Omar Bouhaddou, PhD Contractor supporting Veterans Affairs Office of Interoperability

HIMSS 2016 - March 1st, 2016

Improving Interoperability by Improving C-CDA Data Quality

Agenda

Importance of C-CDA for interoperability C-CDA implementation and data quality: The VA Experience Improvements we can make

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Rapid increase in data sharing and interoperability

eHealth Exchange (Sequoia Project) spans all 50 states and is the largest health information exchange infrastructure in the US, with over 110 members and connects 50% of U.S. hospitals, which serve 100 million patients. DirectTrust - 44 million messages exchanged in 2015. DirectTrust predicts

that this year’s message volume will top 200 million, and 2017’s could quadruple to more than 800 million, if current trends continue. The network now includes more than a million trusted addresses. CommonWell rolled out nationwide in 2015 and claims 5,000 providers in

its network Epic’s Care Everywhere claims more than 300 participating clients, each

representing multiple providers Surescripts - Clinical Messaging and National Record Locator Service

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Interoperability is happening …

Carequality (a public-private collaboration of vendors, providers, health information exchanges and other interested parties) released its Interoperability Framework, a set of guidelines for creating the business agreements to enable trusted information exchange. In late January, five major HIT vendors were the first to commit to using the framework. Sequoia Project Content Testing Workgroup HIMSS ConCERT interoperability certification program NATE BlueButton Trust Bundle ONC/HL7 agreement to improve CCDA implementation VA / DoD Joint Task Force: enhance C-CDA implementation

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C-CDA is the exchange currency

10% of transactions must be C-CDA (Meaningful Use 2) 20 of 33 ACO metrics

Patient access to data

20M CCDAs exchanged per month

20% of patient data available only in HIE (ie, external)

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What is C-CDA?

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HL7 Implementation Guide for CDA®

Release 2: IHE Health Story Consolidation, Release 1.1 - US Realm

Document Templates: 9 • Continuity of Care Document (CCD) • Consultation Note • Diagnostic Imaging Report (DIR) • Discharge Summary • History and Physical (H&P) • Operative Note • Procedure Note • Progress Note • Unstructured Document

Section Templates: 60

Entry Templates: 82

Human readable

Machine readable

Veteran Engagement

Veteran Authorization and Patient-Mediated HIE

Community Partners

Secure network and Trust Agreements

VA Clinical Adoption

Data Content, engaged providers,

value use cases, and integrated clinical

workflow

Improving Veterans Care Coordination by Improving Health Information Exchange

Technology Solutions Exchange

Direct Consent Mgt Blue Button

Next Generation HIE

3 out of 4 Veterans use non-VA Health

Care

Improved Continuity of Care Reduced duplication of tests/ procedures

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VHIE Content Types

VHIE MODE CONTENT USERS PURPOSE of USE Exchange C32, C62s,

C-CDA CCD Providers Treatment,

Emergency, Coverage

Direct CCDA CCD, PDF, text, Images (small), others

Providers, Patients, Staff

Treatment, Payment, Operation

Patient portal (My HealtheVet)

Blue Button, PDF, C32*, C-CDA CCD*

Patients Request for self

Business (CBO), Benefits (VBA)

PDF, text, images, X12, C-CDA~, others

Staff Coverage

• with patient-specific data ranges and hold periods • ~ under development 8

Sections VA C-CDA CCD R1.1

Person Information* Authoritative demographics from Master Veteran Index (MVI)

Language Spoken “Unknown” until available in VistA Information Source “Department of Veterans Affairs” Document Title Health Summary Allergies* All Allergies: including “no known allergies” and “no assessment done” Advanced Directive All completed or amended Advanced and Rescinded Directives Encounters* A maximum of 150 most recent outpatient encounters within the last 36 months

A maximum of 10 Progress Notes per outpatient Encounters. A maximum of 20 most recent Consult Notes within the last 24 months. A maximum of 10 most recent Discharge Summaries within the last 36 months. A maximum of 20 most recent History and Physical Notes within the last 24 months.

Functional Status All FIM Scores within the last 3 years Healthcare Providers Problem List providers and Primary Care Providers

Immunizations* All Immunizations Medications* Outpatient Meds and Non-VA Meds dispensed in the last 15 months

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VA C-CDA CCD Content

Sections VA C-CDA CCD R1.1

Payers/ Insurance Providers*

All Active

Plan of Care* Future Outpatient Appointments with appointment date within the next 12 months, max of 50 Active or Pending Radiology Orders max of 50 within the next 12 months Active or Pending Chem or Hem tests max of 50 within the next 12 months

Problems* All Problems Procedures*

Up to 25 most recent surgical procedures in the last 12 months Max of 10 Surgery Notes per Surgical Procedure. 20 most recent Clinical Procedure Notes within the last 36 months.

Results* A maximum of 20 most recent panel results within the last 24 months 20 most recent Pathology Reports within the last 24 months. 20 most recent Radiology Reports within the last 24 months.

Social History* All Smoking Status health factors Support/Contact All Current Next of Kin and Emergency Contact

Vitals* Last 12 months with maximum of 10 most recent

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VA C-CDA CCD Content - cont’d.

VA Clinical Notes (available as C62s)

Comp & Pen (C&P) Exams** Consults / Referrals Discharge Summaries History and Physicals Microbiology Reports Pathology Studies include:

• Surgical Pathology • Cytology • Cytopathology • Electron Microscopy

Surgery Reports Radiology reports Results of Diagnostic Studies & procedure notes include:

• Cardiology Studies – including Electrocardiogram • Gastroenterology Endoscopy Studies • Pulmonary Studies - including Pulmonary Function

Tests • Ophthalmology/Optometry Studies • Oncology Notes • Neuromuscular Electrophysiology Studies • Miscellaneous Studies • Study Report

**available to SSA only

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EHR to C-CDA and Back

• The TEAM • Mapping between EHR

and C-CDA • EHR APIs • Terminology

translation services • C-CDA construction • C-CDA validation • Data quality

surveillance • Consuming C-CDAs

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Content Testing Process

VA Onboarding VA Production

eHealth Exchange Onboarding

Sequoia Project Certification (3 months)

Partners Onboarding (1-10 months)

Data Quality Surveillance (on going)

• DURSA • Technical testing • Content testing*

(e.g., C-CDA CCD)

• Volume of shared patients

• Technical and content testing

• Review and score sample documents

• Provide feedback

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* Under development

Content Richness

C32 Module

Percent of C32s Populated

Range Populated by Partner

Demographics 100% 100%

Providers 86% 71% ~ 99%

Problems 84% 52% ~ 99%

Allergies 74% 13% ~ 99%

Encounters 74% 35% ~ 94%

Medications 63% <1% ~ 97%

Vital Signs 53% 1% ~ 80%

Laboratory Results 46% 9% ~ 81%

Procedures 42% 9% ~ 61%

Immunizations 35% 2% ~ 63%

Source: Based on a sample of 250 C32s for nine VA exchange partners (including VA) at the time of the evaluation, retrieved July 2012. (n=2,250)

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Semantic Interoperability HITSP C32 Data Element VA DoD 1 2 3 4 5 6 7 8 9 10 11 12 13 Standard Terminology requirement

0.04-Document Code x x x x x x x x x x x x x x LOINC 1.06-Gender x x x x x x x x x x x x x x HL7 Administrative Gender Codes 1.08-Marital Status x x x x x x HL7 MaritalStatus code set 1.10-Race x x x CDC Race and Ethnicity Codes 1.11-Ethnicity x x x CDC Race and Ethnicity Codes Religious Affiliation x HL7 ReligiousAffiliation code set 3.03-Contact Type HL7 Role Class 3.03-Contact Relationship x x x x HL7 Role Code 2.01-Language x value set is defined by IETF RFC 3066. 4.02-Provider role coded x HL7 Provider Role

4.04-Provider Type National Uniform Claim Committee Provider Codes

5.02-Health Insurance Type x HL7-defined value set. 5.09-Patient Relationship to Subscriber

x

6.02-Adverse Event Type x x x x x x x x x SNOMED CT Subset 6.04-Product Coded x RxNorm 6.06-Reaction Coded x SNOMED CT Subset 6.08-Severity Coded x x Subset of SNOMED CT 7.04-Problem Code x x x x x x x Subset of SNOMED CT Problem Type x x x x 7.12-Problem Status x x x x x Subset of SNOMED CT 8.19-Type of Medication x x x x Subset of SNOMED CT 8.20-Status of Medication x x x x x Subset of SNOMED CT Medication coded Product Name x x x x x RxNorm, Route x x HL7-defined value set. Dose UCUM for units Site Product Form FDA dosage form Indication Reaction Subset of SNOMED CT Vehicle Quantity Ordered UCUM for units Quantity Dispensed UCUM for units

Fill Status x HL7 ActStatusNormal (Completed, Aborted) 13.06-Immunization coded Product Name

CVX

13.10-Refusal reason HL7 ActReason 14.03-Result Type (Vital signs) x x x LOINC 14.05-Results Value (Unit of Measure)

UCUM for units of measure Result Status x HL7 ActStatus 15.03-Result Type (Lab) x x x x x x x LOINC 15.05-Results Value (Unit of Measure)

UCUM for units of measure 15.06-Result Interpretation x x x Result Status HL7 ActStatus Encounter Type x CPT-4 Admission Type UB-04/NUBC , UB-04 FL14 Admission Source UB-04/NUBC , UB-04 FL14 17.02-Procedure type x x CPT4 Advanced Directive SNOMED CT Subset

PS: Based on small sample - 2013 15

Data Quality Issues

• Misplaced data – Procedure in Problems section, panel name in analyte,

immunization in medications section • Incorrect use of terminology

– Codes that are semantically nonsensical, incorrect, or vague • Invalid data/data not understandable

– Unreadable values, text in dates • Missing values

– Variable strictness for now • Format problems • Duplicate entries • Inconsistent entries (narrative vs. entries) • Ambiguous or redundant nulls and negatives

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Data Quality (examples) Duplication

Excessive abbreviations

Missing Interpretation

Immunization in Meds section

Confusing lab units

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Data Quality Surveillance

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C-CDA Implementation – Lessons Learned

Content development is an ongoing effort, not a one-time ‘functionality’ release. Plan development efforts accordingly. Standard-based exchange requires both business and technical teams to be

well-versed in the standards. Invest in workforce training. Centralize C-CDA implementation feedback to HL7. HL7 needs to address

identified ambiguities in HL7 specifications and companion guides, provide examples and support desk. Also, HL7 needs to promote a standard C-CDA style sheet In general, more data is better than less. The receiver must have good ways to

browse and incorporate the data received.

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C-CDA Implementation Lessons Learned – cont’d

Invest in tools to support C-CDA developers with creation and validation (e.g., MDHT, SITE, Gazelle) and to support C-CDA analysts (e.g., ‘EHR to CCDA mapping spreadsheet’) Improve content testing. Ensure testing environment is as close to production

as possible. Require fully populated, clinically realistic data. Adopt data quality surveillance; certification of test data is not sufficient. On

going monitoring targets true data quality, as used during care coordination. Identify methods to capture usability feedback from end-users, including

relevance and pertinence of the data. Provide feedback to data sources.

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