© 2013 calvin beebe and health level seven ® international. all rights reserved. hl7 and health...

© 2013 Calvin Beebe and Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

Overview of C-CDA

Health eDecisions All Hands Community Meeting

May 16, 2013

C. Beebe


Presenter

Calvin E. [email protected] SpecialistMayo Clinic, Rochester MN

Co-editor - CDA R1, CDA R2 Author - CDA Certification Exam

Co-chair - HL7 Structured Documents Member - HL7 Technical Steering Committee Treasure - HL7 Board of Directors


Today’s Topics

What’s in the C-CDA Implementation Guide Review sample C-CDA document Identify HL7 & other useful resources Summary


01/01/20114


Basic C-CDA 101

Technical Name:

HL7 Implementation Guides for CDA Release 2: IHE Health Story Consolidation, DSTU Release 1.1 - US Realm

Called: Consolidated CDA, C-CDA …

The C-CDA contains a library of CDA templates. Updates 11 CDA document types, including CCD Harmonizes previous HL7, IHE, HITSP efforts

It consolidated previous document templates into a single library, resolving conflicts, ambiguities as needed!


HL7’s CDA vs. C-CDA

CDAThe HL7 Clinical Document Architecture (CDA) is a document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange.

C-CDAThe HL7 Consolidated CDA is an implementation guide which specifies a library of templates and proscribes their use for a set of specific document types.

defines a set of CDA documents!

the schema for those documents!


Consolidated CDA (C-CDA)

C-CDA

History and Physical Discharge Summary Consultation Notes Diagnostic Imaging Rpt Procedure Note Operative Note Progress Note Unstructured Documents HL7 Health Story Implementation Guides

CCD

ONC - CEHRTHITSP - C32, C80, C83 IHE – PCCHL7 – CCDHL7 – CDA

Continuity of Care Document


Consolidated CDA

The guide contains a library of CDA templates, incorporating and harmonizing previous efforts from:

Health Level Seven (HL7) Integrating the Healthcare Enterprise (IHE) Health Information Technology Standards Panel (HITSP)

It includes harmonized HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination, and the Continuity of Care (CCD). It includes all required CDA templates in Final Rules for Stage 1 Meaningful Use and can support Stage 2 Meaningful Use requirements.*


Templated CDA: C-CDA, QRDA

01/01/20119

Figure 1: Templated CDA

A QRDA Category I report is an individual-patient-level quality report. Each report contains quality data for one patient for one or more quality measures.

(126 Entry Templates)


HL7 C-CDA Implementation Guide

Document Organization Introduction General Header Template Document-Level Templates Section-Level Templates Entry-Level Templates Appendix

Template IDs, Code Systems, Value Sets, Extensions, …


ConsolidatedCDA Documents

H&PH&P Diagnostic Imaging

Diagnostic Imaging ConsultConsult Surgical

Operation

Surgical Operation

ProgressProgress ProcedureProcedure Discharge Summary

Discharge Summary

Unstructured(Non-XML Body)

Unstructured(Non-XML Body)

CCDCCD

9 Document Types

74 C-CDA SectionsAdvance Directives Section (entries optional)Advance Directives Section (entries required)Allergies Section (entries optional)Allergies Section (entries required)Anesthesia SectionAssessment and Plan SectionAssessment SectionChief Complaint and Reason for Visit SectionChief Complaint SectionComplications SectionDICOM Object Catalog Section - DCM 121181Discharge Diet SectionEncounters Section (entries optional)Encounters Section (entries required)Family History SectionFetus Subject ContextFindings Section (DIR)Functional Status SectionGeneral Status SectionHistory of Past Illness SectionHistory of Present Illness SectionHospital Admission Diagnosis SectionHospital Admission Medications Section (entries optional)Hospital Consultations SectionHospital Course SectionHospital Discharge Diagnosis SectionHospital Discharge Instructions SectionHospital Discharge Medications Section (entries optional)Hospital Discharge Medications Section (entries required)Hospital Discharge Physical SectionHospital Discharge Studies Summary SectionImmunizations Section (entries optional)Immunizations Section (entries required)Implants SectionInstructions SectionInterventions SectionMedical (General) History Section

Medical Equipment SectionMedications Administered SectionMedications Section (entries optional)Medications Section (entries required)Objective SectionObserver ContextOperative Note Fluids SectionOperative Note Surgical Procedure SectionPayers SectionPhysical Exam SectionPlan of Care SectionPlanned Procedure SectionPostoperative Diagnosis SectionPostprocedure Diagnosis SectionPreoperative Diagnosis SectionProblem Section (entries optional)Problem Section (entries required)Procedure Description SectionProcedure Disposition SectionProcedure Estimated Blood Loss SectionProcedure Findings SectionProcedure Implants SectionProcedure Indications SectionProcedure Specimens Taken SectionProcedures Section (entries optional)Procedures Section (entries required)Reason for Referral SectionReason for Visit SectionResults Section (entries optional)Results Section (entries required)Review of Systems SectionSocial History SectionSubjective SectionSurgery Description SectionSurgical Drains SectionVital Signs Section (entries optional)Vital Signs Section (entries required)

65 C-CDA EntriesAdmission MedicationAdvance Directive ObservationAge ObservationAllergy ObservationAllergy Problem ActAllergy Status ObservationBoundary ObservationCode ObservationsComment ActivityCoverage ActivityDischarge MedicationDrug VehicleEncounter ActivitiesEstimated Date of DeliveryFamily History Death ObservationFamily History ObservationFamily History OrganizerHealth Status ObservationHospital Admission DiagnosisHospital Discharge DiagnosisImmunization ActivityImmunization Medication InformationImmunization Refusal ReasonIndicationInstructionsMedication ActivityMedication DispenseMedication InformationMedication Supply OrderMedication Use - None Known (deprecated)Non-Medicinal Supply ActivityPlan of Care Activity ActPlan of Care Activity Encounter

Plan of Care Activity ObservationPlan of Care Activity ProcedurePlan of Care Activity Substance AdministrationPlan of Care Activity SupplyPolicy ActivityPostprocedure DiagnosisPrecondition for Substance AdministrationPregnancy ObservationPreoperative DiagnosisProblem Concern Act (Condition)Problem ObservationProblem StatusProcedure Activity ActProcedure Activity ObservationProcedure Activity ProcedureProcedure ContextProduct InstancePurpose of Reference ObservationQuantity Measurement ObservationReaction ObservationReferenced Frames ObservationResult ObservationResult OrganizerSeries ActService Delivery LocationSeverity ObservationSocial History ObservationSop Instance ObservationStudy ActText ObservationVital Sign ObservationVital Signs Organizer

38 C-CDA Code SystemsISO 3166-1 Country Codes DCMInternet Society LanguageVaccines administered (CVX)Adminstrative GenderActMoodReligious AffiliationRoleClassRoleCodeAddressUseActStatusMaritalStatusLOINCNUCC Health Care Provider TaxonomyICD9 CM ProceduresCPT-4Confidentiality CodeNational Cancer Institute (NCI) Thesaurus US Postal Codes

Race and Ethnicity - CDC HealthcareServiceLocationActCodeEntityNamePartQualifierEntityNameUseASC X12LanguageAbilityMode LanguageAbilityProficiencyNDF-RTActPriorityUnique Ingredient Identifier (UNII)ActReasonObservationInterpretationParticipationFunctionParticipationsignatureUnified Code for Units of Measure (UCUM) RXNormFIPS 5-2 (State)SNOMED CT

S&I Companion Guide references (links) on CEHRT Vocabularies: CDT – Dental Codes ICD – 10 CM / PCS CPT – AMA Procedure Codes ISO 639-2 Language Codes HCPCS – Procedure Codes LOINC – Lab Codes CVX – HL7 table 0292 OMB Race / Ethnicity Codes RxNorm – Medication Codes SNOMED CT – via UMLS


C-CDA Header Constraints

It describes constraints that apply to the header for all documents within the scope of this implementation guide. Header constraints specific to each document type are described in

the appropriate document-specific section below. SHALL contain:

realmCode typeId templateId id code title effectiveTime confidentialityCode languageCode

recordTarget

w/ 1 patient name in US realm format administrativeGenderCode birthtime (precise to the year)

serviceEvent effectiveTime performer

author custodian

ethnicity preferred Language race

encompassing Encounter healthcareFacility responsibleParty encounterParticipant

addr name


MU 2 - Document Types

With respect to the Consolidated CDA, certification will not focus on a specific document-level template…

Surprise!

Rather, certification will focus on an EHR technology’s ability to properly implement the US Realm header and the associated section-level templates necessary to support each certification criterion in which the Consolidated CDA is referenced and for the appropriate data specified in each of those certification criteria.

Where vocabularies are specified in § 170.207 the accompanying section-template must be implemented using structured data , i.e. coded entries required.

Unstructured Document template is not permitted.


Document Types

S&I performed a goodness of fitness assessment and deemed the C-CDA CCD best fit.

01/01/201117

However…MU3 advocates that the visit document should not simply be EMR extracts (need exact language!)

You may want to start thinking about generating clinical notes based on C-CDA MU2 requirements.

I.e. H&P Notes, Consult Notes, Diagnostic Imaging Notes, Surgical Notes, Progress Notes, Discharge Summary Notes.

All said, for MU2 – the CCD seems like the likely target.


Continuity of Care Document


Consolidated CDA SectionsMU2 Data Requirements Consolidated CDA Section CCD

Advance Directives (entries optional) OMedication allergies Allergies (entries required) R

Encounters (entries optional) OFamily History O

Functional Status; Cognitive Status Functional Status ODischarge instructions (Inpatient setting) Hospital Discharge InstructionsImmunizations Immunizations (entries optional) O

Clinical instructions; Recommended patient decision aids Instructions

Medical Equipment OMedications Medications (entries required) R

Payers OCare plan, including goals and instructions; Future appointments; Future scheduled tests; Referrals to other providers; Diagnostic tests pending

Plan of Care or Assessment and Plan O

Problems Problem (entries required) RProcedures Procedures (entries required) OReason for Referral Reason for ReferralReason(s) for visit or Reason(s) for hospitalization (Inpatient setting)

Reason for Visit or Chief Complaint or Chief Complaint and Reason for Visit

Laboratory Tests; Values/results of laboratory tests Results (entries required) RSmoking status Social History OVital signs Vital Signs (entries optional) O

We’ll take peek a the Problem section


Problem Section & Entries

This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed.


Problem Section & Entries


Problem Section with Coded Entries Required

Two types of Problem sections are supported, MU2 requires the use of coded entries.


Problem Section example


Problem Act Concern


Problem Concern Act example


Problem Observation


Problem observation example


at the C-CDA sample

We will look at the sample

C-CDA

01/01/201136


Validation of C-CDA documents

Two alternative techniques have been established to validate C-CDA documents.

MDHT – JAVA validation code solution Available on the Open Health Tools Web Site

Trifolia – Schematron (xPath) solution Available on the HL7 Web Site


Tools & Pending NIST testing

The National Institute of Standards and Technology (NIST) provides a list of available validation tooling sites for interoperability specifications. NIST also provides tools for testing MU2 implementations.

Validation: http://xreg2.nist.gov/hit-testing/ Testing: http://healthcare.nist.gov/use_testing/tools.html


Technique 1 - Schematron

.xml

CDA IG

CCD

.xsd

XPath validation of Implementation Guide requirements

Validates against generic CDA schema

<Section code=Plan>

.xPath, .xsl,SchematronTrifolia

Workbench


Technique 2 – MDHT Validation

Domain Model

Domain Model

MDHTModelDriven HealthTools

MDHTModelDriven HealthTools

Add Custom Validations & Constraints

Add Custom Validations & Constraints

Java API(Source Code)

Java API(Source Code)

Validation CodeGeneration

Validation CodeGeneration

Implementation Guide(s)

Implementation Guide(s)

The JAVA code canparse, validate and provides an code able object model !


Identify useful resources

ToC Quickstart: http://wiki.siframework.org/Transitions+of+Care+Quickstart+Page

CDA R2 Product Brief: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7

Consolidated CDA Product Brief: http://www.hl7.org/implement/standards/ product_brief.cfm?product_id=258

HL7 FAQs: http://www.hl7.org/about/FAQs/index.cfm


Additional Tutorials

Available at HL7

Or consider a future HL7 Ed Summit or On-site Training.

Contact Mary Ann ([email protected]) to learn more about on-site training or to schedule on-site training for your organization.


For More Information….

Contact us! [email protected]

HL7 C-CCD Implementation Guide HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, Release 1 - US Realm

S&I Framework – C-CDA Companion Guide http://wiki.siframework.org/Companion+Guide+to+Consolidated+CDA+for+MU2

Open Health CDA Tools: http://cdatools.org/

MDHT: https://www.projects.openhealthtools.org/sf/projects/mdht/ Validation: http://xreg2.nist.gov/hit-testing/ Testing: http://healthcare.nist.gov/use_testing/tools.html

Trifolia Workbench: http://www.lantanagroup.com/resources/products/ Validation & CDA XSL Stylesheets: http://www.lantanagroup.com/resources/free-tools/


Q & A Session

01/01/201144

© 2013 calvin beebe and health level seven ® international. all rights reserved. hl7 and health...

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