Structured Documents
Medical Records/Information Management (Archived)Project Summary for Clinical Guidance on Relevant and Pertinent Data to Include in Automatically Generated Patient Summaries
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Project Details
Number | 1183 View Ballot Items List (with NIBs) |
---|---|
Name | Clinical Guidance on Relevant and Pertinent Data to Include in Automatically Generated Patient Summaries |
Sponsor(s) | Structured Documents Work Group |
Co-Sponsor(s) | |
Steering Division | Administrative |
Description | This project will deliver an informative document providing principles for developing, and guidance on what information should and should not be present and appropriate in both entries and narrative content in an automatically generated clinical summary (e.g. CCD, Discharge Summary, etc.). It will not create new templates or models, but simply explain how to use existing templates in current HL7 work products. The project will also attempt to understand the various contexts and their impacts on the information requirements (e.g., Patient Summary vs. Transfer of Care). We will develop a process to reach out to clinical professional societies, provider organizations and organizations representing patients to present the project, gather feedback, develop recommendations, and review results. We will execute this process with a number of organizations in order to gather the best possible recommendations. Participation will be open to any organization that shows interest and commits to meeting the project requirements and schedule. The guidance delivered in this document would be structured in a way that it could be automatically tested for conformance against coded and structured data, but also could be applied to narrative sections. |
Project Facilitator | Keith W. Boone |
Status | Archived |
SD Approval Date | Apr 24, 2015 |
TSC Approval Date | May 4, 2015 |
Project Type | Ballot - Informative |
Objectives / Deliverables | PSS Approved- Target: 2015 March Outreach Process Developed - Target: 2015 May Outreach to organizations - Target: 2015 May - September Submit for Informative Ballot - Target: 2015 September Complete Reconciliation - Target: 2015 November Submit Publication Request - Target: 2015 December Project End Date (all objectives have been met) - Target: 2015 December |
Next Milestone Date | 2017 May WGM |
Project End Date | 2017 May WGM |
Project Intent | Supplement to a Current Standard, Implementation Guide |
Project Need | The Continuity of Care Document (CCD) Release 1.0 and its successor (version 1.1 found in the C-CDA specification) are required for use under Meaningful Use regulation in the US. Due to short timelines, many organizations have opted to automatically generate these documents. As a result, some organizations and software products are generating CCD documents that span dozens of pages even for the simplest of cases, making these documents unusable for their intended purpose. |
Success Criteria | |
Dependancies | |
Collaboration Efforts | This project will coordinate with a number of external bodies. It has been discussed briefly with the following: ACP, AMIA, HIMSS (Health Story and Standards WG) |
Ballot Cycle Info | 2017 Jan Ballot Cycle Info: INFORMATIVE Ballot results: Met basic vote requirements. 17 Negatives to reconcile Document Name: HL7 CDA R2 IG: Clinical Summary Relevant and Pertinent Data, Release 1 Submitter: Lynn Laakso MPA |
Misc Notes | 2017 March: TSC approved informative publication request for HL7 CDA® R2 Implementation Guide: Clinical Summary Relevant and Pertinent Data, Release 1 at TSC Tracker 13142. PMO archived project. |
Product Type | V3 Documents-Clinical (e.g. CDA) |
Project Document Repository | http://wiki.hl7.org/index.php?title=Relevant_and_Pertinent |
Backwards Compatibility | N/A |
Stakeholders | Regulatory Agency |
Vendors | EHR, PHR; Health Care IT; Clinical Decision Support Systems; HIS |
Providers | Emergency Services; Healthcare Institutions (hospitals, long term care, home care, mental health) |
SDO/Profilers | |
Realms | Realm Specific - Enter "U.S." or name of HL7 Affiliate below |
HL7 Affiliate | U.S. |
Roadmap Reference | |
Start Date | Apr 24, 2015 |
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Visit the Projects, Ballots and Standards Metrics Excel Report to view projects that are behind 120+ days along with other ballots and standards requiring a Work Group's attention.