CDA_IG_C-CDA_RUBRIC_CRIT_R1_O1_2019MAY

 

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HL7 Guidance: C-CDA Rubric Criteria, Release 1

May 2019

 

HL7 Informative Ballot

 

Sponsored by:
Structured Documents

Patient Care

 

 

 

 

 

 

 

 

 

 

 

 

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Table of Figures:

Figure 1: @Code and @ DisplayName Alignment

Figure 2: @Code and @DisplayName Misalignment

Figure 3: Referenced Code System Preferred Name:

1         Overview

This document contains rubric criteria created through an ongoing project in the HL7 Structured Documents Work Group (SDWG), originating in 2016. Throughout 2018 a group of HL7 members created a new set of rubrics to add to the original rubric. This project identified key problematic areas in real system generated C-CDA documents where similar data was consistently represented differently or incompletely. Variably constructed data removes the ability to reliably share and compare data, adversely impacting interoperability. The hope is that the rubric will promote best practices by allowing providers and health IT developers to identify and resolve issues of C-CDA document data representation in their health IT systems thereby promoting interoperability and use of clinical data received in C-CDA documents.

 

A subset of the rubric criteria are utilized to identify best practice tests and quantitative scoring criteria in the Office of the National Coordinator for Health IT (ONC) C-CDA Scorecard . The ONC C-CDA Scorecard is designed to allow implementers insight into C-CDA implementations and highlights areas of improvement which can be made today to move the needle forward.   The intent is to add these additional rubrics to the ONC Scorecard.

 

In order for these rubric criteria to be more exposed, members of SDWG suggested it would be a good idea to put the rubric criteria through an Informative Ballot.

1.1       Need

There is an industry need for disparate systems to be able to communicate with each other. End users can use tools that utilize these rubric criteria to determine the quality of their C-CDA applications, leading to quality improvement discussions with their vendors. The Informative Ballot will help gain widespread consensus on the appropriateness of the rubric criteria.

2         C-CDA Rubric

2.1       Explanation of the Rubric Criteria

The rubric criteria are a set of Rubrics that go above and beyond EHR certification. They are meant to be utilized in best practice testing tools to provide feedback to industry and help drive the EHR vendor community towards consistent implementation of the C-CDA standard.

 

There are two types of Rubric criteria identified:

  • Required – All tools adopting this criteria should throw an error.
  • Informational - All tools adopting this criteria should throw a warning, not an error.

 

3         Common Rubrics

3.1       Required

3.1.1         DisplayName

3.1.1.1        Rubric Intent

If code's DisplayName is present and it conflicts with the codeSystem's preferred displayName then a tool should throw an error. If a DisplayName isn't present, then a tool should not throw an error. Testing tools will require at least a basic terminology service to implement this Rubric.

 

3.1.1.2        Rubric [GD1]

If an @displayName is present with an @code then the text of the @displayName SHALL be the text of the code system’s preferred name.

 

3.1.1.3        Examples

 

Figure 1 : @Code and @ DisplayName Alignment

<manufacturedMaterial>

       <code code = "573621" codeSystem = "2.16.840.1.113883.6.88"

       codeSystemName = "RxNorm"

       displayName = "Albuterol 0.09 MG/ACTUAT [Proventil]" />
</manufacturedMaterial>

 

 

 

Figure 2 : @Code and @DisplayName Misalignment

<manufacturedMaterial>

       <code code = "573621" codeSystem = "2.16.840.1.113883.6.88"

       codeSystemName = "RxNorm"

       displayName = "Aspirin” />
</manufacturedMaterial>

 

 

Figure 3 : Referenced Code System Preferred Name:

 

[GD2]

 

C-CDA Examples Task Force Link: In this case any example: http://hl7-c-cda-examples.herokuapp.com/ [GD3]

3.1.2         Identifiers

3.1.3         Text Reference

3.1.4         Time

3.1.5         Validation

3.2       Informational

3.2.1         Template IDs

3.2.2         Time

4         Header Specific Rubrics

4.1       Required

4.1.1         Patient Name

4.1.2         Time

5         Section/Domain Specific Rubrics

5.1       Required

5.1.1         Goals

5.1.2         Immunizations

5.1.3         Medications

5.1.4         Social History

5.2       Informational

5.2.1         Goals

5.2.2         Medications

6         References

 

This link is where the current rubric is located, where you can find more information about the process for creating a rubric, and where you can find call information.

The Consolidated CDA (C-CDA) implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from Health Level Seven (HL7), Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It represents harmonization of the HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination (IHE PCC), and Continuity of Care (CCD).  

The C-CDA Scorecard leverages the work completed by an ONC-funded grant   SMART (Substitutable Medical Apps Reusable Technologies)   and promotes best practices in C-CDA implementation by assessing key aspects of the structured data found in individual documents. It is a tool designed to allow implementers to gain insight and information regarding industry best practice and usage overall. It also provides a rough quantitative assessment and highlights areas of improvement which can be made today to move the needle forward.  

 

 

 

 

 


[GD1] One comment reconciliation was for each rubric to have a unique ID. Can the heading numbers become the unique IDs (at end of document creation) or should we make up a format?

Suggestions for format?

[Rubric-1]

Have the Rubric number include if its Required or Informative??

[Rubric-R1]

[Rubric-I1]

Remember the challenge is these will not be autogenerated

[GD2] Seems like it may be meaningful to have a screen shot of the reference code system code – thoughts? Should we have additional examples here (i.e. from SNOMED CT and LOINC)

[GD3] Should the link to the C-CDA Examples Task force be under its own Heading number 4 (Like 3.1.13 Examples) or OK to “regular text  under 3.1.13 Examples