Companion Guide to HL7 Consolidated CDA for

Meaningful Use Stage 2

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BACKGROUND INFORMATION

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

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2014 Ed. CEHRT Criteria Requiring C-CDA

Export SummaryElectronically create a set of export summaries for all patients in EHR technology

Data Portability170.314(b)(7)

Transition of Care/ Referral Summary

Electronically create a transition of care/referral summary

Transition of Care170.314(b)(1)&(2)

Clinical SummaryCreate a summary for a patientClinical Summary170.314(e)(2)

Ambulatory Summary or Inpatient Summary

Electronically view, download, and transmit an ambulatory summary or inpatient summary

View/Download/Transmit170.314(e)(1)

Summary TypeCriterion Description

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

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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 Care170.314(b)(1)&(2)

Summary TypeCriterion 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

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

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 CodeCurrent every day smoker 449868002Current some day smoker 428041000124106Former smoker 8517006Never smoker 266919005Smoker, current status unknown 77176002Unknown if ever smoked 266927001Heavy tobacco smoker 428071000124103Light tobacco smoker 428061000124105

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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

To help simplify implementations, commonly used templates were harmonized into a single implementation guide – Consolidated CDA

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What’s in the C-CDA IG?

HL7 Implementation Guide for CDA® Release 2: IHE Health

Story Consolidation, Release 1.1 - 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: 60Entry Templates: 82

Continuity 0f Care

Document (CCD)

AllergiesMedicationsProblem ListProcedures ResultsAdvance DirectivesEncounters

Family HistoryFunctional StatusImmunizationsMedical EquipmentPayersPlan of Care

Document Template Section Template(s)

Section templates in YELLOW

demonstrate CDA’s

interoperability and reusability.

History & Physical (H&P)

AllergiesMedicationsProblem ListProceduresResultsFamily HistoryImmunizationsAssessments

Assessment and PlanPlan of CareSocial HistoryVital SignsHistory of Present IllnessHistory of Present Illness

Chief ComplaintReason for VisitReview of SystemsPhysical ExamGeneral Status

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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

COMPANION GUIDEMU2 requirements in the context of C-CDA

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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

Bridges the gap between MU2 requirements and C-CDA

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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

• 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

Overview of Companion Guide Package

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What you will find in the Companion GuideSection Title Description

1 Introduction Overview of Companion Guide development and TOC Initiative

2 Understanding the C-CDANavigating 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

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What you will find in theRequirements-Mapping Spreadsheet

• List of all MU2 data requirements• Mappings of MU2 data requirements to C-CDA• Breakdown of requirements by summary type

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What you will find in theXML 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

Where can I find it?

• The Companion Guide to Consolidated CDA for Meaningful Use Stage 2 is available at the following address:– http://

wiki.siframework.org/Companion+Guide+to+ Consolidated+CDA+for+MU2

• Also available through the Standards and Interoperability Framework Repository:– http://siframework.org/

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