Florida HIE CCD/C32 Overview

Transcription

1 Florida HIE CCD/C32 Overview The Florida Health Information Exchange s (HIE) Patient Look-Up and Delivery (PLU) service enables participating entities to query and receive authorized patient health information through the exchange of Continuity of Care Document (CCD) Summary files. A C32 is a type of CCD that summarizes a patient s medical information for the purpose of exchange. The CCD C32 is an XML file that is consumable by a computer, but is not conducive for display to a clinician in its raw format. C32 Summary Document C32 s may include both administrative details (e.g., demographics, insurance, etc.) and clinical information (problem list, medication list, allergies, test results, etc.). C32 documents are provided to each participant s system for consumption and display in the participant s own native viewer and style. How a CCD is displayed is completely at the discretion of PLU participant and their constituents. Many entities will provide their participants with a C32 that will have a similar appearance to the way their local clinical data is usually displayed. As stated in the PLU subscription agreement, participants should provide information (if available) for all sections of the C32. A C32 may contain up to 19 different modules. The modules and the descriptions of their contents are listed below. C32 Content Module Advance Directive Allergy/Drug Sensitivity Comment Condition/ Problems Encounter Health Care Provider Immunization Information Description Contains the patient s expectations and requests for care, along with the physical locations of the original documents Contains data on the substance intolerances and the associated adverse reactions suffered by the patient; at minimum, currently active allergies, any relevant historical allergies, and adverse reactions must be listed Contains comments for entries in other content modules Contains data on the problems currently being monitored for the patient Contains information describing the patient s history of encounters. At minimum, current and pertinent historical encounters must be included; a full encounter history may be included Contains health care providers involved in the current or pertinent historical care of the patient; if no health care providers are supplied, the reason must be supplied as free text in the comment section (e.g., no providers, provider unknown, etc.) Contains the patient immunization history Contains information about the original author (The name, role, etc. of the person(s) 1 P a g e

2 Source Insurance Provider Language Spoken Medication: Prescription and Non- Prescription Personal Information Plan of Care Pregnancy Procedure Results Support Vital Sign that authored the info in each section) and a reference to the original document to be provided. This module may be applied to all other entry Content Modules. Contains data on the patient s payer(s), whether a third party insurance, self-pay, other payer or guarantor, or a combination; if no payment sources are supplied, the reason must be provided as free text in the narrative block Contains the patient s primary and (if applicable) secondary language Contains information about the patient s relevant medications; at minimum, the currently active medications must be listed Contains patient demographics including required fields (personal ID, address, phone, , URL, name, gender, DOB, and marital status) and optional fields (religious affiliation, race, ethnicity, birth place, age, mother s maiden name, multiple birth indicator, birth order, and document timestamp) Contains information about the expectations for care, including proposed interventions and goals for improving the condition of the patient Contains pregnancy status of patient Contains a list of surgical procedures that have been performed on the patient Contains information about the results from diagnostic procedures At a minimum, contains the key support contacts relative to health care decisions, including next of kin, if no health care providers are supplied, the reason should be supplied as free text in the narrative block. Contains information documenting the patient s vital signs What does a C32 look like in its raw format? 2 P a g e

3 Below are examples of what the clinician would possibly view. 3 P a g e

4 Example 1 Example 2 4 P a g e

5 REFERENCES Healthcare Information Technology Standards Panel (HITSP) CCD/C32 Summary Document reference documentation: HITSP CDA/C83 Content Modules reference documentation: 5 P a g e