Consolidated CDA (CCDA) and Transitions of Care Comparison Dark shaded cells are covered by MU2 NPRM and CCDA already, and do not need the attention of TOC clinicians. The focus should be on which ADDITIONAL TOC data elements, if any, should be required. Focus on the non-dark cells. (See Legend Below Table) Document Types==> CCDA (Consoli- CCD CCDA dated CDA (HL7 + HITSP Discharge Guide C32) Summary CDA Templates reference) (Gray bars are for logical grouping, and are not CDA sections, and do not imply a hierarchy within the document) CDA Header Personal Information (header template) (18.104.22.168) 22.214.171.124 √ R Information Source (header template) (126.96.36.199) 2.2.2-2.2.8 √ R Language Spoken (header template) (188.8.131.52) 184.108.40.206 √ O Support (header template) (220.127.116.11) 2.2.9 √ O encompassingEncounter (header template) (18.104.22.168) 2.1.11 R Healthcare Provider (header template) (22.214.171.124) 126.96.36.199 √ Medication/Immunization Category Medications Section (188.8.131.52) 4.33 √ Hospital Admissions Medication History Section (184.108.40.206) 4.19 Hospital Discharge Medications Section (220.127.116.11) 4.24 R Medications Administered Section (18.104.22.168) 4.32 Immunizations Section (22.214.171.124) 4.27 √ O IV Fluids Administered Section Condition/Concern Category Allergies and Other Adverse Reactions Section (126.96.36.199) 4.02 √ R Problem Section (188.8.131.52) 4.44 √ O History of Past Illness Section (184.108.40.206) 4.16 O Hospital Admission Diagnosis Section (220.127.116.11) 4.18 O Hospital Discharge Diagnosis Section (18.104.22.168) 4.22 R Chief Complaint Section (22.214.171.124) 4.07 O** Chief Complaint and Reason for Visit Section 4.06 O** Reason for Referral Section (126.96.36.199) 4.53 History of Present Illness Section (188.8.131.52) 4.17 O Reason for Visit Section 4.54 O** Procedure and Surgery Category Procedures Section (List of Surgeries (History of 4.52 √ O Procedures) Section) (184.108.40.206) Care Planning/Assessment Category Plan of Care Section (220.127.116.11) 4.39 √ R Hospital Discharge Instructions Section 4.23 O Instructions Section 4.28 Functional Status Section (18.104.22.168) 4.14 O General Status Section 4.15 Results Category (Diagnostic) Results Section (22.214.171.124) 4.55 √ ? Vital Signs Section (126.96.36.199) 4.60 √ O Hospital Discharge Studies Summary Section 4.26 O Other Templates Payers Section (188.8.131.52) 4.37 √ Advance Directives Section (184.108.40.206) 4.01 √ Physical Exam Section (220.127.116.11) 4.38 Review of Systems Section (18.104.22.168) 4.56 O Hospital Course Section (22.214.171.124) 4.21 R Family History Section (126.96.36.199) 4.12 √ O Social History Section (188.8.131.52) (incl. smoking) 4.57 √ O Encounters Section (184.108.40.206) 4.11 √ Medical Equipment Section (220.127.116.11) 4.30 √ Hospital Discharge Physical Section 4.25 O Hospital Consultations Section 4.20 O Discharge Diet 4.10 O Pregnancy (entry template) (18.104.22.168) 5.42 √ Comment (entry template) (22.214.171.124) 5.10 √ Blue cells with bold text and numbers (2.2.1.x) refer to sections described in HITSP/C83. C83 is relevant for MU Stage 1 CDA Consolidation Guide sections (Implementation Guide for CDA Release 2.0 Consolidated CDA Templates ) are in the same row as their counterparts in C83. However, many template IDs have changed, as described in Appendix B of the Guide. Note on dark green shaded cells: Document sections required for ARRA HITECH Stage 1 certification and Meaningful Use are green cells in the CCR and CCD columns. Only Meds, Allergies, Problems, Procedures (hospital only), Immunizations (EP only), and Diagnostic results are specified in the ONC Final Rule, but Personal Information (about the patient) and Information Source (authors of the document) are implicit in the underlying standards. Green cells are aligned between ToC and CCDA Yellow -- minor issues between ToC and CCDA Pink -- major issues between ToC and CCDA Focus on the data, not the ToC doc types ToC ToC ToC Consult ToC Consult ToC Contraints Issues to Resolve Discharge Discharge Request Summary (David Tao notes) Summary Instrucs (physician) (physician) (hosp) (hosp) A A R R Core data elements for Marital Status, Religion, Race Code, Ethnicity are all optional (MAY or SHOULD) in CCDA US Realm Header and not further constrained by DC Summary Doc Type A A R R A A R R Core data element Language Spoken is optional (SHOULD) in CCDA US Realm Header and not further constrained by DC Summary Doc Type A A R R Support Contacts are Core in ToC, MAY in CCDA Not explicitly mentioned in ToC, but assume that it will be used for both DC Summary and DC Instrucs A A R R "Physicians and Designated Providers" is Core in ToC, but not mentioned at all in CCDA US Realm Header. R R A A Not specifically called "Discharge Meds" in ToC CEDD, but assumed to be in Active Med List B O O A A R R A A R R Optional (MAY) in CCDA; Active Problem List is Core in ToC, and inclusive of Diagnoses (as Problem List in Stage 1 MU also includes Diagnoses). While Admitting and Discharge Dx are covered in separate CCDA sections, Problem List overall is optional B? O In CCDA but not in ToC by this name. Probably maps roughly to "Medical History" in CEDD. B In CCDA as separate section; maps partially to "Admitting and Discharging Diagnoses" CEDD object B In CCDA as separate section; maps partially to "Admitting and Discharging Diagnoses" as well as Problem List CEDD object. Required in CCDA, B in ToC CEDD B? ToC CEDD has no specific object for this, though it is mentioned wrt History of Present Illness B? O O B O B? O This is why the patient is in the office in the terms of the provider (not the patient), used by front office for next appt B R R Called Surgical/Procedure History in ToC CEDD B A O O Could Plan of Care section include discharge instructions? Some systems in Stage 1 MU have use it that way in CCDs. Recommendation is NO, the language for clinician should be different from the language for typical patients. . Per Russ, patients can be given access to what clinicians see, but they generally won't understand it. Most patients would be overwhelmed by DC Summary. See Plan of DC Instructions is a separate document type in ToC Care with specific contents: "The Discharge Instructions CEDD Object would include a standard data set including demographic information, active reconciled medication list (with doses and sig), allergy list and problem list. Discharge Instructions also contains dataset relevant to the Discharge Summary/Discharge Instructions context which includes follow-up/plan of care." It is not a defined CCDA Document Type, but only an optional section within CCDA Discharge Summary, consisting only of a narrative block w. no constraints. So in CCDA it is not guaranteed to contain anything specific. C O O Äctivities of Daily Living (ADL) in ToC CEDD O B ? R R This is the section required in MU Stage 1 C32. In CCDA, but Hospital Discharge Studies Summary section is used in CCDA Discharge Summary, which does not list Results even as a "MAY" section B O O Used in CCDA Discharge Summary instead of the "Results" section of CCD. But it is narrative only. How would structured results be represented? Shouldn't a Results section w. structured entries also be allowed in DC Summary? A A O O ToC Core data, not in CCDA DC Summary A A R O ToC Core data, not in CCDA DC Summary O B Required in CCDA DC Summary but not specifically mentioned in ToC CEDD, but I doubt that anyone would object to including it in ToC DC Summary B O O B O O O O Not mentioned in ToC CEDD Not mentioned in ToC CEDD B Other concerns (better examples, usability, A = Agree, D = Disagree R,B, H etc.) A A A Emergency Contact A Provider list is "buried" under A documentationOf/serviceEvent in 126.96.36.199 for CCD constraints. Why limit providers to CCD only? For CCD, it is a SHOULD in CCDA Want to identify current PCPat a minimum, may want to document other current care team members, this should be included if available There is a gap between noting "discharge meds" and a clinican documenting that the discharge medications have been reconciled with what the home medications were and whether they should be stopped or started along with any new meds coming out of hospital CCDA shall include whether or not the medications have been reconciled Expressing "no known ___" vs "not asked" etc. -- A need to do consistently. See CCDA sections 1.8.8 (null flavor) and 1.8.9 (unknown information) plus specific examples (e.g., Fig. 13 No Known Meds & Fig. 198 No known problems). This is new and consistent: does this solve the problem? Expressing "no known ___" vs "not asked" etc. -- A We believe that there is another gap here, that need to do consistently. See CCDA sections there should be another document type defined 1.8.8 (null flavor) and 1.8.9 (unknown that includes a discharge message that incluydes information) plus specific examples (e.g., Fig. 13 at a minimum core data that goes to the PCP No Known Meds & Fig. 198 No known before the patient even leaves the facvility problems). This is new and consistent: does this solve the problem? A Admission Dx Discharge Dx Free text in the patient's own words, as to why Optional they came in, e.g., "feeling nausea and chills" Requesting a colleague to take care of the Important, though not "A" data element. Want to patient, e.g. New onset Atrial Fibrillation, please populate this conveniently if already collected in the evaluate (what is expected of the consulting EHR software. Also, what is the relationship to the clinician) "Purpose" section in CCD (and what happened to that section anyway, which is in CCD but not Consolidated CDA)? Are there other "purposes" for which CCD is created, e.g., purpose of the document rather than the clinical action. e.g. Follow up HTN, Annual physical, Optional Preoperative evaluation, consultation, etc. POC is "B" per Holly. It's the orders. Some of ToC Implementation Guidance should provide clarity on those are things like labs, images, diet, what to provide to clinicians regarding follow up plans, consultations, FLUP appointments, education. and where those are the same as, or different from, So some of it overlaps with "A" data elements discharge instructions given to the patient. like meds. Most SW is able to collect assessment and the plan related to that assessment, e.g., things to do for diabetes, hypertension... May only want to send the relevant parts of the plan specific to the consulting clinician, not necessarily everything. Practically speaking, aren't Discharge Instructions too ToC Implementation Guidance should provide clarity on open-ended to impose structure like a Med List or what to provide to clinicians regarding follow up plans, Problem List? Perhaps just a narrative block is OK, and where those are the same as, or different from, since structure could be hard to agree upon, could be discharge instructions given to the patient. a barrier to entry, and is not likely to be "consumed" by a receiving system anyway, but rather only displayed. WHEN PATIENT leaves, the discharge instructions are the sum of POCs for the patient in totality, intended for the patient. May contain more detailed instructions for patient that aren't necessary for the POC sent to other clinicians. E.g., DC instructions may contain detailed wound care step by step, vs. clinician POC would just say "wound care instructions were provided." Need different language. Clinician can request to see patient discharge instructions (separate doc). Need to clarify expectation for handling of a CDA ACTION NEEDED: Relevant results are important for section not listed at all (SHALL, SHOULD, MAY) ToC. EHRs must be able to send them as structured for a Document Type. It should have narrative data, though the decision of what to send is up to the block displayed, but no further requirements. clinician. They should be available in whatever IMPORTANT to have the results as document type(s) are agreed upon for ToCs. structured data! Able to be consumable by receiving system. CCD allows for Results; Consolidated CDA does not list it as a section for Discharge Summary. CCDA has examples for Vital Signs section, ToC Implementation Guidance should provide some organizer, and observation. Are they sufficient guidance on what types of Vitals exist and what other guidance? The examples are not filled out with data would be helpful if they're sent. But most of the concrete examples, e.g., a list of blood time, Vitals are not of interest to the receiving clinician. pressures. Rather, it is a "fill in the blank" and the reader needs to go to the Vital Signs Observation to see a single example for height. Filling out the example with more than one observation of more than one type, to be "organized" would be helpful. E.g., should all Pulses be organized together, or should all Vitals collected at the same time be organized together? HOW TO PRIORITIZE? H, W, Blood Pressure, are required for MU1. Vitals won't be imported into the receiving system. Would like to receive "calculated BMI" -- should be sent with the H and W. Additional VS data is also important (e.g., patient position when BP was taken, how temperature was taken, etc.) Needs to be reverified, but could facilitate a This was "A" in CIM/CEDD because it was considered quick registration. Improves door-to-doctor time. "demographics." May not really be an "A" element on its own. Note also that AD entry in CCDA has very Holly and Russ agree that this should be Yes/No, and specific AD type codes (Table 110) not just "is that structured entries are not required, especially the there an AD or not?" RECOMMEND YES/NO IN granular AD type codes in Consolidated CDA, which A NARRATIVE BLOCK. If patient brings AD, it most systems will not be able to capture. may be scanned as separate document. The actual AD should not be contained in a summary document like a CCD, though it might be helpful for the summary to say "The AD exists and it can be found at ____" The work Albany Med has been doing w. MedAllies in the NY Direct pilot may be informative here, specifically on how they're organizing the Hospital Course narrative block. CDA CCD and C32 Descriptions CDA Crosswalk Description: This spreadsheet illustrates a range of content that may be in CDA physician documentation. Many more CDA document types could be listed, e.g., CDC's Healthcare Associated Infection Reports, Personal Healthcare Monitoring Report (Continua), as well as more specialized clinical note types: Antepartum Summary, Emergency Department Referral, Nursing Triage Note, and Immunization Summary. These are specified by HL7, Health Story, or IHE and follow the same patterns. As noted, many CDA document types are in recommendations from the HIT Standards Committee. The ASTM Continuity of Care Record (CCR) is shown in the left column: it contains the same data sections as CCD, but does not have the data model of HL7 Clinical Document Architecture (CDA) is an HL7 document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange. CDA documents derive their machine processable meaning from the HL7 Reference Information Model (RIM) and use the HL7 Version 3 Data Types. CDA is a flexible XML-based clinical document architecture. CDA itself is not a specific document, but can be used to express many types of documents. A CDA document can contain many data sections, all of which contain narrative text, and some of which contain structured data elements describes constraints on the HL7 Clinicalare coded using Continuity of Care Document (CCD) (in "clinical statements"), some of which Document Architecture, Release 2 (CDA) specification in accordance with requirements set forward in ASTM E2369-05 Standard Specification for Continuity of Care Record (CCR). It is intended as an alternate implementation to the one specified in ASTM ADJE2369 for those institutions or organizations committed to implementation of the HL7 Clinical Document Architecture. The Continuity of Care Record (CCR) is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient’s healthcare, covering one or more healthcare encounters.2 It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. CCD is just one type of CDA document. Other types of CDA documents can contain some of the same CCD sections, but different sections as well HITSP C83 describes a library of sections that can be combined into various CDA document types. In addition, a document type can include additional sections, even those not a part of it. So for example a CCD could have a Reason for Referral section added and still be a valid CCD. In addition, the sections in C83 can contain structured data, described as "Entry Content Modules" that are being assembled into a "HITSP Data Dictionary" that describes the data elements and the constrains HITSP C32, The HITSP Summary Document Using HL7 Continuity of Care Document (CCD) Component describes the document content summarizing a consumer's medical status for the purpose of information exchange. The content may include administrative (e.g., registration, demographics, insurance, etc.) and clinical (problem list, medication list, allergies, test results, etc) information. Any specific use of this Component by another HITSP specification may constrain the content further based upon the requirements and context of the document exchange. This specification defines content in order to promote interoperability between participating systems. Any given system creating or consuming the document may contain much more information than conveyed by this specification. Such systems may include Personal Health Records (PHRs), EHRs (Electronic CDA Template: Practice Management of rules constraining persons and systems particular Health Records),A CDA template is a setApplications and otherthe CDA to conform to as identified and business requirements. Templates are reusable building blocks that can be asserted at the document, section, entry (data element) and sub-entry level. The initial library of CDA templates was developed for the CCD and is reused, as illustrated here. Note on Pregnancy and Comment: Pregnancy and Comment entry modules are included in C32, though they are not CDA sections nor specifically mentioned in CCD. Pregnancy is represented as a specific type of Problem Observation and Comment is an Annotation Comment for an Act.
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