HL7 Implementation Guide for CDA R2
This project designed a basic procedure note in XML as a constraint on HL7 version 3 Clinical Document Architecture Release 2. The note is basic enough to be used for all procedures and includes a sample note for endoscopy. To promote standardization and acceptance, it was closely modeled on the current HL7 CDA Operative Note. Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (JCAHO) requirements, with specialty group input, was used to choose the contents. CMS and JCAHO, the primary regulators, requirements dictated the minimum content standards. Implementer institutions were given opportunity for input as to compatibility with current/planned systems.
The Health Story Project collaborated with the American Society of Gastrointestinal Endoscopy (ASGE) with strong volunteer support from Oregon Health & Science University. Within HL7, the project was sponsored by the Structured Documents Work Group.
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HL7/IHE Health Story Consolidation Project
The HL7/IHE Health Story Implementation Guide Consolidation Project is a collaboration of Health Level Seven (HL7) International, Integrating the Healthcare Enterprise (IHE) and the Health Story Project. Working through the HL7 standards development organization, volunteers consolidated exchange standards for eight common types of clinical documents along with the HL7 Continuity of Care Document (CCD) standard into one comprehensive implementation package that establishes a foundation for health information exchange.
Through the consolidation and harmonization effort, the project addressed minor areas of ambiguity within the specific Standards Final Rule requirement to implement HL7 Clinical Document Architecture (CDA) Release 2, Continuity of Care Document according to HITSP C32.
ONC's Office of Standards and Interoperability (S&I) hosted the volunteer effort within its S&I Framework and facilitated the project through HL7 and IHE with support of its contractors. Consolidated CDA is a recommended standard for clinical documents in the proposed rule supporting Meaningful Use Stage 2.
Within HL7, the project was sponsored by the Structured Documents Work Group.
» Access HL7 Implementation Guide Release 2: IHE Health Story Consolidation, Release 1 - US Realm through HL7