October 25, 2013

1. electronic Submission of Medical Documentation (esMD)eDoC Administrative Documents Templates for HL7Orders October 25, 2013

2. Orders Overview • Created by clinicians during the course of care as a written or electronic order • Written orders entered by support staff into EHR • Communication with order recipient made if necessary • Orders are the “in progress” • Other statuses – active, incomplete, pending, canceled • “Completed” orders • Orders may or may not be completed during the episode of care • Order may not be fulfilled within a provider’s organization or by another entity

3. Completed and In Process Orders Section • Purpose – contains the data that defines all active, pending, incomplete, and completed orders for observations, interventions, encounters, services, procedures for the patient for the episode of care. • Order Entry Templates • Observation • Encounter • Act • Procedure • Medication Activity • Supply

4. HL7 Codes • Mood Code – “RQO” (Request) from the ActMood Code System • http://www.hl7.org/implement/standards/fhir/v3/ActMood/index.html • Definition: A request act that is specialized for an event request/fulfillment cycle. • Act.statusCode – “Complete” • http://wiki.hl7.org/index.php?title=Act.statusCode • when applied to an Act with moodCode="RQO" implies that the act of request has been completed. It does not mean that the requested action has been completed.

5. Observation Order Template • This template represents observation orders that result in new information about the patient which cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs, and EKGs. • The importance of the observation to the patient and provider is communicated through Patient Priority Preference and Provider Priority Preference. The effectiveTime indicates the time when the observation is intended to take place and authorTime indicates when the documentation of the plan occurred. • The Observation template may also indicate the potential insurance coverage for the observation.

6. Observation Order Template • Shall contain 1..1 code from LOINC, SNOMED-CT, CPT-4, or CPT-4 indicating the observation • May contain 0..1 effective time • May contain 1..* targetSiteCode (body site targets) • May contain 0..* performer (clinician expected to perform the observation) • May contain 1..* author (clinician requesting the observation) • May contain 0..* entryRelationship • Priority – Patient or provider • Reason • Indication • Instruction • Planned coverage

7. Supply Order • Medicinal and non-medicinal supplies ordered, requested, or intended for the patient (e.g. medication prescription, order for wheelchair). The importance of the supply order to the patient and provider may be indicated in the Patient Priority Preference and Provider Priority Preference. • The effective time indicates the time when the supply is intended to take place and author time indicates when the documentation of the plan occurred. The Supply Order template may also indicate the potential insurance coverage for the procedure. • Depending on the type of supply, the product or participant will be either a Medication Information product (medication), an Immunization Medication Information product (immunization), or a Product Instance participant (device/equipment).

8. Supply Order Template • May contain 0..1 Product Instance • May contain 1..* author (clinician requesting the observation) • May contain 0..* entryRelationship • Priority – Patient or provider • Reason • Indication • Instruction • Planned coverage

9. Product Instance • This clinical statement represents a particular device that was placed in a patient or used as part of a procedure or other act. This provides a record of the identifier and other details about the given product that was used. For example, it is important to have a record that indicates not just that a hip prostheses was placed in a patient but that it was a particular hip prostheses number with a unique identifier. • The FDA Amendments Act specifies the creation of a Unique Device Identification (UDI) System that requires the label of devices to bear a unique identifier that will standardize device identification and identify the device through distribution and use. • The UDI should be sent in the participantRole/id.

10. Other orders • Procedure Order - alterations of the patient's physical condition. Examples of such procedures are tracheostomy, knee replacement, and craniectomy • Encounter Order - The type of encounter (e.g. comprehensive outpatient visit) is represented by SNOMED CT Code. Clinicians participating in the encounter and the location of the planned encounter may be captured. • Medication Activity Order • Act Order - acts that are not classified as an observation or a procedure according to the HL7 RIM. Examples of these acts are a dressing change, the teaching or feeding of a patient or the providing of comfort measures.

11. Summary • Goal – collect data on all completed orders generated during an episode of care including status of order. Collect all results associated with a given order if available. • HL7 CCDA can represent orders at the component level • CCDA Section level template needed to contain all orders generated during an episode of care • CCDA Entry level template needed to represent orders which are more constrained than “planned” activities • RQO mood code can be used for orders • statusCode “complete” signifies that an order (mood code RQO) is entered in the system but does not indicate fulfillment of the ordered actions

12. Summary • Fulfillment of an order/request generates a new information (e.g. and Observation Order Act results in an Observation Act) • Closed loop environment (e.g. Hospital) order and result is available and can be linked. Orders without results are presumed “in progress” unless canceled. • Open loop environment (e.g. private clinics) may not associate results with originating order

13. Questions?