Electronic Submission of Medical Documentation (esMD) eDoC Coded Data

1. Electronic Submission of Medical Documentation (esMD)eDoC Coded Data July 16, 2014

2. Agenda • Review purpose of eDoC data mapping • Review Lower Limb Prosthesis eClinical Template Use Case • Explanation and discussion of mapping approach • Examples

3. Document Encounter CDA Document Documentation collected via EHR forms and templates and stored in the EHR Database Authenticators and Digital Signatures Header Structured Body Lab Orders/Results History of Present Illness Section Section Section Section Text Text Text Text Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Vital Signs EHR Forms/Templates Allergies Medications History and Physical Vital signs Visit Summary Orders / Treatment Textual reports EHR Database Demographics 3

4. Create CDA CDA Document Authenticators and Digital Signatures Header Prior to or at time of signing – create CDA Structured Body Lab Orders/Results History of Present Illness Section Section Section Section Text Text Text Text Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Entry Vital Signs EHR Forms/Templates Allergies Medications History and Physical Vital signs Visit Summary Orders / Treatment Textual reports EHR Database Demographics 4

5. Lower Limb Prosthesis eClinical Template • Collaboratively developed with input from physicians, prosthetists, and other stakeholders through Open Door Forums • Designed to prompt clinicians in gathering and documenting information to support determination of coverage • Useful to eDoC SWG by identifying key clinical elements that should be supported by CDA • LLP eClinical Template - CMS.gov Link

6. eDoC Mapping Process • Identification of available C-CDA value sets nearing completion • Mapping of LLP eClinical Template use case to value sets • Identify LLP eCT clinical elements that currently represented as text vs coded elements • Categorize C-CDA value sets: • Applicable • Directly applicable to condition • E.g. AKA vsBKA, Level of functionality (pt runs marathons) or conditioning • Conditionally applicable • Underlying condition • E.g. Peripheral vascular disease, neuropathy, lower limb ischemia • Supporting information • E.g. Objective studies - EMG • Not-applicable