• Displaying a DI report as part of 170.315(e)(1)
• Empty unit values in CCD or values with spaces (e.g. mg/dl creatinine vs. mg/dl_creat)
• Handling signatures in CCD
• Second observation to indicate number of items - e.g. this section contains 10 lab results
• Identify a medication as an inpatient or outpatient medication
• Sexual Identification and Gender Identity / Intersex birth certificate - http://www.cnn.com/2016/12/30/health/intersex-birth-certificate/index.html
• Text reference linking (Lisa)
• Chart corrections (Ben)
• Goals and status of goals (Alok)
• Header level ID root (Linda)

Discussion

Item	Notes
Introductions and Housekeeping	Dave Hamill welcomed the group. Brief introduction of facilitators and participants.
Scenario 1 - CCD	Key items in this scenario: Care Team representation Section dates Section authors Discussion: Are there any differences between inpatient and outpatient CCD for this scenario? No...should be treated the same. Item for Follow Up - How should authors of an imported document be represented if one creates a subsequent document that includes the imported information? Should not use informant as informant has a specific meaning - i.e. someone who was called to provide information. Item for Follow Up - How does on know when information on a problem list, medication list etc. was reconciled? Item for Follow Up - Causal observations - e.g. brother died of colon cancer in 2009 Item for Follow Up - Amount of information presented in the narrative vs. amount of information presented in the entry - i.e. is it proper to have more information presented in the narrative than information presented in discrete data....or vice versa? Scorecard questions: Is the scorecard validating units (e.g. ucum) correctly? It appears that the scorecard does not support ucum parsing and is looking at specific value set concepts. ID validation (for uniqueness) appears to be looking at the ID element instead of ID attributes. If an author is noted in multiple spots within the CDA, this error will be triggered. Participants should probably be excluded from this check. Effective time rules not appear to be applying correctly (e.g. effective time for all activities should be within the lifespan of the patient) These issues have been raised with Dragon and he will work with the C-CDA R2.1 scorecard team to address these.
Scenario 2 - Care Plan	Key items in this scenario: Concerns, goals, and interventions Linkages and references between concerns, goals and interventions Discussion: Open issue with scorecard where Care Plan documents are not being scored correctly Health concerns may be coded, but may need to be represented in narrative form as there are likely to be terminology system gaps
Scenario 3 - CCD	Key items in this scenario: Documentation of concerns Communication of concepts in Patient History Documentation of a medication dosage that increases over time Discussion: xxx
Discussion	Chart corrections - How does one communicate something was sent in error? Outside of treating a new document as a complete replacement of a prior document, how should this be addressed? Immediate way to address this is to "pick up the phone" Item for Follow Up - Use case needs to be drafted in advance of further work. How to we differentiate between patient goals and provider goals? Patient goals have a patient author, provider goals have a provider author, and goals that have both a patient and provider author are shared/negotiated goals Can we apply meaning to the document ID root so we can determine who created a document? It is permissible to recognize your own document root, but there may not be a way to guarantee meaning for ID roots from documents created by other vendors. Use of authoring device may be better. How to we differentiate between patient goals and provider goals? Patient goals have a patient author, provider goals have a provider author, and goals that have both a patient and provider author are shared/negotiated goals Can we apply meaning to the document ID root so we can determine who created a document? It is permissible to recognize your own document root, but there may not be a way to guarantee meaning for ID roots from documents created by other vendors. Use of authoring device may be better. Handling signatures in CCD. Signature text has been added to authenticator and legal authenticator as an extension. This was work that came out of the attachments WG via CDP1. While this can be technically be done, workflow considerations still need to be worked out - e.g. who is the legal authenticator, what are they attesting to, how does this attestation persist, etc. We need to keep in mind that only a person may be a legal authenticator. Empty unit values in CCD or values with spaces (e.g. mg/dl creatinine vs. mg/dl_creat) Spaces are not allowed by either coded simple or UCUM. Proper UCUM representation i s mg{creat}/dL.
Ask the ONC	Q: When using the scorecard API - there are problems with retrieving/viewing the PDF. JSON is OK. A: Dragon to follow up. Q: Some scorecard issues that were raised at prior IATs have not yet been addressed. How would people know when changes are made to the scorecard? A: Release notes are published. Q: Should the scorecard be scenario or context sensitive? A: This was not the original intent and there is belief that there is value in not being scenario based. Q: The current release cycle has been very well received by the vendor community. Has it been good for the ONC as well? A: Yes - it has allowed for regular release planning. 1.0 release is planned for March 2017. Q: Care plan validation rules appear to be light. Is that the case? A: Yes.

Files

Homework Scenarios

• File:IAT4-Homework-Scenario-1.pdf
• File:IAT4-Homework-Scenario-2.pdf

Pre-Published Patient Information

• File:IAT2-Patient Demographics.xlsx

Pre-Published Practitioner Information

• File:IAT3-Practitioner Demographics.xlsx