C-CDA Scorecard Rubric Update

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Project Summary

The following process has been established and approved by SDWG: the C-CDA R2.1 Rubric Process, it is used to identify and evaluate potential best practice tests (rubrics) that could be added to the C-CDA scoring tools. The current rubric is being utilized by the ONC C-CDA Scorecard. Please review the process and use this page to propose new rubrics.

Meeting Time / Info

Wednesday's from 11 am - 12 pm EST

Next meeting will be February 14th, but we will discuss our current rubric in New Orleans

https://meetingserver.hhs.gov/orion/join?siteurl=meetingserver

Meeting Number: 991 728 992

Audio Connection

2027742300 (Meeting Server Main Number)

Access Code: 991 728 992

Rubrics to be pushed to SDWG

1. Check whether there is an encounter in the Encounter section (not a null flavor)

2. Check whether the encompassing encounter is present in all encounter based documents ie Discharge Summary, Referral Note, etc. (do not ding if using CCD/Care Plan)

3. Check if the Encounter date/time and ID in the header is present in one of the EncounterActivity entries in the Encounter section of the body.

4. Patient Birth Sex must always be present in every C-CDA document

  a. This should be recorded as part of the SocialHistory/BirthSexObservation template

Rubrics to be discussed on a future call/Implementation-a-thon please add below or send to Matt Rahn - matthew.rahn@hhs.gov

1. Author entry must be present within the Problems, Meds and Allergies section

  a. In most cases, the documents are used for reconciliation when received by another system, so having the author entry makes the 
     reconciliation process easier w.r.t timing data (last modified date etc).
  b. So suggest we create a rubric to check for the presence of author entries.

2. Notes Section is present in an Encounter specific document with explicit link to Encounter - Implementation-a-thon discussion

3. Notes Section is present in a CCD with a note for each Encounter included - Implementation-a-thon discussion

4. Allergy Observation entry must have a Reaction (These are should in the IG)

  a. Require a null flavor if you don't know?
  b. Need clinical input - who's the source of the information (author/informant)

5. Allergy Reaction entry must have a severity (These are should in the IG)

  a. Need clinical input
  b. Ask about criticality too

6. History of Immunizations - Lisa Nelson - If there is an immunization present and there is no assertion that there is an immunization history - discuss further