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HIT Standards Committee Clinical Operations Work Group. Workgroup Update Jamie Ferguson Kaiser Permanente John Halamka Harvard University 30 June, 2010. Problem Statement. Implementers of CCR and CCD for transfers of care also need other standard document types, e.g.,:

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Hit standards committee clinical operations work group l.jpg

HIT Standards CommitteeClinical Operations Work Group

Workgroup Update

Jamie Ferguson

Kaiser Permanente

John Halamka

Harvard University

30 June, 2010


Problem statement l.jpg
Problem Statement

Implementers of CCR and CCD for transfers of care also need other standard document types, e.g.,:

Inpatient Discharge Summary

ED Discharge Summary

These documents may contain specialized content not found in CCR or CCD, e.g.,:

Discharge Diet

Surgery Description

Surgical Operation Note Findings

Estimated Blood Loss

Chief Complaint


Review ccr and ccd l.jpg
Review: CCR and CCD

A CCD based document

CCD: A collection of templates representing core content for healthcare summary documents with template content from CCR

Family History

Medications

Problems

Allergies

Social History

Vital Signs

Payer

Demographics

. . . .

CDA: A foundation standard enabling the definition of templates

for a broad range of healthcare documents


Extending and reusing existing templates in other documents l.jpg
Extending And Reusing Existing Templates In Other Documents

A CDA based document

compatible with CCD

A CCD based document

CCD

Template content from CCR

Chief Complaint

DischargeDiagnosis

Mode ofTransport

Surgical Finding

New Section…

Discharge Diet

Family History

Medications

Problems

Allergies

Payer

Social History

Vital Signs

Demographics

. . . .

CDA

Identified by the CCD document ID number

Identified by another identifier, e.g., an

ED Discharge document ID number


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Discussion points

We plan to make recommendations to the Standards Harmonization entity as outlined in the Concept of Operations plan

General direction of WG: Recommend that the process should standardize templated CDA sections to build upon and extend what was done in CCR and CCD

WG direction is consistent with NIST direction for testing


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Discussion points, continued

Must enable more documents and reuse existing work

May also recommend this direction for attachments

Identification of complete documents assembled from templates:

A few complete documents might have complete document IDs, e.g., discharge summaries, ambulance services, etc.

Otherwise, a general method for identification should be devised

Embedded or concatenated identifiers would avoid enumerating a combinatorial explosion of complete documents assembled from templates

Coordination of templates with value set standards

E.g.,: value sets for hospital readmission measures could be coordinated with discharge summary template standards

Next Steps

Seek HIT Standards Committee input

Continue Workgroup discussions to create future recommendations to the full Committee