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