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CDA R2 Implementation Guides in Development

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September 2009 Ballots

US realm - Electronic Quality Measure Specification, Release 1

The purpose of this project is to create a standard to unambiguously represent quality measure specifications, including data elements, logic and definitions. Quality measure developers will encode their measures in this format so that they can be consumed by provider organizations, who will then be able to use the formal definitions query to their EHR data stores. Data gathered in this manner would pre-populate a QRDA. Any missing data elements would be supplied manually and then be communicated from the provider via the QRDA specification.

US realm - Care Record Summary, Release 2: Discharge Summary

The Care Record Summary, issued in June 23, 2006, was the first balloted Implementation Guide for CDA R2. CRS covered CDA Levels 1, 2, however, did not specify Level 3 templates (CDA entries). CCD, meanwhile, developed a rich set of Level 3 templates, however, CCD is not a Discharge Summary and does not specify a hospital course. The purpose of this update will be to issue a Discharge Summary-specific CRS updated for compliance with the current approach to CDA templates in CCD and the HL7 Health Story implementation guides. The resulting specification will be consistent with IHE XDS-MS for Discharge Summary and HITSP C48 and will not introduce conflicting requirements.

US realm - Healthcare Associated Infections (HAI) Release 4

With cooperation from CDC and Healthcare Associated Infections (HAI) software vendors, this project will develop an implementation guide constraining CDA Release 2. The implementation guide will support electronic submission of HAI data to the National Healthcare Safety Network. Release 4 adds the MDROMonthly and LabID reports.

Draft Standard for Trial Use (DSTU)

History and Physical

The H&P implementation guide passed DSTU ballot in January 2008. An H&P Note is a two-part medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. The information forms the basis of most treatment plans.

Consultation Notes

The Consultation implementation guide passed DSTU ballot in January 2008. For the purpose of the Implementation Guide, a consultation visit is defined by the evaluation and management guidelines for a consultation established by the Centers for Medicare and Medicaid Services (CMS). According to those guidelines, a Consultation Note must be generated as a result of a physician or nonphysician practitioner’s (NPP) request for an opinion or advice from another physician or NPP.

Operative Notes Release 1

The Operative Note is a frequently used type of procedure note with very specific requirements set forth by regulatory agencies. The Operative Note or Report is created immediately following a surgical or other high-risk procedure and records the pre and postsurgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure.

Healthcare Associated Infections (HAI) Release 2

The HAI implementation guide for submission of HAI reports to the National Health Safety Network (NHSN) of the Center for Disease Control and Prevention (CDC) passed DSTU ballot in January 2009. The guide includes 10 reports: Bloodstream Infection Numerator Report, Surgical Site Infection Numerator Report, Multi-drug-resistant Organism or Clostridium-difficile-associated Disease Report, Pneumonia Infection Numerator Report, Urinary Tract Infection Numerator Report, Central-line Insertion Practices Numerator Report, Influenza Immunization Numerator Report, Generic (Custom) Infection Numerator Report, Procedure Denominator Report, Population Summary Denominator Report.

A new Release 3 ballot was submitted in May 2009 adding 2 BSI denominator forms.