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Facilitators

  • Lisa Nelson (MaxMD)
  • Jean Duteau (Duteau Design)
  • Joginder Madra (Madra Consulting Inc.)

Goal

  • Improve consistency and quality of information representation in C-CDA exchange documents

Sign in:   Attendee List

Executive Summary

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.

Event Notes 

Item

Notes
Life and Death in C-CDA

Session recording here:

How is death managed in C-CDA documents?

  • use of deceasedInd value="true"
  • use of deceasedTime value ="2018031"

Using stylesheets for consistent representation of death information - see examples from Epic (contact Matt Szczeankiewicz at mszczepa@epic.com) and Allscripts (contact Emma Jones at emma.jones@allscripts.com)

  • e.g. rendering "Deceased" near the patient's name when information about the patient's death is present in the document
  • changing the patient's name to include "deceased" or some other scheme "zz_" or "xx_" in the document content itself - i.e. changing the name itself as opposed to adding an indicator - appears to be a problematic approach as there are patient matching issues should the information be exchanged.
    • Decision - the patient name should not be changed to indicate the patient is deceased in the XML.  Add to rubrics.

Use of Death Reporting C-CDA implementation guide

  • used for vital records
  • concern expressed about using this IG for non-vital records documents.  No consensus on use.

How is pregnancy managed in C-CDA documents?

  • problem section vs social history section
    • could use social history template to include concepts such as: date of conception, date of (estimated) delivery, date of last author update
      • not a lot of evidence of use
    • could use problem list to include pregnancy as a problem with estimated conception date (date of onset), estimated weeks gestation with a date of last author update
      • problem list approach appears to be more common
    • use of problem list may be linked to billing whereas us of social history may be linked to aversion to calling pregnancy a problem.
    • information in a problem list may have more visibility or be given more attention than information in a social history
    • Decision - create gold-standard example of problem list containing pregnancy information
Payer Section in C-CDA Documents

Session recording here.

 

 Representation in C-CDA

  • Payer Section (V3) contains:
    • 0..* Coverage Activity (V3) which contains:
      • 1..1 Insurance Information which contains:
        • 1..1 PolicyActivity (V3) which contains:
          • 1..1 Performer (Responsible Party/Payer)
          • 0..* Performer (Guarantor)
          • 1..1 Participant (Patient)
          • 0..1 Participant (Subscriber).  Only used when the patient is not the subscriber
    • 1..1 Prior Authorization (STU comment logged to suggest this should not always be required)

Payer Representation

  • currently and id with a root and extension e.g. <id root="2.16.840.1.113883.6.300“ extension=“04112”/>
  • Action: determine where these identifiers should go in the document and represent with gold-standard example
Extending CDA to add more useful identifiers

Session recording here.

How do you determine the meaning of a given identifier in a CDA document?  How are applications distinguishing multiple ids?

  • use the OID
  • strong coordination between senders and receivers

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

Session recording here.

Sharing through the encounter lifecycle


A Responder SHALL have the capability to share updates to encounter summaries.

  • If no data contributing to an encounter has changed since the last shared encounter summary, a Responder SHALL return the same stable document entry in response to a query.
  • If any data contributing to an encounter has changed since the last shared encounter summary, a Responder SHALL return a new stable document entry in response to a query.

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:

  • The end time for the encompassing encounter is defined.
  • The encounter has been authenticated.
  • The encounter has been legally authenticated (i.e. completed or “signed off”).

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

Session recording here.

USCDI

NoteApplicable Standard
Consultation NoteConsult Note (LOINC® code 11488-4)
Discharge Summary NoteDischarge Summary (LOINC® code 18842-5)
History & PhysicalHistory and Physical Note (LOINC® code 34117-2)
Imaging NarrativeDiagnostic Imaging Study (LOINC® code 18748-4)
Procedure NoteProcedure Note (LOINC® code 28570-0)
Progress NoteProgress Note (LOINC® code 11506-3)
Laboratory Report NarrativeN/A*
Pathology Report NarrativeN/A*

* Companion Guide comment looks to formalize LOINC code usage for laboratory report narrative and pathology report narrative in USCDI

Implementation Considerations Discussion

  • Unstructured Documents, Comments, Flags – how should differentiation occur?
    • Are all “clinical notes” meant to be shared?
  • Continue to support discrete data
    • Over prescription of clinical notes may inadvertently cause diminished use of discrete data
  • Use of binary (e.g. images) in clinical notes
    • good thing to include

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

Session recording here.

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

  • differences in approach compared to SOA Project
  • cardinality differences in C-CDA between author (1..*) and informant (0..*) vs. recorder (0..1) and asserter (0..1) in US Core Profiles

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

END IF

Author Provenance Rule

  • No explicit Provenance Author Participation in the above C-CDA Allergy - Intolerance Observation, so no ‘Author agent’ Provenance will be derived for the US Core AllergyIntolerance resource.
  • This CDA Allergy - Intolerance section does include an instance of the new Provenance Author Participation template (2.16.840.1.113883.10.20.22.5.6) at the SECTION level; however, it also includes a standard Author Participation (2.16.840.1.113883.10.20.22.4.119) element at the observation level. 

    • CDA Context Conduction rules indicate that the observation level author is the author of the Allergy - Intolerance Observation.
    • Due to Drew’s Rule [1], no FHIR ‘author Provenance’ will be created for the AllergyIntolerance resource derived from this C-CDA Allergy – Intolerance observation.

    [1] Only derive Provenance for the extracted/derived resource if explicit Provenance is included/conveyed in the C-CDA via. the Provenance Author Participation template (2.16.840.1.113883.10.20.22.5.6).

Next Steps

  • Action - Engage with SDWG to clarify how this work can move forward. Perhaps initially focusing on smaller problems to solve.




Open Discussion: Solidify next steps and plan for future C-CDA IATsNext virtual C-CDA IAT proposed for Wednesday, October 21, 2020.

Action/Followup Items

Grouping

Item

Responsible for Follow-up
Life and Death in C-CDAAdd rubric for to check that a patient's name is not changed (using any scheme) to indicate a patient is deceasedJohn D'Amore
Life and Death in C-CDA

Create gold-standard example of problem list containing pregnancy information

John D'Amore
Payer Section in C-CDA DocumentsDetermine where payer identifiers should go in the document and represent with gold-standard exampleLinda Michaelson
Payer Section in C-CDA DocumentsConvey support for the new identifier extensionLisa Nelson
Extending CDA to add more useful identifiersUpdate the Companion Guide to add guidance on using the new extension. Lisa Nelson
Extending CDA to add more useful identifiersDetermine real-world use cases and develop gold-standard examples - e.g. payer identifiersJean Duteau
Implementation Considerations When Generating C-CDA Encounter Summary and Patient Summary DocumentsDevelop guidance for the Companion Guide around when summary documents are exchanged.Joe Lamy
Implementing Clinical NotesSeek clarification from the ONC to update Companion Guide to include more concise guidanceEmma Jones
Implementing Clinical NotesDevelop 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 DocumentsEngage with SDWG to clarify how this work can move forward. Perhaps initially focusing on smaller problems to solveDavid Riddle
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