HIT Standards Committee Clinical Operations Work Group

1. HIT Standards CommitteeClinical Operations Work Group Workgroup Update Jamie Ferguson Kaiser Permanente John Halamka Harvard University 30 June, 2010

2. 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

3. 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

4. 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

5. 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

6. 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