Patient Authored Documents Informative Document
Contents
- 1 Project Details
- 2 Subgroup Members
- 3 Meeting Logistics
- 4 Deliverable Timelines
- 5 Use Cases
- 6 Discussion on Document LOINC Code
- 7 Discussion on Header Attributes
- 8 Discussion on Value Sets
- 9 Implementation Guide History of Development
- 10 FINAL Implementation Guide and Sample Documents
- 11 Other Documents
- 12 Open Issues & Tasks
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
- Every Friday noon EST to 1PM EST
- Phone Number: +1 770-657-9270
- Participant Passcode: 310940
- https://intuitcorp.webex.com/intuitcorp/j.php?J=595268449
Meeting Agendas
- Agenda for 08092012: File:PGHDAgenda08092012.docx
- Agenda for 08172012: File:PGHDMeetingAgenda08172012.docx
- Agenda for 08242012: File:PGHDAgenda08242012.docx
- Agenda for 08312012: File:PGHD Meeting Agenda for 20120831.docx
- Agenda for 09072012: File:PGHD Meeting Agenda for 20120907.docx
- Agenda for 09212012: File:PGHD Meeting Agenda for 20120921.docx
- Agenda for 09282012: MEETING POSTPONED TO NEXT WEEK
- Agenda for 10052012: File:PGHD Meeting Agenda for 20121005.docx
- Agenda for 10122012: File:PGHD Meeting Agenda for 20121012.docx
- Agenda for 10192012: File:PGHD Meeting Agenda for 20121019.docx
- Proposal for review re header participations for care team File:Proposal for Recording Clinicians and Care Team in PANs.docx
- Agenda for 10262012: File:PGHD Meeting Agenda for 20121026.docx
- Agenda for 11022012: File:PGHD Meeting Agenda for 20121102.docx
- Agenda for 11092012: File:PGHD Meeting Agenda for 20121109.docx
- Agenda for 11162012: File:PGHD Meeting Agenda for 20121116.docx
- Meeting on 11/23/2012 cancelled due to Thanksgiving Holiday
- Agenda for 11302012: File:PGHD Meeting Agenda for 20121130.docx
- Agenda for 12072012: File:PGHD Meeting Agenda for 20121207.docx
- Agenda for 12142012: File:PGHD Meeting Agenda for 20121214.docx
- Meetings for 21st December and 28th December cancelled due to Christmas Holidays
- Next meeting will be held on January 04
Meeting Minutes
- Minutes for 07272012: File:PGHDMinutes0727.docx
- Minutes for 08032012: File:PGHDMeetingMinutes08032012.docx
- Minutes for 08102012: File:PGHDMeetingMinutes08102012.docx
- Minutes for 08172012: File:PGHDMeetingMinutes08172012.docx
- Minutes for 08242012: File:PGHD Meeting Minutes for 20120824.docx
- Minutes for 08312012: File:PGHD Meeting Minutes for 20120831.docx
- Minutes for 09072012: File:PGHD Meeting Minutes for 20120907.docx
- Minutes for 09102012: File:PGHD Meeting Minutes for 20120910 HL7 F2F discussions.docx
- Minutes for 09212012: File:PGHD Meeting Minutes for 20120921.docx
- Minutes for 10052012: File:PGHD Meeting Minutes for 20121005.docx
- Minutes for 10122012: File:PGHD Meeting Minutes for 20121012.docx
- Minutes for 10192012: File:PGHD Meeting Minutes for 20121019.docx
- Minutes for 10262012: File:PGHD Meeting Minutes for 20121026.docx
- Minutes for 11092012: File:PGHD Meeting Minutes for 20121109.docx
- Minutes for 11162012: File:PGHD Meeting Minutes for 20121116.docx
- Minutes for 11302012: File:PGHD Meeting Minutes for 20121130.docx
- Minutes for 12072012: File:PGHD Meeting Minutes for 20121207.docx
Deliverable Timelines
- Notice of ballot in September 2012
- Word document (Implementation Guide) by Dec 1, 2012
- Ballot Package Submitted on December 07
- Ballot in WG Meeting in Phoenix January, 2013
Use Cases
- Use Case Template : File:PGHDUseCaseTemplate.docx
- Use Case List Version 20120809 : File:PGHDUseCases08092012.zip
- Use Case List Version 20120814 : File:PGHDUse Cases 20120814.zip (Adjusted Use Cases to use HL7 Scenario Names. Updated Use Case 1 to include the creation of a CDA document from the PHR.)
- Use Case List Version 20120824 : File:PGHD Use Cases 20120824.zip (Adjusted Use Case 1 and Use Case 2 to reflect prior concensus and record on-going open disucussion points.)
- Use Case List Version 20120824-post meeting: File:Use Cases 20120824 post meeting.zip (minor adjustments made to Use Case 1 during the review.)
- Use Case List Updates Version 20120831-post meeting: File:Usecase updates 20120831.zip
- Use Case List Updates Version 20120905: File:Use Cases 20120905.zip
- Use Case List Updates Version 20121213: File:Use Cases 20121213.zip Updated Nutrition Use Case
Discussion on Document LOINC Code
- 20121005 Requested LOINC code for general Patient Authored Note: File:Requested Description.docx
Discussion on Header Attributes
- Date reflects notes following the review date
- 20120803 Review of Header Elements : File:PGHDReviewHeader0805.docx
- 20120810 Review of Header Elements per Use Case : File:PGHD Header Element Analysis 20120810.xlsx
- 20120817 Review of Header Elements per Use Case : File:PGHD Header Element Analysis 20120817.xlsx
- 20120831 Review of Header Elements per Use Case : File:PGHD Header Element Analysis 20120831.xlsx
- 20120907 Review of Header Elements per Use Case : File:PGHD Header Element Analysis 20120907.xlsx
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 History of Development
- Draft Implementation Guide: File:PGHDDocumentHeaderIG.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20120918.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20121005.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20121012.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20121019.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20121026.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20121029.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20121105.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20121106.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20121113.doc
- Draft Implementation Guide: File:PGHD Document Header IG 20121113 d1.doc This version has all changes accepted from prior work.
- Draft Implementation Guide: File:PGHD Document Header IG 20121115 d1.doc This version has the content which was used for the review with SDWG.
- Draft Implementation Guide: File:PGHD Document Header IG 20121115 d1.pdf This is the actual pdf of the content with yellow highlights used to facilitate review discussion.
- Draft Implementation Guide: File:PGHD Document Header IG 20121116 d1.doc This is the live version of draft 1 which we incorporated post SWDG-review changes into.
- Draft Implementation Guide: File:PGHD Document Header IG 20121116 d1.pdf This is the pdf copy which will be used for editorial review.
- Note to editors: Please use Adobe to place sticky notes on the document where changes are needed.
- Draft Implementation Guide: File:PGHD Document Header IG 20121207 Final before accepting changes.docx This copy has all edits included.
- Draft Implementation Guide: File:PGHD Document Header IG 20121207 Final.docx This copy has all edits accepted.
- Draft Implementation Guide Word: File:Patient Authored Note Header IG 20121207 FinalWithLineNum.docx This copy has all edits accepted.
- Draft Implementation Guide PDF : File:Patient Authored Note Header IG 20121207 FinalWithLineNum.pdf This copy has all edits accepted.
Narrative Components Developed and Incorporated into the Implementation Guide
- Draft Purpose: File:Draft Purpose 20121005 LKH.docx - Incorporated, with modifications, into IG on 10/12/2012
- Draft Approach: File:Draft Approach 20121005 LRN.docx - Incorporated, with modifications, into IG on 10/19/2012
- Draft Scope section: File:ProjectScopeStmtIG.docx
- Edit of Scope section: File:ProjectScopeStmtIG 20121026.docx - Incorporated into IG on 10/26/2012
FINAL Implementation Guide and Sample Documents
- Package Submitted for January 2013 Ballot: File:PAN Document Header IG.zip Includes IG and two (2) Patient Authored Note Document Samples
- Package Submitted for January 2013 Ballot: File:PAN Document Header IGLineNum.zip Includes IG and two (2) Patient Authored Note Document Samples
Other Documents
- White Papers
- Policy White Paper : File:PGHDWhitePaper.docx
- Use case actor names: Publishing facilitators guide, Appendix 3: Publishing Facilitators Guide
- Appendix – table 5 has patient information;
- Appendix - table 6 has healthcare staff, etc
- Sample Forms
- Sample Hospital PreVisit/Registration Form : File:AdultAdmissionRegistrationForm.pdf
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
- While making updates to 20121116-d1, we need to revise the open issues and remove issues that are resolved, and add an open issue about the need to resolve the concept domain binding and subsequent US realm binding of a specific value set to the concept domain. We'll need Rob Hausam's help to figure out how that gets done. We can ask for guide to come from ballot comments, too.