More thoughts on Documents

More on Documents

The HIT Standards Committee had an interesting meeting in June. One of the discussions concerned documents. It seemed to me that some of the committee members did not understand current document standards, based on some of the comments. Some of the best sources for information on health documents can be found in previous work by HITSP, IHE, and the standards development organization, HL7.

In discussing document standards, one of the committee members was critical of documents because of the challenges of interoperability with potentially an infinite number of documents. Realistically, in medicine, only a few dozen document types need to be available and are used by clinicians on a regular basis.

In my opinion, the most important document type needed to immediately improve patient care in the US is the patient care summary. This type of document is useful whenever there is a transition of care, in inpatient and ambulatory environments. An example would be when a patient is transferred from one unit to another or from the hospital to a long term care setting. Outpatient use of patient care summaries is needed when a patient is referred to a specialist, sent for special diagnostic studies, and when the patient is sent back to their primary care clinician for continued care. The patient care summary is essential for patient engagement in their health care and personal health information management and may be useful to help update PHRs.

HL7 (CDA 2.0 R2) and HITSP (C32) have well accepted standards and implementation guides for this document type, the CCD. This standard is one of those specified recently in the final standards regulations. Its alternative, the CCR serves the same function but has limitations in that there is no implementation guide and it is not extensible in its current form. HITSP took the HL7 Clinical Document Architecture (CDA) standard and began developing modules that could be selected to be combined to form a variety of summary documents. The relevant information can still be viewed at the HITSP website under C80 and especially C83. Keith Boone's blog is an excellent source for information on CDA and CCD.

Integrating the Healthcare Enterprise (IHE) has taken the lead to expand the list of defined summary documents. Under their system, these are called content profiles and are managed by the Patient Care Coordination (PCC) technical committees. Examples are emergency care summaries, antepartum records, immunization content summaries, and recently, nursing care summaries. I think that there is still an urgent need to develop hospital discharge summary and procedure summary specifications.

One of the advantages of these types of documents is that the standards already have been developed and tested. They can extend established workflows and offer a framework for exchanging structured data. With some work on data flow mapping vendors can use standards that provide solid interoperability. New document types can be developed simply by adding new modules, when needed. IHE, through the IHE Connectathon, and NIST through test specifications can provide the opportunities to test and validate the interoperability of the various health care documents and expand their capabilities as new document types are developed.

For those with further interest in learning about HL7 CDA and CCD there is a free webinar on September 14th. I recommend that you check it out.