TABLE L-1. Standards Available to Support HIE of LTPAC Data
LTPAC Data Frequently Provided to or Requested by Other Health Care Providers | Available Standards | Included in CCDA Ballot (Fall 2013)* |
---|---|---|
Demographic information | In 2014 Edition:
Race & Ethnicity. Administrative Gender: HL7 V3. Preferred language: ISO 639-2 |
The following refinements to the CCDA were being balloted Fall 2013:
1.1 US Realm Header (V2) |
Discharge Summary | In 2014 Edition:
CCDA & several vocabulary standards. (Note: CCD/C32 & CCR are only referenced for receipt to accommodate legacy systems. CCDA is required for send & receive.) |
The following refinements to the CCDA were being balloted Fall 2013:
1.1.10 Discharge Summary (V2)
1.1.6 Continuity of Care Document (V2) The primary use case for the CCD is to provide a snapshot in time containing the germane clinical, demographic, & administrative data for a specific patient. More specific use cases, such as a Discharge Summary or Progress Note, are available as alternative documents in this guide. |
Transfer Summary | In 2014 Edition:
Patient Summary Record. |
The following refinements to the CCDA were being balloted Fall 2013:
1.1.22 Transfer Summary (New) Standardization of information used in this form will promote interoperability; create information suitable for reuse in quality measurement, public health, research, & for reimbursement. |
Consultation Note/ Referral Note | In 2014 Edition:
Patient Summary Record. |
The following refinements to the CCDA were being balloted Fall 2013:
1.14 Consultation Note (V2) 1.1.6 Continuity of Care Document (V2) 1.1.20 Referral Note (New) Examples of referral situations are when a patient is referred from a family physician to a cardiologist for followup for a cardiac condition or a when patient is sent by a primary care provider to an ED. |
Progress Note | CCDA & several vocabulary standards. | The following refinements to the CCDA were being balloted Fall 2013:
1.1.6 Continuity of Care Document (V2) 1.1.18 Progress Note (V2) Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness & treatment. Physicians, nurses, consultants, & therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note & the most recent note." Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, & other health care professionals that describe the patient's condition & the treatment given or planned." A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report. |
Care Plan | In 2014 Edition:
Patient Summary record may include care plan fields, including: goals & instructions. In addition, the 2014 rule requires that the following information be exchanged (if known) as part of transitions & referrals in care: care team, including primary care provider of record & any additional known care team members beyond the referring & transitioning provider. |
The following refinements to the CCDA were being balloted Fall 2013:
1.1.2 Care Plan (New) A Care Plan is a consensus-driven dynamic plan that represents all of a patient's & Care Team Members' prioritized concerns, goals, & planned interventions. It serves as a blueprint shared by all Care Team Members, including the patient, to guide the Care Team Members (including Patients, their caregivers, providers & patient's care. A Care Plan integrates multiple interventions proposed by multiple providers & disciplines for multiple conditions. A Care Plan represents 1 or more POC(s) & serves to reconcile & resolve conflicts between the various POCs developed for a specific patient by different providers. While both a POC & a care plan include the patient's life goals & require Care Team Members (including patients) to prioritize goals & interventions, the reconciliation process becomes more complex as the number of POCs increases. The Care Plan also serves to enable LCC. The CDA Care Plan represents an instance of this dynamic Care Plan at a point in time. The CDA document itself is NOT dynamic. Key differentiators between a Care Plan CDA & CCD (another "snapshot in time" document):
Please see: Appendix E in Volume 1 of this guide to view Care Plan Relationship Diagrams & story board. Care plan contains:
|
Unstructured Document | NOTE: 2014 Edition:
Certification prohibits use of the "unstructured document" document-level template (in the CCDA). |
The following refinements to the CCDA were being balloted Fall 2013:
1.1.24 Unstructured Document (V2) |
Procedures: Note | In 2014 Edition:
Procedures: SNOMED-CT
Optional CDT Optional: ICD-10-PCS |
The following refinements to the CCDA were being balloted Fall 2013:
1.1.16 Procedure Note (V2) The Procedure Note is created immediately following a non-operative procedure & records the indications for the procedure &, when applicable, post-procedure diagnosis, pertinent events of the procedure, & the patient's tolerance of the procedure. The document should be sufficiently detailed to justify the procedure, describe the course of the procedure, & provide continuity of care. |
Procedures: Section | The following refinements to the CCDA were being balloted Fall 2013:
2.62 Procedures Section (entries optional) (V2) The length of an encounter is documented in the documentationOf/encompassingEncounter/ effectiveTime & length of service in documentationOf/ ServiceEvent/effectiveTime. 2.62 .1 Procedures Section (entries required) (V2) |
|
Results: Lab results; Imaging results; Procedure results | In 2014 Edition:
Other standards available. LOINC SNOMED-CT CPT-4 DICOM: Imaging Results Applicable HIPAA code set (i.e., ICD-9-CM or CPT 4) (Procedures) |
The following refinements to the CCDA were being balloted Fall 2013:
2.65 (Results Section (Entries optional)) Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient & submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy. 2.65.1 (Results Section (Entries required)) |
Current problems/diagnoses | In 2014 Edition:
Problems. Use SNOMED CT for:
|
The following refinements to the CCDA were being balloted Fall 2013:
2.19 Health Concerns Section (New) |
Recent Vital Signs & Trending Reports | LOINC (e.g., body temp, BP, heart rate, height, weight) U
CUM (for units of measure) SNOMED-CT Note: The 2014 Edition does not require use of any specific vocabulary set, but ONC has previously considered comments recommending the 3 vocabularies above. |
The following refinements to the CCDA were being balloted Fall 2013:
2.71 Vital Signs Section (entries optional) (V2) Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions. 2.71.1Vital Signs Section (entries required) (V2) Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions. |
Advanced Directives and/or DNR Order | SNOMED-CT (e.g., Intubation, tube feedings, life support, CPR, antibiotics) | The following refinements to the CCDA were being balloted Fall 2013:
2.1 Advance Directives Section (entries optional) (V2) The most recent directives are required, if known, & should be listed in as much detail as possible. This section differentiates between "advance directives" & "advance directive documents". The former is the directions to be followed whereas the latter refers to a legal document containing those directions. 2.1.1 Advance Directives Section (entries required) (V2) Advance Directive Organizers are used to group the observations for each type of Advance Directive by type (e.g., 1 Organizer for Medications, & 1 for Resuscitation). NOTE: The descriptions in this section differentiate between "advance directives" & "advance directive documents". The former are the directions whereas the latter are legal documents containing those directions. Thus, an advance directive might be "no cardiopulmonary resuscitation", & this directive might be stated in a legal advance directive document. |
Allergies | In 2014 Edition:
RxNorm for medication allergies. SNOMED CT for Allergy/Adverse Event Type Value Set (e.g., allergies to: substance, drug, food, dander, propensity to adverse reactions). |
The following refinements to the CCDA were being balloted Fall 2013:
2.2 Allergies Section (entries optional) (V2) 2.2.1 Allergies Section (Entries required) (V2) Both Sections 2.2 & 2.2.1 contain "Allergy Concern Act" |
Cognitive Status | In 2014 Edition:
Patient Summary Record to include cognitive status if known. CCDA includes standards to represent cognitive & functional status using LOINC/SNOMED-CT/ICF. |
The following refinements to the CCDA were being balloted Fall 2013:
2.40 Mental Status Section (New) |
Functional Status & Assessments Service Utilization; Case Management/Care Coordination Notes | In 2014 Edition:
Patient Summary Record to include functional status if known. CCDA includes standards to represent cognitive & functional status (ADL & IADL) using LOINC/ SNOMED-CT/ ICF. |
The following refinements to the CCDA were being balloted Fall 2013:
2.16 Functional Status Section (V2) |
Recent Medications Administration Records (at transition of care) | In 2014 Edition:
For meds: use RxNorm For immunizations use |
The following refinements to the CCDA were being balloted Fall 2013:
2.39 Medications Section (entries optional) (V2) 2.39.1 Medications Section (entries required) (V2) This section requires either an entry indicating the subject is not known to be on any medications or entries summarizing the subject's medications. |
Immunization, Syndromic Surveillance, & Cancer Reporting | In 2014 Edition:
Electronic submission to immunization registries. Electronic submission to public health agencies for surveillance or reporting. Electronic submission of lab results to public health agencies. |
The following refinements to the CCDA were being balloted Fall 2013:
Public health reporting/surveillance 2.32.1 Immunizations Section (entries required) (V2) |
Medication & Treatment Orders | In 2014 Edition:
Electronic prescribing. For meds: use RxNorm. For immunizations use: |
The following refinements to the CCDA were being balloted Fall 2013:
3.50 Medication Activity (V2) 3.51 Medication Dispense (V2) 3.52 Medication Information (V2) Value Set: Medication Clinical Drug 2.16.840.1.113762.1.4.1010.4 All prescribable medication formulations represented using either a "generic" or "brand-specific" concept. This includes RxNorm codes whose Term Type is SCD, SBD, GPCK, BPCK, SCDG, SBDG, SCDF, or SBDF. Value set intentionally defined as a GROUPING made up of: Value Set: Medication Clinical General Drug (2.16.840.1.113883.3.88.12.80.17) (RxNorm Generic Drugs); Value Set: Medication Clinical Brand-specific Drug (2.16.840.1.113762.1.4.1010.5) (RxNorm Branded Drugs). |
Advance Directive Observation (V2) | SNOMED-CT (e.g., Intubation, tube feedings, life support, CPR, antibiotics.) | The following refinements to the CCDA were being balloted Fall 2013:
3.3. Advance Directive Observation (V2)
The general category of the patient's directive is documented in the observation/code element. The observation/value element contains the detailed patient directive which may be coded or text. For example, a category directive may be antibiotics, & the details would be intravenous antibiotics only. |
Cognitive status & Assessments | In 2014 Edition:
Patient Summary Record to include cognitive status if known. Other standards: SNOMED-CT. |
The following refinements to the CCDA were being balloted Fall 2013:
Cognitive Status: Value Set: Mental & Functional Status Response Value Set 2.16.840.1.113883.11.20.9.44 3.16 Cognitive Status Observation (V2) 3.17 Cognitive Status Organizer (V2) |
Functional Status | SNOMED-CT, ICF, LOINC | The following refinements to the CCDA were being balloted Fall 2013:
3.34 Functional Status Observation (V2) |
Assessment Scale | The following refinements to the CCDA were being balloted Fall 2013:
3.8 Assessment Scale Observation |
|
Assessments Instruments such as MDS, OASIS | CDA (but Not included in CCDA) | |
Assessment Summary Documents | Represented using CCD. | The following refinements to the CCDA were being balloted Fall 2013:
1.1.6 Continuity of Care Document (V2) |
Other-Privacy/Security | In 2014 Edition:
(a) Encryption & decryption of electronic health information--(1) General. Any encryption algorithm identified by the NIST as an approved security function in Annex A of the FIPS Publication 140-2, (January 27, 2010) (incorporated by reference in §170.299). (b) Record actions related to electronic health information. The date, time, patient identification, & user identification must be recorded when electronic health information is created, modified, accessed, or deleted; & an indication of which action(s) occurred & by whom must also be recorded. (c) Verification that electronic health information has not been altered in transit. Standard. A hashing algorithm with a security strength equal to or greater than SHA-1 (as specified by the NIST in FIPS PUB 180-4 (March 2012)) must be used to verify that electronic health information has not been altered. (d) Record treatment, payment, & health care operations disclosures. The date, time, patient identification, user identification, & a description of the disclosure must be recorded for disclosures for treatment, payment, & health care operations, as these terms are defined at 45 CFR 164.501. (e) Record actions related to electronic health information, audit log status, & encryption of end-user devices. (1)(i) The audit log must record the information specified in sections 7.2 through 7.4, 7.6, & 7.7 of the standard specified at §170.210(h) when EHR technology is in use. (2)(i) The audit log must record the information specified in sections 7.2 & 7.4 of the standard specified at §170.210(h) when the audit log status is changed. (3) The audit log must record the information specified in sections 7.2 & 7.4 of the standard specified at §170.210(h) when the encryption status of electronic health information locally stored by EHR technology on end-user devices is changed. The date & time each action occurs in accordance with the standard specified at §170.210(g). (f) Encryption & hashing of electronic health information. Any encryption & hashing algorithm identified by the NIST as an approved security function in Annex A of the FIPS Publication 140-2 (incorporated by reference in §170.299). (g) Synchronized clocks. The date & time recorded utilize a system clock that has been synchronized following (RFC 1305) Network Time Protocol, (incorporated by reference in §170.299) or (RFC 5905) Network Time Protocol Version 4, (incorporated by reference in §170.299). (h) Audit log content. ASTM E2147-01(Reapproved 2009), (incorporated by reference in §170.299). Treatment means the provision, coordination, or management of health care & related services by 1 or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from 1 health care provider to another. [65 FR 82802, Dec. 28, 2000, as amended at 67 FR 53266, August 14, 2002; 68 FR 8381, February 20, 2003] |
NOTE: Some of the standards described will change as a result of ballot reconciliation.
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