S&I PAS SWG March 20, 2012 Consolidated CDA (C-CDA) Presentation 1

Agenda Intent of HL7 Project Overview of C-CDA Functional Status additions to C-CDA Note: C-CDA content related to Cognitive Status and pressure ulcers will be addressed on a later call 2

HL7 Project Scope for Spring Ballot The intent of this project is to: Support transitions of care by representing, at a minimum, in the C-CDA: functional status, cognitive status and other elements such as pressure ulcers. Identify generic level patterns that will: – Work further constrain existing tempaltes in C-CDA (“not break”) – Be applicable across ALL assessment instruments – Be applicable to ALL patient populations (young and old) – Be applicable to assessment content in the following areas: Functional status content Cognitive status content Pressure ulcers content 3

Scope of this HL7 Project Identify and fill gaps in the C-CDA in: (i) Section level templates; and (ii) Entry level templates. Out of scope: (i)This project will NOT add document level templates to the C-CDA 4

C-CDA C-CDA: See “Documents and Presentations”, Draft CDA Consolidation, Dec. 4, 2011 Primary components: Document level template Section level template Entry level template 5 Document Level Template Section Level Template Entry Level Template Section Level Template Entry Level Template

C-CDA Document level templates (starts on page 70) – Describe the purpose and rules for constructing a conforming CDA document – Include constraints on the CDA header and refer to section-level templates – 9 Document types (e.g., CCD, consultation note, discharge summary, H&P note, progress note, procedure note, etc.) Section level templates (starts on page 193) – Referenced by one or more document-level templates – Refer to entry-level templates – Describe the purpose of each section and the section-level constraints – 60 Section level templates (e.g., Vital Signs, Problem, Results, Plan of Care, Advance Directives, Social History, Functional Status, etc.) Entry level templates (Clinical statement entry templates ) (starts on page 272) – Referenced by one or more section-level templates – May be referenced by other entry-level templates – Includes guidance on metadata, acts, participants and vocabularies – 66 Entry level templates (e.g., Advance Directives Observation, Problem Observation, Result Observation, Result Organizer, Problem Status) 6

C-CDA Functional Status, Cognitive Status, Pressure Ulcers The current C-CDA Implementation Guide: – Does NOT explicitly address “cognitive status” (however, see description of Functional Status on slide 9) – Does NOT explicitly address “pressure ulcers” – Does include a section-level template for “Functional Status” 7 Discharge Summary (Optional) Functional Status Problem Observation Results Observation CCD (Optional) Document Level Template(s): Section Level Template(s): Entry Level Template(s): Describes the patient’s status of normal functioning at the time the Care Record was created (see C-CDA page 216). A problem is a clinical statement that a clinician has noted. In health care it is a condition that requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any unmet or partially met basic human need (see C-CDA page 380 ). This clinical statement represents details of a lab, radiology, or other study performed on a patient (see C-CDA page 417).

C-CDA 8 Functional Status Section-level Template Description (see C-CDA page 216) The Functional Status section describes the patient’s status of normal functioning at the time the Care Record was created. Functional statuses include information regarding the patient relative to: Ambulatory ability Mental status or competency Activities of Daily Living (ADLs), including bathing, dressing, feeding, grooming Home / living situation having an effect on the health status of the patient Ability to care for self Social activity, including issues with social cognition, participation with friends and acquaintances other than family members Occupation activity, including activities partly or directly related to working, housework or volunteering, family and home responsibilities or activities related to home and family Communication ability, including issues with speech, writing or cognition required for communication Perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance Any deviation from normal function that the patient displays and is recorded in the record should be included. Of particular interest are those limitations that would in any way interfere with self care or the medical therapeutic process. In addition, an improvement, any change in or noting that the patient has normal functioning status is also valid for inclusion.

Previous Discussions in S&I and HL7 Structured Documents a.New templates will NOT include specific valueSets used in specific instruments b. Templates could be re-used for specific instruments (e.g. MDS3.0, OASIS-C, CARE, etc.) and further constrained with specific valueSets c. Functional Status will be represented as follows: Questions shall be coded in: LOINC Answers should be coded in: SNOMED CT or LOINC 9

The focus for Today Today we will hear from Brett on options for enhancing the representation of functional status in the C-CDA. At a later date (in March) we will focus on options for enhancing the representation of cognitive status and pressure ulcers in the C- CDA. 10

Lantana Next Steps: Create new templates – Non-provider caregivers abilities and roles in a functional status observation – Functional status Problems Observation template – Functional Status Result Organizer template – Functional Status Result Observation template Give guidance on when a functional status result observation should be used and when a functional status problem observation should be used Determine if new templates are needed for – Summary scores (eg Brief Interview for Mental Status (BIMS) summary Score) – Pressure ulcer problem observation template is required or If new templates aren’t needed, guidance will be added on how to reuse existing templates 11

Questions/topics for Discussion with Lantana – Some Questions to be addressed during calls include: Result Organizer Is Lantana still recommending that a “Result Organizer” be used for Functional Status? Why or Why not? Does Lantana recommend using a Result Organizer for Cognitive Status? Pressure Ulcers? Why or why not? Representing Functional Status using Either Problem Observation or Result Observation Please describe the appropriate use of a result observation versus a problem observation, including the use of a Problem Concern Act as a wrapper. Is it completely optional under any circumstance to use either the “Problem Observation or Result Observation” template? Are there circumstance when it is preferable to use one template vs. the other? Patterns For Cognitive Status/Pressure Ulcers Are the same section level and entry level templates being considered for functional status also being considered for cognitive status and pressure ulcers? What patterns are being considered for representing cognitive status? Pressure ulcers? – What data elements/sections from CARE is Lantana considering for these sections? 12

Other Topics: What CARE data is being used for functional status, cognitive status, and pressure ulcers? o Sue will identify comparable MDS, OASIS and CMS 485 data elements. o PAS SWG will evaluate if patterns identified for proposed C-CDA modification will support the question/answer pairs from MDS, OASIS and CMS 485. How should/will the proposed Functional Status Result Observation/Problem Observation templates support the use of ICD 9/10 for functional status or cognitive (e.g. to cover items such as deaf, blind, etc.) Describe how proposed modifications to the C-CDA will support/enable reuse of data items in standardized reporting activities. o What is the best approach for learning about how these proposed data standards will be used in the QRDA? 13 Questions/topics for Discussion with Lantana –

Next Steps 1.Continue conversation with Brett: Tuesday March 20 for 90 minutes 2.Sue will provide MDS3.0, OASIS-C and CMS 485 XML examples for draft Functional Status Result Observation that parallel XML examples provided for CARE 3.Terry is working with RTI to identify examples LTPAC ToC data element that re-uses CARE content. 4.Anything else? 14