C-CDA Implementation-a-Thon 2

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April 14-15, 2016 DePaul University Student Center, Loop Campus Chicago, Illinois

Attendees

• Joginder Madra (Facilitator)
• Jean Duteau (Facilitator)
• Dave Hamill (HL7)
• Karen van Hentenryck (HL7)
• Matt Rahn (ONC)
• Nagesh Bashyam aka Dragon (ONC)
• Ben Flessner, Jordan Cohen and Joel Manteufel (Epic)
• Raychelle Fernandez and Ozlem Kurt (Dynamic Health IT)
• Joe Lamy (Aegis / Sequoia)
• George Cole (Allscripts)
• Angel Pinzon (APS Puerto Rico)
• Linda Michaelsen (Optum)
• Luis Jimenez and Michelet Boursiquot (Document Storage Systems)
• Jiaong Mao (NextGen)
• Kenneth Banks (DCCHS)
• Kevin Johnson and Rob Kroll (Dialysis Clinic Inc.)
• Andrew McClellan (Aventura HQ)
• Mohammed Raouf (ModuleMD LLC)
• Luis Silva (Data Info System Solutions)
• Calvin Beebe (Mayo Clinic)
• Rob Kroll
• Wayne Kubick (HL7)
• Ozlem Kurt (Dynamic Health IT)
• Joel Manteufel (Epic)
• Brett Marquard (River Rock Associates)

Agenda

Thursday, April 14, 2016

• 0900-1000 Introductions/Housekeeping
• 1000-1100 CCD Homework Scenarios
• 1100-1200 Discharge Summary Homework Scenarios
• 1200-1300 Lunch
• 1300-1400 Referral Note Homework Scenarios
• 1400-1500 Care Plan Homework Scenarios
• 1500-1700 CCD In-Session Scenarios

Friday, April 15, 2016

• 0900-1100 Discharge Summary In-Session Scenarios
• 1100-1200 Referral Note In-Session Scenarios
• 1200-1300 Lunch
• 1300-1400 Referral Note In-Session Scenarios (cont.)
• 1400-1600 Care Plan In-Session Scenarios
• 1600-1700 Wrap Up and Discussion

Discussion Items

Item	Notes
Introductions and Housekeeping	Housekeeping (Dave) Introductions (Jean) Joginder walked through the Dropbox folder structure that will be used for the IAT.
CCD Homework Scenarios	Equipment implanted during the procedure - does it go in the "Procedures" section or the "Medical Equipment" section? Certification rules expect UDI info to be in the "Procedures" section except when there is no implantable info, then it should be in the "Medical Equipment" section <murmurs from the crowd - particularly when device info is known, but the procedure that implanted the device is not known>. GUIDANCE All devices must be noted in the "Medical Equipment" section. In the circumstance where the procedure that implanted the device is known, the device information may also be noted in the "Procedures" section. Use of "Assessment and Plan" vs. "Assessment" and "Plan of Care" sections Document Authors - system author vs. an author that is a person. Particularly for summary-type documents, the content of the document is a collection of information from multiple sources - difficult to determine who should be the "person" author of record, so the system generates the summary (particularly for pull requests). Person authors may be specified on the individual entries. No Known Allergies: Common approaches including using a negation indicator, or using a SNOMED-CT code for "no known allergies". Some vendors indicated a preference for the negation indicator approach as using a code requires reconciliation by the user. Use of negation indicator does not allow for indicating an effective time and some vendors want to be able to indicate that there was an assessment by the physician that the patient had no known allergies at a specific point Approaches to be shared in Slack and documented in the Companion Guide. "No Information" vs. "No Known Allergies" differences to be documented in the Companion Guide
Discharge Summary Homework Scenarios	Discharge Medications - act.code is different between v2.1 and v1.1. Refer to Errata comment 820 for resolution: The 1. 1 Discharge Medication has a SHALL code=10183- 2, so it is impossible to be backwards compatible with 1. 1 in this case. Recommend the same approach we took to the section code - set code = 1. 1's code and require a translation to the 2. 1 code If a section has an "entries required" and an "entries optional" template. Those sending the "entries required" need to send both the "entries required" and "entries optional" template ids. Follow up with Brett and consider for Companion Guide as offline guidance has been provided stating this approach.
Referral Note Homework Scenarios	Some issues with stylesheet rendering. Latest version is on gforge - http://gforge.hl7.org/gf/project/strucdoc/scmsvn/?action=browse&path=%2Ftrunk%2FCDA%2Fprocessable%2F Some issues with references - e.g. allergy display name referencing adverse reaction.
Care Plan Homework Scenarios	When do you send Care Plan vs. another document type with "care plan type" information - e.g. CCD with "Assessment and Plan" and "Goals". Assessment and Plan information was placed into "Interventions" section by one vendor's SME. Question of when do you use the Assessments section vs. when do you use the Assessment and Plan section. It boils down to how clinicians document information in the system. Care Plan document explicitly precludes the inclusion of the "Plan of Treatment" section (CONF:1198-31044). Some discussion around the differentiation between Health Concerns and Problems. According to the C-CDA R2.1 IG, A Health Concern is a health related matter that is of interest, importance or worry to someone, who may be the patient, patient's family or patient's health care provider. Health concerns are derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.). Health concerns can be medical, surgical, nursing, allied health or patient-reported concerns. Problem Concerns are a subset of Health Concerns that have risen to the level of importance that they typically would belong on a classic “Problem List”, such as “Diabetes Mellitus” or “Family History of Melanoma” or “Tobacco abuse”. These are of broad interest to multiple members of the care team. Examples of other Health Concerns that might not typically be considered a Problem Concern include “Risk of Hyperkalemia” for a patient taking an ACE- inhibitor medication, or “Transportation difficulties” for someone who doesn't drive and has trouble getting to appointments, or “Under-insured” for someone who doesn't have sufficient insurance to properly cover their medical needs such as medications. These are typically most important to just a limited number of care team members. A "Medications" section is not required to be present in the Care Plan even though medications is a CCDS data element C-CDA 2.1 IG is silent on organizing results by subsection (e.g. grouping of DI results, Lab results, etc.). Expectation is that there is only 1 section for Results in general. A use case would need to be brought forward to the Examples Task force for possible approached. Should be treated as a future consideration.
ONC Session	ONC Sample Testing Discussion: Dragon walked through the ONC C-CDA test data located at https://github.com/siteadmin/2015-Certification-C-CDA-Test-Data Participants worked through importing "170.315_b1_toc_inp_ds_r21_sample1_v3.xml" and "170.315_b1_toc_inp_ds_r21_sample2_v3.xml" Feedback: Family relationship codeSystem in Informant appears to be incorrect. Diagnosis and indication codes appear to be incorrect Certification Testing / Meaningful Use Questions/Comments: Information provided for context in the test cases will not be formally tested Discussion about the definition of implantable device status. Resolution is that all "active" implantable devices (i.e. those still in the patient) be included. UDI status is (strictly speaking) not required as all devices still in the patient are assumed to be active. This was clarified in the March 25 update. Reporting Lab information (ID, name, address and telephone) to be represented as the author of the entry.
In-Session CCD Scenarios	Scenario 1 Gender Identity - administrative gender represented as a nullFlavor of 'UNK' and an observation within another section PENDING GUIDANCE To meet certification requirements, the C-CDA recordtarget/Administrative Gender is the field used to record the Birth Sex and must be coded as follows: M (male), F (female) or a nullFlavor of 'UNK'. This may have downstream effects re: clinical decision support Matt Rahn to seek clarification from the ONC and report back to the group. GUIDANCE Gender Identity concepts are to be captured as an observation within the "Social History" section. Scenario 2 Approaches to tapered dose: split into two medications (e.g. one at 750 mg daily for 5 days and one at 500 mg daily for the duration) single medication with free text sig - substanceAdministration/code="76662-6" and text/reference=sig reference to sig instructions in narrative as per https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Dose_Change.xml
In-Session Referral Note Scenarios	Important to assert template conformance to C-CDA R1.1 - e.g. assert C-CDA R2.1 template ID as well as applicable C-CDA R1.1 template ID Important to assert template conformance to "entries optional" templates - e.g assert template ID for "entries required" template as well as applicable "entries optional" template as the "entries required" template also conforms to the "entries optional" template. ONC validation lab tests are expected to be in the "Plan of Treatment" if there are no results yet lab tests with lab results as expected to be in the "Results" section
In-Session Care Plan Scenarios	No samples generated, but some discussion: How would clinical SME's handle historical data being included in the Care Plan (e.g. refused immunizations in the example)? Smoking status - historical information vs. current information. Validation expects this to be in different places depending on context: current smoking status in Smoking Status and historical smoking status in Tobacco Use.
De-Brief and Wrap Up	Dave Hamill canvassed the group about the possibilities of future IATs: HL7 investigating the possibility of remote/virtual participation Possible timings include: summer, September (Baltimore) and January (San Antonio) Participants indicated their strong preference for in-person participation Participants recommended the continued use of the C-CDA/IAT Slack group. Dave Hamill to investigate changing the name of the group as to be less IAT2-centric.

Homework Scenarios

• File:IAT2-CCD-Scenario.pdf
• File:IAT2-DischargeSummary-Scenario.pdf
• File:IAT2-ReferralNote-Scenario.pdf
• File:IAT2-CarePlan-Scenario.pdf

Pre-Published Patient Information

• File:IAT2-Patient Demographics.xlsx

In-Session Scenarios

• File:IAT2-CCD-In-Session-Scenario-1.pdf
• File:IAT2-CCD-In-Session-Scenario-2.pdf
• File:IAT2-ReferralNote-In-Session-Scenario.pdf
• File:IAT2-CarePlan-In-Session-Scenario.pdf

ONC Test Files

• File:IAT2-ONC-Test-Files.zip

C-CDA Instances Generated by Participants

• File:IAT2-Generated-Instances.zip

Deliverables/Documents

• Implementation-A-Thon 2 Summary Report