Difference between revisions of "Product CDA R2 IG"
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=Product Brief - CDA R2 Implementation Guides= | =Product Brief - CDA R2 Implementation Guides= | ||
back to [[Main_Page]]<br/>back to [[Product_List]] | back to [[Main_Page]]<br/>back to [[Product_List]] | ||
| + | |||
| + | Other Common Clinical Document Implementation Guides at [[Product_CDA_R2_IG_CommonClinDocs]] | ||
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| + | <!---====================================================== | ||
| + | | | | ||
| + | | HH HH AAAA IIIIII RRRRRR PPPPPP TTTTTT | | ||
| + | | HH HH AA AA II RR RR PP PP TT | | ||
| + | | HHHHHHH AAAAAA II RRRRR PPPPP TT | | ||
| + | | HH HH AA AA II RR RR PP TT | | ||
| + | | HH HH AA AA IIIIII RR RR PP TT | | ||
| + | | | | ||
| + | =======================================================---> | ||
| + | |||
==Product Name - CDA R2 IG HAIRPT== | ==Product Name - CDA R2 IG HAIRPT== | ||
*HL7 Implementation Guide for CDA Release 2: (NHSN) Healthcare Associated Infection Reports | *HL7 Implementation Guide for CDA Release 2: (NHSN) Healthcare Associated Infection Reports | ||
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===Releases=== | ===Releases=== | ||
| − | *HL7 Implementation Guide for CDA Release 2: Healthcare Associated Infection Reports, Release 1 | + | *HL7 Implementation Guide for CDA Release 2: Healthcare Associated Infection Reports, Release 1 |
*HL7 Implementation Guide for CDA Release 2 - Level 3: Healthcare Associated Infection Reports, Release 2 (US Realm); [http://www.hl7.org/dstucomments/ DSTU] ends Mar 2011 | *HL7 Implementation Guide for CDA Release 2 - Level 3: Healthcare Associated Infection Reports, Release 2 (US Realm); [http://www.hl7.org/dstucomments/ DSTU] ends Mar 2011 | ||
*HL7 Implementation Guide CDA Release 2 - Level 3: Healthcare Associated Infection Reports, Release 3 (US Realm); [http://www.hl7.org/dstucomments/ DSTU] ends October 2011 | *HL7 Implementation Guide CDA Release 2 - Level 3: Healthcare Associated Infection Reports, Release 3 (US Realm); [http://www.hl7.org/dstucomments/ DSTU] ends October 2011 | ||
| − | *Release 4 | + | *HL7 Implementation Guide for CDA Release 2 - Level 3: Healthcare Associated Infection Reports,Release 4 (US Realm);[http://www.hl7.org/dstucomments/ DSTU] ends January 2012 |
| + | *HL7 Implementation Guide CDA Release 2 - Level 3: Healthcare Associated Infection Reports, Release 5 (US Realm);[http://www.hl7.org/dstucomments/ DSTU] ends August 2012 | ||
===Summary=== | ===Summary=== | ||
| − | The purpose of this implementation guide (IG) is to specify a standard for electronic submission of Healthcare Associated Infection (HAI) Reports to the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC). This Draft Standard for Trial Use (DSTU) defines the overall approach and method of electronic submission and develops constraints defining specific HAI report types. | + | The purpose of this implementation guide (IG) is to specify a standard for electronic submission of Healthcare Associated Infection (HAI) Reports to the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC). This Draft Standard for Trial Use (DSTU) defines the overall approach and method of electronic submission and develops constraints defining specific HAI report types. As reports are modified and new report types are defined, additional constraints will be developed and published by CDC and Health Level Seven (HL7). |
| − | + | Throughout this process, CDC remains the authority on NHSN data collection protocols. Occurrences such as specific reportable procedures, even those without complications, and events such as a bloodstream infection, either confirmed by a positive blood culture or supported by a patient‘s clinical symptoms, are reportable to the CDC when health care enterprises choose to participate in NHSN. This specification opens the channel for data submission by all applications compliant with the data coding requirements defined here. | |
| − | |||
Note that participation in the NHSN requires enrollment and filing of reporting plans, which are not defined by this specification. For an overview of NHSN and full information on NHSN participation requirements, see: http://www.cdc.gov/nhsn/ | Note that participation in the NHSN requires enrollment and filing of reporting plans, which are not defined by this specification. For an overview of NHSN and full information on NHSN participation requirements, see: http://www.cdc.gov/nhsn/ | ||
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Future work may develop an overarching set of principles for use of CDA in this context under the project tentatively named "CDA for Reporting". | Future work may develop an overarching set of principles for use of CDA in this context under the project tentatively named "CDA for Reporting". | ||
| − | Future work on HAI reporting will continue to expand the set of forms covered by the specification. In the future, the latest set of any value set referenced in this guide will be made available through CDC‘s Public Health Information Network Vocabulary Access and Distribution System (PHIN VADS; http://phinvads.cdc.gov). | + | Subsequent releases have added new report types and extended the population-summary report to encompass additional data sets. |
| + | |||
| + | Future work on HAI reporting will continue to expand the set of forms covered by the specification. In the future, the latest set of any value set referenced in this guide will be made available through CDC‘s Public Health Information Network Vocabulary Access and Distribution System (PHIN VADS; http://phinvads.cdc.gov). A link to the PHIN VADS vocabularies and other pertinent information are available through the CDC-maintained e-mail list of contacts at organizations interested in or responsible for implementations of CDA for HAI reporting to NHSN. To be added to the list, send a request with your contact information to nhsn@cdc.gov. CDC uses the list for e-mail notifications of changes, including new data requirements. Changes may apply to this IG and to other documents such as business rules that are needed to implement and support CDA for HAI reporting to NHSN. In addition, the CDA tab at the NHSN members’ website (http://www.cdc.gov/nhsn/) will provide access to the current version of this IG. | ||
===Business Case (Intended Use, Customers)=== | ===Business Case (Intended Use, Customers)=== | ||
| + | |||
*Centers for Disease Control and Prevention (CDC), | *Centers for Disease Control and Prevention (CDC), | ||
*National Healthcare Safety Network (NHSN) member Health Care organizations and facilities, | *National Healthcare Safety Network (NHSN) member Health Care organizations and facilities, | ||
| − | *Health Care HIS and Clinical Decision Support (CDS) software vendors | + | *Health Care HIS and Clinical Decision Support (CDS) software vendors<br/> |
| − | + | The audience for this work is all developers of software systems who want to enable their systems for reporting HAI data to the NHSN. | |
===Benefits=== | ===Benefits=== | ||
Data collected in NHSN are used for improving patient safety at the local and national levels. In aggregate, CDC analyzes and publishes surveillance data to estimate and characterize the national burden of healthcare-associated infections. At the local level, the data analysis features of NHSN that are available to participating facilities range from rate tables and graphs to statistical analysis that compares the healthcare facility’s rates with the national aggregate metrics. | Data collected in NHSN are used for improving patient safety at the local and national levels. In aggregate, CDC analyzes and publishes surveillance data to estimate and characterize the national burden of healthcare-associated infections. At the local level, the data analysis features of NHSN that are available to participating facilities range from rate tables and graphs to statistical analysis that compares the healthcare facility’s rates with the national aggregate metrics. | ||
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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=319 Project Insight ID # 319] Implementation Guide for CDA Release 2 Level 3 Healthcare Associated Infection Reports (HAI II) | *[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=319 Project Insight ID # 319] Implementation Guide for CDA Release 2 Level 3 Healthcare Associated Infection Reports (HAI II) | ||
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| + | <!---========================================================================================== | ||
| + | | | | ||
| + | | EEEEEE HH HH RRRRRR IIIIII NN NN TTTTTT EEEEEE RRRRRR OOOOO PPPPPP | | ||
| + | | EE HH HH RR RR II NNN NN TT EE RR RR OO OO PP PP | | ||
| + | | EEEE HHHHHHH RRRRR II NN NN NN TT EEEE RRRRR OO OO PPPPP | | ||
| + | | EE HH HH RR RR II NN NNN TT EE RR RR OO OO PP | | ||
| + | | EEEEEE HH HH RR RR IIIIII NN NN TT EEEEEE RR RR OOOOO PP | | ||
| + | | | | ||
| + | ===========================================================================================---> | ||
==Product Name - CDA R2 IG EHR Interop Profile== | ==Product Name - CDA R2 IG EHR Interop Profile== | ||
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Links to current projects in development | Links to current projects in development | ||
*none | *none | ||
| + | |||
| + | <!---================================ | ||
| + | | | | ||
| + | | PPPPPP HH HH MM MM | | ||
| + | | PP PP HH HH MMM MMM | | ||
| + | | PPPPP HHHHHHH MM MMM MM | | ||
| + | | PP HH HH MM M MM | | ||
| + | | PP HH HH MM MM | | ||
| + | | | | ||
| + | =================================---> | ||
| + | |||
==Product Name - CDA R2 IG PHM Reports== | ==Product Name - CDA R2 IG PHM Reports== | ||
| − | *HL7 Implementation Guide for CDA Release 2: Personal Healthcare Monitoring Report | + | *HL7 Implementation Guide for CDA Release 2: Personal Healthcare Monitoring Report |
===Type=== | ===Type=== | ||
| Line 171: | Line 133: | ||
===Releases=== | ===Releases=== | ||
| − | Release 1 | + | *HL7 Implementation Guide for CDA Release 2: Personal Healthcare Monitoring Report (PHMR), (International Realm) Draft Standard for Trial Use, Release 2; [http://www.hl7.org/dstucomments/ DSTU] (July 2010) |
| + | *HL7 Implementation Guide for CDA Release 2: Personal Healthcare Monitoring Report, Release 1; [http://www.hl7.org/dstucomments/ DSTU] ending Nov 2010 | ||
===Summary=== | ===Summary=== | ||
| − | |||
| − | + | This Draft Standard for Trial Use (DSTU) is an extension of HL7's Continuity of Care Document (CCD) specification. The purpose of this document is to describe constraints on the CDA Header and Body elements for Personal Healthcare Monitoring Report (PHMR) documents mostly containing analysed and raw information of data generated by personal healthcare monitoring devices such as glucometers, BP cuffs, thermometers, weight scales. | |
| + | |||
| + | The PHMR is a document that carries personal healthcare monitoring information. The information is transmitted as notes and as raw data. Notes may be supplied by a disease management service provider. The information may have multiple characteristics, including: | ||
| + | *Representation of measurements captured by devices. | ||
| + | *Representation of notes, summaries, and other kinds of narrative information that may be added by caregivers or by the users themselves. | ||
| + | *Representation of graphs that may be added by intermediary devices that represent trends of users’ health. | ||
| + | |||
| + | A CDA-based format has been chosen to accommodate the wide variety of information available. | ||
| + | |||
| + | Wherever possible, the PHMR reuses templates already set forth by the HL7 Continuity of Care Document (CCD). | ||
| + | |||
===Business Case (Intended Use, Customers)=== | ===Business Case (Intended Use, Customers)=== | ||
| Line 207: | Line 179: | ||
*[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=209 Project Insight ID # 209] IG for CDA R2 - Lvl 3 Personal Healthcare Monitoring Reports, R1 | *[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=209 Project Insight ID # 209] IG for CDA R2 - Lvl 3 Personal Healthcare Monitoring Reports, R1 | ||
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| + | <!---===================== | ||
| + | | | | ||
| + | | QQQQQ AAAA | | ||
| + | | QQ QQ AA AA | | ||
| + | | QQ QQ AAAAAA | | ||
| + | | QQ QQQ AA AA | | ||
| + | | QQQQQ Q AA AA | | ||
| + | | | | ||
| + | ======================---> | ||
| Line 286: | Line 232: | ||
Links to current projects in development: | Links to current projects in development: | ||
*Patient Assessments, Release 1 (Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=381 381]) | *Patient Assessments, Release 1 (Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=381 381]) | ||
| + | |||
| + | |||
| + | <!---======================================= | ||
| + | | | | ||
| + | | QQQQQ RRRRRR DDDDD AAAA | | ||
| + | | QQ QQ RR RR DD DD AA AA | | ||
| + | | QQ QQ RRRRR DD DD AAAAAA | | ||
| + | | QQ QQQ RR RR DD DD AA AA | | ||
| + | | QQQQQ Q RR RR DDDDD AA AA | | ||
| + | | | | ||
| + | ========================================---> | ||
==Product Name - CDA R2 IG QRDA== | ==Product Name - CDA R2 IG QRDA== | ||
| Line 342: | Line 299: | ||
Links to current projects in development | Links to current projects in development | ||
*[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=210 Project Insight ID # 210] Quality Reporting Document Architecture | *[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=210 Project Insight ID # 210] Quality Reporting Document Architecture | ||
| + | |||
| + | <!---============================= | ||
| + | | | | ||
| + | | DDDDD IIIIII RRRRRR | | ||
| + | | DD DD II RR RR | | ||
| + | | DD DD II RRRRR | | ||
| + | | DD DD II RR RR | | ||
| + | | DDDDD IIIIII RR RR | | ||
| + | | | | ||
| + | ==============================---> | ||
| + | |||
==Product Name - CDA R2 IG DIR== | ==Product Name - CDA R2 IG DIR== | ||
| − | *HL7 Implementation Guide for CDA Release 2: Diagnostic Imaging Reports, Release 1 (Informative) | + | *HL7 Implementation Guide for CDA Release 2: Diagnostic Imaging Reports, Release 1; aka Basic Imaging reports in CDA and DICOM, Release 1 (Informative) |
===Type=== | ===Type=== | ||
| Line 353: | Line 321: | ||
===Summary=== | ===Summary=== | ||
| − | This | + | A Diagnostic Imaging Report contains a consulting specialist’s interpretation of image data. It is intended to convey the interpretation to the referring (ordering) physician and become part of the patient’s medical record. The purpose of this Implementation Guide (IG) is to describe constraints on the CDA Header and Body elements for Diagnostic Imaging Reports. It is intended for use in Radiology, Endoscopy, Cardiology, and other imaging specialties. |
| + | |||
| + | This Guide 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 | See http://www.healthstory.com/standards/sec/dir.htm | ||
| Line 365: | Line 335: | ||
*Transcription/Dictation Systems, | *Transcription/Dictation Systems, | ||
*Departmental Systems | *Departmental Systems | ||
| − | * | + | *Imaging Information systems |
| + | |||
| + | Stakeholders include Medical imaging service providers, equipment vendors and information systems implementers. | ||
| + | The audience for this document is software developers and consultants responsible for implementation of Radiology Information Systems, Radiology Reporting Systems, Picture Archiving and Communications Systems (PACS), other image and imaging management systems, and dictation/transcription and document management systems. A secondary audience is developers of specifications for health information networks, both governmental and non-governmental, who may specify use of this Implementation Guide for Diagnostic Imaging Reports. These systems are expected to transmit results of Electronic Health Record (EHR) systems or health information exchange networks as CDA documents created according to this IG. | ||
===Benefits=== | ===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. | 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. | ||
| + | |||
| + | The Implementation Guide allows for creating Diagnostic Imaging Reports in HL7-based information systems and integrating DICOM SR based imaging results, since it is consistent with DICOM Supplement 135 "SR Diagnostic Imaging Report Transformation Guide". | ||
===Implementations/ Case Studies (Actual Users)=== | ===Implementations/ Case Studies (Actual Users)=== | ||
| − | + | *Health Story Proejct (formerly CDA for Common Document Types, or, CDA4CDT) founded by M*Modal, | |
| + | *the American Health Information Management Association (AHIMA), | ||
| + | *and the Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT), now affiliated with the Medical Transcription Industry Association (MTIA). | ||
===Resources=== | ===Resources=== | ||
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Relationship to/ Dependencies on, other standards | Relationship to/ Dependencies on, other standards | ||
| − | *CDA | + | *CDA R2 |
| + | *Digital Imaging and Communications in Medicine (DICOM). This document is being developed jointly by HL7 II WG and DICOM Working Group 20 and will be published by both DICOM and HL7. | ||
Links to current projects in development | Links to current projects in development | ||
*[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=528 Project Insight ID # 528] II coordination with Diagnostic Imaging Report SR/CDA Transformation Guide (DICOM Supplement 135) | *[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=528 Project Insight ID # 528] II coordination with Diagnostic Imaging Report SR/CDA Transformation Guide (DICOM Supplement 135) | ||
| − | + | *Project Insight # 195 (closed) | |
| − | |||
==Product Name - [[Product_CCD|CCD]]== | ==Product Name - [[Product_CCD|CCD]]== | ||
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===Type=== | ===Type=== | ||
Informative | Informative | ||
| + | |||
| + | <!---============================ | ||
| + | | | | ||
| + | | CCCCC RRRRRR SSSSS | | ||
| + | | CC RR RR SS | | ||
| + | | CC RRRRR SSSS | | ||
| + | | CC RR RR SS | | ||
| + | | CCCCC RR RR SSSSS | | ||
| + | | | | ||
| + | =============================---> | ||
| + | |||
==Product Name - CDA R2 IG CRS== | ==Product Name - CDA R2 IG CRS== | ||
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Links to current projects in development | Links to current projects in development | ||
*[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=510 Project Insight ID # 510] Care Record Summary, Release 2: Discharge Summary | *[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=510 Project Insight ID # 510] Care Record Summary, Release 2: Discharge Summary | ||
| + | |||
| + | <!---====================================== | ||
| + | | | | ||
| + | | PPPPPP HH HH CCCCC RRRRRR | | ||
| + | | PP PP HH HH CC RR RR | | ||
| + | | PPPPP HHHHHHH CC RRRRR | | ||
| + | | PP HH HH CC RR RR | | ||
| + | | PP HH HH CCCCC RR RR | | ||
| + | | | | ||
| + | =======================================---> | ||
==Product Name - CDA R2 IG Public Health Case Reports == | ==Product Name - CDA R2 IG Public Health Case Reports == | ||
| Line 467: | Line 465: | ||
*[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=451 Project Insight # 451], Public Health Case Notification | *[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=451 Project Insight # 451], Public Health Case Notification | ||
| + | <!---============================== | ||
| + | | | | ||
| + | | NN NN CCCCC RRRRRR | | ||
| + | | NNN NN CC RR RR | | ||
| + | | NN NN NN CC RRRRR | | ||
| + | | NN NNN CC RR RR | | ||
| + | | NN NN CCCCC RR RR | | ||
| + | | | | ||
| + | ===============================---> | ||
| + | |||
| + | |||
| + | ==Product Name - CDA R2 IG Neonatal Care Reports (NCR) == | ||
| + | *HL7 Implementation Guide for CDA Release 2: Neonatal Care Report (NCR) (US Realm) | ||
| + | |||
| + | ===Type=== | ||
| + | DSTU | ||
| + | |||
| + | ===Releases=== | ||
| + | Release 1 | ||
| + | |||
| + | ===Summary=== | ||
| + | This project is intended to facilitate electronic extraction of a subset of the Children’s Hospitals Neonatal Consortium (CHNC) data set using a standard reporting specification in the form of a Neonatal Care Report (NCR) to support performance improvement and research. CHNC and CHCA, a business alliance of 43 leading children’s hospitals in North America, envision this effort as a building block for more widespread use of the electronic medical record in place of manual data abstraction.. | ||
| + | |||
| + | ===Description=== | ||
| + | |||
| + | This implementation guide is a conformance profile, as described in the Refinement and Localization section of the HL7 Version 3 standards. The base standard for this implementation guide is the HL7 Clinical Document Architecture, Release 2.0. As defined in that document, this implementation guide is both an annotation profile and a localization profile; it does not describe every aspect of CDA. | ||
| + | |||
| + | The CHNC core data set contains around 700 data elements; this Draft Standard for Trial Use (DSTU) addresses a subset of approximately 60 data elements including 37 physiologic and laboratory elements for assessment of illness severity (Acuity indicator data generic organizer) and 21 base data elements found throughout the header and body of the NCR (e.g., name, medical record number, birth weight, and discharge head circumference). Some of the data elements included in the NCR are known to correspond to Vermont Oxford Network (VON); others correspond to data collection sets mapped to national standards such as the Continuity of Care Document (CCD) and the Quality Reporting Document Architecture (QRDA). This effort with an initial portion of the data provides the opportunity to work with the data from the perspective of the underlying model and electronic format and to explore many design issues thoroughly. This initial step ensures that the data set developers and standards community can reach consensus prior to the larger time commitment that would be required to bring the full data set into standard format. | ||
| + | |||
| + | This project supports reusability and ease of data collection through a standard data representation harmonized with work developed through Health Information Technology Expert Panel (HITEP), balloted through Health Level Seven (HL7), and/or recognized by the Health Information Technology Standards Panel (HITSP). | ||
| + | |||
| + | This implementation guide (IG) specifies a standard for electronic submission of NCRs in a Clinical Document Architecture (CDA), Release 2 (R2) format. | ||
| + | |||
| + | |||
| + | ===Business Case (Intended Use, Customers)=== | ||
| + | The audience for this document includes software developers and implementers who wish to develop reporting capabilities within their electronic health record (EHR and Pediatric EHR systems), and developers and analysts in receiving institutions who wish to process CDA NCR documents created according to this specification. The intended audience also includes neonatal experts and other children’s hospital providers. | ||
| + | |||
| + | ===Benefits=== | ||
| + | Through the systematic collection and analyses of clinical data on infants admitted to children’s hospital NICUs, CHNC expects to spearhead benchmarking, quality improvement, and research initiatives that have not previously been possible in their patient population. | ||
| + | |||
| + | ===Implementations/ Case Studies (Actual Users)=== | ||
| + | |||
| + | ===Resources=== | ||
| + | |||
| + | Work Groups | ||
| + | *[http://www.hl7.org/Special/committees/pedsdata/index.cfm Child Health] | ||
| + | *[http://www.hl7.org/Special/committees/structure/index.cfm Structured Documents] | ||
| + | |||
| + | Relationship to/ Dependencies on, other standards | ||
| + | *CDA R2 | ||
| + | |||
| + | Links to current projects in development | ||
| + | *[http://www.hl7.org/Special/committees/pedsdata/index.cfm Child Health] | ||
| + | *[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=567 Project Insight # 567], Implementation Guide for CDA Release 2 - Level 3, Neonatal Care Report | ||
| + | |||
| + | <!---============================================================== | ||
| + | | | | ||
| + | | UU UU NN NN SSSSS TTTTTT RRRRRR UU UU CCCCC | | ||
| + | | UU UU NNN NN SS TT RR RR UU UU CC | | ||
| + | | UU UU NN NN NN SSSS TT RRRRR UU UU CC | | ||
| + | | UU UU NN NNN SS TT RR RR UU UU CC | | ||
| + | | UUUU NN NN SSSSS TT RR RR UUUU CCCCC | | ||
| + | | | | ||
| + | ===============================================================---> | ||
| − | |||
| − | |||
| + | |||
| + | ==Product Name - CDA R2 IG Unstructured Documents == | ||
| + | *HL7 Implementation Guide for Clinical Document Architecture, Release 2: Unstructured Documents, (Universal Realm) Release 1 | ||
===Type=== | ===Type=== | ||
| − | + | DSTU balloted 2010Jan | |
===Releases=== | ===Releases=== | ||
| Line 478: | Line 541: | ||
===Summary=== | ===Summary=== | ||
| − | + | This Implementation Guide provides consistent guidance for sending/receiving unstructured clinical documents including images, scanned documents, faxed and word processor output. This Implementation Guide describes constraints on use of the Clinical Document Architecture (CDA) header and body elements for an Unstructured Document. | |
| + | |||
| + | In many environments much of the patient record is still captured in an unstructured format that is encapsulated within an image file, or as unstructured text in an electronic file such as a word processing or Portable Document Format (PDF) documents. | ||
| + | |||
| + | ===Description=== | ||
| + | |||
| + | This implementation guide is a conformance profile, as described in the Refinement and Localization section of the HL7 Version 3 standards. The base standard for this implementation guide is the HL7 Clinical Document Architecture, Release 2.0. As defined in that document, this implementation guide is both an annotation profile and a localization profile. CDA R2 is not fully described in this guide, so implementers must be familiar with the requirements of the base specification. This guide addresses only Level 1 constraints because of the nature and purpose of this guide: additional levels of coding are not applicable since they require the use of a structuredBody, which this implementation guide prohibits. | ||
| + | |||
| + | |||
| + | The approach taken in the development of this specification was to review existing draft and final specifications or implementation guides for similar artifacts in the U.S.: | ||
| + | *Clinical LOINC® document and section codes | ||
| + | *Health Information Technology Standards Panel (HITSP) Constructs, including the Encounter Document Using IHE Medical Summary (XDS-MS) Component (C48) | ||
| + | *HL7 Clinical Document Architecture, Release 2 Normative Web Edition, 2005 | ||
| + | *Integrating the Healthcare Enterprise (IHE) Profiles, including the content profiles within Patient Care Coordination (PCC) and specifically the IHE IT Infrastructure Technical Framework Volume 3 (ITI TF-3) Cross-Transaction Specifications and Content Specifications Revision 6.0. (See Relationship to IHE's XDS-SD on the relationship of this guide to XDS-SD.) | ||
| + | *Non-CDA sample documents supplied by participating providers and vendors | ||
| + | |||
| + | |||
| + | This guide is not intended to be a replacement for IHE’s XDS-SD (Cross-Transaction Specifications and Content Specifications, Scanned Documents Module) profile. Rather, it serves a more generic use case. XDS-SD is specifically for scanned documents, and limits content to PDF-A or text. This Unstructured Documents implementation guide is applicable not only for scanned documents in non-PDF formats, but also for clinical documents produced through word processing applications, etc. | ||
===Business Case (Intended Use, Customers)=== | ===Business Case (Intended Use, Customers)=== | ||
| − | + | Providers and Clinicians, Vendor: Health Care IT, Provider: Healthcare Institutions; EHR Vendors, PHR Vendors, Vendor: Dictation/Transcription Systems; Health Information Exchange networks | |
| − | + | ||
| − | |||
===Benefits=== | ===Benefits=== | ||
| − | + | In many environments much of the patient record is still captured in an unstructured format that is encapsulated within an image file or as unstructured text in an electronic file such as a word processing or Portable Document Format (PDF) documents. | |
| + | |||
| + | There is a need to raise the level of interoperability for these documents to provide full access to the longitudinal patient record across a continuum of care. Until this gap is addressed, image and multi-media files will continue to be a portion of the patient record that remains difficult to access and share with all participants in a patient’s care. (See Relationship to IHE's XDS-SD on the relationship of this guide to IHE’s XDS-SD.) | ||
===Implementations/ Case Studies (Actual Users)=== | ===Implementations/ Case Studies (Actual Users)=== | ||
| − | + | ||
| − | + | This Draft Standard for Trial Use (DSTU) was produced and developed through the Health Story Project. The project was initiated by the Association for Healthcare Documentation Integrity (AHDI), Medical Transcription Industry Association (MTIA), American Health Information Management Association (AHIMA), and M*Modal and is being managed by Alschuler Associates, LLC and Optimal Accords, LLC. | |
| − | + | ||
===Resources=== | ===Resources=== | ||
| + | |||
| + | Education: | ||
| + | *http://wiki.hl7.org/index.php?title=Health_Story:_Unstructured_Documents | ||
| + | *www.healthstory.com | ||
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] | ||
Relationship to/ Dependencies on, other standards | Relationship to/ Dependencies on, other standards | ||
*CDA R2 | *CDA R2 | ||
| − | |||
Links to current projects in development | Links to current projects in development | ||
| − | *Project Insight # | + | *[http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=569 Project Insight # 569], Implementation Guide for CDA Release 2 - Unstructured Documents |
| + | |||
| + | |||
| + | [[category:Products]] | ||
| + | == External Links == | ||
| + | [http://virilityenhancement.net Vimax] | ||
Latest revision as of 07:18, 23 June 2011
Contents
- 1 Product Brief - CDA R2 Implementation Guides
- 1.1 Product Name - CDA R2 IG HAIRPT
- 1.2 Product Name - CDA R2 IG EHR Interop Profile
- 1.3 Product Name - CDA R2 IG PHM Reports
- 1.4 Product Name - CDA R2 IG QA (Questionnaire Assessments)
- 1.5 Product Name - CDA R2 IG QRDA
- 1.6 Product Name - CDA R2 IG DIR
- 1.7 Product Name - CCD
- 1.8 Product Name - CDA R2 IG CRS
- 1.9 Product Name - CDA R2 IG Public Health Case Reports
- 1.10 Product Name - CDA R2 IG Neonatal Care Reports (NCR)
- 1.11 Product Name - CDA R2 IG Unstructured Documents
- 1.12 External Links
Product Brief - CDA R2 Implementation Guides
back to Main_Page
back to Product_List
Other Common Clinical Document Implementation Guides at Product_CDA_R2_IG_CommonClinDocs
Product Name - CDA R2 IG HAIRPT
- HL7 Implementation Guide for CDA Release 2: (NHSN) Healthcare Associated Infection Reports
Type
DSTU
Releases
- HL7 Implementation Guide for CDA Release 2: Healthcare Associated Infection Reports, Release 1
- 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
- HL7 Implementation Guide for CDA Release 2 - Level 3: Healthcare Associated Infection Reports,Release 4 (US Realm);DSTU ends January 2012
- HL7 Implementation Guide CDA Release 2 - Level 3: Healthcare Associated Infection Reports, Release 5 (US Realm);DSTU ends August 2012
Summary
The purpose of this implementation guide (IG) is to specify a standard for electronic submission of Healthcare Associated Infection (HAI) Reports to the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC). This Draft Standard for Trial Use (DSTU) defines the overall approach and method of electronic submission and develops constraints defining specific HAI report types. As reports are modified and new report types are defined, additional constraints will be developed and published by CDC and Health Level Seven (HL7).
Throughout this process, CDC remains the authority on NHSN data collection protocols. Occurrences such as specific reportable procedures, even those without complications, and events such as a bloodstream infection, either confirmed by a positive blood culture or supported by a patient‘s clinical symptoms, are reportable to the CDC when health care enterprises choose to participate in NHSN. This specification opens the channel for data submission by all applications compliant with the data coding requirements defined here.
Note that participation in the NHSN requires enrollment and filing of reporting plans, which are not defined by this specification. For an overview of NHSN and full information on NHSN participation requirements, see: http://www.cdc.gov/nhsn/
Note that provisions of the Public Health Service Act protect all data reported to NHSN from discovery through the Freedom Of Information Act.
This implementation was the first use of the CDA R2 for public health reporting. Since the initial ballot in spring of 2007, additional use cases have been identified and a CDA Implementation Guide for Public Health Case Reports (PHCR) has been developed.
Future work may develop an overarching set of principles for use of CDA in this context under the project tentatively named "CDA for Reporting".
Subsequent releases have added new report types and extended the population-summary report to encompass additional data sets.
Future work on HAI reporting will continue to expand the set of forms covered by the specification. In the future, the latest set of any value set referenced in this guide will be made available through CDC‘s Public Health Information Network Vocabulary Access and Distribution System (PHIN VADS; http://phinvads.cdc.gov). A link to the PHIN VADS vocabularies and other pertinent information are available through the CDC-maintained e-mail list of contacts at organizations interested in or responsible for implementations of CDA for HAI reporting to NHSN. To be added to the list, send a request with your contact information to nhsn@cdc.gov. CDC uses the list for e-mail notifications of changes, including new data requirements. Changes may apply to this IG and to other documents such as business rules that are needed to implement and support CDA for HAI reporting to NHSN. In addition, the CDA tab at the NHSN members’ website (http://www.cdc.gov/nhsn/) will provide access to the current version of this IG.
Business Case (Intended Use, Customers)
- Centers for Disease Control and Prevention (CDC),
- National Healthcare Safety Network (NHSN) member Health Care organizations and facilities,
- Health Care HIS and Clinical Decision Support (CDS) software vendors
The audience for this work is all developers of software systems who want to enable their systems for reporting HAI data to the NHSN.
Benefits
Data collected in NHSN are used for improving patient safety at the local and national levels. In aggregate, CDC analyzes and publishes surveillance data to estimate and characterize the national burden of healthcare-associated infections. At the local level, the data analysis features of NHSN that are available to participating facilities range from rate tables and graphs to statistical analysis that compares the healthcare facility’s rates with the national aggregate metrics.
Implementations/ Case Studies (Actual Users)
The use of the CDA for NHSN HAI Reports DSTU (based on Release 2) officially went into production use on October 15, 2009. Since that time, multiple vendors and institutions have begun submitting HAI data for Blood Stream Infection (BSI), Surgical Site Infection (SSI) and Procedure and ICU denominator events directly to the CDC using this standard. The vendors who participated in the 2007-2008 pilot activities for Bloodstream and Surgical Site Infection reporting include MedMined™ services from Cardinal Health, EpiQuest, ICPA, Premier, TheraDoc, and Vecna Technologies.
Resources
Work Groups
Relationship to/ Dependencies on, other standards
- CDA R2
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 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)
The link to the Implementation Guide for CDA Release 2: Reference Profile for EHR Interoperability DSTU is at http://www.hl7.org/documentcenter/ballots/2008JAN/support/CDAR2_EHR_Interop_Profile_DSTU_2008SEP.zip
Interested parties are invited to download these DSTUs, and provide comments and feedback on the standards and their implementation at http://www.hl7.org/dstucomments/.
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
Type
DSTU
Releases
- HL7 Implementation Guide for CDA Release 2: Personal Healthcare Monitoring Report (PHMR), (International Realm) Draft Standard for Trial Use, Release 2; DSTU (July 2010)
- HL7 Implementation Guide for CDA Release 2: Personal Healthcare Monitoring Report, Release 1; DSTU ending Nov 2010
Summary
This Draft Standard for Trial Use (DSTU) is an extension of HL7's Continuity of Care Document (CCD) specification. The purpose of this document is to describe constraints on the CDA Header and Body elements for Personal Healthcare Monitoring Report (PHMR) documents mostly containing analysed and raw information of data generated by personal healthcare monitoring devices such as glucometers, BP cuffs, thermometers, weight scales.
The PHMR is a document that carries personal healthcare monitoring information. The information is transmitted as notes and as raw data. Notes may be supplied by a disease management service provider. The information may have multiple characteristics, including:
- Representation of measurements captured by devices.
- Representation of notes, summaries, and other kinds of narrative information that may be added by caregivers or by the users themselves.
- Representation of graphs that may be added by intermediary devices that represent trends of users’ health.
A CDA-based format has been chosen to accommodate the wide variety of information available.
Wherever possible, the PHMR reuses templates already set forth by the HL7 Continuity of Care Document (CCD).
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
The specification will foster the development of automated interface between remote data monitoring services and EHR systems.
The Continua Health Alliance provides an implementation guide that includes guidelines for IHE XDS based transport of the document.
Continua Health Alliance also offers a certification process for data source compliance the interface. This will enable high interoperability with the standard specification.
Implementations/ Case Studies (Actual Users)
The major implementation was performed by IBM. IBM's WebSphere Sensor Events platform collects, processes, and routes medical device and sensor data. We have used Personal Healthcare Monitoring Report (PHM) document format, in the context of Continua HRN interface, to achieve data exchange from WebSphere Sensor Events to various applications, for example chronic disease management application vendor products. IBM also used the HRN interface to achieve data exchange from WebSphere Sensor Events into a health information exchange.
In addition there were several prototypes developed within the continua health alliance scope by NHS, Roche, Phillips, Lamprey Networks and others.
Continua Health Alliance also implemented a test tool for certification of compliance to the specification.
Resources
Work Groups
Presentations - Available from Continua Health Alliance
Relationship to/ Dependencies on, other standards
- CDA
Links to current projects in development
- Project Insight ID # 209 IG for CDA R2 - Lvl 3 Personal Healthcare Monitoring Reports, R1
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, ending April 2011
Summary
The purpose of this Implementation Guide (IG) is to specify a standard for electronic submission for CDA Questionnaire Assessments that will allow health care facilities and providers to communicate reports in an interoperable, industry-standard format. Questionnaire Assessments contain multiple questions with specific answers. These questions typically assess a variety of clinical domains including the patient’s functional and disability status and may include assessment scales to quantify the assessment. Frequently these types of assessments are used in long-term care settings (e.g., nursing facilities, home health agencies, and residential care facilities) or in outpatient settings with patients who have certain chronic physical and mental health conditions.
Description
- Implementation Guide for CDA Release 2: CDA Framework for Questionnaire Assessments (Universal Realm) describes constraints on CDA Release 2 to provide a framework for patient Questionnaire Assessments that can be used internationally.
- CDA Representation of the Minimum Data Set (MDS) Questionnaire Assessment (U.S. Realm) adds further constraints to the constraints outlined for the Universal Realm to define a specific questionnaire commonly used in the United States. These constraints can also be applied to other assessment questionnaires used in the United States, such as the Outcome and ASsessment Information Set (OASIS).
- Questionnaire Assessments are question-based instruments that have psychometric properties. Psychometric properties are elements that contribute to the statistical adequacy of an instrument in terms of reliability, validity, and internal consistency.
Business Case (Intended Use, Customers)
Software systems developers and implementers,
- Government agencies,
- Health care facilities and providers,
- Personal health care records.
Benefits
Enables systems for reporting patient Questionnaire Assessments in an interoperable, industry-standard format to government agencies, between health care facilities and providers, or to personal health care records.
Implementations/ Case Studies (Actual Users)
DSTU implementers:
- ACTS Retirement-Life Communities, Inc. (actslife.org)
- Golden Living, Inc. (goldenliving.com)
Resources
Work Groups
Relationship to/ Dependencies on, other standards
- CDA R2
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, DSTU ending April 2011
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 implementation guide offers specifications for communicating quality measure definitions to, and reporting quality data from, electronic health records.
Description
This implementation guide 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)
- Stakeholder: US Clinical and Public Health Laboratories, Local and State Departments of Health
- Stakeholder: Quality Reporting Agencies
- Stakeholder: Standards Development Organizations (SDOs)
- Stakeholder: Regulatory Agency
- Stakeholder: Immunization Registries
- Provider: Healthcare Institutions (hospitals, long term care, home care, mental health)
- Provider: Medical Imaging Service
- Provider: Emergency Services
- Provider: Molecular Diagnostic/ Genetic Testing Laboratories
- Vendor: Lab
- Vendor: HIS
- Vendor: Clinical Decision Support Systems
- Vendor: Pharmaceutical
- Vendor: Health Care IT
- Vendor: EHR, PHR
- Payers
Benefits
This implementation guide 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.
QRDA is referenced as a standard in the HITSP Quality Interoperability Specification (IS06), labeled component C105, at http://www.hitsp.org/ConstructSet_Details.aspx?&PrefixAlpha=4&PrefixNumeric=105.
Implementations/ Case Studies (Actual Users)
- CMS Physician Quality Reporting Initiative,
- Indiana Health Information Exchange
- Long Beach Network for Health/New York eHealth Collaborative
Resources
Work Groups
Presentations
Relationship to/ Dependencies on, other standards
- CDA
Links to current projects in development
- Project Insight ID # 210 Quality Reporting Document Architecture
Product Name - CDA R2 IG DIR
- HL7 Implementation Guide for CDA Release 2: Diagnostic Imaging Reports, Release 1; aka Basic Imaging reports in CDA and DICOM, Release 1 (Informative)
Type
Informative
Releases
Release 1
Summary
A Diagnostic Imaging Report contains a consulting specialist’s interpretation of image data. It is intended to convey the interpretation to the referring (ordering) physician and become part of the patient’s medical record. The purpose of this Implementation Guide (IG) is to describe constraints on the CDA Header and Body elements for Diagnostic Imaging Reports. It is intended for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.
This Guide 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
- Imaging Information systems
Stakeholders include Medical imaging service providers, equipment vendors and information systems implementers. The audience for this document is software developers and consultants responsible for implementation of Radiology Information Systems, Radiology Reporting Systems, Picture Archiving and Communications Systems (PACS), other image and imaging management systems, and dictation/transcription and document management systems. A secondary audience is developers of specifications for health information networks, both governmental and non-governmental, who may specify use of this Implementation Guide for Diagnostic Imaging Reports. These systems are expected to transmit results of Electronic Health Record (EHR) systems or health information exchange networks as CDA documents created according to this IG.
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.
The Implementation Guide allows for creating Diagnostic Imaging Reports in HL7-based information systems and integrating DICOM SR based imaging results, since it is consistent with DICOM Supplement 135 "SR Diagnostic Imaging Report Transformation Guide".
Implementations/ Case Studies (Actual Users)
- Health Story Proejct (formerly CDA for Common Document Types, or, CDA4CDT) founded by M*Modal,
- the American Health Information Management Association (AHIMA),
- and the Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT), now affiliated with the Medical Transcription Industry Association (MTIA).
Resources
Work Groups
Relationship to/ Dependencies on, other standards
- CDA R2
- Digital Imaging and Communications in Medicine (DICOM). This document is being developed jointly by HL7 II WG and DICOM Working Group 20 and will be published by both DICOM and HL7.
Links to current projects in development
- Project Insight ID # 528 II coordination with Diagnostic Imaging Report SR/CDA Transformation Guide (DICOM Supplement 135)
- Project Insight # 195 (closed)
Product Name - CCD
- HL7 Implementation Guide for CDA Release 2: HL7/ASTM Continuity of Care Document (Informative)
Type
Informative
Product Name - CDA R2 IG CRS
- HL7 Implementation Guide for CDA Release 2: Level 1, 2 and 3 Care Record Summary (US Realm)(Informative)
Type
DSTU
Releases
Release 1 (Informative) Release 2, DSTU ending November 2011
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
The HL7 Implementation Guide for CDA Release 2: Care Record Summary: Discharge Summary was supported by the Health Story Project (www.healthstory.com), a non profit industry collaborative working to integrate narrative notes and electronic medical records.
Business Case (Intended Use, Customers)
Benefits
The specifcation provides disparate hospital systems a standard format to report back to a primary care provider or other parties interested in the patient's hospital care.
Implementations/ Case Studies (Actual Users)
Resources
Work Groups
Relationship to/ Dependencies on, other standards
- CDA R2
Links to current projects in development
- Project Insight ID # 510 Care Record Summary, Release 2: Discharge Summary
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
- Project Insight # 451, Public Health Case Notification
Product Name - CDA R2 IG Neonatal Care Reports (NCR)
- HL7 Implementation Guide for CDA Release 2: Neonatal Care Report (NCR) (US Realm)
Type
DSTU
Releases
Release 1
Summary
This project is intended to facilitate electronic extraction of a subset of the Children’s Hospitals Neonatal Consortium (CHNC) data set using a standard reporting specification in the form of a Neonatal Care Report (NCR) to support performance improvement and research. CHNC and CHCA, a business alliance of 43 leading children’s hospitals in North America, envision this effort as a building block for more widespread use of the electronic medical record in place of manual data abstraction..
Description
This implementation guide is a conformance profile, as described in the Refinement and Localization section of the HL7 Version 3 standards. The base standard for this implementation guide is the HL7 Clinical Document Architecture, Release 2.0. As defined in that document, this implementation guide is both an annotation profile and a localization profile; it does not describe every aspect of CDA.
The CHNC core data set contains around 700 data elements; this Draft Standard for Trial Use (DSTU) addresses a subset of approximately 60 data elements including 37 physiologic and laboratory elements for assessment of illness severity (Acuity indicator data generic organizer) and 21 base data elements found throughout the header and body of the NCR (e.g., name, medical record number, birth weight, and discharge head circumference). Some of the data elements included in the NCR are known to correspond to Vermont Oxford Network (VON); others correspond to data collection sets mapped to national standards such as the Continuity of Care Document (CCD) and the Quality Reporting Document Architecture (QRDA). This effort with an initial portion of the data provides the opportunity to work with the data from the perspective of the underlying model and electronic format and to explore many design issues thoroughly. This initial step ensures that the data set developers and standards community can reach consensus prior to the larger time commitment that would be required to bring the full data set into standard format.
This project supports reusability and ease of data collection through a standard data representation harmonized with work developed through Health Information Technology Expert Panel (HITEP), balloted through Health Level Seven (HL7), and/or recognized by the Health Information Technology Standards Panel (HITSP).
This implementation guide (IG) specifies a standard for electronic submission of NCRs in a Clinical Document Architecture (CDA), Release 2 (R2) format.
Business Case (Intended Use, Customers)
The audience for this document includes software developers and implementers who wish to develop reporting capabilities within their electronic health record (EHR and Pediatric EHR systems), and developers and analysts in receiving institutions who wish to process CDA NCR documents created according to this specification. The intended audience also includes neonatal experts and other children’s hospital providers.
Benefits
Through the systematic collection and analyses of clinical data on infants admitted to children’s hospital NICUs, CHNC expects to spearhead benchmarking, quality improvement, and research initiatives that have not previously been possible in their patient population.
Implementations/ Case Studies (Actual Users)
Resources
Work Groups
Relationship to/ Dependencies on, other standards
- CDA R2
Links to current projects in development
- Child Health
- Project Insight # 567, Implementation Guide for CDA Release 2 - Level 3, Neonatal Care Report
Product Name - CDA R2 IG Unstructured Documents
- HL7 Implementation Guide for Clinical Document Architecture, Release 2: Unstructured Documents, (Universal Realm) Release 1
Type
DSTU balloted 2010Jan
Releases
Release 1
Summary
This Implementation Guide provides consistent guidance for sending/receiving unstructured clinical documents including images, scanned documents, faxed and word processor output. This Implementation Guide describes constraints on use of the Clinical Document Architecture (CDA) header and body elements for an Unstructured Document.
In many environments much of the patient record is still captured in an unstructured format that is encapsulated within an image file, or as unstructured text in an electronic file such as a word processing or Portable Document Format (PDF) documents.
Description
This implementation guide is a conformance profile, as described in the Refinement and Localization section of the HL7 Version 3 standards. The base standard for this implementation guide is the HL7 Clinical Document Architecture, Release 2.0. As defined in that document, this implementation guide is both an annotation profile and a localization profile. CDA R2 is not fully described in this guide, so implementers must be familiar with the requirements of the base specification. This guide addresses only Level 1 constraints because of the nature and purpose of this guide: additional levels of coding are not applicable since they require the use of a structuredBody, which this implementation guide prohibits.
The approach taken in the development of this specification was to review existing draft and final specifications or implementation guides for similar artifacts in the U.S.:
- Clinical LOINC® document and section codes
- Health Information Technology Standards Panel (HITSP) Constructs, including the Encounter Document Using IHE Medical Summary (XDS-MS) Component (C48)
- HL7 Clinical Document Architecture, Release 2 Normative Web Edition, 2005
- Integrating the Healthcare Enterprise (IHE) Profiles, including the content profiles within Patient Care Coordination (PCC) and specifically the IHE IT Infrastructure Technical Framework Volume 3 (ITI TF-3) Cross-Transaction Specifications and Content Specifications Revision 6.0. (See Relationship to IHE's XDS-SD on the relationship of this guide to XDS-SD.)
- Non-CDA sample documents supplied by participating providers and vendors
This guide is not intended to be a replacement for IHE’s XDS-SD (Cross-Transaction Specifications and Content Specifications, Scanned Documents Module) profile. Rather, it serves a more generic use case. XDS-SD is specifically for scanned documents, and limits content to PDF-A or text. This Unstructured Documents implementation guide is applicable not only for scanned documents in non-PDF formats, but also for clinical documents produced through word processing applications, etc.
Business Case (Intended Use, Customers)
Providers and Clinicians, Vendor: Health Care IT, Provider: Healthcare Institutions; EHR Vendors, PHR Vendors, Vendor: Dictation/Transcription Systems; Health Information Exchange networks
Benefits
In many environments much of the patient record is still captured in an unstructured format that is encapsulated within an image file or as unstructured text in an electronic file such as a word processing or Portable Document Format (PDF) documents.
There is a need to raise the level of interoperability for these documents to provide full access to the longitudinal patient record across a continuum of care. Until this gap is addressed, image and multi-media files will continue to be a portion of the patient record that remains difficult to access and share with all participants in a patient’s care. (See Relationship to IHE's XDS-SD on the relationship of this guide to IHE’s XDS-SD.)
Implementations/ Case Studies (Actual Users)
This Draft Standard for Trial Use (DSTU) was produced and developed through the Health Story Project. The project was initiated by the Association for Healthcare Documentation Integrity (AHDI), Medical Transcription Industry Association (MTIA), American Health Information Management Association (AHIMA), and M*Modal and is being managed by Alschuler Associates, LLC and Optimal Accords, LLC.
Resources
Education:
- http://wiki.hl7.org/index.php?title=Health_Story:_Unstructured_Documents
- www.healthstory.com
Work Groups
Relationship to/ Dependencies on, other standards
- CDA R2
Links to current projects in development
- Project Insight # 569, Implementation Guide for CDA Release 2 - Unstructured Documents
