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Thursday, February 3, 2011

Transfers of Care

I was on the ONC S&I Framework Transfers of Care Use case workgroup call yesterday. We got an outline of the project, went over rules of the road, and went into a little detail about the scope of the subgroup. It is tasked to create use cases for transfers of care.

To avoid Deja Vu All Over Again, I thought I'd share where we have been on this topic over the past decade and more.

In 1998, HL7's Claims Attachments Workgroup started development of a number specifications for a couple of different types of clinical reports, one of which included the Discharge Summary.  That specification identified the following key data elements:
  • Admit and Discharge Date
  • Admission and Discharge Diagnosis
  • Course
  • Consultations
  • Disposition
  • Procedures and Studies
  • Physical Exam
  • Discharge Medications
  • Discharge History
  • Followup
  • Treatment Plan
The use case for this specification was to support automation for claims review using attachments.

In 2005, shortly after CDA Release 2 was completed, I edited the Care Record Summary (CRS) Release 1.0.  That supported three main care transition notes:  The Summarization of Episode and its two main subtypes: Discharge Summarization Note and Transfer Summarization Note.  That work was based on the prior claims Attachments efforts and the Vancouver Island Health Authorities eMedical Summary specification which they kindly made available to HL7.
That specification added the following data elements to the Discharge Summary:
  • Chief Complaint/Reason for Visit
  • History of Present Illness
  • Problem List
  • Medications Administered and Medications on Admission (to meet med Reconciliation requirements)
  • History of Allergies
  • Review of Systems
  • Vital Signs
  • Advance Directives
And also created a Referral Summary based on the History and Physical specification that Claims Attachments had done.  That included:
  • Reason for Referral
  • Chief Complaint/Reason for Visit
  • History of Present Illness
  • Problem List
  • Medication List
  • Allergy List
  • Sugical History
  • Immunizations
  • Family History
  • Social History
  • Review of Systems
  • Vital Signs and Physical Exam
  • Advance Directives
That same year, the IHE Patient Care Coordination domain began.  We extended the HL7 CRS work from level 1 header and level 2 section requirements into level 3 entry requirements on problems, medications and allergies, resulting in the XDS-MS profile.

All hell broke lose between ASTM and HL7 over the CRS work in late 2006, which eventually led to the start of the CCD work in December of 2006 collaboratively between ASTM and HL7.

Shortly after that, IHE began work on XPHR which was a profile of CCD.  HITSP began work on the "Registration and Medication Summary" which was originally based on the XPHR work, but was dropped back to be based upon CCD after several protests from CCR promoters.   This became the first version of the HITSP C32.

CCD used much of the work that had already been done in CRS and was adopted by HL7 in January of 2007.  XPHR was completed in August of 2007 based on the final CCD work, and XDS-MS underwent a similar change over that took about two years to get all the bugs out of.

HL7 and Health Story (formerly CDA for Common Document Types) began work on a number of document specifications focused on transcription.  These included the History and Physical Note, which took the general header constraints first established in CRS and made them a template which could be applied to any document.  They also completed work on a Consultation Note.

In 2008, HITSP was given the Consultations and Transfers of Care Use case, for which those specifications were adopted.  In that same year, the Care Management and Health Records TC worked on harmonizing across the HITSP specifications.  HITSP had adoped two other IHE profiles EDES (C28), and XDS-MS (in C38 and C48) but in ways that meant a medications section in C28, C32, C38, C48 were not necessarily compatible with each other.  That resulted in the creation of C83 (Sections and Entries) and C80. 

In 2009 we went a bit crazy in HITSP, replacing our efforts mid-year with a crash priority task assignment by ONC to simplify our specifications even further.  That resulted in more changes to C83 and C80, the creation of the HITSP Data Elements specification (C154), and changes to the various CDA specifications that relied upon them, including C28, C32, C48, C78, C84, C148, C161 and C162.

HL7 and Health Story continued their work in developing specifications for operative note and procedure note, and HITSP also updated C83 and Capability 119 (Exchange Docuemnts) to support a templated CDA approach.

The templated CDA approach supported by the current version of C83 enables not just transfers of care, but also establishes a set of "data molecules" that can be exchanged in different kinds of clinical documents.  RTI and IBM used these capabilities when they created a specification for assessments based on the CMS CARE data set, proving that this approach can rapidly support implementation guide development.

I'm exited about the possibilities that successful completion of the Transfers of Care project would enable, but also concerned about potential changes in direction from the current approach.  There's a lot of existing work that has been done in this space.  Some of it is has been used for more than decade.  Some of it is just as recent as January 2010, when HITSP harminized C83 and C80 with meaningful use vocabulary requirements, enabling C32 Version 2.5 to be selected in the Standards and Certification Regulation.

It's a tightrope walk almost as challenging as the Consolidation Project.  The desire to make it better than it is competes with the desire to avoid breaking changes.  We will need to carefully balance the various tensions to be successful.  These projects are on much to short a timeline to enable "rip and replace" thinking, although there are some I would expect who will want to do just that. 

Over the past seven years time I've been editor for more than a dozen implementation guides, and co-chaired three different committees in three different organizations overseeing this work.  Tommorow I'll outline some of my thoughts on Transfers of Care use cases based on the work that I've seen in this area. 

Well, I have my work cut out for me, I hope to see you there.


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