Reconcile Incoming Transitions of Care (CDA)

OP sets all defaults to share all information. Any individual decisions by Practice-users to restrict information sharing (access, use, or exchange) are the responsibility of the Practice in the implementation of its 21st Century Cures Act Information Blocking policies and procedures for its Practice and patients.

Version 21.0

About

The reconciling of a CDA and management of external documents begins with a Direct Message received in the Unread External tab of the Message Center. Direct Messages may be a CDA, an embedded PDF within a CDA, or a Zip folder that contains many different files. Reconciling CDAs allows users to compare the clinical information in a patient's chart with the information provided in the CDA file. A permission of Admin_Data_Reconciliation is required to perform the Clinical Data Reconciliation. There are currently three clinical areas available for incorporation: 

  • Problems
  • Allergies
  • Medications

Direct Message: Zip file

  1. Navigate to the Direct Message: Main Navigation Panel > External > Unread External tab. Messages will not be associated with a patient (non-patient message).
  2. Select the message; all files within the Zip folder will are displayed.

  1. Click the CDA icon to view the patient's name. The Clinical Document Review and Reconciliation window open.
  2. Click OK in the Warning message that displays stating that there is no patient associated with the document.
  3. Obtain the patient's name from the document and choose one of the workflows listed below.

NoteIf the patient is new to the Practice, create the patient record before proceeding.

  • Select Patient and Reconcile CDA from the Clinical Document Review and Reconciliation Window.
  1. Select the Patient Search button and search for and select the patient.
  2. The CDA options display, proceed to Reconcile a Referral Transition of Care.
  3. Once the CDA is reconciled, proceed to step 6.
  • Select Patient from the message.
  1. Close the Clinical Document Review and Reconciliation window.
  2. From the message, click in the name field, select the Patient Search button and search for and select the patient.
  3. Proceed to step 6.
  1. Navigate to Documents in the Patient Chart. All files in the Zip folder have been saved as individual documents in the Referral Letter Item Type.
  2. Select each document to Edit or Delete from the Patient record. To reconcile the CDA, proceed to Reconcile a Referral Transition of Care.

Note: In Document Management an Item Type of ZIP Archive is created that contains the original files. To view the contents of the Zip folder 

  1. Click on the line item with the date of the message, the Zip Explorer opens.

  1. Click on a document to view.
  2. (Optional) For existing files not previously saved to the patient record, you may select the file in the Zip Explorer and click the Import button. Once imported you can edit or reconcile the CDA. Optionally, you may click Save to Disk if not importing to the patient record at this time and save to your system.

Direct Message: Embedded PDF

  1. Navigate to the Direct Message: Main Navigation Panel > External > Unread External tab. Messages will not be associated with a patient (non-patient message).
  2. Select the message.
  3. Click the CDA icon to open the Clinical Document Review and Reconciliation window.

  1. Click OK in the Warning message that displays stating that there is no patient associated with the document.
  2. Click the Patient Search button and search for and select the patient.
  3. Click the Attachments button to view the document.
  4. Click the Import button. 

Note: Optionally, you may click Save to Disk, if not importing to the patient record at this time, and save to your system.

  1. A Confirmation window displays that the document was successfully imported into OP, click Yes to open the document.
  2. The document opens in the Manage Documents window. Follow your Practice policy on completing the information in the Documents Details panel.
  3. Navigate to the Patient Chart and select Documents. All documents can be viewed in the Referral Letter Item Type.
  4. (Optional) Select each document to Edit or Delete from the Patient record. To reconcile the CDA, proceed to Reconcile a Referral Transition of Care.

Reconcile a Referral Transition of Care

When the Clinical Document Review and Reconciliation window opens, the Overview tab is displayed. The user can continue reviewing and reconciling the CDA. A permission of Admin_Data_Reconciliation is required to perform the Clinical Data Reconciliation.

  1. Review the Overview tab, this tab serves as a face sheet for the CDA. 
  2. (Optional) Attach the referral:
  1. Click the Referrals button.
  2. Click the paper clip button on the referral to attach the document. A line is created in the grid indicating that the referral has been associated.

  • If a Referral/Transition of Care has not been created, the Create TOC button should be used to open the Referral/Transition of Care window to enter the information and attach the document.
  1. Reconcile the CDA:

  1. Click the Reconciliation tab, the Medications tab is selected. If an error message displays, click here for further details.
  2. Review the information in the window, and click the Add or Reject button.

Note: Any entry with a Source of:

  • Patient Chart: The entry exists in the patient record.
  • Office Practicum: The entry is a duplicate and exists in the patient record and the CDA. You must make a decision to Add or Reject the entry.

All other Source entries are new from the CDA. You will make a decision to add or reject the entry by selecting the Add or Reject button.

  1. Click the Problems and Allergies tab and click the Add or Reject button for entries new to the patient record.
  2. Click the Review button. The Review window displays entries that will be added to the patient record and have been rejected.

  1. Click the Finalize button. When complete a Success message displays.
  2. Close the Clinical Document Review and Reconciliation window.
  1. Click the Mark Reviewed button (if accessed from Document Management) or mark the message Read (if accessed from the Message Center).

Note: A Source column is available to add that displays the External Source. This column is available in the Medication, Allergies, and Problem list windows of the Patient's Chart. Example: 


Version 20.18

About

The reconciling of a CDA and management of external documents begins with a Direct Message received in the Unread External tab of the Message Center. Direct Messages may be a CDA, an embedded PDF within a CDA, or a Zip folder that contains many different files. Reconciling CDAs allows users to compare the clinical information in a patient's chart with the information provided in the CDA file. There are currently three clinical areas available for incorporation: 

  • Problems
  • Allergies
  • Medications

Direct Message: Zip file

  1. Navigate to the Direct Message: Main Navigation Panel > External > Unread External tab. Messages will not be associated with a patient (non-patient message).
  2. Select the message; all files within the Zip folder will are displayed.

  1. Click the CDA icon to view the patient's name. The Clinical Document Review and Reconciliation window open.
  2. Click OK in the Warning message that displays stating that there is no patient associated with the document.
  3. Obtain the patient's name from the document and choose one of the workflows listed below.

NoteIf the patient is new to the Practice, create the patient record before proceeding.

  • Select Patient and Reconcile CDA from the Clinical Document Review and Reconciliation Window.
  1. Select the Patient Search button and search for and select the patient.
  2. The CDA options display, proceed to Reconcile a Referral Transition of Care.
  3. Once the CDA is reconciled, proceed to step 6.
  • Select Patient from the message.
  1. Close the Clinical Document Review and Reconciliation window.
  2. From the message, click in the name field, select the Patient Search button and search for and select the patient.
  3. Proceed to step 6.
  1. Navigate to Documents in the Patient Chart. All files in the Zip folder have been saved as individual documents in the Referral Letter Item Type.
  2. Select each document to Edit or Delete from the Patient record. To reconcile the CDA, proceed to Reconcile a Referral Transition of Care.

Note: In Document Management an Item Type of ZIP Archive is created that contains the original files. To view the contents of the Zip folder 

  1. Click on the line item with the date of the message, the Zip Explorer opens.

  1. Click on a document to view.
  2. (Optional) For existing files not previously saved to the patient record, you may select the file in the Zip Explorer and click the Import button. Once imported you can edit or reconcile the CDA. Optionally, you may click Save to Disk if not importing to the patient record at this time and save to your system.

Direct Message: Embedded PDF

  1. Navigate to the Direct Message: Main Navigation Panel > External > Unread External tab. Messages will not be associated with a patient (non-patient message).
  2. Select the message.
  3. Click the CDA icon to open the Clinical Document Review and Reconciliation window.

  1. Click OK in the Warning message that displays stating that there is no patient associated with the document.
  2. Click the Patient Search button and search for and select the patient.
  3. Click the Attachments button to view the document.
  4. Click the Import button. 

Note: Optionally, you may click Save to Disk, if not importing to the patient record at this time, and save to your system.

  1. A Confirmation window displays that the document was successfully imported into OP, click Yes to open the document.
  2. The document opens in the Manage Documents window. Follow your Practice policy on completing the information in the Documents Details panel.
  3. Navigate to the Patient Chart and select Documents. All documents can be viewed in the Referral Letter Item Type.
  4. (Optional) Select each document to Edit or Delete from the Patient record. To reconcile the CDA, proceed to Reconcile a Referral Transition of Care.

Reconcile a Referral Transition of Care

When the Clinical Document Review and Reconciliation window opens, the Overview tab is displayed. The user can continue with reviewing and reconciling the CDA.  

  1. Review the Overview tab. This tab serves as a face-sheet for the CDA. 
  2. Attach the CDA to a referral:
  1. Click the Referrals tab.
  2. Click the paper clip button on the referral to attach the document. A line is created in the grid indicating that the referral has been associated.

  • If a Referral/Transition of Care has not been created, the Create TOC button should be used to open the Referral/Transition of Care window to enter the Transition information. Once that entry is saved, the CDA may be attached.
  1. Review the Problem List section of the report.
  1. Click the Problem List tab.
  2. Review the information provided where clinical information that already existed in the patient's chart is displayed with a blue background, and new clinical information is displayed with a yellow background.

  1. Choose which information should be incorporated into the patient's chart:
  1. Select the new clinical information displayed with a yellow background.
  2. Click the Merge > > button. 
  3. In the Action column, select from the following options:
  • Ignore: This is the default for new clinical data.
  • Add: Adds the data from the document to the patient's chart.
  • Retain: This is the default for the clinical information that already existed in the patient's chart.
  • Remove: When regarding new data, this does not incorporate the data into the patient's chart. When regarding existing patient chart data, this removes data from the patient's chart. An example of when this would be done could be if a specialist provided a more granular description of the patient's problem/diagnosis.
  1. (Optional) Edit the following columns, as needed: Status, Onset Date,  Resolved, Privacy, Sort Order, and Hide.
  2. Click the Review > > button to review the patient's new Problem List.
  3. If the Problem List is acceptable as is, click the Submit button (an irreversible action), and confirm you want to merge the data. If a change needs to be made, click the < < Merge button to return to the previous screen. 
  4. Repeat the steps above for the Allergies/Rxns and Medications tabs of the report (as applicable).
  5. Close the Clinical Document Review and Reconciliation window.
  6. Click the Mark Reviewed button (if accessed from Document Management) or mark the message Read (if accessed from the Message Center).