Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. Precedent Terminology Standardization Works For Ccd Functional Status To Support Assessment Instrument Content

12/01/2011

HL7 representatives, persons with expertise in the federally-required MDS and OASIS instruments, and others have established precedence1, 2, 3 by outlining the following terminology integration steps that support the assessment instrument content exchanged in the functional status section of CCD:

  • Step 1: Encode to a standard coding system: encode assessment instruments' functional status and assessment items into LOINC.

  • Step 2: Concept matching to a standard medical terminology: where possible match LOINC codes of the assessment instruments' items with one or more equivalent terms from a standard medical terminology. The suggested medical terminology is often SNOMED.

  • Step 3: Insert the LOINC codes of the assessment instrument items (e.g., items from the MDS) (and their SNOMED equivalents) into the functional status section of the CCD.

  • Step 4 (Messaging): the CCD is an HL7 CDA document that is sent as a sequence of HL7 messages.

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