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===Summary===
 
===Summary===
 +
The purpose of this implementation guide (IG) is to specify a standard for electronic submission of Public Health Case Reports (PHCR) in a Clinical Document Architecture (CDA), Release 2 format.
  
 +
===Description===
  
===Description===
+
Common data elements found in multiple states’ reportable condition forms were compiled and standardized in a project initiated in 2007 by the Centers for Disease Control and Prevention (CDC) National Center for Public Health Informatics (NCPHI) and Council of State and Territorial Epidemiologists’ (CSTE) Case Report Standardization Workgroup (CRSWg) and leveraged in this project by NCPHI. This CDA for PHCR Implementation Guide will allow healthcare facilities/providers to communicate these data elements to the state and local public health departments in CDA format, an interoperable, industry-standard format.
  
  
 
===Business Case (Intended Use, Customers)===
 
===Business Case (Intended Use, Customers)===
 
+
* Local and State Departments of Health
 
+
*Provider: Healthcare Institutions (hospitals, long term care, home care, mental health)
 +
*Vendor: Health Care IT
 
===Benefits===
 
===Benefits===
 
+
This CDA implementation guide will allow healthcare facilities/providers to communicate common data elements found in multiple states’ reportable condition forms to state and local public health departments in CDA format—an interoperable, industry-standard format.
  
 
===Implementations/ Case Studies (Actual Users)===
 
===Implementations/ Case Studies (Actual Users)===
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Work Groups
 
Work Groups
 
*[http://www.hl7.org/Special/committees/structure/index.cfm Structured Documents]
 
*[http://www.hl7.org/Special/committees/structure/index.cfm Structured Documents]
 +
*[http://www.hl7.org/Special/committees/pher/index.cfm Public Health and Emergency Response]
 +
*[http://www.hl7.org/Special/committees/orders/index.cfm Orders and Observations]
 +
*[http://www.hl7.org/Special/committees/patientsafety/index.cfm Patient Safety]
  
 
Relationship to/ Dependencies on, other standards
 
Relationship to/ Dependencies on, other standards
*CDA
+
*CDA R2
  
 
Links to current projects in development
 
Links to current projects in development
*
+
*[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=451 Project Insight # 451], Public Health Case Notification

Revision as of 13:32, 27 October 2009

Contents

Product Brief - CDA R2 Implementation Guides

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Product Name - CDA R2 IG HAIRPT

  • HL7 Implementation Guide for CDA Release 2: Healthcare Associated Infection Reports

Type

DSTU

Releases

  • HL7 Implementation Guide for CDA Release 2: Healthcare Associated Infection Reports, Release 1; DSTU ending March 2010
  • HL7 Implementation Guide for CDA Release 2 - Level 3: Healthcare Associated Infection Reports, Release 2 (US Realm); DSTU ends Mar 2011
  • HL7 Implementation Guide CDA Release 2 - Level 3: Healthcare Associated Infection Reports, Release 3 (US Realm); DSTU ends October 2011

Summary

This specification is a set of constraints on existing work and the extent to which it can accommodate the expressive requirements of HAI reporting over time is a function of the richness of the model on which it is built, the HL7 Reference Information Model (RIM) and the RIM document standard, and the Clinical Document Architecture Release 2 (CDA R2).

Business Case (Intended Use, Customers)

This DSTU was produced and developed in conjunction with the Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases (NCPDCID), and Centers for Disease Control and Prevention (CDC). Its development and ultimate deployment is a result of the dedication of the team, led by Daniel A. Pollock, M.D., Surveillance Branch Chief, Division of Healthcare Quality Promotion, NCPDCID, CDC, and their support of the development of interoperable data standards for the CDC’s National Healthcare Safety Network (NHSN).

Benefits

The best standards are those driven by business requirements. Each stage of the development of this DSTU has been monitored, evaluated, and tested by a strong set of HAI surveillance application vendors.

Implementations/ Case Studies (Actual Users)

Those vendors who participated in the 2007-2008 pilot activities of Bloodstream Infection Reports and Surgical Site Infection deserve special thanks and acknowledgment: MedMined™ services from Cardinal Health, EpiQuest, ICPA, Premier, TheraDoc, and Vecna Technologies.

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development

  • Project Insight ID # 319 Implementation Guide for CDA Release 2 Level 3 Healthcare Associated Infection Reports (HAI II)


Product Name - CDA R2 IG Consult Note

  • HL7 Implementation Guide for CDA Release 2: Consult Notes, Release 1; DSTU ending August 2010

Type

DSTU

Releases

Release 1

Summary

This DSTU describes how CDA is used to record information for a Consult Note. The Consult Note may contain both narrative and coded data.

See http://www.healthstory.com/standards/sec/consult_note.htm

Business Case (Intended Use, Customers)

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • Transcription/Dictation Systems,
  • Departmental Systems

Benefits

Integrating narrative notes into the EHR is a key benefit as is the fact that it supports meaningful use with minimal change to current practice.

Implementations/ Case Studies (Actual Users)

coming soon

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development

  • none


Product Name - CDA R2 IG H&P

  • HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, Release 1; DSTU ending August 2010

Type

DSTU

Releases

Release 1

Summary

This DSTU describes how CDA is used to record information for a History and Physical Note. The History and Physical Note may contain both narrative and coded data.

See http://www.healthstory.com/standards/sec/history_physical.htm

Business Case (Intended Use, Customers)

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • Transcription/Dictation Systems,
  • Departmental Systems

Benefits

Integrating narrative notes into the EHR is a key benefit as is the fact that it supports meaningful use with minimal change to current practice.

Implementations/ Case Studies (Actual Users)

coming soon

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development

  • none


Product Name - CDA R2 IG EHR Interop Profile

  • HL7 Implementation Guide for CDA Release 2: Reference Profile for EHR Interoperability, Release 1; DSTU ending Sep 2010

Type

DSTU

Releases

Release 1

Summary

This DSTU is a guide describes characteristics of interoperable EHR Records. An EHR Record is a persistent artifact which may be independent of the EHR or other System from which it originated. This profile shows how HL7's CDA, Release 2 fulfills requirements of the Common EHR Record Unit, as specified in the HL7 EHR Interoperability Model DSTU. It is the result of an ongoing collaboration between the HL7 EHR, Structured Documents, and Security Work Groups. Ends September 2010

Description

Business Case (Intended Use, Customers)

Benefits

Implementations/ Case Studies (Actual Users)

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development

  • none


Product Name - CDA R2 IG PHM Reports

  • HL7 Implementation Guide for CDA Release 2: Personal Healthcare Monitoring Report, Release 1; DSTU ending Nov 2010

Type

DSTU

Releases

Release 1

Summary

The implementation guide specifies CDA based representation of data/information (mostly containing analysed and raw information of data generated by personal healthcare monitoring devices such as glucometers, BP cuffs, thermometers, weight scales).

The implementation guide for this HL7 DSTU was co-developed by Continua Health Alliance, which has a Liaison Agreement with HL7. The guide conforms with the HL7 CCD and describes how to use CCD templates for communicating home health data to an electronic health record. Ends November 2010

Business Case (Intended Use, Customers)

The guide will be used by personal health management organizations (such as disease management organizations) to transfer remotely monitored patient data to electronic health records.

Benefits

Implementations/ Case Studies (Actual Users)

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development


Product Name - CDA R2 IG Operative Note

  • HL7 Implementation Guide for CDA Release 2: Operative Notes, Release 1; DSTU ending Mar 2011

Type

DSTU

Releases

Release 1

Summary

This DSTU describes how CDA is used to record information for an Operative Note. The Operative Note may contain both narrative and coded data.

See http://www.healthstory.com/standards/sec/op_note.htm

Business Case (Intended Use, Customers)

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • Transcription/Dictation Systems,
  • Departmental Systems

Benefits

Integrating narrative notes into the EHR is a key benefit as is the fact that it supports meaningful use with minimal change to current practice.

Implementations/ Case Studies (Actual Users)

coming soon

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CCD, CDA

Links to current projects in development

  • none


Product Name - CDA R2 IG QA (Questionnaire Assessments)

  • HL7 Implementation Guide for CDA Release 2: CDA Framework for Questionnaire Assessments, Release 1; DSTU ends Apr 2011

Type

DSTU

Releases

Release 1

Summary

Description

Business Case (Intended Use, Customers)

Benefits

Implementations/ Case Studies (Actual Users)

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development Patient Assessments, Release 1 (Project # 381)


Product Name - CDA R2 IG QRDA

  • HL7 Implementation Guide for CDA Release 2: Quality Reporting Document Architecture (QRDA), Release 1; DSTU ends Apr 2011

Type

DSTU

Releases

Release 1

Summary

Health care institutions routinely collect and report performance measure data to improve the quality of care provided to patients. Measure data conforms to the requirements of defined "quality measures" which are written and maintained by institutions concerned about health care quality. This project will define and bring to ballot a set of specifications for communicating quality measure definitions to, and reporting quality data from, electronic health records.

Description

This HL7 DSTU is formally titled HL7 Implementation Guide for CDA Release 2: Quality Reporting Document Architecture (QRDA), Release 1, and was supported by the Child Health Corporation of America (CHCA) with participation from the American College of Physicians, American Health Information Management Association (AHIMA), Alliance for Pediatric Quality, Iowa Foundation for Medical Care, The Collaboration of Performance Measure Integration with EHR Systems ('The Collaborative'), HITSP, Integrating the Healthcare Enterprise (IHE) and others. The guide covers patient-centric quality data reporting and lays out a framework for aggregate, population-based quality reports.

Business Case (Intended Use, Customers)

Benefits

The specification will foster the development of fully automated EHR-based data submission and reporting. As needed, it will be compatible with semi-automated reporting which continues to rely on information derived from manual chart review and abstraction.

Implementations/ Case Studies (Actual Users)

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development


Product Name - CDA R2 IG DIR

  • HL7 Implementation Guide for CDA Release 2: Diagnostic Imaging Reports, Release 1 (Informative)

Type

Informative

Releases

Release 1

Summary

This DSTU describes how CDA is used to record information for a Diagnostic Imaging Report. Is consistent with the DICOM guide for transforming DICOM Structured Reports to CDA. The report may contain both narrative and coded data.

See http://www.healthstory.com/standards/sec/dir.htm

The implementation guide for this informative document was developed by DICOM, with support from the HL7 Imaging Integration Work Group and CDA4CDT. It is consistent with a companion guide for transforming DICOM Structured Reports to CDA Release 2 and is suitable for use with both structured and narrative data capture.

Business Case (Intended Use, Customers)

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • Transcription/Dictation Systems,
  • Departmental Systems
  • RAD information systems

Benefits

Integrating narrative notes into the EHR is a key benefit as is the fact that it supports meaningful use with minimal change to current practice.

Implementations/ Case Studies (Actual Users)

coming soon

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development

  • Project Insight ID # 528 II coordination with Diagnostic Imaging Report SR/CDA Transformation Guide (DICOM Supplement 135)


Product Name - CCD

Type

Informative

Product Name - CDA R2 IG CRS

  • HL7 Implementation Guide for CDA Release 2: Level 1 and 2 Care Record Summary (US Realm)(Informative)

Type

Informative

Releases

Release 1

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.

Description

Business Case (Intended Use, Customers)

Benefits

Implementations/ Case Studies (Actual Users)

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development


Product Name - CDA R2 IG Public Health Case Reports

  • HL7 Implementation Guide for CDA Release 2: Public Health Case Reports (US Realm)

Type

Informative

Releases

Release 1

Summary

The purpose of this implementation guide (IG) is to specify a standard for electronic submission of Public Health Case Reports (PHCR) in a Clinical Document Architecture (CDA), Release 2 format.

Description

Common data elements found in multiple states’ reportable condition forms were compiled and standardized in a project initiated in 2007 by the Centers for Disease Control and Prevention (CDC) National Center for Public Health Informatics (NCPHI) and Council of State and Territorial Epidemiologists’ (CSTE) Case Report Standardization Workgroup (CRSWg) and leveraged in this project by NCPHI. This CDA for PHCR Implementation Guide will allow healthcare facilities/providers to communicate these data elements to the state and local public health departments in CDA format, an interoperable, industry-standard format.


Business Case (Intended Use, Customers)

  • Local and State Departments of Health
  • Provider: Healthcare Institutions (hospitals, long term care, home care, mental health)
  • Vendor: Health Care IT

Benefits

This CDA implementation guide will allow healthcare facilities/providers to communicate common data elements found in multiple states’ reportable condition forms to state and local public health departments in CDA format—an interoperable, industry-standard format.

Implementations/ Case Studies (Actual Users)

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA R2

Links to current projects in development