Source: https://www.healthit.gov/test-method/clinical-information-reconciliation-and-incorporation
Timestamp: 2019-02-18 04:41:12
Document Index: 506037008

Matched Legal Cases: ['§ 170', '§ 170', '§ 170', '§ 170', '§ 170', '§ 170', '§ 170', '§ 170', '§ 170', '§ 170']

Clinical information reconciliation and incorporation | HealthIT.gov
§ 170.207(d)(2) RxNorm, August 6, 2012 Full Release Update
Using the xml files downloaded in steps 1 and 2, the user demonstrates that a transition of care summary/referral summary Consolidated-Clinical Document Architecture (C-CDA) document, formatted according to the standard adopted at § 170.205(a)(3) HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, DSTU Release 1.1, and a transition of care summary/referral summary C-CDA document, formatted according to the standard adopted at § 170.205(a)(4) HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes, DSTU Release 2.1, can be properly matched to a patient in the Health IT Module. Note that matches can be made automatically or manually.
The tester uses visual inspection to verify the Health IT Module can receive the C-CDA document downloaded in step 1 of the SUT as a C-CDA Release 1.1 document formatted according to the standard specified in § 170.205(a)(3) as either a CCD or a C-CDA with no specific document template.
The tester uses visual inspection to verify the Health IT Module can receive the C-CDA document downloaded in step 2 of the SUT as a C-CDA Release 2.1 documents formatted according to the standard specified in § 170.205(a)(4) using one of the following document templates:
Using the Health IT Module and the human readable xml files from step 1, the tester verifies that the received C-CDA Release 1.1 and Release 2.1 documents can be properly matched to the correct patient record.
Note that Health IT Module will need to separately demonstrate the ability to reconcile summary of care documents formatted according to § 170.205(a)(3) HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, DSTU Release 1.1 and § 170.205(a)(4) HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes, DSTU Release 2.1, and they will need to separately demonstrate each of the following document templates: CCD or C-CDA with no specific document template for C-CDA Release 1.1; and CCD, Referral Note, and (inpatient setting only) Discharge Summary document templates for C-CDA Release 2.1 for the health IT setting(s) being certified.
Further, the tester must verify that the Health IT Module can display the current patient record and a transition of care summary/referral summary C-CDA Release 1.1 and Release 2.1 document, formatted according to the standard adopted at § 170.205(a)(3) and separately the current patient record and a transition of care summary/referral summary C-CDA document, formatted according to the standard adopted at § 170.205(a)(4).
The tester verifies that, for each list type: a simultaneous display (i.e. a single view), duplicates can be consolidated into a single representation, list items can be removed, and any other methods the Health IT Module may use to reconcile the list. The entire reconciliation process must occur within a simultaneous view.
The user accepts the reconciled list and the patient record in the Health IT Module is updated.
The tester uses the ETT: Message Validators Validation Report created as a result of the upload in step 1 to verify the Health IT Module passes without error to confirm that the Clinical Information Reconciliation CCD document is conformant when it is created after a reconciliation of medications, medication allergies, and/or problems has been performed. Furthermore, the tester verifies that it meets the standard specified in § 170.205(a)(4). This verification is only for C-CDA Release 2.1 CCD documents.
The scope of this criterion is limited to the Consolidated CDA (C-CDA) Continuity of Care Document (CCD), Referral Note, and (inpatient setting only) Discharge Summary document templates. [see also 80 FR 62639]
“Incorporation” means to electronically process structured information from another source such that it is combined (in structured form) with information maintained by health IT and is subsequently available for use within the health IT system by a user. [see also 77 FR 54168 and 77 FR 54218]
We are requiring Health IT Modules to be able to reconcile and incorporate information from C-CDAs formatted to both C-CDA Releases 1.1 and 2.1. While Release 2.1 largely ensures compatibility between C-CDA Release 1.1 and 2.0, it does not guarantee compatibility without further development effort. [see also 80 FR 62639]
Health IT Modules do not have to auto-match the patient. Manual patient match is acceptable as long as the received C-CDA can be matched to the correct patient. [see also 80 FR 62640 and 77 FR 54219]
The health IT can enable a user to review, validate, and incorporate medications, medication allergies, and problems in distinct functions, or combined, as long as all three can be demonstrated. [see also 80 FR 62639]
Testing will evaluate health IT ability to incorporate data from C-CDA documents with variations in the data elements to be reconciled to test real-world variation that may be found in C-CDA documents. [see also 80 FR 62639]
ONC encourages developers to incorporate data in a structured format. [see also 77 FR 54219]
Incorporation does not have to be automated. [see also 77 FR 54219]
SNOMED CT® OID: 2.16.840.1.113883.6.96. [see also 80 FR 62612]