The July 2020 C-CDA Implmentation-A-Thon (C-CDA IAT) was held as a full-day virtual event on Wednesday, July 29th, 2020 from 10am to 6pm ET. This was the twelfth running of the Implementation-a-thon. It was well attended with 51 participants including program facilitators and topic presenters. Four EHR vendors sent representative: Allscripts, Cerner, e-Clinical Works, and Epic. Representatives from the Sequoia Project, Carequality, eHealthConnection, and CommonWell communities attended. Representatives from the US Government participated as well. There was a strong showing from the quality and payer communities along with many integrators and innovators who utilize C-CDA in information exchange solutions.
The July 2020 C-CDA IAT covered several topics led by representatives from the implementer community. In the morning, John D’Amore from Diameter Health proposed the creation of several examples which would clarify how to represent and render information for a deceased patient and a patient that is pregnant. Linda Michaelsen from Optum reviewed identifier and value set issues creating challenges for representing a patient’s coverage information in the Payer Section. Linda is working to propose resolutions for the identifier challenges which align across C-CDA and FHIR. The Health Insurance Type and Payer value sets used by C-CDA are being reviewed within the context of several FHIR IGs where the Coverage Resource is being profiled.
Following a break for lunch and a time for general conversation and networking in the Zoom session, Jean Duteau explained the purposed of an extension to CDA R2.0 being considered by the HL7 SDWG to include an alternative identifier which includes identifier type information. The community recommendation to SDWG was to proceed with adding the alternativeIdentifier extension to CDA R2.0 (and CDA R2.1 if applicable). Joe Lamy secured support for requirements proposed by the Joint Content Workgroup (Carequality/CommonWell) to recommend that encounter information may be made available after an encounter has started and should be made available after an encounter has ended (encounter/effectiveTime/high populated). The community was open to the idea of creating documents that are not considered fully completed. More clarity and implementer guidance remains needed and will continue to be drafted by the Joint Content Workgroup. Emma Jones and a team from Allscripts reviewed several questions they have encountered when implementing the new Notes Section and Note Activity templates. A general call for more examples was made to help identify how implementers are utilizing these templates to address real-world use cases for exchanging clinical notes in C-CDA documents. David Riddle from Cerner presented a proposal for how to map C-CDA participations to FHIR resources and when to derive FHIR Provenance resources for author and author.time. The community agreed further clarification was needed and additional follow-up on challenges with the Event Pattern resources will be reviewed with Patient Care and FHIR-I.
C-CDA IAT facilitator Jean Duteau closed the day by thanking the ONC for sponsoring the event and announced the proposed date of Wednesday, October 21st, 2020 for the next IAT. Participants were encouraged to work on advancing the available guidance for implementers by contributing to the ongoing work of the C-CDA Examples Task Force which meets on Thursdays from noon – 1:00pm ET. Conference calls for the group are announced on the HL7.org Conference Call Center. The Zulip chat C-CDA Stream will be used to continue discussion on the topics introduced during the event. (https://chat.fhir.org/#narrow/stream/179311-C-CDA)
The topic sign-up grid for the October 2020 C-CDA IAT is already available on Confluence. Topics need to be identified before September 15th, 2020 so the October session can be confirmed and promoted. C-CDA IAT facilitators are available to help topic presenters develop and prepare their topic presentations.
|Life and Death in C-CDA|
How is death managed in C-CDA documents?
Using stylesheets for consistent representation of death information - see examples from Epic (contact Matt Szczeankiewicz at firstname.lastname@example.org) and Allscripts (contact Emma Jones at email@example.com)
Use of Death Reporting C-CDA implementation guide
How is pregnancy managed in C-CDA documents?
|Payer Section in C-CDA Documents|
Representation in C-CDA
|Extending CDA to add more useful identifiers|
How do you determine the meaning of a given identifier in a CDA document? How are applications distinguishing multiple ids?
FHIR makes use of an identifier type attribute which is bound to a vocabulary. Proposed CDA extension is to add AlternativeIdentification.code bound to an extensible value set (IdentifiedEntityType). However to to further identify the id (e.g. MRN for hospital A vs. MRN for hospital B) may require looking at the id root/OID.
Decision - Update the Companion Guide to add guidance on using the new extension.
Action - determine real-world use cases and develop gold-standard examples - e.g. payer identifiers
|Implementation Considerations When Generating C-CDA Encounter Summary and Patient Summary Documents|
Sharing through the encounter lifecycle
A Responder SHALL have the capability to share updates to encounter summaries.
A Responder MAY share an encounter summary document for an encounter that is in process.
A Responder SHALL share an encounter summary document if any of the following is true:
What is the "right" document for each sharing scenario? Is there a "right" document for each scenario? Appears that much depends on sender and/or receiver capability.
Action - develop guidance for the Companion Guide around when summary documents are exchanged.
|Implementing Clinical Notes|
* Companion Guide comment looks to formalize LOINC code usage for laboratory report narrative and pathology report narrative in USCDI
Implementation Considerations Discussion
Action - seek clarification from the ONC to update Companion Guide to include more concise guidance
Action - develop gold-standard examples for each USCDI note type
|Mapping Author Participation Information to FHIR US CDI Resources Derived from C-CDA Documents|
Intuitive Mapping at the Header Level
Proposed entry-level mapping for PAMPI (Problems/Conditions, Allergies, Medications, Procedures, and Immunizations) Resources (less intuitive)
Potential issues with this proposal
The following logic is proposed for determining what FHIR Resource a C-CDA author participant should be converted into. e.g., Should a C-CDA Problem Observation author be a Condition.recorder reference to a Patient, RelatedPerson, Practitioner or PractitionerRole?
IF author/assignedAuthor includes an assignedAuthoringDevice vs. an assignedPerson THEN
FHIR Conditon.recorder should be null if
ELSE IF author/assignedAuthor/code/@codeSystem=”2.16.840.1.113883.5.111” and author/assignedAuthor/code/@code = “SELF” THEN
assignedAuthor/assignedPerson should be a FHIR Conditon.recorder Patient reference
ELSE IF author/assignedAuthor/code/@codeSystem=”2.16.840.1.113883.5.111” and author/assignedAuthor/code/@code <> “SELF” THEN
assignedAuthor/assignedPerson should be a FHIR Conditon.recorder RelatedPerson reference
ELSE IF assignedAuthor does not include a representedOrganization THEN
assignedAuthor/assignedPerson should be a FHIR Conditon.recorder Practitioner reference
ELSE IF assignedAuthor does include a representedOrganization THEN
assignedAuthor/assignedPerson should be a FHIR Conditon.recorder PractitionerRole
Author Provenance Rule
|Open Discussion: Solidify next steps and plan for future C-CDA IATs||Next virtual C-CDA IAT proposed for Wednesday, October 21, 2020.|
|Responsible for Follow-up|
|Life and Death in C-CDA||Add rubric for to check that a patient's name is not changed (using any scheme) to indicate a patient is deceased||John D'Amore|
|Life and Death in C-CDA|
Create gold-standard example of problem list containing pregnancy information
|Payer Section in C-CDA Documents||Determine where payer identifiers should go in the document and represent with gold-standard example||Linda Michaelson|
|Payer Section in C-CDA Documents||Convey support for the new identifier extension||Lisa Nelson|
|Extending CDA to add more useful identifiers||Update the Companion Guide to add guidance on using the new extension.||Lisa Nelson|
|Extending CDA to add more useful identifiers||Determine real-world use cases and develop gold-standard examples - e.g. payer identifiers||Jean Duteau|
|Implementation Considerations When Generating C-CDA Encounter Summary and Patient Summary Documents||Develop guidance for the Companion Guide around when summary documents are exchanged.||Joe Lamy|
|Implementing Clinical Notes||Seek clarification from the ONC to update Companion Guide to include more concise guidance||Emma Jones|
|Implementing Clinical Notes||Develop gold-standard examples for each supported USCDI note type (e.g. Consultation Note, Discharge Summary Note, etc.)||Emma Jones|
|Mapping Author Participation Information to FHIR US CDI Resources Derived from C-CDA Documents||Engage with SDWG to clarify how this work can move forward. Perhaps initially focusing on smaller problems to solve||David Riddle|