So far, we have completed a big chunk of the Volume I work (overview, scope, use cases, actors and transactions), and are just getting started on Volume II (technical details). Because of the many simplifications that we implemented a month ago, this is mostly a content profile. Accessing the data used for reconciliation is supported by IHE IT Infrastructure profiles (e.g., XDS, XDR, XDM), and the structure of problems, medications, and allergies is specified in IHE PCC Content profiles.
The major additions to content include the following:
A reconciliation act which collects:
- The identity of the person performing the reconciliation. Open question: Other than name, address, telephone and ID, should we gather other data (specialty, licensure, et cetera).
- The sources of information, either as
- Documents, in which case we need to know the Document used, and the system (e.g., HIE home community identifier) from which it came (perhaps captured as an informant).
- Query Results (using QED), in which case we need to know the query used to retrieve the data (captured as observation media), the performer of the query (to address issues of acess ontrol), and the system from which it came (an identifier similar to the home community ID).
- The clinical statements that were produced as a result of the reconciliation process.
- Relevant links between the resulting clinical statements produced from reconciliation, and any previous clinical statements showing the progression of information. For example, if a different medication regiment is intended to replace an existing regimen, this link should be present. A similar case might occur where "back pain" is subsequently diagnosed as a "compressed disk", in which case the latter diagnosis might "replace" the former.
The final piece that is needed is a discussion of the "Concern model" which HL7 used to keep track of problems and allergies as they progress through the care and treatment process. This will likely be added to Volume I at a high level, and then be reflected in some clarifications in Volume II on the Concern, Problem Concern and Allergy Concern entries.
One issue that needs further attention is how to deal with updates to documents or content used in reconciliation. The IHE IT Infrastructure DSUB (pdf) profile allows a system to subscribe to documents for a patient, but in this particular case, we'd actually want to subscribe for updates (replacements) of the specific documents used in the reconciliation act. That's not presently supported by DSUB, but I think we'd want to see that option. It's dealing with an edge case that we'd hope would be infrequent (replacing a document reported in error), but still important to the process.
I don't think there are good answers to this same challenge for QED yet, although the CM profile effectively acts as a subscription using very similar transactions to QED. I'll have to think about that one.