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HITSP CAP119 Communicate Structured Document Version:1.0 25 January 2010


Type:Data Agreement
Start Date:2010-01-31
Scope:HITSP/CAP119 Communicate Structured Document addresses interoperability requirements that support the communication of structured health data related to a patient in a context determined by the author of the document. This Capability supports the exchange of a broad range of CDA documents related to clinical patient care. The following are examples of the type of CDA structured data that are supported:

• Continuity of Care Document (CCD)

• Emergency Department Encounter Summary

HITSP Communicate Structured Document Capability

Review Copy

20100131 V1.0.1

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• Discharge Summary (In-patient encounter and/or episodes of care)

• Referral Summary Ambulatory encounter and/or episodes of care

• Consultation Notes

• History and Physical

• Personal Health Device Monitoring Document

• Healthcare Associated Infection (HAI) Report Document

• Labor and Delivery Record

• Antepartum Record

• Operative Notes

• Procedure Notes

• Plan of Care

• EMR Transfer of Care

• Long Term and Post Acute Care Assessments

1.2 SCOPE

A Capability provides the ability for two or more systems to address a business need for interoperable information exchange. The objective of a Capability is to provide the bridge between the business, policy and implementation disciplines by defining a set of information exchanges at a level relevant to policy and business decisions and specifying the use of HITSP constructs sufficiently for implementation. A Capability supports stakeholder requirements and business processes and includes information content, infrastructure, security and privacy. The design of Capabilities leverages existing HITSP constructs and communication methodologies. As new constructs become available, the scope of this Capability may be extended.

The scope of this Capability is to support the exchange of clinical notes and other clinical documents containing structured information, e.g., remote monitoring data. Example authors would be clinicians, patients or patient representatives documenting clinical care. These clinical notes document a patient encounter, visit or service. Clinicians treating patients as part of a consultation, transfer of care, providing care management or continuity of care may use this Capability to access structured clinical notes to gain a more comprehensive understanding of a patient’s history or to create and share clinical notes with other providers to better support transfers of care.

Documents that are not typically authored by a clinician or not generated for clinical purposes (e.g., patient forms, consents, administrative documents) and do not constitute clinical documentation of a patient encounter or service are not in scope for this Capability. In addition, items that may accompany or support clinical notes, such as images and waveforms, are not in the scope of this Capability.
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Relationship Organization Item
utilizes HITSP HITSP C80 Clinical Document and Message Terminology Compare these items   
older or newer version of HITSP HITSP CAP119 Communicate Structured Document v 0.0.1 Draft Compare these items   
is referenced in HITSP HITSP IS06 Quality Interoperability Specification January 25, 2010 Compare these items   
Relationship Organization Item
is the parent view of HITSP 1.0 CAPABILITY INTRODUCTION   
is the parent view of HITSP 2.0 REQUIREMENTS ANALYSIS (CAPABILITY)   
is the parent view of HITSP 2.1 INTRODUCTION SYSTEM ROLE CAPABILITIES   
is further defined by HITSP CAP 119 CONSTRAINTS AND ASSUMPTIONS   
is further defined by HITSP CAP 119 INFORMATION EXCHANGE OPTIONS   
is composed of HITSP CAP 119 INFORMATION EXCHANGES 2.2.1   
is composed of HITSP CAP 119 INTEROPERABILITY SPECIFICATION REQUIREMENTS ANALYSIS   
is further defined by HITSP CAP 119 REQUIREMENTS MAPPED TO CONSTRUCTS   
is composed of HITSP CAP 119 SPECIFIED INTERFACES BY SYSTEM ROLE   
is composed of HITSP CAP119 DATA AND INFORMATION EXCHANGE REQUIREMENTS   
is the parent view of HITSP GUIDANCE FOR USE OF A CAPABILITY   
utilizes HITSP HITSP SC112 Healthcare Document Management Data Service Collaboration Version 1.0   
utilizes HITSP HITSP SC112 Healthcare Document Management Data Service Collaboration Version 1.1 25 Jan 2010   

There are no Value Domains linked to HITSP CAP119 Communicate Structured Document Version:1.0 25 January 2010.

HITSP Acronyms List
HITSP Data Architecture Technical Note TN903
HITSP TN 901 -Technical Note for Clinical Documents
HITSP TN904 Harmonization Framework and Exchange Architecture Technical Note
Security and Privacy Technical Note
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