Data Standards
The Health Story Project has an Associate Charter Agreement with Health Level Seven and works with related organizations toward harmonization. Over the previous three years, Health Story developed five technical implementation guides (IG) using HL7’s Clinical Document Architecture (CDA).
- HL7 IG for CDA R2: Consultation Notes: Draft Standard for Trial Use
- HL7 IG for CDA R2: History and Physical Notes: Draft Standard for Trial Use
- HL7 IG for CDA R2: Operative Note: Draft Standard for Trial Use
- HL7 IG for CDA R2: Diagnostic Imaging Report, Release 1: Informative Standard
- HL7 IG for CDA R2: Care Record Summary Release 2: Discharge Summary: in publication
The standardization and adoption of these electronic documents unlocks the valuable data from narrative documents and will enlarge and enrich the flow of data into the electronic health record as well as speed the development of interoperable clinical document repositories for use within the enterprise and regional and national networks.
Volunteer input into standards development is welcome. Current and upcoming work includes:
- HL7 IG for CDA R2: Procedure Note (Endoscopy Report): in publication
- HL7 IG for CDA R2: Unstructured Documents: in publication
- Billing and Reimbursement Requirements
- Progress Notes
The Consultation Note and History and Physical are referenced by the Healthcare Information Technology Standards Panel (HITSP) in document C/84, "Consult & History & Physical Note Component." They are also referenced in this regard by the Certification Commission for Healthcare Information Technology (CCHIT) in the current Health Information Exchange work group roadmap criteria, Road.HIE.157, "The HIE shall provide the ability to receive and forward a HITSP C/84 document," slated for 2011 certification.
