C-CDA validator erroneously reporting error 55607006 snomed code needed for problem section

catherin...@cerner.com

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Feb 15, 2017, 3:35:42 PM2/15/17

to Edge Test Tool (ETT)

For a number of the sample data sets including Patient John Wright, 170.315b1 TOC inpatient sample 2 (note others perform the same), the CCDA validator gives this error without further detail.

We believe this error is invalid and blocking certification. We provide the problem code 55607006, generic code for problem in the xml as is the problem section, act, and observation. Example xml with template, act, observation highlighted in blue and entries in yellow relevant to the topic. Please update the tool as needed.

Thank you.

Problems entries required template:

<title>Problems</title>

<text>

<content styleCode="Bold">Encounter Diagnosis</content>

<item>

<content ID="ZProblems.Problems.6887869">First degree burn of multiple sites of wrists and hand Onset Date:2015-07-22 00:00:00, Status:Active. </content>

</item>

</list>

</text>

Shall have an act

</effectiveTime>

</assignedAuthor>

</author>

Shall have an observation

</code>

<text>

</text>

</effectiveTime>

Shall have a value

<text>

</text>

</value>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

</section>

Auto Generated Inline Image 1

Brett Marquard

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Feb 15, 2017, 7:32:03 PM2/15/17

to catherin...@cerner.com, Edge Test Tool (ETT)

Please attach full sample.

Snippet you sent looks ok, but it’s not clear if there is another spot.

Best,

Brett

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Nagesh Bashyam

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Feb 16, 2017, 6:25:04 AM2/16/17

to Brett Marquard, catherin...@cerner.com, Edge Test Tool (ETT)

Catherine,

The ToC Inpatient Sample 2 requires a Problems section that denotes “No Known Problems” which is missing and hence the error you are receiving. The No Known Problems semantics use a problem code of 55607006.

Please refer to the example: https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Doc-No%20Known%20Problems%2020140226.xml

The data that you have published below is for Encounter Diagnosis which can be coded using Problem Observation but wrapped within a Diagnosis Act depending on the Document Template you are using.

Please let us know if you have any further questions.

Thanks

Dragon

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image001.png

catherin...@cerner.com

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Feb 16, 2017, 2:50:10 PM2/16/17

to Edge Test Tool (ETT), catherin...@cerner.com

Nagesh, Brett,

I do not think we are in synch. Please change the error to a warning and consider that your data is contradictory based on a valid implementation. I provide the following to help explain.

1. the SNOMED code 55607006 is not the semantic meaning of no known problems. It is the code that semantically defines the finding category of problem only. Please see: https://phinvads.cdc.gov/vads/http:/phinvads.cdc.gov/vads/ViewCodeSystemConcept.action?oid=2.16.840.1.113883.6.96&code=55607006

. The semantic meaning of a positive assertion of No Known Problems (different than an empty/null list) is covered by the spec with a negation indicator. Note that we are using your required code even though the spec indicates a different one since semantically the two codes are quite similar.

The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.

2. The test data patient does have a problem. ONC has not qualified "encounter diagnosis" through response to comments or other rule making. It could be an admission diagnosis that turns out to be false and marked erroneous. It could be a working diagnosis that turns out to be true but is resolved during the encounter and, therefore, applies to billing but is inactive at the time of discharge - not a patient problem. Or it could be a discharge diagnosis and still active at time of discharge. Further, nothing (rule nor spec) says clearly where to put diagnoses of these various types in the CCDA and specifically not wrap them in a discharge template since it might not be a diagnosis of this type. Therefore, vendors are free to put "encounter diagnosis" of whatever type/status (where ONC guidance of Active with historical optional may apply) wherever we deem best. We always put them in the problem section and try to be explanatory in narrative about them. Once you put them in the problem section and it is active, "no know problems" no longer applies - it's contradictory, the patient has active burns. Only if we inactivated/resolved the burn diagnosis, would No Known Problems be accurate.

3. when we do have a patient with no known problems (i.e., charted as no known, no active diagnosis), we do have an observation as required by specification and as shown it does have the 55607006 code for the category of problems and the required negation indicator, but your data does not match this since the burns are assumed active.

<title>Problems</title>

<text>

<content styleCode="Bold">Encounter Diagnosis</content>

<content ID="ZProblems.Problems.POCPRB-PHL01-NO-DATA">No relevant problems exist.</content>

</paragraph>

</text>

</effectiveTime>

</code>

<text>

</text>

</effectiveTime>

</observation>

</entryRelationship>

</act>

</entry>

</section>

</component>

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Brett Marquard

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Feb 16, 2017, 4:49:36 PM2/16/17

to catherin...@cerner.com, Edge Test Tool (ETT)

Hi, Catherine,

C-CDA includes templates to send a Hospital Admission diagnosis, Hospital Discharge diagnosis, and Encounter Diagnosis.

C-CDA allows systems to list a problem in the problems section and reference that same problem from the encounter diagnosis section. It is contradictory to the specification to list the encounter diagnosis in the problem list section without a secondary act to indicate it is the encounter diagnosis or hospital discharge diagnosis.

Best,

Brett

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Britton,Catherine

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Feb 16, 2017, 4:54:28 PM2/16/17

to Brett Marquard, Edge Test Tool (ETT)

Brett

That is not the issue and subject of the ticket.

- We do differentiate that this is an encounter diagnosis

- The specification does not enforce any specific template, ONC does not define the diagnosis so it is not mandated which dx is used, and what we have done is complaint

- That is not the issue, the issue is that the tool is trying to validate a No Known Problem observation entry in the same section where an active problem in this case, an active discharge dx which is indeed a problem, is entered. It is clinically wrong, patient safety, and not per spec to have an observation entry with negation indicator saying “no known problems” when you indeed know of a problem.

Please update the tool,

Thanks

Catherine

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Brett Marquard

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Feb 16, 2017, 5:30:52 PM2/16/17

to Britton,Catherine, Edge Test Tool (ETT)

Hi, Catherine,

I don’t believe an ‘encounter diagnosis’ is automatically added to the active problem list. Only items that are managed post-visit make the problem list – at least in my experience.

--Would it be more clear if ONC updated the test data to include an active problem?

On ONC ‘requiring’ a specific template, I suspect they are giving you flexibility to use Hospital Discharge Diagnosis or Encounter Diagnosis. Listing in the narrative of the problem list section that it’s the encounter diagnosis is not consistent with the C-CDA requirements

Best,

Brett

From: Britton,Catherine [mailto:Catherin...@Cerner.com]
Sent: Thursday, February 16, 2017 4:54 PM
To: Brett Marquard <br...@riverrockassociates.com>; Edge Test Tool (ETT) <edge-te...@googlegroups.com>
Subject: RE: C-CDA validator erroneously reporting error 55607006 snomed code needed for problem section

Brett

That is not the issue and subject of the ticket.

We do differentiate that this is an encounter diagnosis

The specification does not enforce any specific template, ONC does not define the diagnosis so it is not mandated which dx is used, and what we have done is complaint

aher...@athenahealth.com

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Jul 5, 2017, 1:57:42 PM7/5/17

to Edge Test Tool (ETT), Catherin...@cerner.com

Hello, were there any updates made to the tool? I'm getting this same error with problem codes for "no known problems".

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Nagesh Bashyam

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Jul 5, 2017, 2:39:57 PM7/5/17

to aher...@athenahealth.com, Edge Test Tool (ETT)

No specific updates were made to the tool to remove the validation for the “No Known Problems”.

Are you following the HL7 example at http://hl7-c-cda-examples.herokuapp.com/examples/view/7353a215efda8dfe3fbacb19abbb90756ce14bab

From: edge-te...@googlegroups.com [mailto:edge-te...@googlegroups.com] On Behalf Of aher...@athenahealth.com
Sent: Wednesday, July 05, 2017 1:58 PM
To: Edge Test Tool (ETT)
Cc: Catherin...@cerner.com
Subject: Re: C-CDA validator erroneously reporting error 55607006 snomed code needed for problem section

Hello, were there any updates made to the tool? I'm getting this same error with problem codes for "no known problems".

On Thursday, February 16, 2017 at 4:30:52 PM UTC-6, Brett Marquard wrote:

Hi, Catherine,

I don’t believe an ‘encounter diagnosis’ is automatically added to the active problem list. Only items that are managed post-visit make the problem list – at least in my experience.

--Would it be more clear if ONC updated the test data to include an active problem?

On ONC ‘requiring’ a specific template, I suspect they are giving you flexibility to use Hospital Discharge Diagnosis or Encounter Diagnosis. Listing in the narrative of the problem list section that it’s the encounter diagnosis is not consistent with the C-CDA requirements

Best,

Brett

From: Britton,Catherine [mailto:Catherin...@Cerner.com]
Sent: Thursday, February 16, 2017 4:54 PM
To: Brett Marquard <br...@riverrockassociates.com>; Edge Test Tool (ETT) <edge-te...@googlegroups.com>
Subject: RE: C-CDA validator erroneously reporting error 55607006 snomed code needed for problem section

Brett

That is not the issue and subject of the ticket.

We do differentiate that this is an encounter diagnosis
The specification does not enforce any specific template, ONC does not define the diagnosis so it is not mandated which dx is used, and what we have done is complaint
That is not the issue, the issue is that the tool is trying to validate a No Known Problem observation entry in the same section where an active problem in this case, an active discharge dx which is indeed a problem, is entered. It is clinically wrong, patient safety, and not per spec to have an observation entry with negation indicator saying “no known problems” when you indeed know of a problem.

Please update the tool,

Thanks

Catherine

From: Brett Marquard [mailto:br...@riverrockassociates.com]
Sent: Thursday, February 16, 2017 4:50 PM
To: Britton,Catherine <Catherin...@Cerner.com>; Edge Test Tool (ETT) <edge-te...@googlegroups.com>
Subject: RE: C-CDA validator erroneously reporting error 55607006 snomed code needed for problem section

Hi, Catherine,

C-CDA includes templates to send a Hospital Admission diagnosis, Hospital Discharge diagnosis, and Encounter Diagnosis.

C-CDA allows systems to list a problem in the problems section and reference that same problem from the encounter diagnosis section. It is contradictory to the specification to list the encounter diagnosis in the problem list section without a secondary act to indicate it is the encounter diagnosis or hospital discharge diagnosis.

Best,

Brett

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