Where should the Reason for Referral and Referring Provider info appear in CCDA for TOC?

[Keyea Solorzano]

Conflicting information seems to be circulating regarding where the Reason for Referral and Referring Provider information should appear in the CCDA file for transition of Care 170.314.(b)(2). 

My MU consultant has recommended that we add this information to the Plan of Care section in CCDA, however, we've found two sources that suggest otherwise. Please see below. 

Can someone please confirm where this information is required?

Source 1: 

Source 2: This source is in line with source 1 plus the provider information as free text field, so I think that this section is the right one.

URL: https://github.com/chb/sample_ccdas/blob/master/Greenway%20Samples/26775_ExportSummary_CCDA.xml

 <component>

        <section classCode="DOCSECT" moodCode="EVN">

          <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1" />

          <id root="2.16.840.1.113883.3.441" extension="0f1e9a949c674757" />

          <code code="42349-1" displayName="REASON FOR REFERRAL" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />

          <title>Reason for Referral</title>

          <text mediaType="text/x-hl7-text+xml">

            <table border="1">

              <thead>

                <tr>

                  <th>Reason for Referral</th>

                  <th>Plan Date</th>

                  <th>Provider</th>

                </tr>

              </thead>

              <tbody>

                <tr>

                  <td ID="ref_2bd42e28eb1e465381fa265fa13deb09_referral_1_reason">Pulmonary Function Test</td>

                  <td ID="ref_2bd42e28eb1e465381fa265fa13deb09_referral_1_planDate">1/28/2013</td>

                  <td ID="ref_2bd42e28eb1e465381fa265fa13deb09_referral_1_provider"> Penny Puffer, 1047 Healthcare Drive, , Portland, OR, 97005, 555-555-1049</td>

                </tr>

              </tbody>

            </table>

          </text>

        </section>

      </component>

[Brian Weiss (CDA PRO)]

Keyea,

Note that this is not an authoritative response, just my understanding... I do not represent ONC, NIST, HL7, etc.

I think this needs to be separated into two questions.

1) Reason for referral goes into the section you indicated, as per the S&I Companion Guide (section 3.51):

Reason for Referral

Recommendation is to use the Reason for Referral section for the MU2 data requirement so that the referring provider’s intentions are clear to the consulting provider.  

2) The location of the referring provider in a C-CDA document goes to the larger question of where various care team members belong. You can refer to chapter 3.2 of the S&I guide. It notes, for example:

For example, a patient may be referred by a general surgeon to a surgical specialist in an outpatient surgery center for a specific procedure. In this example, the general surgeon who referred the patient is associated with the clinical encounter that represents the setting during which the procedure occurred. The surgical specialist is then associated with the procedure, or service event, that happened as part of the clinical encounter and is listed as a performer in the documentationOf/serviceEvent header element. Within the document detailing the procedure, these care team members would be captured as participants in distinct header elements associated with the clinical encounter from which the patient was referred or the procedure service event that transpired.

This is challenging wording. But it really comes down to what type of C-CDA document is being used (and in MU terms, what the scenario is in which the transition of care document is being generated). The referring provider is generally going to be part of the header of the document (for example in encompassingEncounter/encounterParticipant).

While including the referring provider as text within the Reason for Referral section (as per the example below) makes sense, that isn't a substitute for ensuring the header (and/or encounter sections) correctly capture relevant providers and their role in the clinical acts being described in the document.

Not really sure why Plan of Care section was suggested to you as being relevant here?

Anyway, just my two cents... happy to learn more from more authoritative sources on this mailing list...

Brian Weiss

www.cdapro.com

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[Brian Weiss (CDA PRO)]

...and shame on me for not checking my own web site before hitting "send"....

• Reason for Referral in MU2 (http://www.cdapro.com/know/25973)

It also notes that the referring provider information should go into that section text - as you noted and as per the example you shared. Again, depending on the type of document and the scenario, the referring provider might also belong in the header and/or in encounter sections.

And, as always, if this thread corrects something in the article or adds to it, I will update the article to reflect that...

Brian Weiss

www.cdapro.com

[jacoha...@gmail.com]

Brian,

Do you think that for MU2 objectives §170.314 (b)(1) & (b)(7) & (e)(2) adding the referring provider to encompassingEncounter/encounterParticipant is required?

Thanks,
Jaco

[Brian Weiss (CDA PRO)]

As always, important to note that my comments on this mailing list are non-authoritative and only reflect my current opinion/understanding (which is subject to change, as official guidance is provided by authoritative folks).

I think from an MU2 perspective, the requirements for document "reason for referral" are intended to be met by including the Reason for Referral Section - which is a text-only section and should include referring provider information as well as reason for referral and date of referral.

What drives the need to place providers (including referring provider) in appropriate places in the header and/or in encounter sections, are overall C-CDA and MU2 principles not directly related to "referrals". So, I would recommend starting here:

• Use of encompassingEncounter in MU2 C-CDA documents (http://www.cdapro.com/know/26197)
  

for a review of how the encompassingEncounter portion of the CDA header is used, overall, in an MU2 C-CDA document.

It really comes down to what encounter(s) the document describes and the role of the referring provider in that context. If the document is focused on the clinical encounter in which the referral was triggered, the referring provider might also be a serviceEvent/performer, as explained in: serviceEvent/performer vs. encompassingEncounter/encounterParticipant (http://www.cdapro.com/know/26915). That article also reference S&I Companion Guide Tables 5-7 "Sample CCD Participant Scenarios". Note that while the title of that table indicated "CCD", even if the C-CDA CCD template is not being used (it is not required by MU2 - in fact, MU2 does not require that any C-CDA document template compliance be asserted), the "default" principles for MU2 C-CDA summary document headers are often those of a CCD - unless a specific different type of C-CDA document is used.

In terms of the MU2 objectives/criteria you noted, "Reason for Referral" is a requirement in all the Ambulatory flavors of the "(b)" objectives/criteria (Transition of Care/Referral Summary and Export Summary) in the context of "Conditions and Concerns". For the "(e)(2)" objectives/criteria, there is a requirement to document Referrals to Other Providers in a "Care Planning" context.  The Reason for Referral section is thus more relevant for the "(b)" criterion. The principles for the use of encompassingEncounter/encounterParticipant and serviceEvent/performer are the same across all objectives/criteria, as outlined in the articles referenced above.

Hope that is helpful...

Brian Weiss

www.cdapro.com