Electronic Case Reporting of STIs: Assessing EHR Generated CCDs

ObjectiveWe reviewed CCDs (a type of consolidated clinical dataarchitecture (C-CDA) document) shared by our clinical partner,Planned Parenthood of the Great Northwest and Hawaiian Islands(PPGNHI) since October, 2015. Analyses focuses on:-Completeness-Degree to which the CCD matches program area informationneeds-Differences in EHR generation methods-Presence and location of triggers (based on the ReportableConditions Trigger Codes) that would initiate CCD generation.IntroductionUnder the CDC STD Surveillance Network (SSuN) Part B grant,WA DOH is testing electronic case reporting (eCR) of sexuallytransmitted infections (STI) from a clinical partner.MethodsTwo methods of CCD generation, based on existing EHRcapabilities, were used to create CCDs that were delivered to WADOH using secure file transport protocol (SFTP). PPGNHI uses theNextGen EHR system.The first batch received was extracted using the Medical SummaryUtility. Random selection of cases (25) from lab positive Chlamydia(CT), Gonorrhea (GC) or Syphilis encounters with a follow-up planin the EHR (1/1/2015-3/31/2015). Each CCD contained manuallyselected encounters (related to STI case).Cases are now extracted directly from a patient chart(File-->Generate CCD). Two types of CCDs can be created: singleencounter CCDs and longitudinal encounter CCDs.The CCDs were analyzed for completeness, crossover with theexisting paper case report, and with relevant CDA and C-CDAImplementation Guide (IG) standards.ResultsThis analysis includes four reportable events across 6 CCDs.One event is represented by both a longitudinal CCD and 2 singleencounter CCDs.The CCDs contained most of the basic demographic informationrequested in the paper case report with the exception of “middleinitial”.Information on the important paper case report components“gender of sex partner” and “partner management plan” are not foundin the CCD.The CCD Results section contained lab tests and results that includesite of infection and could confirm diagnosis. The ordered test (panel)is not coded, though the individual tests performed are LOINC coded.The CCD Medications section meets STI program needs forinformation about treatment in a case report. Information isrepresented using RxNorm codes as specified by the C-CDA IG.The CCD Problems section was not present in documents generatedusing the MSU but was present in documents created using File -->Generate CCD from the patient chart. The Problems section andcoded entries (ICD-9-CM and ICD-10) are required for CCDs. TheProblems do not include effective dates, which are not required bythe IG.Pregnancy status, and information about HIV testing (includingprevious positive), are present in the CCD Problems section only ifthe encounter during which testing occurred is included in the CCDsubmitted.Using the CCD in place of the paper case report requiresunderstanding of the clinical workflow and use of EHR. Twoinstances that require specific attention are the “exposure” status ofthe case (known/possibly exposed vs. not shared/not known), andthe “presentation” of the diagnosis (symptomatic vs asymptomatic).For example, the ICD-10 code Z11.3 (encounter for screening forinfections with a predominantly sexual mode of transmission), cannotbe interpreted as a true “screening”, as this diagnosis is recorded forall visits that include STI testing. Similarly, a code for exposureto STIs is sometimes used, but not consistently enough to allowreliable identification of cases in which the patient was tested due toan exposure or possible exposure. Work with our clinical partner tounderstand what inferences can and should be made is an importantpart of evaluating the CCD as a replacement to the paper case report.ConclusionsThe CCDs submitted to DOH show that most information requestedin an STI case report can be found in a CCD with some exceptions,notably “gender of sex partners” and “partner management plan”.Some information is only inconsistently present, for example,exposure status and presentation.Understanding how the CCD could replace the paper case reportrequires working with the reporter to insure that the information isinterpreted on the receiving end in the same way that it is interpretedin the clinical workflow and entered in the EHR