CCDA Update - How to codify EMR and EHR sections
- Dylan Nigh
In Build 14.5.5 and 15.5.1+ of MacPractice, we introduced some changes in order to better comply with the CURES Act regulations on Information Blocking. Due to the scope of these updates as required by the US Government, we needed to add additional requirements to Form Templates in the EMR/EDR and EHR Abilities of MacPractice.
This article seeks to guide you through these updates and what you'll need to do after you update to MP Build 14.5.5 or Build 15.5.1+. If you'd like some more general information on the CURES Act, click this link instead.
We'll first start by reviewing the areas impacted and how to update a template so you can re-save these templates and use them going forward. We'll walk through the changes that this update brings. Whether you primarily use the EMR/EDR Ability or the EHR Ability, we'll include instructions on how to update those specific types of templates.
IMPORTANT NOTE: When you update to Build 14.5.5 or 15.5.1+ of MacPractice, you will also need to update your RefCon. You can do this by using the "Update Codes" option in the MacPractice Menu:
EDR/EMR Templates
There are two steps to updating an EMR/EDR Template. First, you'll need to codify the Template itself, and then you'll need to ensure the Template contains all the sections required. We'll first start with assigning a LOINC code to a template.
Codifying the EMR/EDR Template
First, you'll need to select the Template you wish to update. These are typically stowed in your pink folders in the sidebar.
With a Template selected, you'll see a new Codified Description field in the Forms Palette, along with a new Codify button.
Clicking the Codify button will bring up a window to select a LOINC code to tie to the currently selected Template. Choose the most appropriate LOINC code that best describes the Template and click Select.
Once a template has a LOINC code assigned to it, you'll see a red triangle appear on the Forms Palette.
If you click this red triangle, you'll be presented with a list of sections that are required to be in this before the Template can be used to generate forms for patients. The name and the corresponding LOINC codes will be shown. We'll use this information when codifying the Sections.
Codifying the EMR/EDR Sections
Once you've tied a LOINC code to a Template, you can then start tying your Form Sections that aren't already Codified with LOINC codes. You'll simply select the Form Section, and using the same Codify button and Codified Desc field to select a LOINC code for this Section.
Selecting a LOINC code for a Section will allow the Section narrative to populate Clinical Notes for use when sharing data with 3rd party entities such as Patients, Referrals, or HIEs (Health Information Exchanges). This data can only be pulled if the Section and Template it belongs to are properly codified.
You may need to add additional Sections with a Text field if the Template is still missing a required section with a LOINC code. If at all possible, try to avoid creating new sections if you have the option to tie to an existing Section.
Once your Templates have been updated, on locked EMR forms, you'll see a new button, "View Clinical Note", that will allow you to review the codified narrative. Only narrative data from codified sections should be included in this generated document, with the exception of Pathology Study and Laboratory Reports. For these two document types, the entire form narrative will be included.
EHR Templates
There are two steps to updating an EHR Template. First, you'll need to codify the Template itself, and then you will need to ensure the Template contains all the sections required. We'll first start with assigning a LOINC code to a Template.
Codifying the EHR Template
When you first navigate to the EHR Ability and select a Template, you'll notice a new field and button, the Codify button and the Codified Description field that you can't directly edit:
Clicking the Codify button will present you with a list of LOINC codes to tie to this currently selected Template. You'll need to select one of these to identify your Template. Choose the most appropriate LOINC code that best describes the Template and click Select.
Once a LOINC code has been chosen for a Template, you'll see a red triangle appear next to the Codified Description (Template) field.
If you click this red triangle, you'll be presented with a list of sections that are required to be in this before the Template can be used to generate forms for patients. The name and the corresponding LOINC codes will be shown. We'll use this information when codifying the Sections.
Codifying the EHR Sections
Next, you'll need to ensure all Custom Sections(Not a Preconfigured Section) in a Template have a LOINC code assigned to identify them in the same way that we needed to link a LOINC code to the Template itself.
Sections have had a new read-only field added, the "Codified Description" field. You'll also notice a "Codify..." button, and a ? button that will link to this article.
This Codify button, when clicked, will allow the user to select a narrative section type identified by a LOINC code. By selecting a LOINC code, the Codified Description field will be populated with the Long Common Name. You'll need to select the most appropriate LOINC code that best describes the selected Section.
You may need to add additional Sections with a Text field if the Template is still missing a required section with a LOINC code. If at all possible, try to avoid creating new sections if you have the option to tie to an existing Section.
Once all of your Sections are properly added, you can view a patient's Codified narrative for a given locked form by using the header bar selector. You'll note that the LOINC code is displayed.
Only narrative data from codified sections should be included in this generated document, with the exception of Pathology Study and Laboratory Reports. For these two document types, the entire form narrative will be included.
You can print from here if desired, but you'll primarily use the Clinical Ability to handle exporting CCDAs as needed.
Generated Clinical Documents Manager
We've added a new Manager in the Clinical Ability; the Generated Clinical Documents Manager. The Generated Clinical Documents Manager can be used to print, export, or send documents to a referral.
If no patient is selected, the Manager will fetch appropriate documents for all patients in the database that fit the criteria. If a patient is selected, Clinical Forms that belong to the selected patient will be fetched instead.
To fetch documents, you'll first need set the range of dates from which you'd like to fetch documents from. You can leave these fields blank if you simply wish to fetch all documents.
You can also choose to narrow documents down to specific document types, including CCDA Documents and other LOINC codes.
When you've set the criteria, click the Apply button to pull the documents that meet the criteria you've set. The documents will be listed in the table below the Apply button, as shown in this screenshot:
Selecting a document will preview the document in the bottom part of the table. You'll also notice a checkbox at the top left of the table, "Available on Patient Portal". As the label suggests, checking this box will make this document available on a Portal User's Portal if they have this patient added to their Portal User.
At the top left of the table, you'll note the Export and Print buttons. The Print button will allow you to print a copy of the document in question, while the Export Button, when clicked, will reveal options to either Export to File or to Send to Referral.
Sending a Document to a Referral
When selecting Send to Referral, you'll need to select a Referral that's been added to the Patients Ability > Patient Tab > Referrals tab. The Referral's Category must be set to "Transition To". You can also create a new Transition To Referral from the pop-up.
To send the referral directly, you'll need to have the recipient Provider's Direct Address, and you'll need to provide that in the "Electronic Transmit Direct Address" field, shown in the screenshot above.