Optimizing Data Collection and Reporting using CCDA

Ruth Jenkins, PhDAugust 28, 2015

Agenda• Present the benefits of reporting using cCDA

• Review Data Contained in Summary (Transition) of Caredocuments

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• Discuss Challenges and Solutions in Data Capture and Export for Reporting

Background

• Meaningful Use Stage 2 (2014 Ed. CEHRT)– Specific Data Requirements for summary documents– Specific Data Format: HL7 Consolidated CDA (c-CDA)

• Standard format for clinical data exchange– Standardized vocabularies promote the use of

common definitions when sharing information

• PPRNet modified its approach to data extraction to accommodate other EHR users

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Benefits of reporting using cCDA

• Encourages practices to implement standards for clinical data exchange

• Better aligns PPRNet reports with other reporting programs

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• Opens PPRNet to users of any EHR that is MU2 certified – can produce Summary (Transition) of Care documents in batch

Data contained in SOC

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Patient name & ID Sex Date of birth Race ** Ethnicity ** Preferred language Care team member(s) Allergies **

Common MU2 Data Set

Medications ** Care plan (goals) Problems ** Laboratory test(s) ** Lab value(s)/result(s) ** Procedures ** Smoking status ** Vital signs (Ht, Wt, BP, BMI)

(**) defined required vocabulary

Additional Data in SOC

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Immunizations (HM)** Usual Provider Name & Office Contact Info Reason for Referral Encounter Diagnoses ** Encounter Date and Location Advance Directives & Functional Status Pending Tests, Future Tests, Future Appt

Data Not in SOC

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Health Maintenance (except Immunizations) Clinical Elements (except Adv Directives &

Functional Status) User Defined Vital Signs Patient Status

Vocabulary Standards

• Vocabularies are used to assign a unique value to a clinical concept

• Vocabulary standards required by MU2 include:• LOINC for laboratory test(s) and results• RxNorm for Medications and Medication Allergies • CVX for Immunization data requirement

• In some instances, specific values from a vocabulary are required, e.g., SNOMED CT values for Smoking Status

• ICD9, ICD10, SMOMED-CT for Diagnoses/Problems • CPT, CPT II, HCPCS-G for Procedures

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Challenges & Solutions

• Export Issues– Technical Delays in Clinical Summary Export– PPRNet members reporting issues to Tech Support:

critically important!– McKesson has been responsive to issues

• Data Capture– Record in Other Chart Sections

• add .PR: codes for Procedures• Update Quick text, visit note or letter templates

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Data Element CaptureClinical Data Location/Code Alternate Location/Code

Problems/Diagnoses Problem or Diagnosis Lists [ICD9, ICD10, SNOMED]

none

Vital Signs: Ht, Wt, BP, BMI Vital Signs none

Medications Medication List [RXNORM] none

Lab tests: Cholesterol, LDL-C, HDL-C, HbA1C, Hgb, Bld Gluc, INR, Albumin, Creatinine, K+

Lab Results [LOINC] none

Lab test: Fecal Occult Blood LAB FOBT [LOINC] PROC [82270, G0107]

Lab test: Cervical CA Screen LAB Pap Smear [LOINC] DX [V76.2] PROC [3015F]

Lab test: Chlamydia Screen LAB Chlamydia Scrn [LOINC] PROC Chlam Cult [87110]

Immunizations Health Maintenance [CVX] RX [RXNORM]

Procedures: AAA Screen PROC [G0389] PROC [698356002, V81.2]

Procedures: Osteoporosis Scrn PROC [77080, G8399, 241686001]

DX [88.98, V82.81]

Data Element CaptureClinical Data Location/Code Alternate Location/Code

Procedures: Mammography PROC [3014F] PROC [77056]

Procedures: Colonoscopy PROC [45378] PROC [3017F]

Procedures: Sigmoidoscopy PROC [45333] DX [45.24] PROC [G0104]

Procedure: Dilated Eye Exam PROC [2022F, S3000] PROC [427478009]

Procedure: DM Foot Exam PROC [2028F] PROC [G9226] [401191002]

Procedure: Depression Scrn PROC [3725F, G0444] PROC [428171000124102]

Procedure: Tobacco Cessation PROC [99406(3-10m) 99407(>10m)]

PROC [D1320, 225323000]

Procedure: Alcohol Use Scrn PROC [3016F] PROC [413475007]

Procedure: Alcohol Use Counseling PROC [4320F] PROC [99408, 99409 (>30m)]

Smoking Status Vital Signs [SNOMED] PROC [1036F]

Pt Status: Inactive; Deceased PROC [18632008] UsualProv: INACTIVE;DECEASED

Mammogram Procedure Codes

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AAA SCREENX Quick Text Example

.H:AAA SCREEN X

.PR: SCREEN FOR ABDOMINAL AORTIC ANEURYSM : G0389

CRC Template Example

COLONOSCOPY (- this is the T line).PV: «MEAP» «GSSP».H:COLONOSCOPY X.H:HEMOCCULT N.PR: COLON CANCER SCREENING : 3017F

Courtesy of Plymouth Family Physicians

Add .PR: Codes

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WHAT WHO WHERE PROCESS RELATED CODES, SEE KEY1 DM EYE DB SCANNING TEMPLATE QT 2022F2 DM FOOT MD MD PROGRESS NOTE QT 2028F3 MAM DB SCANNING TEMPLATE QT 3014F4 PAP DB, QUEST SCANNING TEMPLATE, LAB T SCAN T, QT 3015F5 CRC DB SCANNING TEMPLATE QT 3017F5 CRC LAB LAB PROGRESS NOTE LOINC 29771-36 CHLAM QUEST LAB DOWNLOAD?? LOINC 21613-57 BMD DB SCANNING TEMPLATE QT G83998 AAA DB SCANNING TEMPLATE QT G03899 DEP MD MD PROGRESS NOTE QT G8510 G8431 G843310 TOB SCRN MA VS QT 1036F 71.610 TOB COUNS MD MD PROGRESS NOTE QT 99406 9940711 ETOH + MD MD PROGRESS NOTE QT 4320F 99408 99409 Z71.411 ETOH SCRN MD MD PROGRESS NOTE QT 3016F

CODE KEYCPT CPT II ICD 10 LOINC G CODE

Plymouth Family Physicians Documentation Process

©PPRNet 2015 Courtesy of Plymouth Family Physicians

Discussion

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