electronic submission of Medical Documentation (esMD)
Determination of Coverage (eDoC) Workgroup
Kick-Off of
Structured Data Sub-Workgroup
March 1, 2013
Welcome and Introductions
DAN KALWA
Health Insurance Specialist,
CMS / OFM / Provider Compliance Group
ROBERT DIETERLE
esMD Initiative Coordinator
VIET NGUYEN, MD
Sub-Working Group Lead
Chief Medical Information Officer
Systems Made Simple, Inc.
MARK D PILLEY, MD AAFP, AADEP, ABQAURP
Medical Director
StrategicHealthSolutions, LLC
MICHAEL HANDRIGAN, MD
Medical Officer
CMS / OFM / Provider Compliance Group
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Agenda
Purpose/Goals
Proposed Process
Timeline and Summary
Challenges
Community Participation
Questions
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SWG Goals
• Define a reusable process by which Payors can define and standardize the data they need to perform a DoC
• Identify and apply standards to data utilized in the DoC process - PMD Use Case
• Create a set of artifacts (e.g. CDA template) that can be utilized by Implementers
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SWG Process• Define EXISTING business processes/rules and data
requirements in the DoC• Identify and enumerate existing data capture artifacts for
PMD• Identify and enumerate data elements• Determine if data element is best represented by
narrative or codes• Evaluate and apply existing standards• Create artifacts to support implementation
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BUSINESS PROCESSES
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eDoC General Workflow
Payer
Patient
LCMPSpecialist /Service Provider
Physician
Templates and Rules
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Visits Physician/ PractitionerB
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Su
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Documents the F2F visit in progress note in medical record. Must include: - Purpose of the visit is to document
the need for a PMD - Exam findings
Writes 7-element order
Completes Detailed Product Description
Signs/Dates Detailed Product Description
Receives/Files Signed/Dated Detailed Product Description
Receives/Files F2F visit progress note and order
Submits Documentation Package including:• F2F note• 7-Element Order• Detailed Product Description• Other Supporting Documentation
Request Process for PMD
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Licensed/Certified Medical Professional (LCMP) (PT/OT) Role in Face-to-Face Process
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LC
MP
Visits Physician/ Practitioner
Documents the F2F visit in medical record
Must include:- Send for LCMP evaluation
Writes order for LCMP evaluation
Documents the Mobility Evaluation in medical record
Reviews, states concurrence, signs and dates LCMP evaluation
Visits LCMP for Evaluation
Writes 7-element order
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EXISTING DATA CAPTURE ARTIFACTS AND DATA ELEMENTS
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CMS PMD Clinical Template
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Seven Element Order
1. Patient’s name,
2. Description of item ordered (description may be general [e.g., “power operated vehicle”, “power wheelchair”, or “power mobility device”] or more specific),
3. Date of face-to-face examination,
4. Pertinent diagnoses/conditions that relate to the need for a PMD,
5. Length of need,
6. Physician’s signature, and
7. Date of physician’s signature.
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Evaluate Existing Standards
• Consolidated Clinical Document Architecture (C-CDA)• Predefined and HL7 approved• Documents, Sections and Elements
• Standard Coding Systems• SNOMED• LOINC• ICD
• Standard Evaluation Terminology• International Classification of Functionality
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Consolidated CDA Document Types• Continuity of Care Document 1.1• History and Physical• Consult Note• Discharge Summary• Diagnostic Imaging Report• Procedure Note• Operative Note• Progress Note• Unstructured Document
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C-CDA – History and PhysicalAllergies Section (entries optional)
Assessment and Plan Section
Assessment Section
Chief Complaint and Reason for Visit Section
Chief Complaint Section
Family History Section
General Status Section
History of Past Illness Section
History of Present Illness Section
Immunizations Section (entries optional)
Instructions Section
Medications Section (entries optional)
Physical Exam Section
Plan of Care Section
Problem Section (entries optional)
Procedures Section (entries optional)
Reason for Visit Section
Results Section (entries optional)
Review of Systems Section
Social History Section
Vital Signs Section (entries optional)
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Sample C-CDA SectionHistory of Past Illness
This section describes the history related to the patient’s past complaints, problems, or diagnoses. It records these details up until, and possibly pertinent to, the patient’s current complaint or reason for seeking medical care.
1. SHALL contain exactly one [1..1] templateId (CONF:7828) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.20" (CONF:10390).
2. SHALL contain exactly one [1..1] code (CONF:15474).
a. This code SHALL contain exactly one [1..1] @code="11348-0" History of Past Illness (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15475).
3. SHALL contain exactly one [1..1] title (CONF:7830).
4. SHALL contain exactly one [1..1] text (CONF:7831).
5. MAY contain zero or more [0..*] entry (CONF:8791) such that it
a. SHALL contain exactly one [1..1] Problem Observation (templateId:2.16.840.1.113883.10.20.22.4.4) (CONF:15476).
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Sample C-CDA Entry
PROBLEM OBSERVATION
…
SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHOULD be selected from ValueSet Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:9058).– This value MAY contain zero or more [0..*] translation
(CONF:16749).• The translation, if present, MAY contain zero or one [0..1] @code
(CodeSystem: ICD10CM 2.16.840.1.113883.6.90 STATIC) (CONF:16750).
…
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ValueSet Problem Value SetConcept Code Concept Name
Code System Name Code System Version
89628003 Acute suppurative cholecystitis (disorder) SNOMED-CT 20100731
86279000Acute suppurative otitis media with spontaneous rupture of ear drum (disorder SNOMED-CT 20100731
14948001
Acute suppurative otitis media without spontaneous rupture of ear drum (disorder) SNOMED-CT 20100731
8733006 Acute suppurative peritonitis (disorder) SNOMED-CT 20100731
194201001 Acute swimmer's ear (disorder) SNOMED-CT 20100731
279035001 Acute thoracic back pain (finding) SNOMED-CT 20100731
190293001 Acute thyroiditis (disorder) SNOMED-CT 20100731
17741008 Acute tonsillitis (disorder) SNOMED-CT 20100731
26650005 Acute tracheitis (disorder) SNOMED-CT 20100731
OID 2.16.840.1.113883.3.88.12.3221.7.4
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DATA MAPPING
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Document & Section MappingPMD Clinical Template C-CDA H&P Document
A. Chief Complaint Chief Complaint SectionB. History of Present Illness HPI SectionC. Past Medical History History of Past Illness SectionD. Social History Social History SectionE. Review of Systems (ROS) Review of Systems SectionF. Physical Exam Physical Exam SectionG. Patient Assessment Assessment SectionH. Plan Plan of Care Section
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Entry Level Mapping
Clinical Data Element Potential Target Coding
Past Medical History Diagnoses or Problems
SNOMED codes in Problem Value SetICD Code Sets
Functional Assessments International Classification of Functionality
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SWG Artifacts
Data Set Requirements
Data Model
Harmonization with existing C-CDA Document Template and other standards
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Sub Workgroup PMD Structured Data
PMD Phase 1Implementation Guide
Use Case #1: PMD Phase 1PMD Phase 1Pilots (TBD)
Pre-DiscoveryWorkgroup
Charter/Scope
Kick-Off
Mar ‘13 May ‘ 13 July ‘13Feb ‘13 Apr ‘13 Jun ‘13 Aug ‘13
Standards/Data Model/Harmonization
Sub Workgroup PMD Data Capture Template
Sub Workgroup PMD Decision Support
PMD Phase 2Implementation
Guide Use Case #1: PMD Phase 2 Standards/Data
Model/HarmonizationPMD Phase 2 (TBD)
PMD Phase 1
eDoC Timeline
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ChallengesCoordinating work with other S&I Framework Initiatives (HeD and SDC)
Coordinating document types in EMR
Issues of coordination with HL7 regarding gaps in C-CDA or additional templates that must be part of C-CDA
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Community Involvement• Assist with elaboration of use case and variations
• Identification of data elements
• Identification and mapping to standards
• HL7 CDA expertise
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Sub-Work Group Meeting Times
Wednesdays – 2-3 PM Eastern following the esMD Author of Record
Fridays – 2-3 PM Eastern
Next Meeting – Wednesday, March 13. 2-3 PM Eastern
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