Tip:
Highlight text to annotate it
X
Welcome to the recording of Implementing Consolidated Clinical Document Architecture (C-CDA) for
Meaningful Use Stage 2, presented for you by the ONC Implementation and Testing Division,
April 17, 2013. This is the second part of a three part self-paced module on Implementing
Consolidated Clinical Document Architecture for Meaningful Use Stage 2 and the 2014 Edition
EHR Certification Criteria.
Part One of this three-part module presented an overview of C-CDA Implementation for Meaningful
Use Stage 2 and the 2014 Edition EHR Certification Criteria. Topics included Health Information
Exchange and the 2014 Edition EHR Certification Criteria and Meaningful Use Stage 2 objectives,
the purpose, functionality, usage, and structure of HL7�s Clinical Document Architecture
(CDA), and how the C-CDA Implementation Guide can be used to help providers meet applicable
MU objectives. In this second part of module, we�ll discuss implementation of the Consolidated-CDA
standard in greater detail.
So how can you implement clinical documents that meet both Meaningful Use and Consolidated
CDA data requirements?
First, you should choose the Consolidated CDA document template that best fits your
clinical workflow. You start by including the consolidated CDA components defined by
the document template, and there are required components, and then optional components that
are appropriate for your clinical situation. When you�re done, you then add the consolidated
CDA components that are necessary to meet the Meaningful Use data requirements. You
should review which data requirements have already been met through your prior inclusions,
and then add any additional CDA components that are necessary to align with data requirements
that haven�t yet been met.
Let�s walk through an example of how you might want to pursue the Transitions of Care
criterion.
In this scenario, a patient is experiencing severe knee pain and is referred to an Orthopedist
by their Primary Care Provider, or ***. The *** needs to generate a summary document to
provide to the Orthopedist. This use case exhibits the Transition of Care criterion
in action. In this case, no single Consolidated CDA document template inherently includes
all of the elements needed to satisfy the criterion�s data requirements. Another point
to note is that document templates within Consolidated CDA are considered open templates,
which means that in addition to required and optional sections, which are defined in the
template, an implementer can add to the document whatever consolidated CDA sections are necessary
for his purposes.
So Step 1: Pick a Document Template. In this case, we are considering a couple different
document templates: perhaps a consultation note, continuity of care document, or discharge
summary. Now each of these document templates was designed to satisfy a specific information
exchange scenario, and each document template defines the CDA structures to be used to document
the applicable clinical information.
Now the best fit document to this particular scenario is the continuity of care document
or CCD. In this scenario, treatment has been provided by a ***, and given that this treatment
is in an ambulatory setting, a Discharge Summary would not be appropriate. Since the Primary
Care Provider has not been providing care at the request of another provider, a Consultation
Note would not be appropriate. Given the clinical scenario to be described, a Continuity of
Care Document is the most appropriate CCDA document to use.
Step 2, we�re starting with the sections required by the CCD template in the C-CDA
Implementation Guide. In this case we start with the US Realm Header, the Allergy section,
Medication section, Problems section, and Results section. And just a note, the sections
that are required for a document template within the implementation guide are required
when the information contained in those sections will always be clinically relevant to the
clinical scenario the document template is intended to describe.
The next step is to continue by adding the clinically relevant sections that may be optional
in the template definition in the Implementation Guide. In this case, we�ll be adding an
encounters section, the plan of care section, and a vital signs section. We�re choosing
to ignore the other sections that are option, deeming them not clinically relevant at this
point in time. And for reference, sections are optional in the document template definition
when the information considered for those sections will sometimes be clinically relevant
to the clinical scenario the document is intended to describe.
The last step is to review the data required by this particular certification criterion.
In reviewing the data requirements for this certification criterion, we note that many
of them have already been met through the use of the consolidated CDA document templates.
There are also some that don�t apply because this is an ambulatory care setting.
For those few remaining data requirements that have not yet been met, the corresponding,
appropriate sections out of the consolidated CDA Implementation Guide are added to the
CCD to address the outstanding data requirements.
So in summary, in this case where a patient is experiencing knee pain and was referred
to an Orthopedist by their Primary Care doctor, the Continuity of Care document was chosen
as the best fit for the clinical workflow we�re describing here. We found that many
of the transitions of care criterion data requirements were met using the consolidated
CDA document template. To meet outstanding data requirements, additional sections were
added as necessary.
Here�s what the resulting Continuity of Care document, or CCD, might look like when
rendered through a web browser. What you�re seeing is the human readable version of this
document, which would not necessarily display the coded entry and information that is intended
for machine interpretability.
In this next example, we�ll look at how you might want to pursue the View, Download,
and Transmit Criterion.
In this scenario, the orthopedist, after consulting with the patient, schedules surgery to be
performed and provides an ambulatory summary to the patient including the care plan to
be followed leading up to the surgery. This use case exhibits the View, Download, and
Transmit criterion in action, and just as before, no single Consolidated CDA template
covers all the data requirements to successfully meet this criterion using only the template�s
baseline required components.
As before, the first step in this process is to pick the appropriate document template
to work with. In this case, we�re going to consider three different document types,
all from the Consolidated CDA Implementation Guide, and we�re going to keep in mind what
the specific information exchange requirements are that are faced here in this particular
clinical scenario.
Given the circumstance that this is an orthopedist performing a consultation on behalf of a Primary
Care Physician, we recognize that this treatment�s happening in an ambulatory setting, which
means that a Discharge Summary isn�t really appropriate. The Continuity of Care Document,
which is intended to summarize full episodes of care, might be a bit too heavy for this
scenario, and since this is an Orthopedist again providing care at the request of a Primary
Care Physician, a consultation note might be the best fit for this clinical work flow.
As before, the second step in this process is to start with the sections required by
the Document Template in the Consolidated CDA Implementation Guide. In this case we
start with the US Realm Header, the Assessment and Plan Section, the Reason for Visit Section,
the Chief Complaint Section, and the History of Present Illness Section.
The next step is to continue by adding the sections that are optional in the Consultation
Note Template in the Consolidated CDA Guide, but that we consider clinically relevant to
this circumstance. In this case, we choose to add the Problem Section, the Procedures
Section, the Results Section, and the Vital Signs Section.
The last step in the process is to review the certification criterion and the data requirements
that it includes. In this case for the View Download and Transmit criterion, we�re working
with the Common MU Data Set as well as several criterion-specific data requirements which
apply only to the View, Download and Transmit criterion.
In reviewing the document that we�ve built so far, we note that a lot of the data requirements
for this particular criterion have already been addressed.
Since we�re working in an ambulatory environment in this case, all the data requirements that
are specific to an inpatient environment do not apply. The only remaining data requirements
that we�ve not yet addressed are allergies, medications, and smoking status. For each,
we review the Consolidated CDA Implementation Guide and choose the appropriate corresponding
section to include the document to contain that information.
So in summary, in this case where an Orthopedist scheduled surgery to be performed and provided
the patient with an ambulatory summary, the Consultation Note document was chosen as the
best fit for the clinical workflow we�re describing here. We found that many of the
view, download, and transmit criterion data requirements were met using the consolidated
CDA document template. To meet outstanding data requirements, additional sections were
added as necessary.
When we�re done with this process, we have a document that the patient can either retain
for their records or share with another provider as they see fit. This document can be viewed
through the use of simple web browser technology, but it also has underlying coded entries that
are intended for machine interpretability that another provider could incorporate into
their EHR Technology to be used in the provision of further care.
This concludes the second part of ONC�s three part self-paced module on Implementing
Consolidated Clinical Document Architecture for Meaningful Use Stage 2 and the 2014 Edition
EHR Certification Criteria. In part three, we will discuss the testing and certification
of EHR capabilities. Additional information and helpful resources are available at the
links below. If you�re interested in learning more about the Consolidated CDA or its use
for Meaningful Use, we recommend you look at the S&I Framework Wiki for the latest version
of the Companion Guide to Consolidated-CDA for Meaningful Use Stage 2 at the address
listed below.