HL7 CDA Implementation Guide for National Health Care Surveys

This wiki page will support review and feedback for proposed updates to the HL7 Implementation Guide for CDA Release 2: National Health Care Surveys Release 1, DSTU US Realm. This IG consist of two volumes: Volume 1 provides narrative introductory and background material pertinent to this implementation guide, including information on how to understand and use the templates in Volume 2. Volume 2 contains the Clinical Document Architecture (CDA) templates for this guide along with lists of templates, code systems, and value sets used.

Announcements

April 13 - 19, 2015 - HL7 Implementation Guide for CDA R2: National Health Care Surveys R1, DSTU US Realm - Available for Comments

An update has been made to the HL7 Implementation Guide for CDA Release 2: National Health Care Surveys Release 1, DSTU US Realm. This update is available to HL7 members here: [20150416 DRAFT FOR COMMENT CDAR2 IG NHCS R1 D2 1 2015APR.zip] as a DOT release for commenting prior to reconciliation and publication. As a DSTU update, this new version will not go through the usual HL7 balloting process but will use the DSTU Update process with industry review on the HL7 wiki. The full list of changes in this release are documented in the update and can be summarized as follows:

1. Many templates were versioned due to the versioning of contained templates (see the detailed section “Changes from Previous Version” in Volume 2 of this guide for a detailed view of these changes).
2. Document-Level Templates. The document-level templates were refactored to report the survey data by setting of visit (inpatient, outpatient and emergency department) rather than by survey as in the previous release. To reflect this organizational change the names of all three document-level templates have changed:
   1. Inpatient Encounter (NHCS-IP) (V2) (was National Ambulatory Medical Care Survey)
   2. Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V2) (was National Hospital Ambulatory Medical Care Survey - OPD)
   3. Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V2) (was National Hospital Ambulatory Medical Care Survey - ED)
3. Section-Level Templates. Also to reflect the organization change, the related encounters have been split into three sections:
   1. Inpatient Encounters Section
   2. Outpatient Encounters Section (V2) (was Continuity of Care Section)
   3. Emergency Department Encounters Section
4. Diagnosis Section has been renamed Problems Section to allow problems, symptoms etc. rather than constraining to just Diagnoses.
5. Two sections-level templates were retired and their contained templates moved into the Emergency Department Encounters Section:
   1. Hospital Admission Section
   2. Observation Unit Stay Section
6. Entry-Level Templates - The current visit encounter has been split into three specialized encounters:
   1. Current Inpatient Visit
   2. Current Outpatient Visit (V2) (was Current Visit)
   3. Current Emergency Department Visit
7. Ten new entry-level templates were added:
   1. Admission Priority Observation
   2. Current Inpatient Visit (see above)
   3. Current Emergency Department Visit
   4. Specialty Unit Stay Encounter
   5. Follow-Up Attempt Outcome Observation
   6. Point of Origin Observation
   7. Present on Admission Observation
   8. Admission Diagnosis Observation
   9. Patient's Reason for Visit Observation
   10. Procedure Follow-Up Attempt Observation
8. Five new value sets were added:
   1. Follow-up Attempt Outcome (NCHS)
   2. Point of Origin (NCHS)
   3. Priority (Type) of Admission or Visit (NCHS)
   4. Specialty Unit Type (NCHS)
   5. Type of clinic/location (NCHS)

Please note that we have currently included placeholders for codes that have been requested from LOINC and SNOMED. These placeholders will be replaced with proper codes before publication. Likewise, there are dummy value set OIDs for the new value sets. These will also be replaced with real OIDs before publication.

During the one week comment period running from April 13 - 19, 2015, please submit your comments here: NHCS R1 Comments including at least your name, item, existing wording, proposed wording, and comment. Thank you.