




























Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
Recommendations for implementing Encounter Summary Documents with Clinical Notes in C-CDA, including the use of specific templates, the inclusion of clinical notes, and the management of document versioning and reconciliation. It also discusses best practices for smart senders and resilient receivers in CDA document exchange.
Typology: Lecture notes
1 / 36
This page cannot be seen from the preview
Don't miss anything!
In the Fall of 2017, the independent Car e quality and CommonWell Content Work Groups were attempting to solve a set of common issues: unacceptably large C-CDA documents, an absence of clinical notes in exchanged documents, support for encounter summary documents, and the need for document version management. The initiatives agreed to launch a Joint Document Content Work Group (JDCWG) in January 2018 with participants that included clinicians, vendor representatives, and standards development representatives. This white paper defines a path to improve the content in C-CDA exchange, while acknowledging the realities of present day documentation and exchange practices. The intended audience of this guidance is C-CDA implementers, product development teams, and software developers. The recommendations resulting from this joint effort include the following:
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018
This guide was developed through a joint effort of Car e quality and CommonWell. The editors appreciate the collaborative efforts and commitment from all participants to improve the quality of C-CDA documents. Work Group participants included: Primary Editor Organization Brett Marquard DoD / VA Interagency Program Office (IPO) / WaveOne Ed Donaldson OneRecord / Ready Computing Contributor Organization Alan Swenson Kno Anand Prabhu Mediportal Ava Spetalnick Athenahealth Becky Shoemaker Dignity Health Benjamin Flessner Redox Christopher Dickerson Carequality Christopher J. Hills DoD / VA Interagency Program Office (IPO) Corey Parker Greenway Health Dana Grove Cerner Dave Cassel Carequality David Camitta MD, MS Dignity Health David Parker MD DoD / VA Interagency Program Office (IPO) / Defined IT Didi Davis eHealth Exchange Elizabeth R. Ames Sutter Health Eric Heflin The Sequoia Project Farah Saeed eClinicalWorks Holly Miller MD, MBA MedAllies Jason Goldwater Cedar Bridge Group Jitin Asnaani CommonWell Health Alliance Joe Wall MEDITECH Justin Ware Epic Kelly Bundy Surescripts Leanna Evans Cerner Lisa R. Nelson MaxMD Lizz Restat athenahealth Luke Doles NY eHealth Collaborative Madhav Darji eClinicalWorks Margaret Donahue, MD US Department of Veterans Affairs Marie Swall US Department of Veterans Affairs / JP Systems Marty Prahl Social Security Administration
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018
Car e quality and the CommonWell Health Alliance are two industry initiatives committed to the seamless exchange of healthcare information. This guide is the result of a joint development effort of the Content Workgroups within each initiative to improve the content of Consolidated CDA exchange.
This document provides guidance for including Clinical Notes, and guidance for exchanging Encounter Summary CDA Documents. A Clinical Note is narrative text a clinician wrote, dictated, or copied from other portions of the patient’s chart. An Encounter Summary CDA document will include this Clinical Note (required) plus other relevant sections with discrete data as generated by the system and/or included per clinician instructions. This document complements the Health Level Seven (HL7) CDA® R2 IG: C-CDA Templates for Clinical Notes STU Release 2.1. It is also not a replacement for the C-CDA Templates for Clinical Notes R Companion Guide, which primarily supports the requirements of the ONC 2015 Edition Certification Criteria (2015 Edition) Certified Electronic Health Record Technology requirements. The guidance provided here will be considered in a future update to C-CDA.
The primary audience of this guide is C-CDA implementers, product development teams, and software developers. This guide provides detailed guidance for placement of clinical information in C-CDA and best practices for system generators and receivers. Software architects, business analysts, and policy managers can also benefit from understanding the preferred approach of supporting Encounter Summary documents in addition to Patient Summary documents.
In the fall of 2017, independent Car e quality and CommonWell Content Work Groups were attempting to solve a set of common issues: unacceptably large C-CDA documents, an absence of clinical notes in exchanged documents, support for encounter summary documents, and the need for document version management. Participants from both content work groups approached the Directors of Car e quality and CommonWell to consider a single joint effort to tackle these common issues. The Joint Work Group launched in January 2018. Participants in the Joint Content Work Group included clinicians, vendor representatives and participants involved in standards development. The principles of the Joint Content Work Group were as follows:
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018
The Joint Content Work Group considered the C-CDA R2.1, and Companion Guide as the baseline for all discussions. As a guiding principle, the Joint Content Work Group focused on providing complementary, (^1) With support from our Argonaut colleagues!
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018
An encounter summary document is primarily a clinician authored collection of information specific to a single patient interaction with a clinician, care team or hospitalization. The document may be provided to a patient immediately upon, or soon after, the conclusion of their visit even if all the information related to that visit is not yet available. For example, an encounter may have pending laboratory results or may lack a finalized clinician note or discharge summary when a patient departs. However, an encounter summary document may be updated when additional encounter specific data is available (i.e. finalized). A complete encounter summary includes any information that may have been updated after the conclusion of the encounter. See Document Versioning section for guidance on how to manage documents versions and updates. For the purposes of document exchange, this guide focuses on two Encounter Summary Document types: ● Outpatient/Ambulatory Encounter Summary ● Inpatient/Hospital Encounter Summary It is important to note these two broad categories may not perfectly align with patient billing classes. This guide does not define exact scenarios of when to use each type of encounter summary. The group consensus was to use the outpatient/ambulatory encounter summary for office visits, and use the inpatient/hospital encounter summary for overnight stays in hospitals. For hospital outpatient services (ambulatory surgery, etc.) or inpatient rehabilitation the provider/organization may need to determine which encounter summary document type is most appropriate. This supplement provides guidance for generating the C-CDA Progress Note Document to exchange information associated with an Outpatient/Ambulatory Encounter, and the C-CDA Discharge Summary Document to exchange information associated with an Inpatient/Hospital Encounter. The Joint Content Work Group selected these information exchange documents because they were designed to support the most generic, encounter level documents currently available. After systems support the Progress Note Document, and the Discharge Summary Document, implementers are encouraged to implement additional document types that support specific use cases, for example Consultation Note Document. Implementation of the Encounter Summary Documents complements the existing Patient Summary document exchanged by systems today. Encounter Summary Documents provide information about the patient used or generated during the encounter. Patient Summary Documents provide the current and historical information about a patient. The Joint Content Work Group decided that in order for systems to provide a complete picture of a patient's history, they SHALL provide access to, at a minimum, one Encounter Summary Document for each available encounter and a current Patient Summary Document. To help understand this decision, the Joint Content Work Group considered the following scenario:
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018
The CDA document body communicates clinical content through sections. C-CDA R2.1 includes robust recommendations for required and optional sections for the C-CDA Progress Note Document and the C- CDA Discharge Document which were determined by the review of thousands of clinical documents. The additional guidance here complements this prior work. When HL7 considers a new ballot, members of the Joint Content Work Group will submit these recommendations for inclusion. The content work group selected sections for the Progress Note Document and Discharge Summary Document using these guidelines:
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018 The Joint Content Work Group recommends all sections include this observation and corresponding text. The text should be included underneath the section header and state either: ● The section includes all information for this encounter ● Or, the section includes information corresponding to a time range with a low and a high value Figure 1 – Sample display of Section Time Range
The content work group selected the C-CDA Progress Note document template^6 to support Outpatient/Ambulatory Encounter Summary Document exchange. The Progress Note is a generic document which supports any outpatient visit. It is a first step towards systems exchanging more specific document types per encounter type. The preferred LOINC document type code is 11506-3, Provider-unspecified Progress note, although systems may send more specific codes from the ProgressNoteDocumentTypeCode urn:oid:2.16.840.1.113883.11.20.8.1 value set. Figure 2 – Progress Note Document Section Requirements, below, identifies the sections the Joint Content Work Group recommends be required for implementations of the Progress Note document type intended to serve as an Outpatient/Ambulatory Summary. (^6) C-CDA R2.1 Progress Note templateId: 2.16.840.1.113883.10.20.22.1.9:2015- 08 - 01
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018 Required Required if Reviewed^7 Outpatient/Ambulatory Summary (Progress Note Document) Assessment and Plan Section (V2) Allergies and Intolerances Section (entries required) (V3) Clinical Notes^8 (may include Subjective) Medications Section (entries required) (V2) Encounter Section (V3) with encounter diagnoses for the specific encounter Immunizations Section (entries required) (V3) Figure 2 – Progress Note Document Section Requirements The Progress Note Document is not restricted to these sections. Clinicians, or specific sites, may choose to include other sections relevant to the encounter (Results, Vital Signs, etc.).
The content work group selected the C-CDA Discharge Summary document template^9 to support Inpatient/Hospital Encounter Summary Document exchange. The Discharge Summary is a key document for patients transitioning from the hospital to a new care setting. The preferred LOINC document type code is 18842-5, Discharge Summary note, although systems may send more specific codes from the DischargeSummaryDocumentTypeCode value set urn:oid:2.16.840.1.113883.11.20.4.1. Figure 3 – Discharge Summary Document Section Requirements, below, identifies the sections the Joint Content Work Group recommends be required for implementations of the Discharge Summary document type intended to serve as an Inpatient/Hospital Summary. (^7) Only include if the system is confident a user has reviewed or reconciled the list and is current to the Encounter Summary Document. On generation, systems may include the IHE Reconciliation template to record an explicit reconciliation act. (^8) C-CDA R2.1 Companion Guide Notes Section 2.16.840.1.113883.10.20.22.2.65:2016- 11 - 01 (^9) C-CDA R2.1 Discharge Summary templateId: 2.16.840.1.113883.10.20.22.1.8:2015- 08 - 01
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018 exchanging in the HL7 C-CDA companion guide^15 using the new Notes Section^16 and Notes Activity^17. The HL7 guidance provided a baseline for the additional guidance here.
The LOINC terminology includes thousands of different note types. To focus the industry, the Argonaut participants and the Department of Veterans Affairs contributed their most commonly used note types to develop the following list of top notes: ● Discharge documentation (8648-8 and/or 18842-5) ● Consultation (11488-4) ● Imaging narrative (18726-0) ● Lab/path narrative ● History & Physical (34117-2) ● Progress note ● Procedures note (28570-0) The list is not in a priority order, nor does it represent the exclusive list of what systems can and will support. All systems are encouraged to support this list and additional notes from the Note Types value set. Any future standards publications should not be restricted to this list.
The introduction of the Notes Section and Notes Activity entry templates in the HL7 C-CDA companion guide provided structure and guidance for sending notes. Depending on the clinician workflow, and the discrete information available at time of document creation, the participants agreed on three potential approaches in priority order:
When a note is specifically about an action a clinician performed, the note should reference that action. For example, a Procedure Note is linked, or nested within, the procedure it documents. When direct attribution is possible (as an entryRelationship), the clinical note should be included in the appropriate section where the act is included. Receiving systems should be prepared for Clinical Notes directly embedded in an act and provide a control to display, at minimum, and be able to expand or collapse the note. For example, if the Procedure section had 5 procedures, it is preferable to display the 5 procedures in a flat list or table, with an option, possibly a ‘+’ sign, to allow the user to expand and read each individual Procedure note. (^15) HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes R1 Companion Guide, Release 1 (^16) C-CDA R2.1 Companion Guide Notes Section 2.16.840.1.113883.10.20.22.2.65:2016- 11 - 01 (^17) C-CDA R2.1 Companion Guide Note Activity 2.16.840.1.113883.10.20.22.4.202:2016- 11 - 01
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018 Figure 4 – Example of Note Attached to an Act
Procedure | Date |
---|---|
Appendectomy | January 25, 2018 |
|
...
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018 for which there are many consultation notes, may choose to put those notes in a standalone Notes Section to avoid cluttering up the Encounter Section. Figure 6 – Example of Stand-alone Notes Section
Clinical Notes are written by a clinician in the context of an encounter. Every Clinical Note must have an Author and should be linked to an Encounter, whether a short telephone encounter or a lengthy Hospital Encounter. Encounter linking is important since some systems parse entries and may not properly retrieve header information. When the C-CDA is an ‘Encounter Summary’ the Clinical Note should use an entryReference to the
Deploying Encounter Summary CDA Documents with Clinical Notes June 2018 encompassingEncounter/id^18. Figure 7 below provides an XML example for how this should be done. Figure 7 – Example of Encounter Linking with entryRelationship reference When C-CDA is ‘Patient Summary’ each Note must have explicit encounter reference within the entry. If the document contains an Encounters section with the associated encounter, the Note Activity can reference the encounter ID as demonstrated in Figure 7. Otherwise, the entire encounter should be included in the Note Activity as demonstrated in Figure 8 below. Figure 8 – Example of Encounter Linking with encounter nested
The best practices for clinical note exchange will evolve as exchange of this type of information becomes more common. For a start, these are suggested best practices: