A number of folks have asked the question about what they can do in CCDA for Meaningful Use Stage 2 when there are no medications, allergies or problems to report in the document, or when, because MU Stage 2 allows the physician to customize the content.
This is an interesting question. MU Stage 2 says you have to provide the content for 17 different data elements, but it doesn't specifically say what you do when that isn't present. Certified products have to pass tests which verify that they can create the data elements, but those tests at present DO NOT verify that they've correctly produced a CCDA document where there is no data for a medications, labs, allergies or problems section. But clearly this can happen, and CCDA has allowed for it, although it is missing good examples (that's a work stream happening in the Structured Documents Example Document task force)
My recommendation is to supply the empty section with an appropriate flavor of null for the entry that would be required in that section. You can find some information above in my various posts on moving from C32 to CCDA. This needs to be addressed better in future certification and regulation.
These would be valid instances of a CCDA for Meaningful Use, but using them won't get you certified. In other words, what you have to do for certification is everything. What you have to do in the real world is report the data that you have, or in some cases, report that you don't have that data to report.
Keith
I have been told that hospitals are required to always have all of the elements populated in order to have a complete CCDA. The only time we can use "Data Not Available" is if it is a pending test result. For medications and allergies, we can report that the patient has none, but not that it is not available. My question is about Procedures. Until the chart is coded by HIM, the procedures are not in the record. This can be after 36 hours. Is it appropriate and allowed to report "Data not Available" in this section for the VDT and TOC EH measures? If so, can you provide a reference.
ReplyDeleteMy advice doesn't change, nor do my comments, specifically "This needs to be addressed better in future certification and regulation." It isn't addressed well, and so I cannot provide a reference.
ReplyDelete