Posted by: RedaChouffani
CCD, CCR, consilidated CDA, HL7, Meaningful use Stage2
One of the areas that has seen changes in the NPRM for meaningful use stage 2 includes the standards according to which health data is exchanged. In this case, the affected areas are related to clinical messaging, electronic prescribing, and patient summary and transport specifications.
Specifically, one of the standards has been substituted for another. In meaningful use stage 1, the selected standard was CCD/CCR (HITSP C32); however, in the new ruling this was replaced with consolidated CDA. The original standards (C32) included administrative and clinical information — registration, demographics, insurance, problem list, medication list, allergies, test results, etc.
One of the reasons the consolidated CDA was selected as the standard is due to its single implementation guide, as well as the centralization of many of its templates. These templates allow for more information to be exchanged amongst different clinical applications and systems.
The consolidated CDA provides a library of reusable templates, such as:
- Consultation Note
- Diagnostic Imaging Report
- Discharge Summary
- Operative Note
- Procedure Note
- Progress Note
- Unstructured Document
Meaningful use stages 1, 2 and 3 all call for clinical information and summary records to be exchanged. In section § 170.210, Standards for health information technology to protect electronic health information created, maintained, and exchanged”, as documented in the proposed ruling ” Health Information Technology; Implementation Specifications, and Certification Criteria”, there is a clear outline of the different data elements that will be required from vendors seeking certification of their products as certified EHR.
As these standards become widely adopted by vendors, they will help facilitate the exchange of meaningful health information. Enabling clinicians to access health information and having the ability to work with a more comprehensive data set will have a significant value in terms of real time information extraction, as well as for data analytics capabilities.