Section 1a: Clinical Document Architecture (CDA®)
Section 3: Implementation Guides
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan Document, Edition 1 STU3.1 - US Realm
DESCRIPTION
The PACP document is a CDA document template designed to share advance directive information created by an individual to express his or her personal health goals and priorities, treatment intervention preferences under certain health scenarios and care experience preferences in case the individual cannot make medical treatment decisions or communicate with the care team. It also can express a person's designated healthcare agent(s) selected by the person to make treatment decisions on their behalf when they can't communicate for themself. The purpose of the PACP document is to ensure that the information created or updated by the individual is available and considered in treatment and care planning. The focus of the standard is sharing patient generated information. This specification provides a means to encode information in a standard way with systems that maintains clinical records for the person. A PACP can reference a legal document, and it can represent information contained in a legal document such as the appointment of healthcare agents and the identity of witnesses or a notary. This IG is aligned with the FHIR Advance Directive Information Interoperability Guide for patient authored advance directives (Type-1 ADI).
ALTERNATIVE NAMES
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan Document, Edition 1 STU3.1 - US Realm may also go by the following names or acronyms:
TARGETS
- Payors
- Patients or Consumers
- EHR, PHR Vendors
- Health Care IT Vendors
- Clinical Decision Support Systems Vendors
- Health Information Exchange
- Patient Portal Vendors
- Emergency Services Providers
- Local and State Departments of Health
- Healthcare Institutions (hospitals, long term care, home care, mental health)
- Architects and developers of healthcare information technology (HIT) systems in the US Realm that exchange patient generated health data
BENEFITS
- Improves the guidance available on how to include advance care plan and advance care planning information in a C-CDA document.
- Creates a standard for expressing personal health goals, treatment intervention preferences and care experience preferences which can be used to inform care and treatment planning.
- Enables a person to make their wishes known to their care team, even when he or she cannot speak for his or her self
- Supports patient-centered care coordination and care delivery
- Informs clinical decision-making by providing critical information on the individual’s values related to his or her health care and medical treatments
- Creates a standardzed document which can be referenced by Clinical Summary documents and Care Plan documents as supporting evidence for goal concordance in care delivery and treatment plans.
IMPLEMENTATIONS/CASE STUDIES
- ADVault, Inc. (MyDirectives.com)
DEVELOPMENT BACKGROUND
Advance directives and advance care plans are documents that people have traditionally used to express their medical treatment wishes. Advance directives typically consist of two documents – the “living will,” and the “medical power of attorney.” A living will documents whether a person wants “life-sustaining treatments” (e.g., artificial nutrition or hydration, dialysis or the use of a ventilator to help with breathing) should that person suffer a medical emergency and be unable to communicate with the care team. A person uses a medical power of attorney to appoint one or more people to serve as advocates or “healthcare agents” empowered to make medical treatment decisions on behalf of the person if he or she is incapacitated and cannot communicate with medical personnel. The living will provides information that helps the healthcare agent make treatment decisions on the person’s behalf. Advance care plans cover the same subjects as living wills and medical powers of attorney; however, they are broader in scope and often include an individual’s thoughts on religion, hospice and palliative care options, and the person’s desired care experience more generally.
A new CDA R2 schema extension has be released by SDWG to support the extensions used in this implementation guides.
The July 2016 CDA_SDTC schema extension release package is available at: http://gforge.hl7.org/gf/project/strucdoc/frs/
RELATED DOCUMENTS
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan Document, Edition 1 STU3.1 - US Realm |
STU DOCUMENTS
HL7 CDA® R2 IG: Personal Advance Care Plan Document, Edition 1 STU 3.1 - US Realm | (Submit Feedback on STU) |
(Download) (2.03 MB) |
|
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan Document, Release 1 - US Realm STU R2 | Expiration Aug 2022 |
(Download) (7.54 MB) |
|
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan Document, Release 1 - US Realm | Expiration Aug 2020 |
(Download) (4.10 MB) |
TOPICS
- Care Provision
- Clinical Quality
- Decision Support
- Medical Records
- Patient Care
BALLOT TYPE
- STU
STATUS DATE
2016-07-01RESPONSIBLE WORK GROUP
STAKEHOLDERS
- EHR, PHR Vendors
- Emergency Services Providers
- Health Care IT Vendors
- Healthcare Institutions
FAMILY
- CDA
CURRENT STATE
- Active
REALM
- US Realm