The HITSP Summary Documents Using HL7 Continuity of Care Document (CCD) Component describes the document content summarizing a consumer's medical status for the purpose of information exchange. The content may include administrative (e.g., registration, demographics, insurance, etc.) and clinical (problem list, medication list, allergies, test results, etc) information. Any specific use of this Component by another HITSP specification may constrain the content further based upon the requirements and context of the document exchange. This specification defines content in order to promote interoperability between participating systems. Any given system creating or consuming the document may contain much more information than conveyed by this specification. Such systems may include Personal Health Record Systems (.1.s), Electronic Health Record Systems (EHRs), Practice Management Applications and other persons and systems as identified and permitted.
This Component is essentially a subset of the healthcare data that has been developed for specific business Use Cases. This subset contains the minimum critical or pertinent medical information sections as specified by the business case. Information conveyed according to the Component Construct is a representative extract of the information available on the creating system. The information in the HITSP Summary Documents Using HL7 Continuity of Care Document (CCD) Component and the creating systems must be consistent. Furthermore there should be no data elsewhere in the creating system that would contradict the meaning of any data in this construct. The expectation is that consuming systems will be able to use this specification as a source of information to input and/or update information in their instantiation of the healthcare record. This specification does not define the policies applicable to the import of this information.
It is anticipated and desirable that some implementers of the HITSP Summary Documents Using HL7 Continuity of Care Document (CCD) Component will want to add data and sections to permit greater communication between systems. The underlying standards (primarily HL7 CCD - Continuity of Care Document) have additional modules that may serve such purposes. This practice is beyond the scope of this HITSP Component. Implementers should be aware that they must assume that receivers of the document may only be able to view or process content modules as described in this specification, and may not be able to use the additional modules in the document. This means that the HITSP Summary Documents Using HL7 Continuity of Care Document (CCD) Component must be able to stand-alone. Applications may wish to display the document in two different user-selected views, one of which is restricted to the minimal dataset contents of this component. Adding optional sections and data elements should not generate errors. Optional data should be used if understood by the receiving system, but must not change the meaning of the document.
This Component refers to the HITSP 2008 work cycle. It expands upon the prior version of the specification for a consumer's registration/medication history information to include content to support the consumer's access to clinical information, medication management activities and supportive information for quality of care assessment.
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This section provides a list of key reference documents and background material.
A list of key reference documents and background material is provided in the table below. These documents can be retrieved from HITSP Web Site [www.hitsp.org].
|Reference Document||Document Description|
|HITSP Acronyms List [publicaa.ansi.org]||Lists and defines the acronyms used in this document|
|HITSP Glossary [publicaa.ansi.org]||Provides definitions for relevant terms used by HITSP documents|
|TN901 - Clinical Documents||TN901 is a reference document that provides the overall context for use of the HITSP Care Management and Health Records constructs|
This section describes the conformance criteria, which are objective statements of requirements that can be used to determine if a specific behavior, function, interface, or code set has been implemented correctly.
In order to claim conformance to this construct specification, an implementation must satisfy all the requirements and mandatory statements listed in this specification, the associated HITSP Interoperability Specification, its associated construct specifications, as well as conformance criteria from the selected base and composite standards. A conformant system must also implement all of the required interfaces within the scope, subset or implementation option that is selected from the associated Interoperability Specification.
Claims of conformance may only be made for the overall HITSP Interoperability Specification or Capability with which this construct is associated.
A HITSP Interoperability Specification must be implemented in its entirety for an implementation to claim conformance to the specification. HITSP may define the permissibility for interface scoping, subsetting or implementation options by which the specification may be implemented in a limited manner. Such scoping, subsetting and options may extend to associated constructs, such as this construct. This construct must implement all requirements within the selected scope, subset or options as defined in the associated Interoperability Specification to claim conformance.
This section describes the specific Content Modules used by this Component. Implementers will need to refer to HITSP/C83 CDA Content Modules, to see the fields that HITSP is constraining differently from the standard. NOTE: Content Modules in this document map to the CCD Entry elements. The CCD sections themselves are not repeatable.
Table 2-3 Content Modules
|Constraint ID||Content Module||HITSP Optional Entry1||HITSP Repeatable Entry2||Specification Reference|
|C32-[CT1--1]||Advance Directive||O||N||See HITSP/C83 Section 220.127.116.11 Advance Directive|
|C32-[CT1--2]||Allergy / Drug Sensitivity||O||N||See HITSP/C83 Section 18.104.22.168 Allergies and Other Adverse Reactions Section|
|C32-[CT1--3]||Comment||O||Y||See HITSP/C83 Section 22.214.171.124 Comment|
|C32-[CT1--4]||Condition||O||N||See HITSP/C83 Section 126.96.36.199 Problem List Section|
|C32-[CT1--5]||Encounter||O||N||See HITSP/C83 Section 188.8.131.52 Encounters Section|
|C32-[CT1--6]||Healthcare Provider||O||Y||See HITSP/C83 Section 184.108.40.206 Healthcare Provider|
|C32-[CT1--7]||Immunization||O||N||See HITSP/C83 Section 220.127.116.11 Immunizations Section|
|C32-[CT1--8]||Information Source||R||Y||See HITSP/C83 Section 18.104.22.168 Information Source|
|C32-[CT1--9]||Insurance Provider||O||N||See HITSP/C83 Section 22.214.171.124 Payers Section|
|C32-[CT1--10]||Language Spoken||R2||Y||See HITSP/C83 Section 126.96.36.199 Language Spoken|
|C32-[CT1--11]||Medication - Prescription and Non-Prescription||O||N||See HITSP/C83 Section 188.8.131.52 Medications Section|
|C32-[CT1--12]||Person Information||R||N||See HITSP/C83 Section 184.108.40.206 Personal Information|
|C32-[CT1--13]||Plan of Care||O||N||See HITSP/C83 Section 220.127.116.11 Plan of Care Section|
|C32-[CT1--14]||Pregnancy||O||N||See HITSP/C83 Section 18.104.22.168 Pregnancy|
|C32-[CT1--15]||Procedure||O||N||See HITSP/C83 Section 22.214.171.124 List of Surgeries Section|
|C32-[CT1--16]||Support||R2||Y||See HITSP/C83 Section 126.96.36.199 Support|
|C32-[CT1--17]||Vital Sign||O||N||See HITSP/C83 Section 188.8.131.52 Vital Signs Section|
|C32-[CT1-18]||Results||O||N||See HITSP/C83 Section 184.108.40.206 Diagnostic Results Section|
NOTE: Optionality = "R" for Required, "R2" for Required if Known or "O" for Optional, or "C" for Conditional. Conditional footnotes are further described below. Repeatable = "Y" for yes, "N" for No.
NOTE 2: See HITSP/C83 for information regarding the repeatability of Data Elements with a Section