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Difference between revisions of "201805 Clinical Notes Track"

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===Background For Clinical Notes===
 
===Background For Clinical Notes===
  
This track is based upon [https://github.com/argonautproject/clinicalnotes/wiki Argonaut Clinical Notes Profile]. It is based upon the FHIR 3.0.1 Standard.
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Clinical Notes are a critical element for clinicians to communicate the status of a patient to another caregiver. These notes occur in various formats, such as: unstructured (XHTML, ASCII), fixed file format (PDF, RTF), or structured (HL7 CDA/FHIR Composition). Common clinical notes as identified by the Argonaut participants:
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* Discharge documentation (8648-8 and/or 18842-5)
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* Consultation (11488-4)
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* Imaging narrative (18726-0)
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* Lab/path narrative
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* History & Physical (34117-2)
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* Progress note
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* Procedures note (28570-0)
  
<!-- What will be the actions performed by participants? -->
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Many others …Transfer note, Referral note, Surgical Operation note, Nurse note. This track will explore a limited set with the intention it will cover other note types..
  
For additional background, review the [http://build.fhir.org/documentreference.html DocumentReference] resource.
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The current FHIR STU3, and ballot version of FHIR STU4, does not include concrete guidance for exchanging notes. Various work groups within HL7 have considered DocumentReference, Observation, Composition, DiagnosticReport, or a brand new resource. After discussions at the January 2018 during the Connectathon, and subsequently in the HL7 working group Patient Care the initial, the consensus was to proceed with a connectathon track to test out a few different Resources. This track will test use of the DocumentReference and DiagnosticReport to exchange Clinical Notes. A draft [https://argonautproject.github.io/clinicalnotes/ Argonaut Clinical Notes Profile] will be available middle of April. It is based upon the FHIR 3.0.1 Standard.
  
 
==Submitting WG/Project/Implementer Group==
 
==Submitting WG/Project/Implementer Group==

Revision as of 13:16, 9 April 2018

Return to May 2018 Proposals

Zulip Chat stream for this Track is here and issues can be posted here

Background For Clinical Notes

Clinical Notes are a critical element for clinicians to communicate the status of a patient to another caregiver. These notes occur in various formats, such as: unstructured (XHTML, ASCII), fixed file format (PDF, RTF), or structured (HL7 CDA/FHIR Composition). Common clinical notes as identified by the Argonaut participants:

  • Discharge documentation (8648-8 and/or 18842-5)
  • Consultation (11488-4)
  • Imaging narrative (18726-0)
  • Lab/path narrative
  • History & Physical (34117-2)
  • Progress note
  • Procedures note (28570-0)

Many others …Transfer note, Referral note, Surgical Operation note, Nurse note. This track will explore a limited set with the intention it will cover other note types..

The current FHIR STU3, and ballot version of FHIR STU4, does not include concrete guidance for exchanging notes. Various work groups within HL7 have considered DocumentReference, Observation, Composition, DiagnosticReport, or a brand new resource. After discussions at the January 2018 during the Connectathon, and subsequently in the HL7 working group Patient Care the initial, the consensus was to proceed with a connectathon track to test out a few different Resources. This track will test use of the DocumentReference and DiagnosticReport to exchange Clinical Notes. A draft Argonaut Clinical Notes Profile will be available middle of April. It is based upon the FHIR 3.0.1 Standard.

Submitting WG/Project/Implementer Group

The Argonaut Project

Justification

The Argonaut Clinical Notes Profile is a vendor agnostic specification providing FHIR RESTful APIs and guidance for access to Clinical Notes by both patient and practitioner end users. This specification is based on FHIR Version 3.0.1 and specifically the DocumentReference, and DiagnosticReport resources.


The US ONC released a draft U.S. Core Data for Interoperability which proposed support for Clinical Notes access.

Proposed Track Lead

Coordinator: Brett Marquard

Expected participants

Servers: Epic, Cerner. Plan to contact Argonaut organizations for additional participants.


Clients: TBD

Roles

Provider or 3rd Party consumer application (Client)

An application that should be used by an end user (e.g., patient or practitioner) to support search for and retrieval of Clinical Notes.

FHIR Server (EHR)

A Server that contains Clinical Data.


If creating a client application, this track should require minimal work in advance of the connectathon, though at least a bit of playing is recommended. If creating a server, advanced preparation will be required.

Scenarios

This track will test a patient and provider access to Clinical Notes. Patient so that they are better informed and able to make important decisions about their health. Providers so that the continuity of care is maintained across multiple settings and healthcare workers.

A typical EHR may have hundreds of different Note types. For testing, this track will focus on three broad categories, and formats:

  • Encounter Summary Notes - information covering the entire encounter (Discharge Summary, H&P, Consultation, Transfer note Referral note)
  • Diagnostic Reports - supporting an order (Procedure, Lab/Pathology, Imaging)
  • 'Sub-encounter' Notes - Occurs within an encounter but doesn’t summarize the encounter (Nurse note, Progress Note, Procedure note, Surgical Operation note)

EHRs (servers) may return a Note in a variety of formats:

  • ASCII or XHTML
  • RTF or PDF -
  • Mixed document - structured information and narrative (Composition, CDA).

In each case, the content may be embedded directly in DocumentReference.Attachment.data or as reference to a Binary resource.

Requesters (clients) should be capable, at minimum, of displaying each format.

1. Retrieve an Encounter Summary Note

Action: A patient or provider requester (client) queries for a Discharge Summary Note. The EHR (server) may return the note or a pointer to retrieve the note.
Precondition: There is a patient and note in the system.
Success Criteria: Clinical Note is returned and displayed in interface.
Bonus point: The Server supports multiple versions and Clients can query and display previous versions of the Note
GET [base]/DocumentReference?patient=[id]&type=[type]
GET [base]/DocumentReference?patient=1234&type=http://loinc.org | 11488-4

2. Retrieve a Diagnostic Report

Action: A patient or provider requester (client) queries for an Imaging report. The EHR (server) may return the note or a pointer to retrieve the note.
Precondition: There is a patient and note in the system.
Success Criteria: Clinical Note is returned and displayed in interface.
Bonus point: The Server supports multiple versions and Clients can query and display previous versions of the Note
GET [base]/DocumentReference?patient=1234&type=http://loinc.org | 18726-0

3. Retrieve a Speciality Note

Action: A patient or provider requester (client) queries for a Cardiology Progress Note associated with an encounter. The EHR (server) may return the note or a pointer to retrieve the note.
Precondition: There is a patient and note in the system.
Success Criteria: Clinical Note is returned and displayed in interface.
Bonus point: The Server supports multiple versions and Clients can query and display previous versions of the Note
GET [base]/DocumentReference?encounter=1234&type=http://loinc.org | 11506-3  <-- need to double check

TestScript(s)

The supporting TestScripts and corresponding fixtures have been committed to the FHIR documents Github repository at: TBD

Please note that the available TestScripts test the TBD

Security and Privacy Considerations

  • What Authentication/Authorization will be used (e.g. SMART on FHIR (OAuth), HEART (UMA/OAuth), IHE IUA (OAuth), generic OAuth, generic SAML, mutual-Auth-TLS), is out of scope and left to implementations. Expectation is many systems will use SMART on FHIR (OAuth)