Section 1a: Clinical Document Architecture (CDA®)
Section 3: Implementation Guides
HL7 CDA® R2 Implementation Guide: Clinical Summary Relevant and Pertinent Data, Release 1
DESCRIPTION
This guide is primarily focused on improving the relevance and pertinence of C-CDA documents as experienced by the clinician, which means as displayed or “rendered.” Other guides, including the C-CDA Companion Guide, focus mainly on the structured content. This is an informative document providing principles for development, and guidance on what information should and should not be present and appropriate in both coded clinical statements (entries) and narrative content in an automatically generated clinical summary (e.g., CCD, Discharge Summary, Referral Note, Consultation Note, etc.). It does not create new templates or models, but simply explains how to use existing Consolidated CDA (C-CDA) templates.
ALTERNATIVE NAMES
HL7 CDA® R2 Implementation Guide: Clinical Summary Relevant and Pertinent Data, Release 1 may also go by the following names or acronyms:
TARGETS
- EHR, PHR Vendors
- Health Care IT Vendors
- HIS Vendors
- Regulatory Agency, e.g., ONC
- Healthcare Institutions (hospitals, long term care, home care, mental health)
- Patients and other persons such as patient representatives, who generate C-CDA clinical summaries
BENEFITS
- Creates specific guidance for developers as to what C-CDA content is considered most useful by physicians. This is information heretofore unavailable or only reported in unspecific and unactionable anecdotal testimony (e.g., “C-CDA documents not usable” or “bloated”)
- Primarily, this document enables EHR or other HIT developers to modify the C-CDA documents they create (as senders), and or the rendering and incorporation capabilities they provide (as receivers), to provide better default settings, as well as needed flexibility, for providers to both send and receive/render/incorporate documents that are more clinically relevant and usable
- Secondarily, this document raises awareness among the persons who use EHR/HIT systems, so they can modify the content of the documents they create to be more relevant to their intended recipients
- Also assists policymakers such as ONC and CMS, as they consider updating policies and regulations (certifications, MACRA/MIPS/ACI) to address issues raised in testimony about Meaningful Use
IMPLEMENTATIONS/CASE STUDIES
Not yet available
DEVELOPMENT BACKGROUND
We reached out to clinical professional societies, provider organizations and other organizations to present the project, gather feedback, develop recommendations, and review results. We proposed RnP as an opportunity to let their voice be heard and have a positive effect on the EHRs that they use. We executed this process with multiple organizations in order to gather the best possible recommendations. Participation was open to any organization that showed interest and commited to meeting the project requirements and schedule.
RELATED DOCUMENTS
HL7 CDA® R2 Implementation Guide: Clinical Summary Relevant and Pertinent Data, Release 1 |
(Download) (1.65 MB) |
TOPICS
- Care Provision
- Patient Care
- Patient Referral
BALLOT TYPE
- Informative
STATUS DATE
2017-04-13RESPONSIBLE WORK GROUP
STAKEHOLDERS
- EHR, PHR Vendors
- Health Care IT Vendors
- Healthcare Institutions
- HIS Vendors
- Regulatory Agency
FAMILY
- CDA
CURRENT STATE
- Stable
REALM
- US Realm