HL7 Version 3 Standard: Care Provision; Care Record Topic, Release 1

DESCRIPTION

The Care Provision Domain describes information structures and vocabulary used to communicate information pertinent to the care of living subjects, devices, geographic sites, and other physical entities by a responsible care provider. This domain supports multiple referrals and record communication that support the collaboration and continuity of care between providers of care. The Care Provision Domain addresses the information that is needed for the ongoing care of individuals, populations, and other targets of care. It deals with both the dynamics of continuing care and communications in that and the structural content of a care record.

The Care Record Topic covers all data in a patient record, such as Electronic Health Record or Personal Health Record. The health professional responsible for can store any data element in the record, which can be specified as clinical statements in the Care Record R-MIM, and hence communicated for continuity of care or for reporting.

 

This standard is available in the Normative Edition: see http://www.hl7.org/implement/standards/product_brief.cfm?product_id=306.

 

Members can access the latest Normative Edition online.

 

ALTERNATIVE NAMES

HL7 Version 3 Standard: Care Provision; Care Record Topic, Release 1 may also go by the following names or acronyms:

TARGETS

• Healthcare Institutions (hospitals, long term care, home care, mental health)
• Health Information Exchange Infrastructures
• Immunization Registries
• Quality Reporting Agencies
• Standards Development Organizations (SDOs)
• EHR, PHR Vendors
• Health Care IT Vendors
• Clinical Decision Support Systems Vendors
• Emergency Services Providers
• Local and State Departments of Health

BENEFITS

• Provides a pattern for planning specialized care activities
• Promotes sharing of health record extracts and event summaries between collaborating providers (including the patient) in order to support the continuity of care and clinical decision support activities of the receiving persons or systems
• Supports request for the transfer of patient care responsibility of a specific type of care among collaborating healthcare providers, including a responsible party, such as a care coordinator, advocate, family member and the patient
• Facilitates acceptance or rejection of a request for care transfer as well as the ability to provide information about the intent to provide care to the requesting party
• Allows for communication of a summary of relevant findings and outcomes as a result of the care provided.

IMPLEMENTATIONS/CASE STUDIES

• Ontario, Canada for different applications of a care record exchange
• Integrating the Healthcare Enterprise (IHE) for using the Care Record query and query profiles in the Patient Care Coordination workflow
• Two National IT Institute for Healthcare in the Netherlands (Nictiz) projects for perinatology and diabetes care
• The national Perinatal Registration the Netherlands (PRN) for using the care record message for submitting clinical data from midwifes, gynecologists and pediatricians to the national registry 
• The Clinical Data Ware House project in Zwolle, the Netherlands, for exchanging nursing oncology data from hospital to home care and vice versa.

DEVELOPMENT BACKGROUND

The "Act of Care Provision" is the referral of the patient to another provider for additional care. It clarifies exactly who is responsible for the care of a patient at a specific moment or care episode.

The care record can be used to document the patient’s condition on transfer of care. It excludes activities meant to evaluate in depth a characteristic of a patient (i.e. all observations), or all laboratory tests, although interventions such as colonoscopies which include removal of samples may be classified as professional services. It also excludes the administration of drugs or vaccines, as these are handled by more specialized transactions.

RELATED DOCUMENTS

HL7 Version 3 Standard: Care Provision; Care Record Topic, Release 1

(Download) (210.22 MB)

ADDITIONAL DETAILS

For specific clinical activities, such as prescribing medications, the Care Record R-MIM is not complete; please refer to the Pharmacy R-MIMs for that. However, it is quite possible to include a current medication list in the Care Record message for continuity of care reasons.

TOPIC

• Care Provision

BALLOT TYPE

• Normative

STATUS DATE

2018-04-20

RESPONSIBLE WORK GROUP

STAKEHOLDERS

• Clinical Decision Support Systems Vendors
• EHR, PHR Vendors
• Emergency Services Providers
• Health Care IT Vendors
• Healthcare Institutions
• Immunization Registries
• Local and State Departments of Health
• Quality Reporting Agencies
• Standards Development Organizations (SDOs)

FAMILY

• V3

CURRENT STATE

• Stable

REALM

• Universal