EU-US eHealth/Health IT Cooperation Initiative Interoperability of EHR Work Group

1. EU-US eHealth/Health IT Cooperation InitiativeInteroperability of EHR Work Group January 15, 2014

2. Meeting Etiquette • Participants automatically enter the webinar in “listen only” mode. The organizer will then unmute all participants. We ask if you are not speaking to manually mute yourself • NOTE: VoIP participants have the ability to “Mute” themselves by clicking on the green microphone. However, if you would like to speak, only you can unmute yourself. • If you are dialing in using a telephone and NOT using the VoIP you MUST dial the audio pin in order for the organizer to unmute you – if you do not use the audio pin and just push # when prompted the Organizer cannot unmute you

3. Meeting Etiquette CONTINUED • If you are calling from a telephone, please do not put your phone on hold. If you need to take a call, hang up and dial in again when you have completed your other call • This meeting is being recorded • Another reason to keep your phone or your VoIP on mute when not speaking • Use the “Chat” or “Question” feature for questions, comments and items you would like the moderator or other panelists to know.

4. Agenda

5. Meeting Times Washington, DC 10:00am (ET) Interoperability of EHR Work Group meets everyWednesday London 3:00pm/15:00 (GMT) Germany 4:00pm/16:00 (CET) Athens 5:00pm/ 17:00 (EET)

6. General Announcements • To join our weekly webinars, visit the EU-US eHealth Collaboration Wiki Homepage for the latest meeting information: http://wiki.siframework.org/EU-US+eHealth+Cooperation+Initiative • To subscribe to our mailing list, simply complete the EU-US MOU Project Signup Form: http://wiki.siframework.org/EU-US+MOU+Roadmap+Project+Sign+Up • To submit a brief biography of yourself (150 words or less), review the criteria listed at http://wiki.siframework.org/Interoperability+of+EHR+Work+Group#Work Group Membersand e-mail your bio and photo (optional) to GayathriJayawardena at gayathri.jayawardena@esacinc.com • To access current and archived meeting materials, visit the Project Meeting Artifacts section: http://wiki.siframework.org/Project+Meeting+Artifacts

7. Mapping Sub-Work Group • Launching a mapping sub-work group to further examine the epSOS/C-CDA Section Level Mapping • Polling group for availability for one of the time slots listed below: • Monday’s (9-10am ET) • Monday’s (10-11am ET) • Tuesday’s (10-11am ET) • Tentative launch date will be the week of January 27th. • This SWG is expected to meet for approximately eight (8) consecutive weeks

8. Standards and Harmonization • In Scope: • Semantic Interoperability • Syntactic Interoperability • Out of Scope: • Transport • Privacy & Security • Continuity of Care Document (CCD) • CDA R2 NE (May 2005) • HL7 IG: CDA R2 C-CDA R1.1 (July 2012) • CCD template Standards for: Clinical Summary Document US EU • epSoSPatient Summary (PS) Form • CDA R2 NE (May 2005) • HL7 IG: CDA R2-CCD (April 1, 2007) • epSoS IG: • Appendix II epsos_revised_data-set_25april2013.pdf Sources: US http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 EU http://www.epsos.eu/

9. Phases of Harmonization <clinicalDocument> (Clinical Summary Form) Completed <header> (document ID, author, patient ID…) Data Granularity and Complexity <component> [Body] <section> [Procedures] <entry> (Colonoscopy) <procedureCode> <procedureDate> <…> <entry> [Gastroscopy] <entry> [CABG] … <section> [CurrentMedications] <entry> [ASA] <entry> [Warfarin] <entry> [CABG] <section>… Remaining <entry>

10. Mapping Review/Validation:Resources and Process • All harmonization/mapping work is done on Google spreadsheet: • Link: https://docs.google.com/spreadsheet/ccc?key=0AiAfdYPeAnM-dG1mczY3dXN4WEl5eEpYVE5fV0pFWUE&usp=drive_web#gid=11 • Access: anyone with link • Privileges: • “View and Comment” – everyone with link (the one above) • “Edit” – selected • EU: one designated XML/epSoS PS subject matter expert • US: Mark Roche (for now) • Above may be reviewed/updated as project continues • Review Process: • Review/validate mapping outcomes after each phase with community • Review points: • Mapping completeness • Mapping accuracy • Mapping gaps

11. Review Resources • Implementation Guides (IG) • Examples: • PDF • XML

12. Google Spreadsheet demo • All harmonization/mapping work is done on Google spreadsheet: • Link: https://docs.google.com/spreadsheet/ccc?key=0AiAfdYPeAnM-dG1mczY3dXN4WEl5eEpYVE5fV0pFWUE&usp=drive_web#gid=11

13. EMERGE demo • What is EMERGE? • EMERGE is a web based application that provides synthetic (dummy) clinical data for ~700 patients • Clinical Data is available in HTML format (human-readable) • Clinical Data is also available in XML format (machine-readable) • XML format is compliant with C-CDA R1.1 CCD standard • Why was EMERGE developed? • To provide EHR vendors in US with examples that will help them more easily understand C-CDA CCD Implementation Guide (IG) and thus configure EHR to comply with provisions of Meaningful Use Stage 2.

14. Review Comments: Phase 1, Section-level mapping • Are all Sections listed? • Are section names correct? • Are section LOINCs and OIDs correct? • Are requirements (R,R2,O) correct? • Is mapping complete (section-level)? • Is mapping accurate (correct)? • Are there mapping gaps? • Is mapping clear and unambiguous? • What is missing?

15. Review Comments: Phase 1, Section-level mapping (continued) • Tomasz Adamusiak • Are there additional observations? Vocabularies section is missing CVX (vaccinations) and CDT (dental procedures) • JozefAerts: • One of the major problems in my opinion is that less than 40% of the EU countries are ITHSDO members which means that in the other 60% SNOMED-CT is not used (except in academia). • If we count by population, #1, 3 and 4 (Germany, France and Italy) are among these, not being able to use SNOMED. In these countries only a few percent of non-academic hospitals have acquired a license, so in these 60% of the EU countries, SNOMED-CT usage is almost inexistent.

16. Review Comments: Phase 1, Section-level mapping (continued) • David Tao – What is missing? • ReadMe – row 24 Clinical Summary Document should not be “synonym” of CCD, but CCD is a primary example. There are other summary documents (e.g., Transfer Summary) added to CCDA 2.0, and even in 1.1 (Discharge Summary). Row 26 should say “Official name of one type of Clinical Summary Document…”• Should mapping be to CCDA CCD 2.0, given that this EU-US exchange is not constrained by MU? I could lean either way on this, just raising the question. • Not sure what the “US Order” is for. I don’t think there is a prescribed order to the sections, even though they are listed in an order in CCDA (alphabetically, required then optional)• Medications mapping seems problematic. “Prescription” and “Medication Dispensed” according to epSOS 12 (page 87) are for two different documents specific for ePrescription, which are distinct from the Patient Summary. For the PS document, only the Medication Summary is listed (table at line 585). I am not an epSOS expert by any means, but reading the IG leads me to this conclusion. So I recommend that Prescription and Medication Dispensed rows be removed from the mapping, and only Medication Summary be kept. It could be confusing to have all three in a PS document (even though Mark lists Medication Summary as R and the other two as O). IT would be much more straightforward to have a one-to-one section mapping between epSOS PS and CCD. 13.1 says the Medication Summary Section is required in a PS.

17. Review Comments: Phase 1, Section-level mapping (continued) • David Tao – What is missing? • I don’t understand why List of Surgeries is twice (rows 9 and 10). I only see one section, 13.1.5, in epSOS PS. It says in 13.1.5.2 that “the Surgical Procedures prior past six months (optional) and shall be used to record the Major Surgical Procedures past 6 months23 (required). Each surgical procedure shall be described using the “Procedure Entry” template 2475 (1.3.6.1.4.1.19376.1.5.3.1.4.19)” To me, that’s just one section with requirements for the dates of the procedures that must be included vs those that may be included, but it’s not two sections. Also, the many-to-one mapping of “Coded List of Surgeries” and “Procedures and Interventions” to the same “Procedures” section in CCD needs further discussion. The CCD Procedures Section LOINC code matches the “Coded List of Surgeries” but not the “Procedures and Interventions.” It can’t have two LOINC codes, so I’m not sure what to do about this. Since Coded List of Surgeries is required in epSOS PS, it is probably the more important one to match. • While History of Present Illness CAN be mapped to CCD Problems, it would be better to map it to History of Present Illness, which is a more direct fit, even though that is not specified by CCD. It is still permitted in CCD since CCD is an open document template. Similarly addition of sections is needed for MU2 anywayMAPPING GAPS: the four CCD sections at the bottom that don't have a corresponding section in epSOS. If these sections were generated in the US, I suggest that they be included in the transformed document "as is." The epSOS consuming system would not have to do anything processing of the entries in these sections, but must render these sections text in human readable form, as required by base CDA r2. .

18. Homework: Review Phase 2, Header’ Data Element mapping • Are template names and OIDs correct? • Are all Header Data Elements (DE) listed? • Are DE names correct? • Are X-Path Statements correct? • Are requirements (R,R2,O) correct? • Are Data Types correct? • Is mapping complete (within header)? • Is mapping accurate (correct)? • Are there mapping gaps (sth. Exists in epSoS PS but not in C-CDA CCD and vice verse)? • Is mapping clear and unambiguous? • What is missing?

19. Homework: Review Phase 2, Header’ Data Element mapping • Review Google Doc • Demonstrate how to comment

20. Preparing for our Next Meeting • Next meeting will be on Wednesday, January 22, 2014 at 10:00 am (ET)/5:00 pm (EET) • Who will be attending HL7 or the ONC Annual meeting next week? • Please review the epSOS/C-CDA Section Level Mapping spreadsheet and submit comments through the online comment form located here: http://wiki.siframework.org/Interoperability+of+EHR+Work+Group#Work Group Activities • Complete the homework (see previous slide)

21. Interoperability of EHR Project Support Team • US Point of Contacts • Mera Choi, Mera.Choi@hhs.gov • Jamie Parker, jamie.parker@esacinc.com • Gayathri Jayawardena, gayathri.jayawardena@esacinc.com • Amanda Merrill, amanda.merrill@accenturefederal.com • Mark Roche, mrochemd@gmail.com • Virginia Riehl, virginia.riehl@verizon.net • EU Point of Contacts • Benoit Abeloos, Benoit.ABELOOS@ec.europa.eu • Frank Cunningham, frank.cunningham@ec.europa.eu • Catherine Chronaki, chronaki@gmail.com

22. Questions

23. Initiative Resources • EU-US Wiki Homepage • http://wiki.siframework.org/EU-US+eHealth+Cooperation+Initiative • Join the Initiative • http://wiki.siframework.org/EU-US+MOU+Roadmap+Project+Sign+Up • EU-US Initiative Reference Materials • http://wiki.siframework.org/EU-US+MOU+Roadmap+Project+Reference+Materials • Interoperability of EHR Homepage • http://wiki.siframework.org/Interoperability+of+EHR+Work+Group