Improving Interoperability by Improving C-CDA Data Quality Omar Bouhaddou, PhD Contractor supporting Veterans Affairs Office of Interoperability HIMSS 2016 - March 1st, 2016

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?

Human readable

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

Machine readable 6

Improving Veterans Care Coordination by Improving Health Information Exchange 3 out of 4 Veterans use nonVA Health Care

Veteran Engagement Veteran Authorization and Patient-Mediated HIE

Technology Solutions

VA Clinical Adoption Data Content, engaged providers, value use cases, and integrated clinical workflow

Exchange Direct Consent Mgt Blue Button Next Generation HIE

Community Partners Secure network and Trust Agreements

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, Staff X12, C-CDA~, others • •

Coverage

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

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VA C-CDA CCD Content Sections

VA C-CDA CCD R1.1

Person Information*

Authoritative demographics from Master Veteran Index (MVI)

Language Spoken Information Source Document Title Allergies* Advanced Directive Encounters*

Functional Status Healthcare Providers

“Unknown” until available in VistA “Department of Veterans Affairs” Health Summary All Allergies: including “no known allergies” and “no assessment done” All completed or amended Advanced and Rescinded Directives 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. All FIM Scores within the last 3 years Problem List providers and Primary Care Providers

Immunizations* Medications*

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

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VA C-CDA CCD Content - cont’d. VA C-CDA CCD R1.1

Sections Payers/ Insurance Providers* Plan of Care*

Problems* Procedures*

Results*

All Active 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 All Problems 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. 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* Support/Contact

All Smoking Status health factors All Current Next of Kin and Emergency Contact

Vitals*

Last 12 months with maximum of 10 most recent

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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

eHealth Exchange Onboarding

Sequoia Project Certification (3 months)

• DURSA • Technical testing • Content testing* (e.g., C-CDA CCD)

VA Onboarding

Partners Onboarding (1-10 months)

• Volume of shared patients • Technical and content testing

VA Production

Data Quality Surveillance (on going)

• Review and score sample documents • Provide feedback

* Under development

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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%