Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. Recommendations For Standards Development

12/01/2011

The expert informant interviews identified several standards gaps in need of strengthening and refinement: functional status, cognitive status, and advance directives.

Functional Status and Cognitive Status

CCD has a section for representation of a patient’s functional status and cognitive status. This section provides high-level guidance but there is no detailed modeling of functional or cognitive status represented in CCD. Without detailed modeling standardized there will be considerable variability in the way different modelers represent the concepts in CDA. What is needed is to further constrain and ballot the representations of pertinent functional and cognitive status concepts in CCD.

Using existing CCD templates, SDOs need to work with domain experts to develop granular templates that adequately express functional and cognitive status in the elderly population. Policy makers will need to be made aware of these templates as they are developed so that they can be reviewed and their use encouraged. These templates should be able to be used in any type of CDA document. Their design should be consistent with HITSP C32/C83 template requirements that have been cited in the meaningful use final rule. If there are conflicts with HITSP C32/C83 templates, they should be addressed through a formal process such as the S&I Framework to establish an updated national standard.

Advance Directives

The need to communicate a patient’s or family’s desires and a clinician’s orders for a patient’s end-of-life choice is especially critical in the age group represented in LTPAC settings. CCD has a section for defining a patient’s advance directives and for referencing supporting documentation such as legal documents containing these directives. CCD defines in this section how to represent data at a high level such as CPR and resuscitation status, and the existence of living wills and health care proxies. Referenced documents, if available, can be included in the CCD exchange package.

The CCD Advance Directive section is not a complete advance directive document. An advance directive CDA document conformance specification has not been created, although any type of document (e.g., a PDF file) may be referenced from a CCD. What is needed is to further constrain and ballot the representation of advanced directive concepts both as a separate document for communication and to represent the key concepts in a CCD.

The Meaningful Use Final Rule criteria 170.306 require that a complete certified EHR be capable of recording that a patient has an advanced directive document.

OASIS CDA Implementation Guide Evaluation

Currently a Questionnaire Assessment CDA Implementation Guide (IG) exists with an example specified for the MDS. HL7 Structured Documents committee should evaluate the IG and determine whether it can be applied to OASIS or should be updated to reflect guidance on developing a CDA representation of the OASIS-C Assessment form.

CCD for Patient Assessment Summary

As LTPAC organizations exchange MDS and OASIS data, the need to extract a subset of assessment items into a clinically relevant summary (Patient Assessment Summary) will make the content more consumable to physicians and other clinicians. A single standard for the content of a Patient Assessment Summary of the MDS and a Patient Assessment Summary of the OASIS is needed. If it is not developed, different LTPAC providers, vendors, health information exchange organizations and others will develop their own requirements making standardized implementation difficult.

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