HL7 SDWG Topic October 29, 2015 David Tao

 HL7 Success! C-CDA 2.1 is cited, and Care Plan is in 2015 Edition Certification Final Rule  Common Clinical Data Set (CCDS) has been expanded with specific C-CDA sections related to Care Plan  CCDS is required in Transition of Care (ToC) exchanges  The net effect looks like a conflation of ToC documents and parts of Care Plan ◦ Will this be what clinicians want? ◦ Will developers know what they should do?

 ToC objective in MU2 is being met by summary documents such as CCD, Consultation Note, Discharge Summary…  ToC document in 2015 edition is not significantly different, except for expanded CCDS. Most vendors will probably want to continue producing the same doc types  Care Plan document is brand new in 2015 edition, and follows C-CDA as intended

A couple of commenters expressed concern regarding whether this proposal aligned with the C-CDA standard… A few commenters noted that we should clarify the intent of the “Goals Section” and “Health Concerns Section.” These commenters noted that the “Goals Section” and “Health Concerns Section” of the C- CDA Care Plan document template provide more structure and were originally designed to be used with the Care Plan document template. However, other C- CDA document templates, like CCD, allow for health concerns and goals to be included as a narrative within the “Assessment Section (V2),” “Plan of Treatment Section (V2),” or “Assessment and Plan Section (V2).”

We have reviewed the CCDA 2.1 standard and believe there is no misalignment…Therefore we have adopted the specific data elements as proposed (i.e., “Assessment Section (v2)” and “Plan of Treatment Section (v2)” or “Assessment and Plan Section (v2);” Goals Section;” and “Health Concerns Section”). We clarify that we will certify Health IT Modules to the “Goals Section” and the “Health Concerns Section” from the Care Plan document template for the purposes of meeting the Common Clinical Data Set definition. Thus, other C-CDA document templates such as CCD, Referral Note, and Discharge Summary would need to be able to exchange the structured “Goals Section” and “Health Concerns Section” in order to meet the “Common Clinical Data Set definition.”

 Care Plan document SHALL contain Health Concerns and Goals sections  CP SHOULD contain Interventions and Health Status Evaluation & Outcomes sections (note: Cert Rule requires these in Care Plan doc)  ALL of these sections are only specified in a Care Plan document  Care Plan SHALL NOT contain a Plan of Treatment Section (V2) (CONF: )

 PoT (known as “Plan of Care” section in CCDA 1.1) was renamed in CCDA 2.x.  PoT is required in Discharge Summary, optional in other document types, but prohibited in Care Plan  PoT section includes narrative and may include structured entries such as “planned x” where x can be act, encounter, immunization, medication, observation, procedure, or supply. May also include Goal observation, handoff communication participants, instruction, nutrition.  Most EHRs probably don’t create structured PoT section; if structured, there was little or no guidance. Care Plan document attempted to provide a better structure  “Assessment” + “PoT” sections are logically equivalent to the single “Assessment and Plan Section”

 First Impression: the Rule introduces issues ◦ Internal Redundancy because Assessment and PoT section(s), Health Concerns and Goals sections must now be in the same document ◦ Overlap between ToC and Care Plan certification criteria ◦ Increased size of ToC document ◦ Potential Confusion:  Developer: which data goes in which sections and entries?  Provider: where do I find the Plan? Is it in one place or several? ◦ Care Plan document is co-opted by ToC document. If produced, much of it is redundant with ToC doc. (Note: Care Plan is a certification requirement, but not a MU3 requirement)  Is this a major problem, or not a problem, or something in between that can be clarified by guidance?

 Clarify how to implement ToC such that it is relevant and pertinent to clinicians, right-sized, easily readable, internally consistent, non-redundant, not “choppy”  Clarify Range of Care Plan Info: longitudinal patient- centered vs provider/encounter-specific? If both, what goes where?  Expand Care Plan diagram, showing relationships among sections and entries beyond the original CP document (Lisa’s PACP diagrams are an example). For example, should PoT Section be a shell that points to other sections?  Dual-compliant ToC/CP document that adds remaining Care Plan sections (Interventions, Health Status Evaluation). At least that would be holistic, rather than having “half a Care Plan”  Ideas?