Electronic Submission of Medical Documentation (esMD) eDoC Coded Data July 16, 2014

Agenda 2 Review purpose of eDoC data mapping Review Lower Limb Prosthesis eClinical Template Use Case Explanation and discussion of mapping approach Examples

Document Encounter EHR Forms/Templates History and Physical Vital signs Visit Summary History of Present Illness Lab Orders/Results Allergies Medications Vital Signs Textual reports Orders / Treatment CDA Document Header Structured Body Authenticators and Digital Signatures Section Entry Text Entry Section Entry Text Entry Section Entry Text Entry Section Entry Text Entry EHR Database Demographics Documentation collected via EHR forms and templates and stored in the EHR Database 3

Create CDA EHR Forms/Templates History and Physical Vital signs Visit Summary History of Present Illness Lab Orders/Results Allergies Medications Vital Signs Textual reports Orders / Treatment CDA Document Header Structured Body Authenticators and Digital Signatures Section Entry Text Entry Section Entry Text Entry Section Entry Text Entry Section Entry Text Entry EHR Database Demographics 4 Prior to or at time of signing – create CDA

Lower Limb Prosthesis eClinical Template Collaboratively developed with input from physicians, prosthetists, and other stakeholders through Open Door Forums Designed to prompt clinicians in gathering and documenting information to support determination of coverage Useful to eDoC SWG by identifying key clinical elements that should be supported by CDA LLP eClinical Template - CMS.gov Link

eDoC Mapping Process Identification of available C-CDA value sets nearing completion Mapping of LLP eClinical Template use case to value sets Identify LLP eCT clinical elements that currently represented as text vs coded elements Categorize C-CDA value sets: –Applicable Directly applicable to condition E.g. AKA vs BKA, Level of functionality (pt runs marathons) or conditioning –Conditionally applicable Underlying condition E.g. Peripheral vascular disease, neuropathy, lower limb ischemia –Supporting information E.g. Objective studies - EMG –Not-applicable