John Quinn HL7 CTO. (with content contributed by Bob Dolin, MD HL7 Chair Elect) IHIC Kyoto, Japan, May
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1 Continuity of Care Document (CCD) USA Health Information Technology Standards Panel (HITSP) John Quinn HL7 CTO (with content contributed by Bob Dolin, MD HL7 Chair Elect) Health Level Seven, Inc. and 2009 Semantically Yours, LLC. All rights reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office IHIC Kyoto, Japan, May
2 HL7 CCD The HL7 Continuity of Care Document (CCD) is an Implementation Specification of an HL7 CDA R2 Electronic Document. CCD is based on the ASTM Continuity of Care Record (CCR) Functional Specification. CCD has been adopted for you by the US Health Information Technology Standards Panel (HITSP) in several of its published Implementation Specifications. Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office IHIC Kyoto, Japan, May. 2009
3 ASTM CCR The ASTM Continuity of Care Record was developed by various individuals from the American Academy of Family Physicians (AAFP), The Massachusetts Medical Society, HL7 and others. The intention was to carry electronic clinical information that would be sufficient to assist a physician in a medical encounter (e.g., ER, referral to specialist, etc.) Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office IHIC Kyoto, Japan, May. 2009
4 ASTM CCR ASTM CCR did not have a reference information model (e.g., HL7 RIM), an electronic document framework definition (e.g., HL7 CDA), or XML schemas and syntax definitions. Combining CCR and CDA into CCD solved these issues. Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Office IHIC Kyoto, Japan, May. 2009
5 HITSP/C32 Implementation Specification (IS) Summary Documents using HL7 CCD HL7 uses templating to layer constraints atop the HL7 CDA Standard. This templating applies the ASTM Continuity of Care Record (CCR) functional standard and is called the HL7 Continuity of Care Document (CCD). HL7 has worked with HITSP to then layer additional constraints atop the HL7 CCD to produce HITSP/C32 HITSP/C32 HL7/ASTM CCD HL7 CDA 5
6 HITSP/C32 Summary Documents using HL7 CCD C32 further constrains the following CCD templates Content Module HITSP Optional Entry HITSP Repeatable Entry Advance Directive O N Allergy / Drug Sensitivity O N Comment O Y Condition O N Encounter O N Healthcare Provider O Y Immunization O N Information Source R Y Insurance Provider O N Language Spoken R2 Y Medication Prescription and Non-Prescription O N Person Information R N Plan of Care O N Pregnancy O N Procedure O N Support R2 Y Vital Sign O N 6
7 HITSP/C32 Summary Documents using HL7 CCD Caveats Where no constraints are stated, instances are subject to and are to be created in accordance with the base CDA R2 specification. For example, the CDA R2 specification declares an attribute to be optional and the CCD specification contains no additional constraints, that attribute remains optional for use in a CCD instance. 7
8 HITSP/C83 CDA Modules Component C32 templates (and all other HITSP CDA templates) are collected together in HITSP IS /C83 8
9 HITSP/C83 CDA Modules Component HITSP/C83 is a collection of CDA templates for use in: HITSP/C28 Emergency Care Summary HITSP/C32 - Summary Documents Using HL7 Continuity of Care Document (CCD) HITSP/C38 - Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS) HITSP/C48 Encounter Document constructs HITSP/C84 Consult and History & Physical Note Document HITSP/C78 Immunization Document HITSP/C74 PHRM HITSP/C62 Scanned document 9
10 HITSP/C83 CDA Modules Component Caveats HITSP/C83 only contains CDA templates, and only those cited within a HITSP recognized specification. There currently is no single comprehensive repository of all HITSP, IHE, and HL7 CDA templates, although plans are underway to construct one. Layering of constraints poses implementation challenges (which we ll address in upcoming slides). HITSP/C32 HITSP/C83 IHE PCC Tech Framework HL7/ASTM CCD HL7 CDA 10
11 HITSP/C80 Clinical Document and Message Terminology Clinical terminology referenced by CDA and HITSPrecognized messages are collected together in HITSP/C80 11
12 HITSP/C80 Clinical Document and Message Terminology Caveats ITSP/C80 only contains clinical terminology cited within a HITSP recognized specification. There currently is no single comprehensive repository of all HITSP, IHE, and HL7 value sets, although plans are underway to construct one. 12
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