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


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

Sign in:   Attendee List

Executive Summary

The May 2020 C-CDA Implmentation-A-Thon (C-CDA IAT) was held as a half-day virtual event on Wednesday, May 20, 2020 from noon to 5pm ET. This was the eleventh running of the implementation-a-thon. It was well attended with 82 participants including program facilitators and topic presenters. Five EHR vendors sent representative: Allscripts, Cerner, e-Clinical Works, Epic, and NextGen. 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 May 2020 C-CDA IAT covered several topics requested by the implementer community in order to remain informed of changes and updates. Gay Dolin of Namaste Consulting and Matthew Rahn from the ONC provided an update on changes coming this June for the Score Card validator. They also reviewed the new set of Rubric Rules balloted through the HL7 Community in 2019 and published on May 17, 2020. These rules are established to "raise the bar" on the quality of

the Event Results

Security and Privacy Considerations

Do not supply, test or post sample files that include any PHI that has not been consented to be shared for educational purposes. 

C-CDA documents and they are used to create the rules used in the Score Card validator. Representatives from the National Committee for Quality Assurance (NCQA) Wendy Talbot and Anne Marie Smith provided an updated about the processes developing at NCQA to audit and validate processes used to create C-CDA CCD documents which provide data used in quality measure assessment programs. These two topics led to conversations regarding the need for the industry to orchestrate and manage changing data quality expectations. The group discussed what would be a reasonable frequency for validation tools and processes to change. They also discussed the need for alignment between validation tools to reduce burden on implementers and avoid inconsistencies in the validation tools. Didi Davis from the Sequoia Project described the validation tools available through their suite of testing tools. She explained Sequoia Project presently offers free access to their validators as an additional option for implementers who want to confirm the quality of their C-CDA exchange documents.

Discussions in the afternoon covered C-CDA and FHIR. Lantana Consulting Group CTO Rick Geimer explained the challenges and possibilities for data transformation and co-use of the two standards to support a variety of information exchange needs within the community of implementers who are maximizing existing investments as well as implementers making new investments in interoperable data exchange.

Joe Lamy, representing issues being explored within the CommonWell/Carequality Community, described several technical topics this large Community of C-CDA implementers is struggling with as they progress toward the creation and consumption of C-CDA encounter summaries such as Discharge Summary and Progress Note documents. Topics ranged from questions about document creation workflows, such as "on demand" documents, to questions about versioning of information and expectations for Content Consumers.

The day closed with a presentation from C-CDA IAT facilitator Jean Duteau explaining what implementers can expect from the next C-CDA IAT to be held virtually on Wednesday, July 22, 2020. As a result of implementer feedback requesting a greater focus on specific use cases and examples stemming from production uses of C-CDA, the next C-CDA IAT will focus on topics selected and driven by implementers. The C-CDA implementer community is being supported to initiate discussion of topics relevant to use cases and challenges they or their customers are facing in production environments. The topic sign-up grid for the July 2020 C-CDA IAT is already available on Confluence. Topics need to be identified before June 15, 2020 so the July session can be confirmed and promoted. C-CDA IAT facilitators are available to help topic presenters develop and prepare their topic presentations. Ideas discussed as possibilities included focusing on consuming and comparing collections of production-level documents, looking at a variety of "clinical note" sections within C-CDA documents, and exploring specific implementer-defined use cases for C-CDA document exchange.

If you have a C-CDA implementation topic you would like to explore on July 22, 2020 with the growing C-CDA Implementer Community, sign-up ( ) BEFORE JUNE 15, 2020.

Event Recordings

You will be asked to submit contact information to access the recordings.

Event Notes 


USCDI - Rubric Rules – Scorecard Updates 

Session 1 Handout

The United States Core Data for Interoperability (USCDI) standard will replace the Common Clinical Data Set (CCDS) definition 24 months after publication of the final rule (May 1, 2020) - i.e. May 2, 2022.  However the enforcement date has been pushed back three months to August 2, 2022.

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The C-CDA Rubric Guide was published on May 19, 2020 - providing guidance for required and informative rubrics and organized into three categories:

  • Common Rubrics
  • Header Rubrics
  • Section/Domain Specific Rubrics

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Goal of the Rubrics Guide is to promote the development of quality assessment tools and improve interoperability and secondary use of data.  People can suggest rubrics on the HL7 C-CDA Rubric Criteria Project Page.

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ONC C-CDA Scorecard R2.0 Beta Demo.  R2.0 will be pushed out to production on June 1, 2020.  The downloadable scorecard on Github will also be updated.  Updated companion guide templates will be incorporated on June 30, 2020.

Q: Will the validator the rubric is using also be updated by June 1?  A: Yes, but it will not be in the June 1 version of the scorecard.

Q: What is the go-forward process for adding requirements as USCDI grows?  For example, is there path or idea around how notes will be brought into the fold?   A: With respect to the Rubrics guide, criteria suggestions can be logged on the HL7 C-CDA Rubric Criteria Project Page (link above).  As this is an HL7 artifact, there may also be opportunities to leverage the HL7 JIRA process to capture suggested changes against the guide.  The ONC is committed to continuing to update the scorecard (provided funds are available).  As the community coalesces around best practices - i.e. above and beyond certification - those can be added as an update.

Q: Will ONC offer tools for validation of the various clinical notes named in USCDI?  A: Yes...but only for notes section within the CCD, Referral Note, Discharge Summary, and optionally the Care Plan document types.

Q: Are pediatric vitals required for all EHRs or is there a % of children to require EHRs to capture this information?  A: This is a good question for the program, but implementers will need to meet the requirements related to vital signs as specified.

Q: Implementers are waiting on detail regarding expectations around clinical notes and pediatric vital signs.  e.g. reference range related to growth charts.  A: Unless  otherwise specified in the final rule, implementers should follow the base standard.  There may be clarifications issued by June 15 as part of the Certification Companion Guide.  Questions related to ONC Cures Act Final Rule can be submitted at

Q: The number of issues is hard to see when you expand format.  A: Yes.  Matt will work with the team to see if there is a clearer way to present the information.

C-CDA for Quality Measuresxxx

Data Aggregator Validation: Pilot Program

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Goals of the program are to:

  • Ensure integrity of data is maintained from source through to end-user
  • Ensure Aggregator adheres to NCQA Implementation Guide (IG)
  • Minimize audit burden on vendors and health plans who receive data

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Aggregators MUST pass both the input data validation and the output file validation in order to be considered validated.

Anticipated timelines- June 2020 for pilot completion, soft launch in the fall and 2021 for the official program launch.

Q: How can we learn from your project putting into consideration we are outside of the US and we rely only on HL7 CDA?  A:  Best way would be reach out to Wendy via email or to visit the NCQA DAV webpage.  It is believed that many of the learnings coming out of this process will have applicability outside the US.

Q: What falls into the category of "aggregator"?  A: Pilot is working with HIEs, but it really includes anyone who aggregates data and passes it along for reporting - e.g. health plans, EMR vendors, etc. but there is not a hard definition.

Q: How does this process/validator work in conjunction or relate to the ONC validator/scorecard?  A: Right now, the validators are different.  However, the goal is to align.  This will be a discussion for for team to see how it can leverage and feed back to the ONC tools.

Q: Focus seems to be on CCD.  What about other document types?  A: The CCD is what is tested as the output.  There are no limits in what the aggregator takes in.  NCQA checks after ingestion are related to manual primary source verification processes such as policies, procedures, data capture receipts, repository sampling and auditing, etc.

Q: Is there going to be a mapping document between C-CDA elements and Quality Measure elements?  When an element is required by QM but it is not supported by the CDA IG, will the IG be updated accordingly?  A: Volume 1 in QRDA includes an appendix where the QRDA templates are mapped to the C-CDA templates.

C-CDA on FHIR and transforming C-CDA to FHIRxxx

Session objectives:

  • Key characteristics of clinical documents
  • The FHIR document paradigm
  • How to find and navigate the C-CDA on FHIR specification
  • Challenges mapping between CDA and FHIR documents

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Link to FHIR Documents, FHIR Composition Resource and C-CDA on FHIR Implementation Guide.

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Q: Is there use of the list resource in this work?  If not, why? A: It was considered but was deemed unnecessary as much of what is covered in list could be found in section.  Use of list is not prohibited though.

Q: What are the use case differences between documentReference vs. composition? A: documentReference is used for unstructured FHIR content.  Composition is used when you have structured FHIR content. 

Q: Will FHIR document replace C-CDA at some point? A: Hope to move away from "data dump" scenarios such as full CCD exchange between EHRs when using FHIR.  FHIR lends itself well to exchanges scenarios involving "human-generated" document types. That said, it is unlikely C-CDA will go away any time soon.

Q: We'd like there to be some discussion on how a system should incrementally move towards FHIR. i.e. start with basic context-free queries to replace need for CCDs, while keeping encounter summaries in a document form, incrementally moving from C-CDA to FHIR documents or maintaining both.  A: It will depend on use cases.  However, it is likely there will be duplicative information for point-in-time documents that are generated from dynamic data. More work needs to be done in the areas of data de-duplication and normalization.

Q: What is the best community to engage with regarding C-CDA to FHIR conversion? A: C-CDA/FHIR mapping stream on  There are various open source projects out there as well - e.g. PHCP public transforms repository in Github (note...this project uses STU3).

Q: Are there any suggestions for addressing negation in CDA→FHIR? A: This will vary by resource.

Top issues from CommonWell – Carequalityxxx

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Link to Concise Consolidated CDA:Deploying Encounter Summary CDA Documents with Clinical Notes white paper.

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Discussion: One possible approach for the Patient Summary (CCD) newly generated scenario: create a new document ID, and then create a parent id of some sort that you need to look at to find the link back to find out that it's the same.  However the intent is not to drive to consensus here - instead it is to highlight issues uncovered.

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Discussion: There can be sharing of incomplete encounters - e.g. sharing of anticipated orders prior to a patient being discharged.

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These are examples of pain points and issues discovered through the workgroup.  If you want to contribute to driving towards consensus approaches to these issues, Carequality has many committees and workgroups that can be joined. In the spirit of transparency and community, non-members are invited to join many of our workgroups as well. We encourage anyone who would like to participate to contact us at to let us know of your interest. Here is the link to the website listing all workgroups convened by Carequality.

New format for Implementer Led IATsxxx

Goal is for topics for the July 22 IAT to be implementer-led.  Confluence page to sign up for topics. 

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See attached handouts page for examples of deep-dive topics.

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Feedback, Questions, and Parting Thoughts


Action/Followup Items



Responsible for Follow-up
USCDI / ScorecardFollow up with program area to determine if there is a threshold of pediatric patients before EMRs are required to support pediatric vital signsMatt Rahn
USCDI / Scorecard

The number of issues is hard to see when you expand format.

Matt Rahn
C-CDA for Quality MeasuresDiscuss with the project/pilot team to see how it can leverage and feed back to the ONC tools (e.g. validators)Wendy Talbot