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


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

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Executive Summary

The October 2020 C-CDA Implementation-A-Thon (C-CDA IAT) was held as a full-day virtual event on Wednesday, October 21st, from 10am to 6pm ET. This was the thirteenth running of the Implementation-A-Thon.

This IAT was well attended with 41 participants including program facilitators and topic presenters. Five EHR vendors sent representative: Allscripts, Cerner, e-Clinical Works, NextGen, and Epic. Representatives from the Sequoia Project, Carequality, eHealthConnection, and CommonWell communities attended. Representatives from the US Government participated as well. Optum participated from the payer communities. Two DirectTrust HISPs along with many integrators and innovators who utilize C-CDA in information exchange solutions also attended.

The October 2020 C-CDA IAT covered several topics led by representatives from the implementer community. Giorgio Cangioli from HL7 Europe led off sharing a comparison of the C-CDA Problem Concern and Allergy-Intolerance templates. He showed a draft template for each that combines the constraints to achieve templates that are conformant to both C-CDA and IPS. The takeaway action is to consider how to incorporate these findings into the design of these templates going forward to achieve greater harmony and alignment.

Diameter Health’s John D'Amore followed with a topic to clarify the participation roles in C-CDA. Using an ER visit use case, John walked through several scenarios and explained how the different CDA document participation roles are used to tell the story of who performed certain activities, who recorded the information in the chart, who the informant was and what other participants were involved. Keep an eye out for new examples and additional guidance to be covered in an update of the Companion Guide. The CDA implementer community acknowledged the need for greater clarity around how these roles should be used and how to determine WHO belongs in each.

Andrew Statler from Cerner described the importance of clear use cases in implementation guides.  He explained why IGs are more effective when they include well defined Use Cases.  He discussed two projects where the eICR specification was attempted to be applied.  In one case, there wasn't a clear use case, and since the specification didn't provide one either, it was very challenging to understand how to apply the guidance in the IG.  In another case, there was a very clear COVID Reporting use case, and the adoption was easier and faster. Andrew shared an example of using FHIR as a triggering mechanism for information exchange, and a CDA eICR (electronic initial case report) document as the mechanism for delivering a well-defined, rich set of data elements that were relevant to a specific case. ”More exact standards don't limit innovation, they accelerate it,” he asserted. Without use cases, this important aspect of development is missing, and development goes slower. Better use cases provide the HOW and WHEN of the spec and accelerates their use. Implementers bring and discuss use case at the IAT as a way of understanding how the C-CDA specification is expected to work.  The IGs need to be based on use case to allow implementations to take the full story telling power of CDA into consideration and so that semantically meaningful information will be conveyed.  If we required more use case information to be included in the IG as the basis for developing the constraints, then implementers would be more enabled to use the spec. The CDA implementer community moved to bring this recommendation back to SDWG to see what could be done to encourage the inclusion of use cases in CDA IGs.

ONC representatives Matt Rahn and Al Taylor presented on the new Cure Act rule and USCDI.  They reviewed the revised criteria and summarized where to find all the rule related information. Health IT modules that have already certified against the 2015 CEHRT only need to attest to conformance against certain criteria that hasn't changed, they explained. Matt Rahn announced a recently detected errata in 170.315(f)(5) and explained that updated language will be coming in a Certification Companion Guide. There are no specific IG requirements for electronic case reporting at this time, and the guidance in 170.315(f)(5) is currently incorrect. Implementers have till August 2022 (due to COVID) to update from supporting CCDS to USCDI. ONC is accepting USCDI v2 submissions until this coming Friday 10/30.

Al Taylor reviewed the existing USCDI v1 and how it is organized. There may not be an applicable standard --you can drill into the data element level on the USCDI web page. Al reminded implementers that the USCDI v1 had a published errata in June. The requirements to exchange USCDI v1 differ depending on the use of C-CDA or FHIR US Core. The USCDI Draft V2 reflects incoming submissions. Comment is the lowest level of maturity, Level 1 is higher and Level 2 is the highest (most ready, most feasible).

Link to errata USCDI V1

More on USCDI here:

Al reviewed the ONDEC submission system and explained that everyone can make a submission. He explained that ONC will draft USCDI V2 from items ranked as Level 2. He also explained the ONDEC submission page includes a prep sheet to help submitters gather the information needed to do a submission. Al described the annual cycle for developing newer versions of the USCDI and then the ONC would decide if the update could be included in the Health IT rule before new regulation from ONC comes out. ONC is adjudicating their evaluation of the submissions as they come in. 20 new data classes and about 200 new data elements have been submitted so far. The process includes an annual cycle with voluntary adoption.

Matt and Al also went over the new Standards Version Advancement Process (SVAP) to enable health IT developers’ ability to incorporate newer versions of Secretary-adopted standards and implementation specifications, as part of the “Real World Testing” Condition and Maintenance of Certification requirement . Working with industry stakeholders and providing ample notice, ONC will follow a collaborative process to identify a more advanced version of the standards or implementation specifications, for approval by the National Coordinator. More details, including timelines, anticipated comment periods, and other operational information for the SVAP will be made available at this page soon. 

Joe Lamy from the Carequality/Commonwell Joint Content workgroup reported on the issue of how to determine when an encounter is over. The debate has lots of facets to it and it is impacted by many different perspectives.  Some definitive conclusions have been made, but the topic will be picked up in the newly announced Sequoia Data Usability Workgroup. On the question of including section time range in CCD documents, the joint workgroup has suggested that the Section Time Range template be used on every section.  Lots of discussion ensued, and the current guidance was explained.  Alignment with FHIR came up with a business case.

CDA Management Co-chair Lisa Nelson reported on the progress made toward completing action items from the July C-CDA IAT.  Of the eleven (11) actions items resulting from the previous IAT, 2 had been completed, 6 had been started, 2 were waiting on other actions to complete before they could get started, and 1 item was escalated to the FHIR Management Group to address (an escalation for Patient Work Group).  Eight (8) new action items were identified during this IAT.  Action was started on 50% of the new actions.  Lisa also noted a new job opening within HL7 for a US Program Manager to take on oversite for US specific projects.

C-CDA IAT facilitator Jean Duteau closed the day by thanking the ONC for sponsoring the event and thanking Natasha Kreisle for the amusing break-out slides inspired so much fun conversation.  He solicited feedback from participants which was mostly positive regarding the new implementer-led format. Everyone agreed to do more to encourage newcomers to participate more. He announced the proposed date of Wednesday, March 24th, 2021 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 Conference Call Center. The Zulip chat C-CDA Stream will be used to continue discussion on the topics introduced during the event. (

Dave Hamill reminded everyone how important and valuable the feedback surveys were to improving future IATs. The topic sign-up grid for upcoming C-CDA IATs is already available on Confluence. Topics for the March IAT need to be identified before January 15th, 2021. C-CDA IAT facilitators are available to help topic presenters develop and prepare their topic presentations. Next year’s IATs will all be held as virtual events.  Save the dates:  March 24th, 2021; July 21st, 2021; October 20th, 2021.

Event Notes 


Topic 1: Potential advancements for representing Problems and Allergies resulting from harmonization between C-CDA and IPS Templates

The International Patient Summary (IPS)

  • European patient summary is the eHDSI Patient Summary
  • is a snapshot in time of subject's health information and care
  • designed for unscheduled (cross-border) care

C-CDA vs. IPS structure

C-CDA vs. IPS structure

Conformance Crosswalk

Conformance Crosswalk

Concern Act and Problem Observation - Mapping to FHIR

Mapping to FHIR

Concerns and Problem Observations

  • Key status is the problem status
  • Concerns are often not used or do not have clear alignment to clinical/business we see in the mapping above FHIR does not use the concern structure
  • Action: rework problem/concern templates - perhaps only having concerns be a mechanism to get to the problem observation
Topic 2: Participation Roles in C-CDA


  • How to deal with IDs that would have had different assignment schemes over time? Action: refer back to Structured Documents.
  • Medication lists - how to link back to the prescriber? Need to add structure that includes information about the substance administration request...and its performer.
  • Action: post sectional guidance and bring examples for approval

Topic 3: Use Cases Driven IG's for CDA

By having use cases to ground analysis, the project team was able focus on the usage scenarios that needed to be met / problems that needed to be solved.  They were able to pivot to a different approach than was originally designed (and one that was completed in less time and would be easier to deploy) because they were able to focus on the use case.

Call to action: formalize requirement to include use cases in IGs by adding this to the quality criteria.  This includes:

  • Use case description
  • A well-defined example
  • Defining how/when it will be used
  • A process flow from from beginning to end

Action: bring forward to SDWG

Topic 4: Update on Conditions of Certification – any new expectations relevant to C-CDA?​

Update on USCDI, SVAP​

Ask the ONC

No requirement to support (f)(5) - Electronic Case Reporting.

USCDI submission deadline is midnight, October 22, 2020.

SVAP comment period ends on November 9, 2020.


  • In the 2014 edition, (e) 2 clinical summary was required.  (e) 2 clinical summary is encounter-based.  This has since been dropped as certification criteria. Where is the link from this to any new encounter-based documents?  CCD is still used.  Matt needs to dig into this.  Action: Matt Rahn to dig into why the (e) 2 clinical summary was dropped and what is the linkage to newer certification criteria.

Topic 5: Clarifying document lifecycles for Encounter and Patient Summary Documents

Does the use of legalAuthenticator indicate the underlying encounter is complete? 

  • The legalAuthenticator may not always be present, or it may be an implicit entity. 
  • The legalAuthenticator is attesting that the document is correct.
  • Differences in approaches in determining when an encounter is done - e.g. time based, billing complete, etc.  As it is possible to exchange documents that indicate progress, it seems to be a stretch to rely on the presence of legalAuthenticator to determine if the underlying encounter is complete...just that the document exchanged is correct.
  • Discussion to continue in the Sequoia Data Usability Work Group that will be picking up work started by the CommonWell Carequality group.  First meeting will be Oct. 29.

Action: discuss further with examples task force

Topic 6: Update on Progress from July C-CDA IAT Topics

Break discussion: Context conduction is generally not being done, but there are multiple approaches in the community to deal with it.

Life to Death in CDA

  • add rubric to check that a patient's name is not changed.  Rubric rule request has been added.
  • Create gold-standard example of a problem list.  Done

How to identify payers

  • Working with Linda to create an example of the alternateIdentifier for use with representing Payer’s identifier.
  • Stalled on working with FM to determine how to represent a person’s insurance card information.
    • Doing work in FHIR R5 which may bring clarity that could be back-ported to C-CDA.

Alternate Identifiers

  • Extension definition started, needs to be improved and then implementation needs to be finished.
  • Working with Linda to create an example for use with representing Payer’s identifier.

Encounter Document Creation

  • Continuing to work with Carequality/CommonWell Communities. What can implementers commit to offering and sharing other clinical note document types?

USCDI Clinical Notes

  • Revisions are being proposed to USCDI V1

C-CDA Participant Mappings to FHIR Resources

  • Issue is being escalated through Patient Care WG

C-CDA Maintenance roadmap topics:

  • Errata Releases (technical corrections)
  • Value Set Updates (updates that only impact dynamically bound value sets)
  • Minor Updates (a point release to absorb available template changes)
  • Major Updates (like going to the Web Publication)
  • Companion Guide Updates
  • Rubric Rule Updates

FYI Job Posting - 9/24/2020 Program Manager, US Realm

Reporting to the HL7 Chief Technical Officer (CTO), the Program Manager, US Realm (USR) is a funded, full-time (or near-full-time), non-volunteer contract position in HL7 International. This individual will have primary responsibility for defining and applying a methodology for managing and monitoring US Realm projects and standards products, including Implementation Guides, Resources, Extensions, Value Sets and other documents and guidance materials.

The Program Manager will define and apply quality systems, tools and process improvements to more rapidly achieve project approvals and to reduce overhead effort in order to reduce the cycle time required for updates to specifications in order to coordinate updates with new versions of the US Core Data for Interoperability (USCDI) and other regulatory requirements.

The role will include reviewing and enhancing project management systems as necessary to improve visibility and status tracking. The Program Manager will also be responsible for regular tracking, reporting on and maintaining key metrics on all US Realm projects (as well as critical dependencies that extend beyond the US Realm, such as the FHIR Core Specification and vocabularies). The Program Manager will also work with HL7 leaders to extend outreach to adopters of US Realm standards and monitor adoption levels.

TODO - Review recording

Recap, Next Steps, Closing Thoughts​

Plans for next C-CDA IAT – March 2021​

Proposed dates for next C-CDA IATs

Proposed annual cycle with three virtual events.  Tentative dates for 2021:

  • Wednesday, March 24th, 2021
  • Wednesday, July 21st, 2021
  • Wednesday, October 20th, 2021

Continued Participation

  • Contribute to the work of the C-CDA Examples Task Force
    • Thursdays, noon – 1:00pm ET (following SDWG call)

Visit Conference Call Center for meeting invite information

Topics to ponder

  • Mapping between C-CDA and FHIR
  • Updating the C-CDA spec
  • Granularity of C-CDA (e.g. manage individual templates in a github repo with regular releases similar to FHIR)


Is there a timeline for publishing CDA on the web?  There is a timeline that HL7 is trying to get to, however it keeps slipping.

Action/Followup Items



Responsible for Follow-up
C-CDA and IPSPoll larger implementer community about use of problem/concern templateCDA Management Group
C-CDA and IPSRework problem/concern templates to better align with clinical/business use - e.g. allow use of either concern/problem structure or problem observations, limit to one problem observation per concern, etc.CDA Management Group

Report and STU comment against the Companion Guide to fix the IG references CDA_SDTC schema in footnote #19 in chapter 2.2Lisa Nelson
Participation Roles in C-CDAPost sectional guidance and bring examples for approval.  End goal would be to add this to the Companion Guide.John D'Amore
Participation Roles in C-CDAHow to deal with IDs over time (e.g. with different assignment schemes)?  Refer to SDWG.CDA Management Group
Use Cases Driven IG's for CDABring forward to SDWG the suggestion to formalize the inclusion of use cases as part of the quality criteria for IGsCDA Management Group
Ask the ONCMatt Rahn to dig into why the (e) 2 clinical summary was dropped and what is the linkage to newer certification criteriaMatt Rahn
Document LifecyclesTime-constrained section requirements to be discussed further with the examples task force/SDWGCDA Management Group

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