Health eDecisions (HeD) All Hands Meeting

1. Health eDecisions (HeD)All Hands Meeting May 16th, 2013

2. Meeting Etiquette • Remember: If you are not speaking, please keep your phone on mute • Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call • Hold = Elevator Music = frustrated speakers and participants • This meeting is being recorded • Another reason to keep your phone on mute when not speaking • Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know. • Send comments to All Panelists so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute  All Panelists

3. Agenda

4. Announcements • Vocabulary and Terminologies sub work will be meeting this week Friday 12:30-1:30 EDT • http://wiki.siframework.org/Health+eDecisions+Homepage • Updates from the HL7 Meeting • vMR updates • We are starting the preparation process for balloting UC 2 through HL7 in September • Stay tuned for updates and ways to participate • We are submitting the Project Scope Statement (PSS) this week for Use Case 2 (due May 17th) • AMIA????

5. HL7 Update • We have completed a rough draft of the Implementation Guide • http://wiki.siframework.org/HeD+Pilot+Tools • The Vocabulary and Terminology IG is also complete and will be incorporated into our IG. • To view and comment on the work of the Vocab and Terminology team please see the pilots tool page: http://wiki.siframework.org/HeD+Pilot+Tools • We met this week and approved the pending issues as discovered during the Pilot process with CDC: • Next week: we will determine after HL7 meeting if we need to meet next week • http://wiki.siframework.org/Health+eDecisions+Homepage ) • We are beginning the process of preparing UC 2 for HL7 balloting • We will resume these meetings in the near future for UC 2 disscussions

6. HeD Pilots Update • We met this week • Pilots Update • CDC and Practice Fusion –ECA Rule • Aziz is working on the transformation from HQMF to HeD (90% complete) • There will be 2 rules – one of the Laboratory and one for the clinic • NewMentor and AllScripts – ECA Rule (98% complete) • The team has transformed the NQF 0068 (Million Hearts) into HeD and then into the Allscripts native format (CREF) • The initial pass was completed and we have successfully loaded the rule into the AllScripts test environment • Still need tweaks • Zynx and DesignClinicals - Order Set (60% complete) • Working on simple and complex order sets • VA and Wolters Kluwer - Documentation Template (75% complete) • UTI Documentation Template was transformed into HeD schema • Wolters Kluwer is checking the rule to ensure it captures what is needed • Ken, Robert Lario and Dave Sheilds are working with the VA to prepare for the final rule to be implemented into their system.

7. HeD Pilots Goal • Goal • The goal of this initiative is to produce, consume and where feasible, execute implementable CDS interventions. • Event Condition Action Rules (ECA Rules) • Order Sets • Documentation Templates • Pilot Scope • Health eDecisions will apply defined aspects of the Implementation Guide in a real-world setting. • Modify the Implementation Guide to ensure it is usable • Submission of explicit feedback to sub workgroups such as vMR and Vocabulary and Terminology work group to close gaps • The real-world pilots evaluate not only the technology, standards and model (VMR), but also provide a test bed to evaluate the interaction of technology, implementation support, and operational infrastructure required to meet Health eDecisions use case 1 objectives at the stakeholder or organization levels. • Demonstrate intent of artifact (specifically structures and semantics) are communicated either by direct execution or by translation to native format • Ensure completeness and consumability of artifact New

8. Timeline We are Here

9. Vendor Partners

10. vMR Overview Presented by Claude Nanjo and Dave Shields

11. Overview of C-CDA Health eDecisions All Hands Community Meeting May 16, 2013 C. Beebe

12. Presenter Calvin E. Beebe cbeebe@mayo.edu Technical Specialist Mayo Clinic, Rochester MN Co-editor - CDA R1, CDA R2 Author - CDA Certification Exam Co-chair - HL7 Structured Documents Member - HL7 Technical Steering Committee Treasure - HL7 Board of Directors

13. Today’s Topics • What’s in the C-CDA Implementation Guide • Review sample C-CDA document • Identify HL7 & other useful resources • Summary

15. Basic C-CDA 101 Technical Name: HL7 Implementation Guides for CDA Release 2: IHE Health Story Consolidation, DSTU Release 1.1 - US Realm Called: Consolidated CDA, C-CDA … • The C-CDA contains a library of CDA templates. • Updates 11 CDA document types, including CCD • Harmonizes previous HL7, IHE, HITSP efforts It consolidated previous document templates into a single library, resolving conflicts, ambiguities as needed!

16. HL7’s CDA vs. C-CDA • CDA The HL7 Clinical Document Architecture (CDA) is a document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange. • C-CDA The HL7 Consolidated CDA is an implementation guide which specifies a library of templates and proscribes their use for a set of specific document types. defines a set of CDA documents! the schema for those documents!

17. Consolidated CDA (C-CDA) History and Physical Discharge Summary Consultation Notes Diagnostic Imaging Rpt Procedure Note Operative Note Progress Note Unstructured Documents HL7 Health Story Implementation Guides Continuity of Care Document CCD ONC - CEHRT HITSP - C32, C80, C83 IHE – PCC HL7 – CCD HL7 – CDA C-CDA

18. Consolidated CDA • The guide contains a library of CDA templates, incorporating and harmonizing previous efforts from: • Health Level Seven (HL7) • Integrating the Healthcare Enterprise (IHE) • Health Information Technology Standards Panel (HITSP) It includes harmonized HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination, and the Continuity of Care (CCD). It includes all required CDA templates in Final Rules for Stage 1 Meaningful Use and can support Stage 2 Meaningful Use requirements.*

19. Figure 1 : Templated CDA Templated CDA: C-CDA, QRDA (126 Entry Templates) A QRDA Category I report is an individual-patient-level quality report. Each report contains quality data for one patient for one or more quality measures.

20. HL7 C-CDA Implementation Guide • Document Organization • Introduction • General Header Template • Document-Level Templates • Section-Level Templates • Entry-Level Templates • Appendix • Template IDs, Code Systems, Value Sets, Extensions, …

21. ConsolidatedCDA Documents CCD 9 Document Types H&P Diagnostic Imaging Consult Surgical Operation Progress Procedure Discharge Summary Unstructured (Non-XML Body)

22. 74 C-CDA Sections By the numbers

23. 65 C-CDA Entries By the numbers

24. 38 C-CDA Code Systems By the numbers S&I Companion Guide references (links) on CEHRT Vocabularies:  CDT – Dental Codes  ICD – 10 CM / PCS  CPT – AMA Procedure Codes  ISO 639-2 Language Codes  HCPCS – Procedure Codes  LOINC – Lab Codes  CVX – HL7 table 0292  OMB Race / Ethnicity Codes  RxNorm – Medication Codes  SNOMED CT – via UMLS

25. C-CDA Header Constraints • It describes constraints that apply to the header for all documents within the scope of this implementation guide. • Header constraints specific to each document type are described in the appropriate document-specific section below. • SHALL contain: • realmCode • typeId • templateId • id • code • title • effectiveTime • confidentialityCode • languageCode • recordTarget w/ 1 patient • name in US realm format • administrativeGenderCode • birthtime (precise to the year) • serviceEvent • effectiveTime • performer • author • custodian • encompassing Encounter • healthcareFacility • responsibleParty • encounterParticipant • ethnicity • preferred Language • race • addr • name

26. MU 2 - Document Types • With respect to the Consolidated CDA, certification will not focus on a specific document-level template… Surprise! • Rather, certification will focus on an EHR technology’s ability to properly implement the US Realm header and the associated section-level templates necessary to support each certification criterion in which the Consolidated CDA is referenced and for the appropriate data specified in each of those certification criteria. • Where vocabularies are specified in § 170.207 the accompanying section-template must be implemented using structured data , i.e. coded entries required. • Unstructured Document template is not permitted.

27. Document Types • S&I performed a goodness of fitness assessment and deemed the C-CDA CCD best fit. • However… • MU3 advocates that the visit document should not simply be EMR extracts (need exact language!) • You may want to start thinking about generating clinical notes based on C-CDA MU2 requirements. • I.e. H&P Notes, Consult Notes, Diagnostic Imaging Notes, Surgical Notes, Progress Notes, Discharge Summary Notes. All said, for MU2 – the CCD seems like the likely target.

28. Continuity of Care Document

29. Continuity of Care Document

30. Consolidated CDA Sections We’ll take peek a the Problem section

31. Problem Section & Entries This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed.

32. Problem Section & Entries

33. Problem Section with Coded Entries Required • Two types of Problem sections are supported, MU2 requires the use of coded entries.

34. Problem Section example

35. Problem Act Concern

36. Problem Act Concern

37. Problem Act Concern

38. Problem Act Concern

39. Problem Concern Act example

40. Problem Observation

41. Problem Observation

42. Problem Observation

43. Problem Observation

44. Problem Observation

45. Problem observation example

46. at the C-CDA sample We will look at the sample C-CDA

47. Validation of C-CDA documents • Two alternative techniques have been established to validate C-CDA documents. • MDHT – JAVA validation code solution • Available on the Open Health Tools Web Site • Trifolia – Schematron (xPath) solution • Available on the HL7 Web Site

48. Tools & Pending NIST testing • The National Institute of Standards and Technology (NIST) provides a list of available validation tooling sites for interoperability specifications. NIST also provides tools for testing MU2 implementations. • Validation:http://xreg2.nist.gov/hit-testing/ • Testing:http://healthcare.nist.gov/use_testing/tools.html

49. Technique 1 - Schematron .xPath, .xsl, Schematron Trifolia Workbench √ .xsd .xml Validates against generic CDA schema <Section code=Plan> CDA IG CCD √ XPath validation of Implementation Guide requirements

50. Technique 2 – MDHT Validation Add Custom Validations & Constraints The JAVA code can parse, validate and provides an code able object model ! Java API (Source Code) Domain Model MDHT Model Driven Health Tools Validation Code Generation Implementation Guide(s)