Cancer Reporting Errata and Clarification Document for Electronic Health Record (EHR) Technology Certification December 2012
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1 Cancer Reporting Errata and Clarification Document for Electronic Health Record (EHR) Technology Certification December 2012 National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control
2 Introduction This supplement, Cancer Reporting Clarification Document for Electronic Health Record (EHR) Technology Certification, identifies errors and clarifies conformance requirements and other aspects of the Implementation Guide for Ambulatory Healthcare Provider Reporting to Central Cancer Registries, August 2012 (the Cancer Reporting Implementation Guide). This supplement does not specify additional requirements. Rather, it clarifies existing requirements given in the Cancer Reporting Implementation Guide. Clarifications and errata 1. Where discrepancies exist, constraints enumerated in the conformance statements take precedence over the constraints enumerated in the table. 2. Section Use Case Details a. Page 8, step 1, business rule 1: add link for ICD 10 CM reportability list VADS link: b. Page 8, step 2, business rule 3 should read The Ambulatory Healthcare Provider Cancer Event Report shall contain data elements as defined in the specifications in Section 2.5 of this document instead of The Ambulatory Healthcare Provider Cancer Event Report shall contain data elements as defined in the specifications in Section of this document. c. Page 8, step 2, business rule 3 Remarks/Links should read Refer to Appendix B, Ambulatory Healthcare Provider Cancer Event Report Data Elements Table of this document for list of data elements and Section 2.3 for the concepts used to define optionality (,, ) instead of Refer to specifications in Section of this document for list of data elements and the concepts used to define optionality (required, recommended, optional). 3. Cancer Diagnosis Section a. Page 29, Table 2-4 Cancer Diagnosis Section and Conformance Statement 2: LOINC Code should read instead of Implementers are encouraged to use the correct LOINC code , but both LOINC codes will be accepted by the conformance test tool. 4. Coverage Entry a. Page 50, Conformance Statement 5: contain exactly one [1..1] code=" " Financing and Insurance (CodeSystem: LOINC ). This LOINC code is not the same LOINC code that is used by the CCD parent template and therefore breaks a CCD validation rule. The correct LOINC code is Payment sources, which implementers are encouraged to use. The conformance test tool will not return an error if either LOINC code is used. A change proposal has been submitted to the Integrating the Healthcare Enterprise (IHE) Patient Care Coordination (PCC) domain that has responsibility for this template. 2
3 5. Encounters Entry a. Page 52, Conformance Statement 5 and the corresponding row in Table 2-21 Encounters Entry Constraints Overview should read ValueSet ActEncounterCode instead of ValueSet ActEncounterCode Medications Entry a. Pages 54-55, Table 2-22 Medications Entry Constraints Overview should read: Name XPath Card. Verb Data Type Fixed Value Dose dosequantity 0..1 IVL<PQ> low translation 0..* SET<PQR> originaltext 0..1 ED reference/@value 0..1 high translation 0..* SET<PQR> originaltext 0..1 ED reference/@value 0..1 b. Page 61, Conformance Statement 12.a should read: (HL7 UnitsOfMeasureCaseSensitive) (HL7 UnitsOfMeasureCaseSensitive) a. contain exactly one [1..1] low. i. This low contain zero or more ii. This low contain zero or more which be selected from ValueSet HL7 UnitsOfMeasureCaseSensitive DYNAMIC. iii. If the dose is in countable units (tablets, caplets, "eaches"), then the unit attribute is not sent. Otherwise the units are sent. iv. This low contain zero or more [0..*] translation. 1. This translation contain zero or one [0..1] originaltext. a. The originaltext, if present, contain zero or one [0..1] reference/@value. i. This reference/@value begin with a '#' and point to its corresponding narrative (using the approach defined in CDA Release 2, section ). a. contain exactly one [1..1] low.
4 i. This code contain zero or one [0..1] originaltext. 1. The originaltext, if present, contain zero or one [0..1] a. This begin with a '#' and point to its corresponding narrative (using the approach defined in CDA Release 2, section ). ii. This code contain zero or more [0..*] translation. c. Page 61, Conformance Statement 12.b should read: a. contain exactly one [1..1] high. i. This high contain zero or more ii. This high contain zero or more which be selected from ValueSet HL7 UnitsOfMeasureCaseSensitive DYNAMIC. iii. If the dose is in countable units (tablets, caplets, "eaches"), then the unit attribute is not sent. Otherwise the units are sent. iv. This high contain zero or more [0..*] translation. 2. This translation contain zero or one [0..1] originaltext. a. The originaltext, if present, contain zero or one [0..1] reference/@value. i. This reference/@value begin with a '#' and point to its corresponding narrative (using the approach defined in CDA Release 2, section ). a. contain exactly one [1..1] high. i. This code contain zero or one [0..1] originaltext. 1. The originaltext, if present, contain zero or one [0..1] reference/@value. a. This reference/@value begin with a '#' and point to its corresponding narrative (using the approach defined in CDA Release 2, section ). ii. This code contain zero or more [0..*] translation. d. Page 62, Conformance Statement 12.d should be removed: The dosequantity, if present, contain zero or one which be selected from ValueSet HL7 UnitsOfMeasureCaseSensitive DYNAMIC. i. If the dose is in countable units (tablets, caplets, "eaches"), then the unit attribute is not sent. Otherwise the units are sent. e. Note: While it also is valid Clinical Document Architecture (CDA) for the dosequantity element to attributes without the low and high child elements when a dose range is not specified, we would not expect to see the dosequantity element implemented this way since the Cancer Reporting Implementation Guide requires the low and high elements. 4
5 f. Page 62, Conformance Statement 13.e should read: ValueSet HL7 UnitsOfMeasureCaseSensitive instead of ValueSet HL7 UnitsOfMeasureCaseSensitive g. Page 64, Figure 2.28, Medication Example should read: <dosequantity> <low value="" unit=""> <translation> <originaltext> <reference value=""/> </originaltext> </translation> </low> <high value="" unit=""> <translation> <originaltext> <reference value""/> </originaltext> </translation> </high> <dosequantity value='' unit=''/> 7. Payer Entry a. Page 67, Conformance Statement 5.a.i: ValueSet Source of Payment Typology OID should read instead of b. Page 67, conformance statement 7.c.v.1 and the corresponding row in Table 2-28 Payer Entry Constraints Overview should read: contain exactly one instead of contain exactly one c. Page 69, Figure 2.29 should read: <representedorganization classcode='org'> instead of <representedorganization typecode='org'>. 8. Procedure Activity a. Page 78, Conformance Statement 2 should read: be selected from Code System MoodCode instead of be selected from ValueSet MoodCode Product Entry a. Page 84, Table 2-36 Product Entry Constraints Overview: i. XPath for Coded Product Name should read code instead of Code. ii. Name should read Product instead of Medication brand name. iii. Name should read Product Name and Strength instead of Product Name Description. 10. TNM Clinical Stage Information Entry 5
6 a. Page 102, Table 2-52 NAACCR TNM Clinical Metastasis Value: LOINC code should read instead of Appendix A Code System Table a. Should read: Code System OID Code System Name Minimum Standard (version) International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2011 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Code System OID Code System Name Minimum Standard (version) International Classification of Diseases b. Add the following rows to the Code System Table: 2011 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Code System OID Code System Name Minimum Standard (version) Source of Payment Typology Version 5.0 Oct ICD-9 CM, Volume 3 (Procedures) FY 2013 (Version 30) ICD-10 PCS FY Appendix B a. Add the following rows to the Ambulatory Healthcare Provider Cancer Event Report Data Elements table: Procedures Narrative Radiation Oncology Section Radiation Oncology Narrative nt/section[templateid[@root=' ']] nt/section[templateid[@root=' ']]/text b. Modify the Ambulatory Healthcare Provider Cancer Event Report Data Elements table (page D-5) for Active Problems Section to read: Start date of problem nt/section[title='active Problems Section']/entry/act/effectiveTime/low/@value 6
7 Stop date of problem be present for concerns in the completed or aborted state NOT be present otherwise nt/section[title='active Problems Start and Stop date of problem nt/section[title='active Problems Section']/entry/act/effectiveTime c. Modify the Opt column of the Ambulatory Healthcare Provider Cancer Event Report Data Elements table (page D-6) for Coded Results Section to read: Procedure DateTime ']]/entry/procedure/effectiveTime/* Facility [Simple Observation] 3.28']]/entry/observation/author/assignedAuthor/represe ntedorganization/name Facility ID [Simple Observation] 3.28']]/entry/observation/author/assignedAuthor/represe ntedorganization/id d. Modify the Opt column of the Ambulatory Healthcare Provider Cancer Event Report Data Elements table (page D-6) for Procedures Section to read: Body Site of procedure ,1210 Procedure DateTime ']]/entry/procedure/effectiveTime/* e. Modify the Opt column of the Ambulatory Healthcare Provider Cancer Event Report Data Elements table (page D-7) for Medications Section to read: 7
8 Rate [Medications] 3.19']]/entry/substanceAdministration/rateQuantity f. Modify the Data Element Name column of the Ambulatory Healthcare Provider Cancer Event Report Data Elements table (page D-7) for Medications Section to read: Medication Brand Name Product [Product Entry] 3.19']]/entry/substanceAdministration/consumable/manu facturedproduct/manufacturedmaterial/name Strength Product Name and Strength [Product Entry] 3.19']]/entry/substanceAdministration/consumable/manu facturedproduct/manufacturedmaterial/code/originaltex t g. Modify the Opt column of the Ambulatory Healthcare Provider Cancer Event Report Data Elements table (page D-7) for Medications Administered Sectionto read: Rate [Medications] 3.21']]/entry/substanceAdministration/rateQuantity h. Modify the Data Element Name column of the Ambulatory Healthcare Provider Cancer Event Report Data Elements table (page D-8) for Medications Administered Section to read: Strength Product Name and Strength [Product Entry] 3.21']]/entry/substanceAdministration/consumable/manu facturedproduct/manufacturedmaterial/code/originaltex t Code Coded product name [Product Entry] 3.21']]/entry/substanceAdministration/consumable/manu facturedproduct/manufacturedmaterial/code/@* i. Modify the Opt column of the Ambulatory Healthcare Provider Cancer Event Report Data Elements table (page D-9) for Care Plan Section to read: 2420, 2425, 2460, 2470, 2480, 2490, 2500 Provider Referred To [Encounters] 3.31']]/entry/encounter/performer/assignedEntity/assign edperson/name/* 8
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