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Section 1a: Clinical Document Architecture (CDA®)
Section 3: Implementation Guides

HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Infectious Disease, Release 1, STU 1 - US Realm

DESCRIPTION

This guide defines optional additions to the C-CDA R2.1 Continuity of Care Document (CCD), Transfer Summary, and Discharge Summary standards. These additional templates are  available for use in any other CDA document-type where needed. They specify infectious disease data that should be included in the above-mentioned documents or any other relevant CDA document-type when patients are transferred between healthcare facilities, discharged home, or discharged to locations other than home (e.g. law enforcement).

 

ALTERNATIVE NAMES

HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Infectious Disease, Release 1, STU 1 - US Realm may also go by the following names or acronyms:

"HL7 CDA® R2 IG: C-CDA R2.1 Supplemental Templates for Infectious Disease, R1 - US Realm", C-CDA Supplemental Templates, C-CDA ID, Infectious Diseases, ID, Supplemental Templates for ID, Supplemental Templates for Infectious Diseases

TARGETS

  • Clinical and Public Health Laboratories
  • Quality Reporting Agencies
  • Regulatory Agency
  • Payors
  • Pharmaceutical Vendors
  • EHR, PHR Vendors
  • Health Care IT Vendors
  • Clinical Decision Support Systems Vendors
  • Lab Vendors
  • HIS Vendors
  • Emergency Services Providers
  • Local and State Departments of Health
  • Healthcare Institutions (hospitals, long term care, home care, mental health)

 

BENEFITS

  • Enhance standards-based exchanges of infectious disease data to improve health care and public health.
  • Provide solutions that can be generalized and are not specific to healthcare-associated infection (HAI) reporting.

 

IMPLEMENTATIONS/CASE STUDIES

  • Centers for Disease Control and Prevention (CDC) 
  • U.S. Council of State and Territorial Epidemiologists (CSTE)

 

DEVELOPMENT BACKGROUND

The immediate impetus for this project is a call for action by the U.S. Council of State and Territorial Epidemiologists (CSTE), specifically a CSTE Position Statement approved by the organization’s voting members in 2016 on Interfacility Communication to Prevent and Control Healthcare-Associated Infections and Antimicrobial Resistant Pathogens Across Healthcare Settings: www.cste.org/resource/resmgr/2016ps/16_ID_09.pdf. The CSTE Position Statement describes gaps in interfacility communication that are widely recognized and widespread in healthcare.

This guide specifies an Infectious Diseases Section that uses templates defined here for use in the CCD, Transfer Summary, and Discharge Summary C-CDA documents, and that are also available for use in any other CDA document type where needed.

The laboratory templates found in this guide are designed to convey portions of a laboratory result that are deemed relevant to infectious disease diagnoses. The templates are not intended to represent an entire laboratory report.

By design, much of the laboratory data identified in these templates is left as SHOULDs or MAYs even where the equivalent fields in the V2 ORU message have been constrained to be required. The rationale for this approach is to enable a provider (and the EHR system) to determine what information is relevant for inclusion in the Infectious Disease section of a CDA document. Again, the intent is to enable portions of laboratory results to be included, based upon the judgment of the provider with regard to what parts of the laboratory result are relevant to the infectious disease section.

 

RELATED DOCUMENTS

HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Infectious Disease, Release 1, STU 1 - US Realm

STU DOCUMENTS

HL7 CDA® R2 IG: C-CDA R2.1 Supplemental Templates for Infectious Disease, Release 1 STU 1- US Realm (Submit Feedback on STU)

(Download) (1.46 MB)

ADDITIONAL DETAILS

 SUPPORT FILES

Additional informative XML support files (such as sample files and Schematron validation files) can be downloaded from this GForge link (https://gforge.hl7.org/gf/project/strucdoc/scmsvn/?action=browse&path=%2Ftrunk%2FC-CDA_INFECTIOUS_DISEASES%2FCDAR2_IG_C-CDA_INFECT_DIS_R1_D1%2F). See the “_readme.txt” file included in the STU document download for more details.

TOPICS

  • Care Provision
  • Clinical Statement
  • Patient Care
  • Public Health

BALLOT TYPE

  • STU

STATUS DATE

2019-07-10

RESPONSIBLE WORK GROUPS

Orders and Observations

Pharmacy

Public Health

Structured Documents

STAKEHOLDERS

  • Clinical and Public Health Laboratories
  • Clinical Decision Support Systems Vendors
  • EHR, PHR Vendors
  • Emergency Services Providers
  • Health Care IT Vendors
  • Healthcare Institutions
  • HIS Vendors
  • Lab Vendors
  • Local and State Departments of Health
  • Payors
  • Pharmaceutical Vendors
  • Quality Reporting Agencies
  • Regulatory Agency

FAMILY

  • CDA

CURRENT STATE

  • Stable

REALM

  • US Realm