Module 13 Interoperability CCDs and CDA questions n answers

Module 13 Interoperability CCDs and CDA Clinical Document (CD) - correct answer any type of report or document CD Examples - correct answer 1. Surgeon's report 2. anesthesiologists consults 3. pathologists report 4. radiologist report 5. cardiologists report 5. continuity of care document Continuity of Care Document Sections (CCD) - correct answer 1. payers 2. AD 3. support 4. functional status 5. problems 6. family history 7. social history 8. alerts, allergies, AE 9. medications 10. medical equipment 11. immunizations 12. vital signs 13 results 14 procedures 15. encounters 16. plan of care CCD - correct answer a summary of a patient's status and can be sent from one EHR system to another Clinical Document Architecture (CDA) - correct answer document markup base standard that specifies the structure and semantics of electronic clinical documents for the purpose of exchange. building block template CDA features - correct answer defined information objects that can include text, image, sounds, and other multimedia content. the architecture specifies the schemas required for exchange Characteristics of CDA - correct answer 1. Persistence 2. stewardship 3. potential for authentication 4. wholeness 5. human readability Persistence - correct answer continues to exist in an unaltered state, for a time period defined by local and regulatory requirements; it may or not be important, depending on what happens on the receiving end. It can be stored as a persistent document, or its contents can be extracted and included in an EHR. stewardship - correct answer is maintained by an organization entrusted with its care potential for authentication - correct answer is an assemblage of information that is intended to be legally authenticated wholeness - correct answer means that authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document. human readability - correct answer means the contents can be read by a human. Why is this important? CDA can include both structured data for input into EHR in systems that have a structured EHR, or, for systems that are text based, can include human readable narrative that can be directly displayed. In the absence of interoperability, this still provides a method for sharing data. Key Aspects of CDA - correct answer 1. CDA specifications is richly expressive and flexible 2. encoded in XML 3. data elements from HL7 RIM 4. HL7 data types CDA allows - correct answer cost effective implementation across as wide a spectrum of systems as possible CDA supports exchange - correct answer of human-readable documents between users, including those with different levels of technical sophistication. CDA promotes - correct answer exchange that is independent of the underlying transfer or storage mechanism Major components : A CDA document is wrapped by the - correct answer clinical document element, and contains a header and a body Major components : The header lies between the - correct answer ClinicalDocument and theStructured Bodyelements and indentifies and classifies the document and provides information on authentication, the encounter, the patient, and the involved providers. CDA is expressed in - correct answer XML. The document wrapper is the XML tag ClinicalDocumentwith the ending tagClinicalDocumentthe body is wrapped by the tagStructuredBody