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Health Care Industry Template Analysis

Evaluate, update, or create templates aligned with standard codes for various medical document types. Determine common use and fit, ensuring inclusion of all necessary data elements.

malik-wright
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Health Care Industry Template Analysis

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  1. Analysis Process

  2. Background Analysis • Identify templates in document types (Transfer Summary, Consult Note, Referral Summary) that closely align with data elements • Analyze selected templates • What templates will have widest common use across the health care industry? • What templates best fit the concept? • Does the template use industry standard terminology codes? • Does the template fully represent all the needed parts?

  3. Background Analysis Determine if a template needs an update or if a new template is needed Evaluation includes but is not limited to items such as: • Determination if specific coded terms are needed (value sets of standard codes) • Assessment for temporal component requirements • Need for specifying participants or number of participants ( i.e. providers, care team members, health care agents).

  4. Example: Common Template and Further Constraints Widely Used Concept: Advance Directive Observation Additional Constraints needed: • Health Care Agent(s) • Patient affirmation • Expiration date (start/stop time) • Verification (MD, RN) • Versioning • Forms – MOLST/POLST

  5. NEXT STEPS: DESIGN These steps are iterative: • Create an XML example conforming to the harmonized Consolidation Template re-using and updating the pre-existing work • Enter the template into the template library database (Trifolia) • Export the human readable word template • Review with templates with S&I (stakeholders) • Review with HL7 structured documents work Group (SDWG) • Make design edits as needed • Integrate into C-CDA guide

  6. Example: Sample File Artifact • entry> <observation classCode="OBS" moodCode="EVN"> <!-- ** Advance Directive Observation ** --> <templateId root="2.16.840.1.113883.10.20.22.4.48"/> <id root="9b54c3c9-1673-49c7-aef9-b037ed72ed27"/> <code code="89666000" codeSystem="2.16.840.1.113883.6.96" displayName="CPR"> <originalText>Cardiopulmonary resuscitation: for a patient in cardiac or respiratory arrest</originalText> </code> <statusCode code="completed"/> <effectiveTime> <low value="20110213"/> <high nullFlavor="NA"/> </effectiveTime> <value xsi:type="ST">Yes</value> <participant typeCode="VRF"> <templateId root="2.16.840.1.113883.10.20.1.58"/> <!-- 8.6.2 Represent date of verification/signature --> <time value="201102013"/> <participantRole> ... </participantRole> </participant> <participant typeCode="CST"> <participantRole classCode="AGNT"> ... </participantRole> </participant> <reference typeCode="REFR"> <seperatableInd value="false"/> <externalDocument> ... </externalDocument> </reference> </observation></entry>

  7. Questions

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