PHR (Personal Health Record) - CCD Development

Question

We are developing a PHR App. The Patient information should go as CCD to the clinic that they want to go. Whether the CCD should have only the narative block or should this accompany with semantic block too?

Answer 1

Here are some assumptions I am making about your question with my answer: 1) The PHR App has data that needs to be formatted as a CCD and sent to the clinic EMR. 2) The CCD that we are sending from the PHR to the clinic is primarily patient entered data. I presume it could also have data that was fed into it from other source systems.

The standard that EMR systems use and are certified to currently is the HL7 IG for CDAR2: C-CDA Templates for Clinical Notes (US Realm) DSTU Release 2.1. The document was published in August 2015. It contains the templates for several document types including the CCD.

The CCD document requires several Sections within it, including:

• Allergies and Intolerances Section (entries required) (V3)
• Medications Section (entries required) (V2)
• Problem Section (entries required) (V3)
• Procedures Section (entries required) (V2)
• Results Section (entries required) (V3)
• Social History Section (V3)
• Vital Signs Section (entries required) (V3)

As you can see, there are entries required for all of the sections except for the Social History Section. That means that the semantic data is required for all those Sections that state "entries required". Since these Sections are required, it is necessary to include both narrative and semantic data.

This would be desirable in any case, as most systems are now required to have the ability to parse the semantic data and add the semantic elements to the EMR as discrete data elements. Sending the semantic data will help the clinic EMR provide a unified view of the patient medical record that is more complete. Even though other Sections are optional and entries may be optional, it is still beneficial to the EMR to get the semantic data elements when possible.

Answer 2

1. How do you discriminate those sections are Entry Required? Do you mean the entry required from Health Providers? 2. Since the Patient is given data and get ready his CCD to be shared for an appointment for the FIRST TIME, are these semantic data is required?