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Patient Authored Documents Informative Document

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Project Details

Overview

In the “era of patient empowerment”, we want to define a specification for patient-authored clinical documents. Medical practices are looking for ways to allow patients to electronically complete certain tasks online such as filling out registration forms, health history forms, consenting to certain practice policies, and other types of clinical documents yet to be defined. As electronic document interchange increases, we see a growing need to communicate documents created by patients (including those needed by providers and/or those document types defined by patients). Often, this is done through a secure web interface controlled by the patient such as a patient portal or a personal health record. As more and more practices incorporate EMR technology into their practice workflow, they want to be able to import patient provided structured information into their EMR’s. This is being driven by the need to meet Meaning Use 2 requirements for patient engagement as well as other needs to reduce manual processes managing patient-provided data.

The HL7 CDA Consolidation Documents types only address provider-initiated documents and do not incorporate guidance for patient-generated documents. It is necessary to create a new implementation guide describing how to incorporate patient-generated input. In many cases, existing templates within the current Consolidation Template Library can be re-used with minimal modification.

The scope of this project is to create an implementation guide, which will guide the users on using the elements of the C-CDA consolidation header for patient authored documents. New CDA document types for patient authored documents is NOT in scope for this project. The document described by this guide could be characterized as a parallel to Consolidated CDA, that would ultimately cover specific patient-authored document types. We anticipate that Consolidated CDA templates will be heavily reused. If required, we may extend the project scope or introduce another project for defining an implementation guide for a set of patient authored document types.

HL7 Project Scope

  • HL7 Project Scope Statement (approved June 07, 2012 by SDWG, pending review/approval by Steering Division and TSC):

http://wiki.hl7.org/images/4/4c/HL7_Project_Scope_Statement_v2012_Patient_authored_notes.docx

Subgroup Members

  • Virinder Batra, Intuit Health
  • Lisa Nelson, Life Over Time Solutions
  • Elaine Ayres, Academy of Nutrition and Dietetics, National Institutes of Health
  • Catherine Welsh, St. Jude Children's Research Hospital
  • Bob Dolin, Lantana Consulting
  • Emma Jones, Allscripts
  • Shawn Meyers, Healthwise
  • Brian Scheller, Healthwise
  • Chris Schultz, Child Health & Development Interactive System (Chadis)
  • Gordon Raup, Datuit
  • David Tao, Siemens Healthcare
  • Jessi Formoe, Intuit Health
  • Leslie Kelly Hall, Healthwise
  • Kevin Harbauer,Healthwise
  • Allen Traylor, Child Health & Development Interactive System (Chadis)
  • Stephen Chu, National e-health Transition Authority (Nehta), Australia,
  • Vin Sekar, National e-health Transition Authority (Nehta), Australia

Meeting Logistics

Meeting Schedule

Meeting Agendas

Meeting Minutes

Deliverable Timelines

  • Notice of ballot in September 2012
  • Word document (Implementation Guide) by Dec 1, 2012
  • Ballot in WG Meeting in Phoenix January, 2013

Use Cases

Discussion on Document LOINC Code

Discussion on Header Attributes

Discussion on Value Sets

  • Summary of Value Sets used and needed: File:Value Set Summary 20121026.xlsx
  • Files to be reviewed for completeness and applicability
  • Code System: HL7 RoleCode 2.16.840.1.113883.5.111
  • RoleCode Value Set: PersonalRelationshipRoleType 2.16.840.1.113883.1.11.19563: File:PersonalRelationshipRoleType.docx NOTE: Request for new code "SELF" has been made to support this PAN IG
  • RoleCode Value Set: ResponsibleParty 2.16.840.1.113883.1.11.19830: File:ResponsibleParty.docx
  • Code System: HL7 ParticipationType 2.16.840.1.113883.5.90
  • ParticipationType Value Set: ParticipationType 2.16.840.1.113883.1.11.10901
  • CodeSystem: NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101

Implementation Guide


Implementation Guide Components

Other Documents

Open Issues & Tasks

  • When will the Patient Authored CDA documents be created; What are the trigger points;
    • These will be application workflow dependent
    • The CDA document will define the content, NOT the workflow or the application business logic
  • Looking thru the errata of the C-CDA document & reconciling with changes in the draft IG
  • Work with the Vocabulary group on the new / changed value sets
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