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Thursday, March 15, 2012

Using the CDA Consolidation Guide to Make Sense of MeaningfulUse Stage2 Summary Care Records

Here is my next installment in making sense of the Meaningful Use Summary Care Record definitions.  On Tuesday I explained the problem.  Yesterday, I mapped each of the regulations into different data elements.  Today, I show how each of these can be implemented using the required standard:  The CDA Consolidation Guide.

There are two tables below.  The first one maps data elements in the CDA Header.  These are supported in all CDA Documents (not just those in the Consolidated Guide).

Header Data Elements CDA Location
Name patient/name
Gender patient/administrativeGenderCode
Date of Birth patient/birthTime
Race patient/raceCode
Ethnicity patient/ethnicityCode
Preferred Language patient/languageCommunication
Provider Info encompassingEncounter/responsibleParty
Visit Date encompassingEncounter/effectiveTime
Visit Location encompassingEncounter/location
Care Team Members documentationOf/serviceEvent[@classCode'PCPR']/performer

The second table maps data elements to CDA Sections, listing the CDA Consolidation Guide section, and the entries needed in that section to conform to Meaningful Use.  On the right hand side it shows which of those sections appear in the different documents in the consolidation guide.  In looking at this table, it seems impossible to meet the Meaningful Use requirements with the CDA Consolidation guide, but you should realize that you can add sections to any of the documents in the CDA Consolidation Guide that are appropriately specified, so if it were appropriate in a provider workflow to generate a Consultation Note, but it didn't have a section listed as being optional (O) or required (R) for Patient Instructions, you could still include the Instructions Section (perhaps as a subsection under the Care Plan).

It appears from this spreadsheet, that the Consultation Note, CCD 1.1, Discharge Summary and History and Physical Note, Procedure Note and Progress Note could all readily meet the Meaningful Use requirements with just a few added sections.  The operative note doesn't really work without adding quite a few sections that fall outside of the normal workflows for documenting a surgical procedure, but could still be made to work.

I've updated the spreadsheet from yesterday from which these tables came, linking the first sheet to the appropriate rows from these two tables.  Maybe we can convince Robin Raiford to make a pretty poster out of this one too.


Section
Data Elements
Section Type Section
Template(s)
CDA Entries Entry
Template(s)
Notes Consultation Note Continuity
of Care Document
Discharge
Summary
History and
Physical
Procedure
Note
Operative
Note
Progress
Note
Smoking Social
History
2.16.840.1.113883.10.20.22.2.17 Social
History Observation
2.16.840.1.113883.10.20.22.4.38 observation/code = SNOMED CT:229819007

observation/value needs a vocabulary (possibly SNOMED) and value set for:
Current every day smoker; current some day smoker; former smoker; never
smoker; smoker, current status unknown; and unknown if ever smoked
O O O O O

Vitals Vital Signs 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs
Organizer
2.16.840.1.113883.10.20.22.4.26 O O O R O
Vital Signs Observation 2.16.840.1.113883.10.20.22.4.27
Problems Problem 2.16.840.1.113883.10.20.22.2.5 Problem
Concern Act
2.16.840.1.113883.10.20.22.4.3 O R O O O
Problem Observation 2.16.840.1.113883.10.20.22.4.4
History
of Past Illness
2.16.840.1.113883.10.20.22.2.20 Problem
Observation
2.16.840.1.113883.10.20.22.4.4 Relevant Past problems (not recent history) O O R O
Medications Medications 2.16.840.1.113883.10.20.22.2.1.1 Medication
Activity
2.16.840.1.113883.10.20.22.4.16 O R O O O
Admission
Medications
2.16.840.1.113883.10.20.22.4.36 Medication
Activity
2.16.840.1.113883.10.20.22.4.16 Template does not require Medication Activity, but Rule does O
Hospital
Discharge Medications
2.16.840.1.113883.10.20.22.2.11.1 Medication
Activity
2.16.840.1.113883.10.20.22.4.16 R
Medications
Administered
2.16.840.1.113883.10.20.22.2.38 Medication
Activity
2.16.840.1.113883.10.20.22.4.16 O
Allergies Allergy 2.16.840.1.113883.10.20.22.2.6.1 Allergy
Problem Act
2.16.840.1.113883.10.20.22.4.30 O R O O O O
Allergy Observation 2.16.840.1.113883.10.20.22.4.7
Procedures Procedures 2.16.840.1.113883.10.20.22.2.7.1 Procedure
Activity Act
2.16.840.1.113883.10.20.22.4.12 O O O O O

Procedure Activity Observation 2.16.840.1.113883.10.20.22.4.13
Procedure Activity Procedure 2.16.840.1.113883.10.20.22.4.14
Labs Lab Results 2.16.840.1.113883.10.20.22.2.3.1 Results
Organizer
2.16.840.1.113883.10.20.22.4.1 O R
R

O
Results Observation 2.16.840.1.113883.10.20.22.4.2
Patient
Instructions
Instructions 2.16.840.1.113883.10.20.22.2.45 Instructions 2.16.840.1.113883.10.20.22.4.20 May be included in Care Plan section






Reason for Visit/Admission Reason for Visit 2.16.840.1.113883.10.20.22.2.12 Problem
Observation
2.16.840.1.113883.10.20.22.4.4 O
O O O
Chief Complaint and Reason for Visit 2.16.840.1.113883.10.20.22.2.13 Problem
Observation
2.16.840.1.113883.10.20.22.4.4 O O O O
Chief Complaint 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Problem
Observation
2.16.840.1.113883.10.20.22.4.4 O
O O O O
Reason for Referral 1.3.6.1.4.1.19376.1.5.3.1.3.1 Problem
Observation
2.16.840.1.113883.10.20.22.4.4 O
Admission Diagnosis 2.16.840.1.113883.10.20.22.2.43 Problem
Observation
2.16.840.1.113883.10.20.22.4.4
Preoperative Diagnosis 2.16.840.1.113883.10.20.22.2.34 Preoperative
Diagnosis
2.16.840.1.113883.10.20.22.4.65 R
Care Plan Care Plan 2.16.840.1.113883.10.20.22.2.10 O O R O O O O
Assessment and Plan 2.16.840.1.113883.10.20.22.2.9 Plan of Care
Activity Act
2.16.840.1.113883.10.20.22.4.39 O O O O
Plan of Care
Activity Encounter
2.16.840.1.113883.10.20.22.4.40
Plan of Care Activity Observation 2.16.840.1.113883.10.20.22.4.44
Plan of Care Activity Procedure 2.16.840.1.113883.10.20.22.4.41
Plan of Care Activity Substance Administration 2.16.840.1.113883.10.20.22.4.42
Plan of Care Activity Supply 2.16.840.1.113883.10.20.22.4.43
Diagnosis Assessment 2.16.840.1.113883.10.20.22.2.8 Problem
Observation
2.16.840.1.113883.10.20.22.4.4  @codeSystem = 2.16.840.1.113883.6.90
(ICD-10-CM)
Assessment and Plan 2.16.840.1.113883.10.20.22.2.9 Problem
Observation
2.16.840.1.113883.10.20.22.4.4
Hospital Discharge Diagnosis 2.16.840.1.113883.10.20.22.4.33 Problem
Observation
2.16.840.1.113883.10.20.22.4.4
Postoperative Diagnosis 2.16.840.1.113883.10.20.22.2.35 Problem
Observation
2.16.840.1.113883.10.20.22.4.4 R
Postprocedure Diagnosis 2.16.840.1.113883.10.20.22.2.36 Postprocedure
Diagnosis
2.16.840.1.113883.10.20.22.4.51 R
Immunizations
Administered
Immunization 2.16.840.1.113883.10.20.22.2.2.1 Immunization
Activity
2.16.840.1.113883.10.20.22.4.52 O O O O
Patient
Decision Aids
Instructions 2.16.840.1.113883.10.20.22.2.45 Instructions 2.16.840.1.113883.10.20.22.4.20 Details about Patient Decision Aids should appear in the
Instructions section.
Futured
Scheduled Tests
Care
Plan
2.16.840.1.113883.10.20.22.2.10 Plan of Care
Activity Observation
2.16.840.1.113883.10.20.22.4.44 Details about future tests should appear in the care plan
section
Futured
Scheduled Visits
Care
Plan
2.16.840.1.113883.10.20.22.2.10 Plan of Care
Activity Encounter
2.16.840.1.113883.10.20.22.4.40 Details about future visits should appear in the care plan
section
Referrals Care
Plan
2.16.840.1.113883.10.20.22.2.10 Plan of Care
Activity Encounter
2.16.840.1.113883.10.20.22.4.40 Details about referrals should appear in the care plan section


4 comments:

  1. I just asked Robin-stand by!

    ReplyDelete
  2. Hello,

    I am looking for a sample CCDA for Clinical Office Visit Summary but i had no luck. I have created one by using the guide but it fails when I run through the validation tool. I would appreciate if you can help on that.
    Thanks...

    ReplyDelete
  3. Anonymous: What you need is someone to help you on a discussion forum. I have successfully implemented the MU Stage 1 requirements in producing a Level 3 CDA document using the mdht api. The people there are very responsive. I can help you there if you post your questions.

    ReplyDelete
  4. I can't access "Care Plan" https://www.blogger.com/blogger.g?blogID=733074358901582680&pli=1
    Your current account (######@#####.###) does not have access to view this page.
    :'( <== Sad face there
    Also I didn't find a way to send you a message mister Keith

    ReplyDelete