HL-7 Medical Record/Information Management
Technical Committee Meeting
Minneapolis, MN
May 8 & 9, 2001
Attendees:
Tuesday Morning: Joint meeting between Medical Records/Health Information and Structured Documents. Wayne Tracy, Bob Dolin, Michelle Dougherty, Rhonda Sato, Mike Cassidy, Vassil Peytchev, Sandy Boyer, Calvin Beebe, Shekhar Sharma, Pai Jung Huang, Janet Washington.
Tuesday Afternoon: (Discussion on HIPAA privacy issues) Wayne Tracy, Michelle Dougherty, Rhonda Sato, Dean Ibaraki.
Wednesday Morning: Joint meeting between Medical Records/Information Management and the Structured Documents. Wayne Tracy, Bob Dolin, Michelle Dougherty, Rhonda Sato, Calvin Beebe, Andrew Woyak.
Wednesday Afternoon: Wayne Tracy, Michelle Dougherty, Rhonda Sato, Robin Zimmerman, Joann Larson, Jean Spohn, Suzanne Nagami.
Highlights:
· Analyzed and discussed the merged MDM/CDA Hierarchical descriptions presented by Bob Dolin in a joint meeting between MR/IM and Structured Documents. (Tuesday morning and Wednesday morning).
· Reviewed HIPAA privacy rules and discussed items which will need to be or potentially will need to be addressed. (Tuesday afternoon)
· Reviewed submitted proposal to clarify MDM usage. This proposal was previously proposed and approved by the Orders and Observations TC on Monday, May 7, 2001 and was presented and approved by the MR/IM TC.
· Ballots and Results:
· Voted unanimously to use the VISIO graphic tool (will be modified to an enhanced version) as the way to analyze and vote on the content of the R-MIM.
· Voted unanimously to accept a proposal to clarify MDM usage as approved by the Orders and Observations TC on Monday, May 7, 2001 and is presented for approval by the MR/IM TC.
· The group discussed and took a ballot to agree in principal with the modifications to add full ordering context to the existing MDM messages.
· Deprecation Issues:
· (CDA) Move the “signature time” from interval to point in the following– originator, patient, provider.
· Move “transcriptionist” to a singular rather than multiple.
· Outstanding/Future Issues:
· Vocabulary for the term “provider.”
· Address handling of documents originated by a patient (pre-admission questionnaire or patient amendment).
· Multiple providers in the heading for legal authenticator for the document as a whole.
· TX19 – Document Availability Status: Discussion related to whether an “unavailable” document is defined as “new” in version 3. Concerned that this definition/vocabulary is a poor word to describe a document’s availability status rather than the “newness” of a document.
· Address in the future a shortfall in which a use case where collaborative (multi-authored) documents are not deterministically treated.
· Need ability to track the actual assigned legal authenticator who is assigned separate from the actual authenticator. Need to add a refinement that doesn’t exist in the current CDA chapter.
· Nested OBX’s: It was discussed to allow Structured Documents to have OBX’s associated with a header to allow nesting. MR/IM will want to be involved in the future, but will allow structured documents to create the mechanism. Discussed need to use multi-media in a document.
· Discussed the originator in the act-context in the R-MIM. At this time will not include additional messaging for the originator in the act-context. This should be addressed in the future.
· A formal ballot will need to be taken in follow up with the discussion and vote-in-principle- on modifications to full ordering context to the existing MDM messages.
· Further discussion needed -- the group discussed obtaining use cases for a note for OBX and what it means in the document.
Tuesday Morning:
Joint meeting between Medical Records/Information Management and Structured Documents.
Wayne reviewed issues related to a confidentiality hierarchy to apply to an entire document rather than components of a document. Applying the 3 level hierarchy used by Structured Documents that would lend itself well to the medical records component. Wayne has worked with Bob from the Structured Documents TC to apply the 3 level hierarchy to medical records.
Bob from Structured Documents presented the VISIO used to describe the MDM/CDA R-MIM. He delivered a presentation to help the joint TC to understand the merged MDM/CDA R-MIM and hierarchical description to get the committee to a level where we will be comfortable balloting by the end of the day Wednesday.
· Bob reviewed TXA Mapping. There was discussion related to whom the role was scoped by.
· Maintaining of unique document names will be included in Clinical LOINC, but it will be an open table and allow additional document names to be added. Clinical LOINC will include unique names for documents and will be the keeper of the document names. Advantage over 1.02 architecture where we had to maintain table 270.
Open Issue for Data Types to be resolved prior to ballot:
· Discussion related to the TMR and assigning one time stamp versus an interval of time. When there is capability to record an interval, however, only one time will be applied, it is ambiguous whether the time recorded should be at the start or at the stop. The group concurred that if it is ambiguous that we will have to supply the final HMD with the assumption of which one it will be when the structure supports two times. One company present (Softmed) has addressed this and reports the end time when the TMR can be reported in intervals. After discussion it was decided that this be consider this an open issue for Data Types. MR/IM TC recommends that there be a single data type.
· Currently birth date time and origination are the only times that are defined as points. Would like to remove interval times for the following and move to a point – authenticator, legal authenticator.
· Deprecation Issue (CDA) – The following will move from interval to a point – originator, patient, provider. In the e-mail announcing the deprecation, will ask for real case studies. If there is a use for interval, then will keep as interval rather than moving to a point. If there are no real life examples will deprecate it and move to a point.
Vocabulary Issue: Need to work on a vocabulary issue for “provider” term used in the header. Separate from that responsible/primary provider concept that are in use in specialized use settings (teaching hospitals, OR’s).
Future Enhancement: Need further evaluation on how to address patient amendments/patient entries in the medical record under this model. Currently, only providers are “participant” which is constrained to formal members of organization. There is a potential need to expand to patient, parent, or legally responsible party. For example, this could be for the implementation of a pre-admission questionnaire or a patient amendment.
Tuesday Afternoon:
Medical Record/Information Management TC: Discussion focused on HIPAA privacy mandates.
In version 2.4 the Orders and Observation TC began to put consent information.
HIPAA Privacy Issues:
· Consent for treatment, payment, and healthcare operation (as mandated by HIPAA) as well as other healthcare consents related to specific medical treatment. Need ability to report status of a consent (i.e. one has been obtained) and a second message is the communication of the content of the consent (what did they consent to, who signed, etc.), and third the potential to electronically obtain a consent (message to send and message to return when signed). Also consider the ability to track patient’s advanced directives (i.e. living will, durable power of attorney, etc.).
· Need to build messaging related to a consent including the signatures and restrictions in time and purpose.
· Under HIPAA, the patient has the ability to request limited access to their health information that may include excluding specific providers from access to their records/information. Will need ability to allow for limitations in access and restrict their uses (restriction in purpose of uses and restriction in time for use of information).
· Outlined four classes of potential users of the medical record:
1) Formal association with patients – i.e. attending, admitting, consulting physicians.
2) Direct care providers involved in care delivery, but having no established formal relationship to a patient; healthcare providers not documenting in the chart who have a temporal need to access your record or know your information – appropriate access should only be for the short period of time; (e.g. the nursed assigned to the patients current care location).
3) Indirect care providers with broad patient responsibility (no direct care or temporary limitation but a functional need to access information). Need access to a broad number of patient records. Example, hospital hematologist, staff epidemiologist.
4) Administrative (versus clinical) functions which require access to records/information. Example, chart financial auditors.
· Discussed not actually prohibiting a provider from accessing records to prevent unnecessary steps for obtaining access in emergency situations that may compromise patient care. Would recommend using audit trails, timely review, and follow up with staff who inappropriately access records.
The following HIPAA requirements will need to be discussed in the future to determine if there are messaging requirements.
· Authorization for Release of Information with required elements and ability to tracking release of information.
· Minimum necessary – ability to limit access/disclosure of information to only the minimum data necessary.
· Amendments made by patients to their records
· De-identification of Information
· Notice of Health Information Practices
· Reporting of Complaints – don’t expect that there will be any messaging requirements although it is expected that there will be applications similar to incident reporting developed.
DHHS in the comments to introduce the final privacy rule, indicated that they will write guidelines to assist in further clarifying information requirements.
AHIMA produced practice briefs (practice guidelines) for HIM professionals in addressing HIPAA related issues particularly related to privacy. The practice briefs are available on AHIMA’s website to both members and non-members at www.ahima.org, click on “Ready Resources” and then “Practice Briefs.”
The HIPAA regulations can be accessed and downloaded on the Administrative Simplification website at: http://aspe.hhs.gov/adminsimp/
Wednesday Morning:
Joint meeting between Medical Records/Information Management and Structured Documents.
Bob Dolin will be revising the graphic display of the merged MDM/CDA hierarchical description based on discussion from this meeting. Group continued to review the VISIO of R-MIM and analyzed/discussed content.
Ballot:Voted to use the VISIO graphic tool (will be modified to an enhanced version) as the way to analyze and vote on the content of the R-MIM.
Ballot Results: Unanimous – 6 in favor, 0 opposed, 0 abstentions
Clarification requested/discussed: Primary activity provider – is the provider that has primary responsibility for the services that took place. Discussed whether provider can be misconstrued to mean the organization rather than a person, however, this was clarified as the “responsible individual healthcare provider” as defined by the role.
Open Action Item: Need ability to track the actual assigned legal authenticator who is assigned separate from the actual authenticator. Need to add a refinement that doesn’t exist in the current CDA chapter.
Discussed whether it was necessary to scope the identifier to the health care institution. It was decided that it was necessary to scope to the healthcare institution because of limitations in the OID reference table. There are two ways to bind the identifier to the reference table 1) communicate/messages via a HL7 reference table or 2) define the scope for identifier, authenticator, legal authenticator, originator, provider, transcriptionist.
Discussed TX19 – Document Availability Status: Discussion related to whether an Unavailable document is defined as “new” in version 3. Concerned that this definition/vocabulary is a poor word to describe a document’s availability status rather than the “newness” of a document. (Open Issue)
TX23 - Distributed copies field has been represented in version 3 as intended recipient and is fully covered.
Signature codes: Will add a value to the RIM – three values = required, intended, or obtained.
Intended Recipient = no signature code (not applicable)
Intended Authenticator = there is an intention to have a value of signature required,
intended or obtained
Intended Legal Authenticator = signature code can be required or obtained.
Deprecation Issues:
Plan to announce deprecation issues via the Web/List-Serve and request comments on the change. Feedback from the web/list-serve should show cases in which this is required or planned to be used.
· Move “transcriptionist” to a singular rather than multiple.
Open, Outstanding, or Future Issues:
· Multiple providers in the heading for legal authenticator for the document as a whole.
· TX19 – Document Availability Status: Discussion related to whether an Unavailable document is defined as “new” in version 3. Concerned that this definition/vocabulary is a poor word to describe a document’s availability status rather than the “newness” of a document.
· Address (in the future) the use case where collaborative (multi-authored) documents are not now deterministically treated.
· Nested OBX’s: It was discussed to allow Structured Documents to have OBX’s associated with a header to allow nesting. MR/IM will want to be involved in the future, but will allow structured documents to create the mechanism. Discussed need to use multi-media in a document.
· Discussed the originator in the act-context in the R-MIM. At this time will not include additional messaging for the originator in the act-context. This should be addressed in the future.
· Note: Compound documents mandated by HCFA (i.e. Minimum Data Set) require document to be authenticated by all authors and that the specific sections of the document be linked back to the author/authenticated.
Wednesday Afternoon:
Joint meeting between Medical Records/Information Management
Proposal 1:
Reviewed submitted proposal to clarify MDM usage. This proposal was previously proposed and approved by the Orders and Observations TC on Monday, May 7, 2001 and is presented for approval by the MR/IM TC.
The proposal is included here:
Clarify MDM vs. ORU Usage
Short Description:
Add language to chapters 7 and 9 clarifying when the MDM message should be used rather than the ORU.
Justification:
Continuation of a portion of a proposal originally submitted by Kaiser Permanente to the Fall 2000 Working Group meeting in St. Louis. The MDM Subcommittee has reviewed and modified the proposal again in Orlando’s January Working Group meeting. The current proposal supports the general consensus that Chapters 7 and 9 should be clarified to reduce the current ambiguity regarding the ORU and the MDM.