CDA Crosswalk by langkunxg


									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
(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) (                           √            R

Information Source (header template) (                         2.2.2-2.2.8         √            R
Language Spoken (header template) (                                √            O

Support (header template) (                                        2.2.9            √            O

encompassingEncounter (header template) (                         2.1.11                        R

Healthcare Provider (header template) (                            √

Medication/Immunization Category
Medications Section (                                              4.33            √
Hospital Admissions Medication History Section (                   4.19
Hospital Discharge Medications Section (                           4.24                         R

Medications Administered Section (                                 4.32
Immunizations Section (                                            4.27            √            O
IV Fluids Administered Section
Condition/Concern Category
Allergies and Other Adverse Reactions Section (   4.02   √   R

Problem Section (                                 4.44   √   O

History of Past Illness Section (                 4.16       O

Hospital Admission Diagnosis Section (           4.18       O

Hospital Discharge Diagnosis Section (           4.22       R

Chief Complaint Section (                         4.07       O**

Chief Complaint and Reason for Visit Section              4.06       O**
Reason for Referral Section (                     4.53

History of Present Illness Section (              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) (
Care Planning/Assessment Category
Plan of Care Section (           4.39   √   R

Hospital Discharge Instructions Section   4.23       O

Instructions Section                      4.28
Functional Status Section (       4.14       O
General Status Section                    4.15
Results Category
(Diagnostic) Results Section (   4.55   √   ?
Vital Signs Section (                      4.60   √   O

Hospital Discharge Studies Summary Section          4.26       O

Other Templates
Payers Section (                            4.37   √

Advance Directives Section (               4.01   √

Physical Exam Section (                    4.38
Review of Systems Section (                4.56       O
Hospital Course Section (                  4.21       R

Family History Section (                   4.12   √   O
Social History Section ( (incl. smoking)   4.57   √   O
Encounters Section (                       4.11   √
Medical Equipment Section (                4.30   √
Hospital Discharge Physical Section                 4.25       O
Hospital Consultations Section                      4.20       O
Discharge Diet                                      4.10       O
Pregnancy (entry template) (                                    5.42   √
Comment (entry template) (                                     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
                                                    Not explicitly mentioned in ToC, but assume that
                                                    it will be used for both DC Summary and DC
    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
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
B?       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

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

A   A   O   O   ToC Core data, not in CCDA DC Summary

A   A   R   O   ToC Core data, not in CCDA DC Summary

                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
 Other concerns (better examples, usability,     A = Agree, D = Disagree R,B, H



Emergency Contact                                              A

Provider list is "buried" under                                A
documentationOf/serviceEvent in 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
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?

                                                                         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
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
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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