C-CDA® Direct Message—Are We There Yet?

As part of the HIMSS Health Story Project’s goal to promote implementation of the Consolidated Clinical Document Architecture (C-CDA) standard, we were pleased to welcome the C-CDA implementation team from Baylor Scott & White Health (BSWH) to our Winter 2016 Roundtable.

Presenters from BSWH, the largest not-for-profit healthcare system in Texas, included:

  • Cherie Price, RN, CTT+, ICQI;
  • Oscar Glorioso, RN, MSN;
  • Cindy Sunderman Neese, MSN, RN-BC, CPHIMS

BSWH’s team described their journey to implement C-CDA and Direct Messaging to exchange clinical and administrative information for transitions of care.

Background: BSWH serves two large geographic areas in North Central Texas and Central Texas. The 46-hospital organization serves close to 9 million people and includes nearly 200 ambulatory care clinics. This sprawling integrated healthcare delivery network chose C-CDA as a solution to achieving safer transitions of care from the inpatient setting to the next level of care.

BSWH took an incremental approach to full implementation, starting with a C-CDA inpatient Discharge Summary in March of 2014 and culminating with inbound and outbound summary documents being transmitted via Direct Messaging in June of 2015.

Input was needed from various stakeholders to determine the contents and configuration of the C-CDA Visit Summary, which ultimately contained a more robust set of data compared to prior continuity of care documents.

Challenges: Several logistical challenges were encountered with the use of Direct Messaging.

  1. Some clinics used a single Direct Messaging address for all providers in the same practice and others used unique addresses for each provider.
  • A small number of summary documents exceeded the 10 MB limit imposed by the HISP (this 10 MB limit is currently under evaluation and may be raised).
  • Some outbound transmission failures occurred due to network problems and from simple typographical errors in the Direct Messaging address.
  • Challenges appeared with conformance to required document content, particularly with capturing Functional Status as discrete data, because some physicians documented this required element as free text within the electronic record.
    • Medication reconciliation and matching of generic and brand-name drugs by the receiver is not always performed because different medication dictionaries are in use throughout the BSWH system.
  • Various ways of capturing and managing the patient’s problem list represented a challenge to the implementation team.
    • Some physicians routinely document a discharge diagnosis while others document a current or historical problem list. This issue is under review by physician leadership.

    Meaningful Use Attestation: BSWH successfully reached the requirement for meaningful use attestation. To accomplish this goal, a meaningful use dashboard tracked compliance and identified underperforming providers and facilities.

    The team encouraged high-volume providers at each facility within the BSWH system to create and send summary documents, and the team worked proactively with underperforming facilities to educate providers, solve technical issues, and increase compliance.

    Lessons Learned: The implementation team realized they needed to include the HIPAA privacy officer as well as health information management professionals to operationalize a release-of-information protocol and to address other record management and regulatory guidelines.

    During this presentation, webinar attendees were eager to glean practical advice on achieving interoperability through summary of care documents using the C-CDA standard. The high level of interest and engagement in this topic demonstrates a real need in the industry to share successes and challenges in the practical application of the C-CDA standard.

    The HIMSS Health Story Project Leadership Council would like to thank Cherie, Oscar and Cindy for generously sharing their time and expertise, and we invite others in the industry to share their experiences with implementation of C-CDA.

    This presentation had the Health Story Project’s highest webinar attendance to date with a very engaged audience that ran out the clock during the Q&A portion.

    A recording of the presentation is available on the Health Story Project Roundtable Archives webpage.

    Members of the HIMSS Health Story project encourage dialogue in the community on this topic – please share your thoughts with us.

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