HL7/IHE Health Story Implementation Guide Consolidation

Description

This project will take a series of existing CDA implementation guides for various types of clinical documents and consolidate them into a single publication as a DSTU. These publications include IGs for the following types of clinical notes: - Continuity of Care Document - History & Physical - Consult Note - Operative Note - Procedure Note - Diagnostic Imaging - Discharge Summary (CRS R2) - Progress Note - Unstructured Documents The Project will review and reconcile related IHE Templates. The Project will not address IHE CDA Templates that do not overlap with the HL7 Implementation Guides listed above, although that could be considered for future collaboration. Where a Health Story document is appropriate as an attachment, we will review the attachment requirements as part of the scope of this project, recognizing that some attachment requirements (e.g. the need for the CDA to point to a billing identifier) may not be part of the consolidated guide, but could be part of a supplemental attachments guide. The project will not introduce a review of content of these notes and will be limited to the following objectives: 1. Reconciling discrepancies among the guides (HL7, IHE, HITSP) 2. Disambiguate current templates: should clarify; should not add requirements or expand scope 3. Updating to meet regulatory requirements (C32, C83 where they overlap with the implementation guides listed here) 4. Adopting consistent publication format/style for conformance statements The project will not introduce new templates, where not required per the objectives above. ADDITIONAL SCOPE ADDED IN FEBRUARY 2012: This project will review, update, and add new templates to the Consolidated CDA Templates DSTU. New section and entry-level templates will provide guidance to implementers for more consistent implementations. For example, the current Functional Status section describes functional statuses and then references generic Problem and Result Observations. This project will add more detailed functional status templates. The project will be scoped to elements that support transitions of care in the CMS Continuity Assessment Record and Evaluation (CARE) assessment tool. The ballot will be scoped to the new and updated templates, and the SDWG agreed upon errata. The project will not introduce a review of content of existing document-level templates. The entire DSTU will not be re-balloted. ADDITIONAL SCOPE ADDED IN MAY 2012: The Patient Assessment Summary Work group (PAS WG), a work group within the ONC Standards and Interoperability (S&I) framework, identified a subset of data elements from patient assessment instruments for exchange in a summary document.

Misc Notes
Jan 2014: TSC approved request for expiration date extendtion for HL7 Implementation Guides for CDA Release 2: IHE Health Story Consolidation, DSTU Release 1.1 - US Realm at TSC Tracker 2870. Expiration date now through 2017-09-22. Jan 2013: TSC approved DSTU publicaton of HL7 IG for CDAR2: Patient Questionnaire Assessment Summary, DSTU Release 1 - (US Realm) for 24 months with the name: CDA Release 2: Long-Term Post-Acute Care (LTPAC) Summary, DSTU Release 1 thru Mar 05, 2015 Oct 2012: The TSC approved a motion to withdraw this ANSI project via their Oct 22, 2012 call at http://hl7tsc.org/wiki/index.php?title=2012-10-22_TSC_Call_Agenda: HL7 IG for CDA R2: Operative Notes, Release 1 DSTU test period accepting comments thru July 24, 2014 HL7 Implementation Guide for CDA Release 2: Operative Notes, Release 1 May 2012: SD WG submitted a revised PSS. The Patient Assessment Summary Work group (PAS WG), a work group within the ONC Standards and Interoperability (S and I) framework, identified a subset of data elements from patient assessment instruments for exchange in a summary document. April 2012: TSC approved an out of cycle ballot request for HL7 Implementation Guides for CDA Release 2: IHE Health Story Consolidation, Release 1.1 (US Realm). DSTU Period - Accepting Comments until December 14, 2013 Feb 2012: Additional Templets scope added to the project by Brett Marquard. PMO originally created project 854 to capture this work, but have since archived 854 and modified this project. Dec 2011: TSC approved the DSTU publication for 24 months Feb 2011: SD WG has requested a 1 year extension of the following DSTU: HL7 Implementation Guide for CDA Release 2: Operative Notes, Release 1 via TSC Tracker # 1818. TSC approved request. DSTU-Accepting Comments Mar. 20, 2011 for HL7 Implementation Guide for CDA Release 2: Operative Notes, Release 1 NOTE TO THE TSC: The project deliverable will be a publically available document. When a deliverable is specified as a Public Document, the TSC must make a determination as p