Clinical Document Architecture for Common Data Types

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Clinical Document Architecture for Common Data Types Powered By Docstoc
					                                                                                        October 2009

The Health Story Project bridges the gap between dictation/transcription and electronic health
records by developing technical implementation guides for structured narrative documents and
bringing them to ballot through HL7. Five guides for various clinical notes have been published
and are made available by industry vendors today, and additional guides are in development.
The Health Story approach is exciting in that it supports clinicians in moving toward electronic
medical record system adoption and ARRA Meaningful Use targets while allowing them to retain
preferred methods of care. The approach also leverages current technology investments and
supports creation of a comprehensive electronic clinical record that tells a patient’s complete
health story. Health Story offers the following suggested requirements to assist providers in
working with their vendors to integrate narrative notes with their EMR systems.

     Suggested Requirements                           Suggested Requirements
   for Electronic Health Record                   for Medical Transcription Service
          System Vendors                                   Organizations

Electronic health information system shall       Transcription system shall support HL7’s
support       HL7’s    Clinical   Document       Clinical Document Architecture Release 2
Architecture Release 2 (CDA-R2) standard         (CDA-R2) standard for the encoding of
for the encoding of narrative, text-based        narrative, text-based clinical information.
clinical information. More specifically, the     More specifically, transcription system shall,
system shall receive, display, transform,        at a minimum, support the creation and
and parse CDA-encoded clinical documents         delivery of CDA-R2 compliant documents with
as described in the HL7 Implementation           document header information encoded using
Guides for CDA-R2 for document types             the CDA-R2 General Header Constraints
including History and Physical Note,             Template.     Transcription systems should
Consultation     Note,    Operative    Note,     create CDA-R2 documents which comply with
Diagnostic Imaging Report, and Discharge         Level 2 encoding as specified in the HL7
Summary. System shall receive, display,          Implementation Guides for CDA-R2 for
transform and parse CDA-R2 compliant             document types including History and
documents with encoded headers (Level 1          Physical Note, Consultation Note, Operative
encoding). System should process CDA-R2          Note, Diagnostic Imaging Report, and
compliant documents that include Level 2         Discharge Summary. Transcription system is
encoding, and are encouraged to process          encouraged to support the creation and
CDA-R2 compliant documents that include          delivery of CDA-R2 compliant documents that
Level 3 encoding. Systems that support the       include Level 3 encoding (based on the
creation of narrative clinical information       above-referenced      HL7      Implementation
shall create CDA-R2 compliant documents,         Guides).
consistent with, at a minimum, the HL7
Implementation Guides for CDA-R2 (US             Note: The Implementation Guides listed here are
Realm) for document types including History      those available at the time of release of these
and Physical Note, Consultation Note,            suggested requirements.       Final requirements
Operative Note, DICOM Radiology Imaging          should include the addition of applicable HL7
Report, and Discharge Summary.                   Implementation Guides published at the time of
                                                 the actual request for proposal. A complete list of
                                                 related CDA Implementation Guides for Common
                                                 Document      Types      can    be    found      at

                Ask a Health Story member for more information, or contact:
    Joy Kuhl, The Health Story Project, or

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