Companion Guide to HL7 Consolidated CDA for Meaningful Use Stage 2

1. Companion Guide to HL7 Consolidated CDA for Meaningful Use Stage 2

2. Meaningful Use Stage 2 & HL7 Consolidated CDA (C-CDA) Background Information

3. 2014 Ed. CEHRT Criteria Requiring C-CDA 2014 Edition Certification Program for Health Information Technology (2014 Ed. CEHRT) criteria specifies the use of HL7 Consolidated CDA to capture data requirements in a summary type Summary Type Criterion Description Electronically create a transition of care/referral summary Transition of Care/ Referral Summary Transition of Care 170.314(b)(1)&(2) Electronically create a set of export summaries for all patients in EHR technology Data Portability 170.314(b)(7) Export Summary Electronically view, download, and transmit an ambulatory summary or inpatient summary Ambulatory Summary or Inpatient Summary View/Download/Transmit 170.314(e)(1) Clinical Summary 170.314(e)(2) Create a summary for a patient Clinical Summary

4. 2014 Ed. CEHRT Data Requirements Example: Transition of Care Criterion Criterion Description Summary Type Electronically create a transition of care/referral summary Transition of Care/ Referral Summary Transition of Care 170.314(b)(1)&(2) Objective-Specific Data Requirements Common MU2 Data Set • Patient name • Sex • Date of birth • Race ** • Ethnicity ** • Preferred language • Care team member(s) • Allergies ** • Medications ** • Care plan • Problems ** • Laboratory test(s) ** • Laboratory value(s)/result(s) ** • Procedures ** • Smoking status ** • Vital signs • Provider Name & Office Contact Information (Ambulatory Only) • Reason for Referral (Ambulatory Only) • Encounter Diagnoses ** • Cognitive Status • Functional Status • Discharge Instructions (Inpatient Only) • Immunizations ** NOTE:Data requirements marked with a double asterisk (**) also have a defined vocabulary which must be used

5. 2014 Ed. CEHRT Vocabulary Requirements • Standardized vocabularies promote the use of common definitions when sharing information across diverse clinical environments. • Vocabularies are used to assign a unique value to a clinical concept • Vocabulary standards required by 2014 Ed. CEHRT include: • LOINC for laboratory test(s) and results data requirements • RxNorm for Medications and Medication Allergies data requirements • HL7 CVX for Immunization data requirement • In some instances, specific values from a vocabulary are required • SNOMED CT values for the Smoking Status data requirement must be one of the following:

6. Clinical Document Architecture (CDA) and Templates Clinical Document Architecture (CDA) is the base standard for building electronic clinical documents for exchange Templates apply CDA for a specific concept, such as a diagnosis or hospital discharge summary Templates are reusable and interchangeable “building blocks” that can build a variety of clinical documents To help simplify implementations, commonly used templates were harmonized into a single implementation guide – Consolidated CDA

7. What’s in the C-CDA IG? HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, Release 1.1 - US Realm • Document Templates: 9 • Continuity of Care Document (CCD) • Consultation Note • Diagnostic Imaging Report (DIR) • Discharge Summary • History and Physical (H&P) • Operative Note • Procedure Note • Progress Note • Unstructured Document • Section Templates: 60 • Entry Templates: 82 Section templates in YELLOW demonstrate CDA’s interoperability and reusability.

8. How does C-CDA meet 2014 Ed. CEHRT requirements? Sets of CDA templates are arranged to create a purpose-specific clinical document CDA standardizes the expression of clinical concepts which can be used/re-used Templates are used to specify the ‘packaging’ for those clinical concepts 2014 Ed. CEHRT data requirements can be captured through C-CDA templates MU2

9. MU2 requirements in the context of C-CDA Companion Guide

10. Why a “Companion Guide?” • Consolidated CDA (C-CDA) Implementation Guide (IG) not enough for implementers • Call for public collection of implementation guidance, sample clinically-valid documents and testing procedures • 2014 Edition CEHRT requirements (for Meaningful Use Stage 2) do not provide technical guidance for implementations using the C-CDA IG • No practical roadmap for using the C-CDA IG for implementations to meet the needs of clinicians and achieve Meaningful Use

11. Bridges the gap between MU2 requirements and C-CDA C-CDA MU2 data elements sections & entries value sets vocabularies observations smoking status acts laboratory tests header elements documents medications care plan care team members conformance statements

12. Purpose of the Companion Guide • Supplements the C-CDA IG to provide additional context to assist implementers and connect them to tools and resources • Provides technical guidance for representing the 2014 Ed. CEHRT data requirements using the C-CDA IG • Includes clinically-valid examples of C-CDA components necessary to meet 2014 Ed. CEHRT requirements • Recommends an approach to implementations using the C-CDA IG to meet the needs of clinicians and achieve Meaningful Use

13. Overview of Companion Guide Package • Contents of the Companion Guide Package: • Companion Guide • Requirements-mapping spreadsheet • XML sample files • Examples of recommended C-CDA templates for 2014 Ed. CEHRT data requirements • A complete sample CCD meeting 2014 Ed. CEHRT requirements

14. What you will find in the Companion Guide

15. What you will find in theRequirements-Mapping Spreadsheet • List of all MU2 data requirements • Mappings of MU2 data requirements to C-CDA • Breakdown of requirements by summary type

16. What you will find in theXML Sample Files • Annotated examples of recommended C-CDA sections including entries for MU2 data requirements to demonstrate how MU2 data requirements are represented • CCD XML example to show how MU2 requirements can be met

17. Where can I find it? • The Companion Guide to Consolidated CDA for Meaningful Use Stage 2 is available at the following address: • http://wiki.siframework.org/Companion+Guide+to+ Consolidated+CDA+for+MU2 • Also available through the Standards and Interoperability Framework Repository: • http://siframework.org/