Difference between revisions of "Product CDA R2 IG"
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Revision as of 14:40, 14 November 2009
Contents
- 1 Product Brief - CDA R2 Implementation Guides
- 1.1 Product Name - CDA R2 IG HAIRPT
- 1.2 Product Name - CDA R2 IG Consult Note
- 1.3 Product Name - CDA R2 IG H&P
- 1.4 Product Name - CDA R2 IG EHR Interop Profile
- 1.5 Product Name - CDA R2 IG PHM Reports
- 1.6 Product Name - CDA R2 IG Operative Note
- 1.7 Product Name - CDA R2 IG QA (Questionnaire Assessments)
- 1.8 Product Name - CDA R2 IG QRDA
- 1.9 Product Name - CDA R2 IG DIR
- 1.10 Product Name - CCD
- 1.11 Product Name - CDA R2 IG CRS
- 1.12 Product Name - CDA R2 IG Public Health Case Reports
Product Brief - CDA R2 Implementation Guides
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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; 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
- Release 4
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".
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).
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
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
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)
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, 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
- Project Insight ID # 209 IG for CDA R2 - Lvl 3 Personal Healthcare Monitoring Reports, R1
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, 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 (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
- 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 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
- 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
