Hi Keith,
Thanks for the great resource (and the book!). Part of the MU2 requirement is the ability to select specific sections to include in the CCDA. In order to validate, the document must have all the sections, but they need to be somehow marked as having no information. Is there some document that tells exactly how to indicate that? I've been trying to create the sections with observations and codes with nullflavor of noinformation, but that doesn't always make the validator happy.
Thanks!
Tony Kennedy
Exscribe, Inc.
We're running into conflicting info in our preparation for §170.314(e)(2) Clinical summary (ambulatory). Our specific issues revolve around the ability to customize what data to include in the clinical summary. To pass the TTT validator for (e)(2), we need to include everything in the MU2 Data Set. What happens if a user decides to exclude a piece of data that's in the MU2 Data Set? I.e.: Say the user wants to exclude the smoking status from the clinical summary. We have to still include a smoking status observation to pass the validator, so do we just say that we don't know the smoking status? The root of our question really comes down to what data should be allowed to be customized. Are we allowed to allow our users to remove the things required by the MU2 Data Set? Because it covers just about everything, so if we have to leave all of it in there, there's really not much to customize.
CCD and CCDA specify that you should include the relevant stuff. Meaningful Use requires that you enable the user to create various summaries that include the MU Data Set as a minimum. For MU Compliance testing, the EHR actually has to show that it can create everything there. But the incentive rule doesn't say that providers have to include everything in that set, or at least I haven't found anywhere that it says that.
Hi again!
Is there a sample (or instructions) on how to create a QRDA Category III report with multiple denominators? The sample included with the HL7 spec doesn't have it and I can't seem to find anything online - except comments that there's no sample. Do the numbers all get added together into one big aggregate? or is there a separate section for each set?
Thanks
Tony
Tony, I've asked several times for an example. I don't personally know the answer although my guess is that there is. I know that doesn't help. When I get back into messing around with Categtory III I'll look into this.
My organization uses primarily HL7 Version 2.3 for interfacing messages. Do we need to rewrite our interfaces to use HL7 Version 2.5.1 in order to be MU 2 certified?
Thanks for your blog. We have referenced it many times while preparing for MU Stage 2 certification!
Question, please. We understand problems, meds, & medication allergies have to be coded in the C-CDA for stage 2. What if we don't have a code for one of them? Can we include the item but use a null flavor OTH for its code? (an example is medications. if a patient only knows they are on a 'blood pressure med' but doesn't know the name, we are unable to find the RxNorm code for such a med but need to include it in the patient's C-CDA.)
In general, yes, you can use nullFlavor according to CCDA. It may not pass the NIST Validator because that is testing for the capability to display a code, not correctness against CCDA.
Hi Keith,
Looking for the appropriate codeset to use for non-medication allergies. RxNorm for the med allergies, but what about non-med allergies? Cool blog, thanx. --Paul
Meaningful Use doesn't specify the codes to use. In C-CDA, it specifies:
In an allergy to a food or other substance the code SHALL be selected from the ValueSet 2.16.840.1.113883.3.88.12.80.20 Ingredient Name DYNAMIC (CONF:10084).
Hi Keith.
Some time ago you wrote "Some Sample Messages for Disease Surviellance". Please, could you give us "Some Sample Messages for Disease Surviellance using HL7 V3"?. I really appreciate you could comment us some initiatives or status of HL7 V3 for Disease Surveillance/Public Health.
Thanks.
Paul Mendoza del Carpio
I was wondering if you could point me in the right direction for linking QRDA templateID to a set of SNOMED codes? For example how do I know a set of CPT or SNOMED that would represent
"qrda_name": "Encounter Performed",
"qrda_oid": "2.16.840.1.113883.10.20.24.3.23
We're struggling with understanding what "types" of lab tests we might see modeled as a "Battery". That is, a CBC with Diff is the example most often cited, and will clearly be modeled as a Battery (we call these Panels though), but in your experience are Battery elements also used to model any arbitrary grouping of tests/results, such as a Chest Pain (rule out MI) workup that includes multiple lab tests (i.e. CK-MBs, Troponin, etc). Are there any best practices for when to use a Battery and when not to?
That's a question for the O&O list, not for me, as I'm not a lab specialist. IN my own understanding, Battery is more like what you specified, but might also include Blood Typing, Cholesterol Panel, or similar panels. What you appear to be describing is an Order Set, which probably should be represented using separate orders. However, like I said, this isn't my area.
Statewide HIE, I am seeking alternatives for MU2 criteria for sending a CCDA to our HIE (Be able to parse the discreet data and hold the CCDA as a structured/transcribed document) and to send this discreet data to a patient portal.
Due to so many roadblocks, my alternatives would be to utilize a data warehouse. Interfacing with a Data warehouse. Create a CCDA (XML Format) with Headers. Send and parse the data to our Virtual Health Record (VHR). Send the discreet data to a patient portal (we would need some filters in place). The filters for the PHR or patient portal would be in place to prevent a patient from receiving news that that they have cancer, etc prior to hearing it directly from the physician.
Are you aware of anyone that has a CCDA creator that we could utilize with a Rhapsody interface from our Data Warehouse?
Any thoughts would be greatly appreciated. Thank you.
I have a question about the medication section in the cCDA for View Download and Transmit. In the CMS Final Rule (pg 54040) it states “[Patients] who view, download or transmit health information, CMS and ONC have worked together to define the following for this objective: • Current medication list and medication history.” Also, on in the Final Rule (pg 54039), it is noted that "we are modifying the language in the list of required elements below to read ‘‘Active medication list and medication history." This implies that medication history is required. In the Companion Guide to cCDA (pg 20), it states "MU2 requires the inclusion of medications. All current and active medications must be clear to the recipient, so detailing all historical medications is not recommended." This seems to contradict and we are trying to determine if we need inactive medications (such as stopped home meds) and how these should be identified in the status of the medication section in the cCDA.
Given that you've found what appears to be a discrepancy in the regulation, I'd have to refer you to the regulator authorities. The companion guide however, seems to be giving you good advice, and I know the thoroughness with which that group (and the primary editor) put into it. Take your pick, ask CMS or go with the best advice available (the Companion Guide).
Strange question/topic, but I keep running into this one. For Meaningful Use, is a site intended to use a certified tool in the manner certified? i.e. during attestation, are you attesting that you are using the tool in the certified manner? I'm hearing from more and more organizations that the two (possessing vs. using a certified tool) aren't related, which I find confusing. The claim is that it's not explicitly stated anywhere in the final rule or CMS guidelines that you're intended to use the certified tool in the certified manner. You have an opinion?
I hesitate to get into the details of the CMS rule, since it's about what hospitals and providers have to do, rather than about the standards. My own understanding (which may be incorrect) is that you must be BOTH possessing and using the certified functionality for MOST (there are some explicit exceptions) to obtain incentive payments. The one exception I vaguely remember is related to how you exchange (transport) the content for a transition of care, since CMS as I recall was concerned that a provider need not use a standard means if they already had a working method (e.g., two systems from the same vendor with an established exchange mechanism).
Up until today, it was my understanding that for MU Stage 2, the Transition of Care measure (all 3 parts) was fulfilled by using the CCDA. Today, I heard for the 50% threshold, it can be met using any report that contains the same data. The 50% can be printed, faxed, etc so from a logic standpoint, I can see the reasoning. As we all know, logic sometimes has no bearing to regulatory requirements. I can find no substantiation of that statement (which was made by a vendor). Can you comment on the validity of that statement?
Keith,
Have tools emerged to do create CDA compliant doc from HL7 2.x messages? In an old blog post you give some guidance but curious if there is a service I can call with a 2.x message and it returns the CDA equivalent (however rough it is)?
See Chapter 17 of my book for details on how to do that. Has someone implemented that in source code? Not that I know of outside of a few commercial systems. I don't know of any open source implementations.
Since I don't promote commercial EHR products on this blog (neither my employers nor a competitors), I'm afraid I cannot answer your question.
I saw you at HIMS and actually won one of your books. Thank you for signing it.
My question is about where to put Referrals to Providers information. Everything I've read says that it goes in the Plan of Care Section, but It doesn't say exactly where and I haven't been able to find find any examples. Do you know where exactly this information should go? Also, could you provide a small example?
This would go into the Plan of Care Activity Encounter in CCDA. The requirements are quite minimal, with only the encounter ID and template being required. However, you might want to put in the code and performer to indicate the type of encounter and person or organization responsible for performing it.
Here's the bare minimum. The remainder is basic CDA since there are no specific requirements around how to do it in CCDA. <encounter moodCode="INT" classCode="ENC"> <templateId root="2.16.840.1.113883.10.20.22.4.40"/> <!-- **** Plan of Care Activity Encounter template **** --> <id root="9a6d1bac-17d3-4195-89a4-1121bc809b4d"/> </encounter>
I have a question that is specific to incorporating allergy data from the C-CDA.
For allergies there is a status at the Allergy Problem Act level as well as at the Allergy Status Observation level and we are trying to figure out how to handle the possibility of having discrepancies between these two statuses. See question below.
My understanding is as follows:
For the Allergy Problem Act the possible statuses come from the ValueSet ProblemAct statusCode and they are: Active, Suspended, Aborted, Completed
For the Allergy Status Observation the possible statuses come from the ValueSet HITSPProblemStatus and they are: Active, Inactive, Resolved
Our planned approach will be to look for the status from the allergy status observation and use that, but here are my questions:
1) Are we correct to use the status from Allergy Status Observation first?
2) What should we do if that status is null in the C-CDA? Do we use the status from the Allergy Problem Act instead?
3) What if the status in Allergy Status Observation is in conflict with the status in Allergy Problem Act? Is there one that should ‘override’ the other? (see examples):
> Allergy Status Observation status is Active but Allergy Problem Act status is suspended?
> Allergy Status Observation status is Inactive but Allergy Problem Act status is active?
> Allergy Status Observation status is Resolved but Allergy Problem Act status is active?
Thanks for any help/insight you can provide.
Nicole
This was a challenging set of questions that Structured Documents covered a while back. If there is an Allergy Status Observation, then my guess is that since the developer put it there, they have some data you should be using. And if it isn't there or has not code, then I'd go to the Allergy Problem Act, since an active act indicates an ongoing concern, whereas a completed act indicates a resolved concern. If you have conflicts, go with the Allergy Status Observation, since if they went to the trouble to put it there, they probably made sure it had a correct value. However, this are simply recommendations. The current recommendation from SDWG is to eliminate use of the Observation Status altogether and just go with the status values on the Act, but you cannot expect everyone to conform to that in 1.1.
Hi Keith,
When you have, for instance, an ordered Procedure Activity Act that wasn't executed yet and without a confirmed date to be executed, what information is expected to be in effectiveTime?
1. Ordered date?
2. This property is intended to have the date of the procedure and so will be filled with a nullFlavor (because it wasn't executed yet)?
Hi Keith,
What is on offer in terms of healthcare reference architecture at the moment. Do you know of any good healthcare framework that contains all best practices. For example in the telecomm world there is eTOM.
Thanks
Bob
Hi Keith, can you comment on the codes from the CDC Race and Ethnicity when a user is forced to choose Declined to Answer, what code for Race and Ethnicity would be ok to populate in the CDA... Thanks Clifford
We are a vendor building a system to calculate clinical quality measures to meet MU2 objective 170.314(c)(1)-(3) for our clients. Would a CCDA document be appropriate to request from hospitals to contain all of the necessary data for the measure calculations? If this is not an appropriate format to use, do you have any suggestions as to what would work best?
Many of the details needed to calculate clinical quality can be captured in a CCDA document, and that is a key component of many organizations executing in a similar fashion. However, there is no guarantee that ALL details necessary could be such conveyed. It really depends on the measure. The most difficult challenge is often in working through how to capture information about exceptions and exclusions. QRDA is better suited to capture all of the detail, but if you can generate a QRDA category I document for any given patient, you are already executing the measure computation logic, which defeats the purpose. A mix of the two CCDA and QRDA may work best.
Keith, is there a basic rule when trying to differentiate between a procedure and an observation? As I understand, a procedure changes the body in some way. But when considering past procedures that one asks for medical history, should these be modeled as observations?
thank you
Past surgeries would be modeled as procedures in event mood [procedure moodCode='EVN']. But non-surgical/diagnostic (e.g., colonoscopy) procedures would be modeled as observations [observation moodCode='EVN'].
This may be a very basic question, but we haven't been able to find a good answer for it. When in the HL7 implementation guide for CDA it requires at least one id and the example shows something like: id root="9a6d1bac-17d3-4195-89a4-1121bc809b4d" ... Is there any document or specification that governs the nature of these ids? Do they have to be UUIDs?
The id uses the HL7 II data type. The root attribute must be EITHER a UUID, or an OID. If you look into the II data type in CDA specifications, or in the XML ITS, you'll see other examples.
Could patients appoint the EH (Eligible Hospital) as their 'authorized rep', where the EH transmits the health summary for the patient outside the portal (but still via Direct/CEHRT), and can the EH count these in the numerator of the 5% VDT measure?
We have patients that don't have email, don't have a computer, don't or can't access the portal, but they may appreciate it if the EH transmits their health information to their family doctor.
An interesting question, but unfortunately, one that I cannot answer, as it deals with regulatory rather than standards interpretation, in a policy area that is pretty gray. Nice idea though. Perhaps you could offer patients access to computers, because there is clearly no reason that the computer that they use to perform VDT need be there own.
I'm using two formats CDA and CCD for generating patient clinical documents. The problem is how can I identify whether document is following CDA or CCD?
A CCD is ALWAYS a CDA. You an look at the /ClinicalDocument/templateId element to see if the document carries the CCD template identifier, and thus distinguish the two. This works also to distinguish between CCD and CCDA.
Here's a real world question so crazy I know ... When sending TOC document to the TTT, the tool rejects the document ("fail") if there is no lab section, and when there is a lab section, it rejects the document if there is not at least one result. This is great until the real world use case of an inpatient document (Emergency department) where there are no lab results. Is there something I'm missing here?
How do we represent non-numeric (both text and string) lab results in a CCDA document? I am assuming that the xsi type would be 'ST' for string. Is this correct? If so, How do I represent text results?
My question is regarding to CCD. I would like enter Organization ID followed by Provider ID?
Is that possible. If yes, which one is the Better section to give the information. My client wanted me to find that one.
roles encompass two parties, that of player (usually the person) and that of scoper (usually the organization). The role/id element is the id of the provider. The role/representedOrganization/id element is where you'd put the organization ID.
Hi Keith,
I will rephrase the question above. We want to know the section in C-CDA in which a unique combination of Provider ID and Organization ID can go or can fit-in best. Since a provider can be mapped to multiple organizations, we want to make a unique identifier with the combination of both IDs in 1 section. This is in relation to MU2.
We are just starting building standard lab interfaces to get lab data from vendors. I was reading about the standards and got confused between IHE XD-LAB profile and HL7v2.5.1 Laboratory Results Interface (LRI). Can you please shed some light on both and why would one be implemented over the other?
XD-LAB is the way of the future, and provides access to laboratory data in both a machine and human readable way. HL7 V2.5.1 LRI is the way you MUST do it for Meaningful Use certified products, the way that MOST labs and providers support today. If you want the best way to handle it in my opinion, you'll do XD-LAB. If you must comply with Meaningful Use, you'll use LRI.
Thanks Keith that was very helpful. Since you mentioned, XD-LAB is the best way to handle lab data, wondering why it's better than LRI if we don't want to support MU2?
Hi Keith, excellent Blog and references. We have a question in relation to the CDA "custodian" field. If the CDA is a report is generated by a cross web Telemedicine platform in a HealthCare Institution, which could be the appropiate entity for the "custodian" field : the entity who management the web healthcare platform or the Health Care Insitution ? Thanks !
Tghe notion of custodian is the organization that is required to maintain a true and accurate copy of the original document. Typically, that is the Healthcare Institution, even if it hires someone (e.g., an entity managing a web platform) to do it for them.
To answer your question, you must first answer mine: Who is responsible for keeping the true and accurate copy of the document? If it is the entity who manages the platform, then they are likely the custodian. If they are acting on behalf of the Health Care institution as a business associate, or the provider is keeping the record, then they are the custodian.
I have a question regarding the Value Sets maintained by VSAC (https://vsac.nlm.nih.gov). Where does this whole thing called Value Sets fit into an EMR, in terms of data capture? Sorry if my questions are off the topic.
1) Are clinicians expected to capture the Value Sets in EMR, such as a value set for a diagnosis, procedure etc, in addition to capturing the clinical concept in SNOMED or ICD-10 for example? That sounds too much to expect from a clinician.
2) Are the EMR systems expected to store/maintain the Value Sets database as part of the EMR system and periodically update the data as and when VSAC releases them?
3) If I ask the clinician to capture only SNOMED code for a concept such as Diagnosis and program my system such that it will automatically find out the Value Set, is that an option? After a little survey, I found that it may not be possible to automatically identify the Value Set given a SNOMED code, as there is no 1-1 mapping between the two. For example, the SNOMED code 12428000 (Asthma) is mapped to the following Value Sets as per the VSAC site: 2.16.840.1.113883.3.117.1.7.1.271, 2.16.840.1.113883.3.526.3.362, 2.16.840.1.113883.3.526.2.61, 2.16.840.1.113883.3.117.1.7.1.471. So, I cannot uniquely identify a Value Set given a SNOMED code.
These are all questions that relate to "how to I design my EMR". The idea of a value set is that it describes the codes that need to be exchanged to express a set of concepts for a particular use case. You need to be able to do that in the EMR system. How you store those values, and how you configure the EMR to make use of them is really up to you. The typical answers to your questions are: 1. Right, it is too much to expect from a clinician. But it isn't too much to expect the EMR System to take the clinician input and store it in such a way as to be able to map to the specified value sets. 2. That's one way to handle it, and probably the most common. 3. Right, codes don't tell you the value sets they came from. That's because the concept being selected from is use case driven, and not all use cases need all values. And some values may be useful in more than one use case.
There appears to be a conflict for the "Care Plan" requirement. I have read documentation (Meditech best practices) that the Care Plan is required for > 10% of patients seen during the reporting period. However, in the Summary of Care and the Patient Electronic Access element requirements - the threshold for "required element" (including Care Plan) are much higher (> 50%). This directly affects our workflow for Nursing so we don't know where to go with this. Can you help?
I'm not familiar with the Meditech Best Practices document you mention, but what these sound like are MU requirements. Care Plan is an element in the Common MU Data elements that must appear in documents exchanged. If there is none, you must send the element and state that it is not present. A required data element need not have any data. Some patients aren't on medications for example, but you must still have a medications section. The other requirement is stating that you must create a care plan for some percentage of patients. So one is talking about sections that must be present, and which must be available for a certain number of patients (whether or not they do anything with it), and the other is talking about the presence of content in that section.
As a follow up to my previous question, regarding the "Common MU Data Set" elements: does every one of these elements require data in order to be in compliance with, for example, Summary of Care or Patient Electronic Access (Patient Portal)? The requirement uses the phrase "the following information must be available to satisfy the objective and measure" when referring to the Common MU Data Set elements within each of these measures.
Hello Keith, this is in case my previous post didn't make it.
I'm currently implementing the logic to generate qrda category 1 and 3's. We were wondering if there was documentation for what clinical data should be included for each patient per CQM. Or, if you knew. This is in general for all CQMs, but currently we're implementing CMS69 (the version for June2014).
Thanks for your help. Your blog has been a great resource.
Solomon Staggs
Looking for some guidance on the C-CDA document. I posted this question to the IHE PCC group and didn’t get a response.
In the CDA based document, is there a way to record the overall story of the provider on a patient? Looking for a way that a provider can record his/her findings on a patient the way they want to tell the story - all narrative - but I would still like to output that story plus the supporting content in CDA format. Meaning it they talk about procedures, lab results, family history, problems, etc, I want to make sure that is correctly coded.
Maybe I'm overlooking it. Didn't know if there was a Section Level template that would allow - like "General Status"
What I would like to do is have a Human Readable section at the header level of the document, but still have the coded pieces fall below. We have some providers who would like to have their interpretations about the patient, but we would like to have that final output meet the C-CDA requirements. However, if there is a more “general” section we could record the providers info, then we could control the display through a stylesheet.
You can put the narrative in a number of places. Generally what I've seen is that providers put key narrative in HPI (History of Present Illness) for the story up to the encounter, and the remainder goes into Assessment and Plan to indicate what the problem is, and what the provider and patient are going to do about it.
We are going for complete certification of EHR this august but we are struck with this CQM especially in generating QRDA category 3 XML file for reporting aggregate quality. can you help me with it??
Hi Keith,
We are having difficulty with the UCUM Units of Measure with respect to medication Dosage Units. I feel the website http://unitsofmeasure.org/trac/ is geared toward people with a deep understanding of mathematics or chemistry, of which most users attempting to map these units do not have these skills (Me included).
If you know of any other resources which provide a more readable explanantion or with a particular slant toward medication dosage units, we would really appreciate it.
LOVE the book!
Thanks,
Jen
Quick questions on Ambulatory Summary and Transition of Care/Referral Summary C-CDA formats:
Both of these require Procedures to be included. Is the expectation that all procedures for history of patient care be included or just the ones from the most recent visit?
Apart from a few extra fields on the Transition of Care/Referral Summary, these two formats are using the same data. What distinguishes the two formats from each other? Why would I use one or the other?
The QRDA Category 3 includes a sample .xml file. The document has a ‘documentationOf’ section which includes a ‘serviceEvent’. The serviceEvent has an ‘effectiveTime’ of 20120601 to 20120915. The serviceEvent also has a ‘performer’ with its own ‘time’ section of 20120101 to 20120331. Both times are about 3 months in length. But the times are altogether different.
What do each of the times represent? The time span from which the EHR’s quality measures are reported?
Hello Keith, how are implementers managing the large amount of value lists they have, given that clinicians provide input and need a good UI? Are EHRs building their own ontologies to manage them? Are there open source (or not) tools available that easily plug in?
In regard to the Clinical Quality Measures, CMS eMeasure ID # 178 ( number of days a urinary catheter is used) must be tracked. How are databases flagging the insertion and removal time ? Are they using a hard code like CPT ?
Hey Keith,
I'm working on implementation with C-CDA and I've noticed that the Lantana Group's validator is throwing errors on some items with "May" and "Should" verbs, rather than warnings. Do you have any idea who I could reach out to request review of a criteria in the validator?
Keith....have you see any tools that would allow someone to directly manipulate a human readable CCDA by adding or removing structured or unstructured data and then saving the results as a valid CCDA?......Thanks.......Jim
I want to know about diagnostic imaging results C32, how are they supported in C-CDA document.
In C32 results section can contain both lab results and diagnostic result.
But not sure about C-CDA.
Thanks
NS
Hi Keith - I was trying to find all the code values for ClinicalDocument/documentationOf/serviceEvent/performer/functionCode but have been unsuccessful so far.
Any help or pointers would be immensely appreciated.
Hello Keith,
I am trying to map HL7v2.5.1 attributes to some procedures. I'll take the example of "Long Term Oxygen" therapy. this procedure is generally represented by CPT codes. I am a bit confused as to which message and segment should be used to represent this information.
My take is- we can use OBX segment in the ORU^R01 or PR1(procedure) segment or RXA/RXR segment from RAS message.
I would be grateful if you could share your take on this and tell me the best option for representing this.
Thanks & Regards,
Tushar
For the answer to this quesion, I'd need to know the context. The message in which the procedure is being communicated is important, as is the function of the procedure in the communication. Also, the term procedure itself is unclear, you could mean a diagnostic procedure, in which case there are a couple of places it might show up in an ORU. Or you might be talking about another kind of procedure being ordered, which might show up in a different kind of message. Both the purpose of the communication, and the role the procedure plays in that communication are needed before I can answer this question.
do you know if there is a 'crosswalk' or hierarchy between PHVS_Allergen_CDC snomed and PHVS_AllergyOrAdverseEventType_HITSP snomed. it would be nice to be able to group the snomed allergens by type, e.g., food, drug, environment. thanks.
In order to count and use the medications from a CCD just once how does one understand the way Meds present in terms of translations. The first translation is the generic equivalent, the second is the actual order string and there could even be a third. Our application needs to consume and report no. of meds and the exact med form a CCD not the translations.
In the MDM event type every OBX carries one line for a consult note and could be followed by a set of OBX for discharge summary. How does the parser recognize these - is there a document type identifier to know when to parse and separate ?
People use the MDM event in a variety of ways, so there is no one answer to your question. However, what I see in what you read is something I've not encountered, where someone is reporting TWO documents in one MDM, that's suspect. The MDM message itself has a document type listed in it in the TXA segment (See chapter 17 of the CDA Book for how this would be mapped to document type in CDA), or check out the Version 2 chapter on MDM messages.
How is it possible that an OID e.g., (2.16.840.1.113883.3.88.12.80.16) referenced on https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.3.88.12.80.16
is not listed in HL7.org OID Registry? what am I missing?
OIDs don't HAVE to be registered. it is simply a best practice. PHIN VADS and HL7 both produce a large number of OIDs and there is no easy way to batch load them.
Keith - do you know of any discussions/change proposals out to include Medication status observation in the CCDAs? Seems like an important attribute of medications that didn't find a spot in the CCDA spec - a regression from the C32.
That's because there is a better way to capture this information in the newer version. See http://motorcycleguy.blogspot.com/2012/08/moving-on-from-hitsp-c32-medications.html.
I agree that if start/stop dates are used correctly, one can glean active/no longer active information. However, in practice, there are cases where a patient might provide historical medication information (no longer active meds) but doesn't remember exact start/stop dates. In such cases, its still useful to know that info as part of medication history and marking it just as inactive even though dates are not known. In that way, the medication status observation could be useful. However, like you said, I guess there's no restriction to using the status observation from C32 in the CCDA. An explicit mention in the CCDA would give it a better chance of being used though.
They appear to be written a version that I can no longer find the documentation for at hl7.org.
I'm basing this on that the CMS HQMF's use the extension value of "POQM_HD000001" and the R1_2014FEB and R2.1_2014AUG I can download from hl7.org state "POQM_HDHD000001UV02"
From http://ushik.ahrq.gov I was able to find a copy of HL7 V3 QM, R1 dated February 2010
which does indeed state the same "POQM_HD000001", but searching this website you have a posting that mentioning a March 2010 version which I can't find anywhere.
I also can't find it mentioned which implementation guide is being used for Cypress for certification, which I would hopefully assume is the same as the one CMS is publishing their files in.
I just want to be sure I'm following the correct IG because I believe I read in hl7's 2.1_2014Aug guide that there are enough changes as to make them incompatible and there was actually a conversion program.
HQMF has two version, Release 1.0, and Release 2.0. You can find Release 1.0 in expired DSTUs at HL7's web site here: http://www.hl7.org/dstucomments/ex_showdetail.cfm?dstuid=55
Hi Keith, We are going to appear for MU stage 2 certification. At present we got stuck with g.1 where you mentioned like patient /action eligible to be included in the measure’s numerator.
My questions are,
1.should the patient list be generated for numerator or Numerator recorded [in scorecard for g.1]
2. What are the details necessary in that list apart from patient demographics?
3. What the certifying vendor will look for in the list generated?
Kindly help me. If anyone knows the answer, i will be thankful for you valuable inputs.
Keith, I am hoping you can help! We are developing a project and want to leverage the re-use of C-CDA templates to lower the "cost of entry" of EHR's to implement data to us. However, we want to bind the template to a subset of its value set and, in many cases, a different value set. Is this respecting the intention of re-use?
Keith, if I have multiple patient ID's, and need to mask them or show that there was no answer, it is invalid to return nullFlavor as the extension w/ the root. So how can I indicate which ID was masked and which was not answered?
The use of nullFlavor with the II doesn't forbid use of root when nullFlavor is present. Instead, it says when nullFlavor is NOT present, root cannot be null. That's different. So, you can use both nullFlavor and root at the same time. However, some systems will NOT interpret that II as being null, but that is because they are not correctly interpreting the II data type.
Hello! After reading your book and staring development I've came up with question: How to deal with changes?
My government came up with implementation guide, and proposed hl7 cda documents that will be sent to central repository. But in my specific case those documents are too general. Let's assume that I have to extend diagnosis entry by adding some additional information e.g. comment. Should I template this entry inside my organization using our OID or maybe there are other approaches? And then when there will be need to extend it even more I should template it with new OID?
Most recently for a national project, we added constraints for national use, but did not create new templates, simply asserted that use of RealmID was sufficient to declare conformance to national requirements
ok, but let's say that on national level they designed diagnosis entry, but after awhile they've changed it because it was poorly designed. There are already signed documents so both entries will exist and there's no possibility to get rid of them. How I can distinguish between those two entries to process them if they are not templated? I would have to check existence of some specific elements inside those entries or maybe there's a better way?
Following on from the above question, if we want to use a different value set for Social History Observation than the one that is defined (as Should) in the template, we specify compliance w/ that template and then a new template ID for the new value set? Or do we define a completely new template ID?
Thank you.
§170.314(e)(2) Clinical summary (ambulatory) for this criteria we have included all the data item which they have mentioned to include as minimum.. but how user will test by excluding the items.. in my system we are displaying common data as by default and allow rest of the items to exclude if they want.. is this correct to pass this criteria?
Hi,
I am currently reading trough the IHE XDS.b specifications. Could be that this question is already answered, but I couldn't find it in the archive.
I am wondering for which purpose a SubmissionSet is required?
SubmissionSets can carry DocumentEntries and Folders. It is used to perform ITI 41 and 42 (for XDS.b). But if I want to read data from the repository, I am just asking for single documents. In ITI-43 it is not specified that I can ask for a SubmissionSet.
So why do I have to put documents/folders in to a SubmissionSet to put them in the repository and registry. It doesn't make sense to me.
I am currently researching what the current CCD version is for Meaningful Use 2. Information I am looking for are the section list (required/optional) and the code sets that need to be utilized for each coded item within each Section (ie: Problem: SNOMED CT / ICD-9-CM).
Hello Keith, I'm considering getting the CDA book, but noticed that it was published prior to CCDA. Is the current edition still relevant for some new to CDA and CCDA? Is there a updated edition planned anytime soon?
I am having great difficulty with displaying a "middle name" with the CDA style sheet.
Documentation suggests:
"John"
"Martin"
"Doe"
but the middle name, Martin, will not display.
The CDA scheme does not have a node for "middle names", just "given" and "family"
Any help would be greatly appreciated.
Do we have a comprehensive guide for implementation of HITSP C32 document?
I specifically need the template id's and the conformance specifications as to which tag is mandatory or optional for C32 document.
I tried to refer the guide for CDA (CDAR2_IG_IHE_CONSOL_R1_DSTU_2011DEC) but it is not of much help.
Any reference to C32 implementation would be helpful.
Hi Keith,
Could you please explain
in which cases CCDA CCD should be used and in which cases CCDA Summary Of Care Record
according to MU requirements.
Thanks in advance.
Vadim.
The version of CCDA has 9 document types, one of which includes the CCD version 1.1. Of these, all are acceptable for Meaningful Use 2014 Certification EXCEPT the Unstructured Document. For Stage 2 incentives, you could use any of these to generate the the summary of care record requirement by Stage 2.
Thanks for the great resource (and the book!). Part of the MU2 requirement is the ability to select specific sections to include in the CCDA. In order to validate, the document must have all the sections, but they need to be somehow marked as having no information. Is there some document that tells exactly how to indicate that? I've been trying to create the sections with observations and codes with nullflavor of noinformation, but that doesn't always make the validator happy.
Thanks!
Tony Kennedy
Exscribe, Inc.
We're running into conflicting info in our preparation for §170.314(e)(2) Clinical summary (ambulatory). Our specific issues revolve around the ability to customize what data to include in the clinical summary. To pass the TTT validator for (e)(2), we need to include everything in the MU2 Data Set. What happens if a user decides to exclude a piece of data that's in the MU2 Data Set? I.e.: Say the user wants to exclude the smoking status from the clinical summary. We have to still include a smoking status observation to pass the validator, so do we just say that we don't know the smoking status? The root of our question really comes down to what data should be allowed to be customized. Are we allowed to allow our users to remove the things required by the MU2 Data Set? Because it covers just about everything, so if we have to leave all of it in there, there's really not much to customize.
Thanks Keith,
Ben Chase
I have same question. Which sections we should keep optional?
Mahesh
Is there a sample (or instructions) on how to create a QRDA Category III report with multiple denominators? The sample included with the HL7 spec doesn't have it and I can't seem to find anything online - except comments that there's no sample. Do the numbers all get added together into one big aggregate? or is there a separate section for each set?
Thanks
Tony
My organization uses primarily HL7 Version 2.3 for interfacing messages. Do we need to rewrite our interfaces to use HL7 Version 2.5.1 in order to be MU 2 certified?
Thanks for your blog. We have referenced it many times while preparing for MU Stage 2 certification!
Question, please. We understand problems, meds, & medication allergies have to be coded in the C-CDA for stage 2. What if we don't have a code for one of them? Can we include the item but use a null flavor OTH for its code? (an example is medications. if a patient only knows they are on a 'blood pressure med' but doesn't know the name, we are unable to find the RxNorm code for such a med but need to include it in the patient's C-CDA.)
Thanks!
See http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=254
can a problem, med, med allergy be included in the CCDA but use null flavor OTH when not known and still meet MU stage 2 certification?
thanks!
Looking for the appropriate codeset to use for non-medication allergies. RxNorm for the med allergies, but what about non-med allergies? Cool blog, thanx. --Paul
In an allergy to a food or other substance the
code SHALL be selected from the ValueSet
2.16.840.1.113883.3.88.12.80.20 Ingredient
Name DYNAMIC (CONF:10084).
Which is essentially UNII
Some time ago you wrote "Some Sample Messages for Disease Surviellance". Please, could you give us "Some Sample Messages for Disease Surviellance using HL7 V3"?. I really appreciate you could comment us some initiatives or status of HL7 V3 for Disease Surveillance/Public Health.
Thanks.
Paul Mendoza del Carpio
"qrda_name": "Encounter Performed",
"qrda_oid": "2.16.840.1.113883.10.20.24.3.23
Thanks
We're struggling with understanding what "types" of lab tests we might see modeled as a "Battery". That is, a CBC with Diff is the example most often cited, and will clearly be modeled as a Battery (we call these Panels though), but in your experience are Battery elements also used to model any arbitrary grouping of tests/results, such as a Chest Pain (rule out MI) workup that includes multiple lab tests (i.e. CK-MBs, Troponin, etc). Are there any best practices for when to use a Battery and when not to?
Thanks,
Keith
Great blogs, thank you for all of your input.
Statewide HIE, I am seeking alternatives for MU2 criteria for sending a CCDA to our HIE (Be able to parse the discreet data and hold the CCDA as a structured/transcribed document) and to send this discreet data to a patient portal.
Due to so many roadblocks, my alternatives would be to utilize a data warehouse. Interfacing with a Data warehouse. Create a CCDA (XML Format) with Headers. Send and parse the data to our Virtual Health Record (VHR). Send the discreet data to a patient portal (we would need some filters in place). The filters for the PHR or patient portal would be in place to prevent a patient from receiving news that that they have cancer, etc prior to hearing it directly from the physician.
Are you aware of anyone that has a CCDA creator that we could utilize with a Rhapsody interface from our Data Warehouse?
Any thoughts would be greatly appreciated. Thank you.
Strange question/topic, but I keep running into this one. For Meaningful Use, is a site intended to use a certified tool in the manner certified? i.e. during attestation, are you attesting that you are using the tool in the certified manner? I'm hearing from more and more organizations that the two (possessing vs. using a certified tool) aren't related, which I find confusing. The claim is that it's not explicitly stated anywhere in the final rule or CMS guidelines that you're intended to use the certified tool in the certified manner. You have an opinion?
Thank you,
Confused
Have tools emerged to do create CDA compliant doc from HL7 2.x messages? In an old blog post you give some guidance but curious if there is a service I can call with a 2.x message and it returns the CDA equivalent (however rough it is)?
http://www.hl7standards.com/blog/2010/11/16/converting-from-an-hl7-version-2-message-to-cda/
Thanks,
Mark
Since I don't promote commercial EHR products on this blog (neither my employers nor a competitors), I'm afraid I cannot answer your question.
I saw you at HIMS and actually won one of your books. Thank you for signing it.
My question is about where to put Referrals to Providers information. Everything I've read says that it goes in the Plan of Care Section, but It doesn't say exactly where and I haven't been able to find find any examples. Do you know where exactly this information should go? Also, could you provide a small example?
Thank you,
-Lance
Here's the bare minimum. The remainder is basic CDA since there are no specific requirements around how to do it in CCDA.
<encounter moodCode="INT" classCode="ENC">
<templateId root="2.16.840.1.113883.10.20.22.4.40"/>
<!-- **** Plan of Care Activity Encounter template **** -->
<id root="9a6d1bac-17d3-4195-89a4-1121bc809b4d"/>
</encounter>
For allergies there is a status at the Allergy Problem Act level as well as at the Allergy Status Observation level and we are trying to figure out how to handle the possibility of having discrepancies between these two statuses. See question below.
My understanding is as follows:
For the Allergy Problem Act the possible statuses come from the ValueSet ProblemAct statusCode and they are: Active, Suspended, Aborted, Completed
For the Allergy Status Observation the possible statuses come from the ValueSet HITSPProblemStatus and they are: Active, Inactive, Resolved
Our planned approach will be to look for the status from the allergy status observation and use that, but here are my questions:
1) Are we correct to use the status from Allergy Status Observation first?
2) What should we do if that status is null in the C-CDA? Do we use the status from the Allergy Problem Act instead?
3) What if the status in Allergy Status Observation is in conflict with the status in Allergy Problem Act? Is there one that should ‘override’ the other? (see examples):
> Allergy Status Observation status is Active but Allergy Problem Act status is suspended?
> Allergy Status Observation status is Inactive but Allergy Problem Act status is active?
> Allergy Status Observation status is Resolved but Allergy Problem Act status is active?
Thanks for any help/insight you can provide.
Nicole
When you have, for instance, an ordered Procedure Activity Act that wasn't executed yet and without a confirmed date to be executed, what information is expected to be in effectiveTime?
1. Ordered date?
2. This property is intended to have the date of the procedure and so will be filled with a nullFlavor (because it wasn't executed yet)?
Thanks,
Luis
What is on offer in terms of healthcare reference architecture at the moment. Do you know of any good healthcare framework that contains all best practices. For example in the telecomm world there is eTOM.
Thanks
Bob
We are a vendor building a system to calculate clinical quality measures to meet MU2 objective 170.314(c)(1)-(3) for our clients. Would a CCDA document be appropriate to request from hospitals to contain all of the necessary data for the measure calculations? If this is not an appropriate format to use, do you have any suggestions as to what would work best?
Thank you.
thank you
Could patients appoint the EH (Eligible Hospital) as their 'authorized rep', where the EH transmits the health summary for the patient outside the portal (but still via Direct/CEHRT), and can the EH count these in the numerator of the 5% VDT measure?
We have patients that don't have email, don't have a computer, don't or can't access the portal, but they may appreciate it if the EH transmits their health information to their family doctor.
Thanks!
How do we represent non-numeric (both text and string) lab results in a CCDA document? I am assuming that the xsi type would be 'ST' for string. Is this correct? If so, How do I represent text results?
[value xsi:type='ST']text result[/value]
Is that possible. If yes, which one is the Better section to give the information. My client wanted me to find that one.
I will rephrase the question above. We want to know the section in C-CDA in which a unique combination of Provider ID and Organization ID can go or can fit-in best. Since a provider can be mapped to multiple organizations, we want to make a unique identifier with the combination of both IDs in 1 section. This is in relation to MU2.
Awaiting reply.
We are just starting building standard lab interfaces to get lab data from vendors. I was reading about the standards and got confused between IHE XD-LAB profile and HL7v2.5.1 Laboratory Results Interface (LRI). Can you please shed some light on both and why would one be implemented over the other?
Thanks!
Since you mentioned, XD-LAB is the best way to handle lab data, wondering why it's better than LRI if we don't want to support MU2?
1) Are clinicians expected to capture the Value Sets in EMR, such as a value set for a diagnosis, procedure etc, in addition to capturing the clinical concept in SNOMED or ICD-10 for example? That sounds too much to expect from a clinician.
2) Are the EMR systems expected to store/maintain the Value Sets database as part of the EMR system and periodically update the data as and when VSAC releases them?
3) If I ask the clinician to capture only SNOMED code for a concept such as Diagnosis and program my system such that it will automatically find out the Value Set, is that an option? After a little survey, I found that it may not be possible to automatically identify the Value Set given a SNOMED code, as there is no 1-1 mapping between the two. For example, the SNOMED code 12428000 (Asthma) is mapped to the following Value Sets as per the VSAC site: 2.16.840.1.113883.3.117.1.7.1.271, 2.16.840.1.113883.3.526.3.362, 2.16.840.1.113883.3.526.2.61, 2.16.840.1.113883.3.117.1.7.1.471. So, I cannot uniquely identify a Value Set given a SNOMED code.
1. Right, it is too much to expect from a clinician. But it isn't too much to expect the EMR System to take the clinician input and store it in such a way as to be able to map to the specified value sets.
2. That's one way to handle it, and probably the most common.
3. Right, codes don't tell you the value sets they came from. That's because the concept being selected from is use case driven, and not all use cases need all values. And some values may be useful in more than one use case.
There appears to be a conflict for the "Care Plan" requirement. I have read documentation (Meditech best practices) that the Care Plan is required for > 10% of patients seen during the reporting period. However, in the Summary of Care and the Patient Electronic Access element requirements - the threshold for "required element" (including Care Plan) are much higher (> 50%). This directly affects our workflow for Nursing so we don't know where to go with this. Can you help?
As a follow up to my previous question, regarding the "Common MU Data Set" elements: does every one of these elements require data in order to be in compliance with, for example, Summary of Care or Patient Electronic Access (Patient Portal)? The requirement uses the phrase "the following information must be available to satisfy the objective and measure" when referring to the Common MU Data Set elements within each of these measures.
I'm currently implementing the logic to generate qrda category 1 and 3's. We were wondering if there was documentation for what clinical data should be included for each patient per CQM. Or, if you knew. This is in general for all CQMs, but currently we're implementing CMS69 (the version for June2014).
Thanks for your help. Your blog has been a great resource.
Solomon Staggs
Looking for some guidance on the C-CDA document. I posted this question to the IHE PCC group and didn’t get a response.
In the CDA based document, is there a way to record the overall story of the provider on a patient? Looking for a way that a provider can record his/her findings on a patient the way they want to tell the story - all narrative - but I would still like to output that story plus the supporting content in CDA format. Meaning it they talk about procedures, lab results, family history, problems, etc, I want to make sure that is correctly coded.
Maybe I'm overlooking it. Didn't know if there was a Section Level template that would allow - like "General Status"
What I would like to do is have a Human Readable section at the header level of the document, but still have the coded pieces fall below. We have some providers who would like to have their interpretations about the patient, but we would like to have that final output meet the C-CDA requirements. However, if there is a more “general” section we could record the providers info, then we could control the display through a stylesheet.
Thanks for your help.
We are having difficulty with the UCUM Units of Measure with respect to medication Dosage Units. I feel the website http://unitsofmeasure.org/trac/ is geared toward people with a deep understanding of mathematics or chemistry, of which most users attempting to map these units do not have these skills (Me included).
If you know of any other resources which provide a more readable explanantion or with a particular slant toward medication dosage units, we would really appreciate it.
LOVE the book!
Thanks,
Jen
Both of these require Procedures to be included. Is the expectation that all procedures for history of patient care be included or just the ones from the most recent visit?
Apart from a few extra fields on the Transition of Care/Referral Summary, these two formats are using the same data. What distinguishes the two formats from each other? Why would I use one or the other?
The QRDA Category 3 includes a sample .xml file. The document has a ‘documentationOf’ section which includes a ‘serviceEvent’. The serviceEvent has an ‘effectiveTime’ of 20120601 to 20120915. The serviceEvent also has a ‘performer’ with its own ‘time’ section of 20120101 to 20120331. Both times are about 3 months in length. But the times are altogether different.
What do each of the times represent? The time span from which the EHR’s quality measures are reported?
Thanks for the great blog.
javapda
Thank you for your help in CDA implementation.
I'm working on implementation with C-CDA and I've noticed that the Lantana Group's validator is throwing errors on some items with "May" and "Should" verbs, rather than warnings. Do you have any idea who I could reach out to request review of a criteria in the validator?
Thanks!
I want to know about diagnostic imaging results C32, how are they supported in C-CDA document.
In C32 results section can contain both lab results and diagnostic result.
But not sure about C-CDA.
Thanks
NS
Any help or pointers would be immensely appreciated.
I am trying to map HL7v2.5.1 attributes to some procedures. I'll take the example of "Long Term Oxygen" therapy. this procedure is generally represented by CPT codes. I am a bit confused as to which message and segment should be used to represent this information.
My take is- we can use OBX segment in the ORU^R01 or PR1(procedure) segment or RXA/RXR segment from RAS message.
I would be grateful if you could share your take on this and tell me the best option for representing this.
Thanks & Regards,
Tushar
In order to count and use the medications from a CCD just once how does one understand the way Meds present in terms of translations. The first translation is the generic equivalent, the second is the actual order string and there could even be a third. Our application needs to consume and report no. of meds and the exact med form a CCD not the translations.
is not listed in HL7.org OID Registry? what am I missing?
Long story short, when I download the HQMF's from the CMS Library at:
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html
They appear to be written a version that I can no longer find the documentation for at hl7.org.
I'm basing this on that the CMS HQMF's use the extension value of "POQM_HD000001" and the R1_2014FEB and R2.1_2014AUG I can download from hl7.org state "POQM_HDHD000001UV02"
From http://ushik.ahrq.gov I was able to find a copy of HL7 V3 QM, R1 dated February 2010
which does indeed state the same "POQM_HD000001", but searching this website you have a posting that mentioning a March 2010 version which I can't find anywhere.
I also can't find it mentioned which implementation guide is being used for Cypress for certification, which I would hopefully assume is the same as the one CMS is publishing their files in.
I just want to be sure I'm following the correct IG because I believe I read in hl7's 2.1_2014Aug guide that there are enough changes as to make them incompatible and there was actually a conversion program.
Thank You.
My questions are,
1.should the patient list be generated for numerator or Numerator recorded [in scorecard for g.1]
2. What are the details necessary in that list apart from patient demographics?
3. What the certifying vendor will look for in the list generated?
Kindly help me. If anyone knows the answer, i will be thankful for you valuable inputs.
Thank you for your blog!
My government came up with implementation guide, and proposed hl7 cda documents that will be sent to central repository. But in my specific case those documents are too general. Let's assume that I have to extend diagnosis entry by adding some additional information e.g. comment. Should I template this entry inside my organization using our OID or maybe there are other approaches? And then when there will be need to extend it even more I should template it with new OID?
Thank you.
I am currently reading trough the IHE XDS.b specifications. Could be that this question is already answered, but I couldn't find it in the archive.
I am wondering for which purpose a SubmissionSet is required?
SubmissionSets can carry DocumentEntries and Folders. It is used to perform ITI 41 and 42 (for XDS.b). But if I want to read data from the repository, I am just asking for single documents. In ITI-43 it is not specified that I can ask for a SubmissionSet.
So why do I have to put documents/folders in to a SubmissionSet to put them in the repository and registry. It doesn't make sense to me.
Cheers!
I am currently researching what the current CCD version is for Meaningful Use 2. Information I am looking for are the section list (required/optional) and the code sets that need to be utilized for each coded item within each Section (ie: Problem: SNOMED CT / ICD-9-CM).
Thanks!
What does JASON stand for?
Thanks!
Documentation suggests:
"John"
"Martin"
"Doe"
but the middle name, Martin, will not display.
The CDA scheme does not have a node for "middle names", just "given" and "family"
Any help would be greatly appreciated.
Try the adding Martin as value for second tag under recordTarget/patientRole/patient/name/
Do we have a comprehensive guide for implementation of HITSP C32 document?
I specifically need the template id's and the conformance specifications as to which tag is mandatory or optional for C32 document.
I tried to refer the guide for CDA (CDAR2_IG_IHE_CONSOL_R1_DSTU_2011DEC) but it is not of much help.
Any reference to C32 implementation would be helpful.
Could you please explain
in which cases CCDA CCD should be used and in which cases CCDA Summary Of Care Record
according to MU requirements.
Thanks in advance.
Vadim.