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Product CDA R2 IG

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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(http://www.continuaalliance.org), which also provides a certification of compliance to the specification. Continua Health Alliance also 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

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


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, 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


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

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


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


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


Product Name - CDA R2 IG Procedure Note

  • HL7 Implementation Guide for Clinical Document Architecture, Release 2: Procedure Note, Release 1; DSTU ending July 2012

Type

DSTU

Releases

Release 1

Summary

This project is to design a basic procedure note in XML as a constraint on HL7 v3 CDA r2. The note will be basic enough to be used for all procedures and will develop a sample note for endoscopy. To promote standardization and acceptance, it will be closely modeled on the current HL7 CDA Operative Note. CMS and JCAHO requirements, with specialty group input, will be used to choose the contents.

Business Case (Intended Use, Customers)

The audience for this document includes software developers, consultants, and clinicians responsible for implementation of Electronic Health Record (EHR) systems, Personal Health Record (PHR) systems, dictation/transcription systems, and document management applications, and local, regional, and national health information exchange networks that wish to create and/or process CDA documents developed according to this specification.

  • 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 R2

Links to current projects in development

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