Cardiac Procedure Note

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Summary

This supplement provides an Implementation guide consisting of a library of templates to be used for various cardiac subspecialty procedure notes and clinical data exchange. Initial focus of this supplement are Cath Lab Reports (including Transcatheter based interventions) and Electrophysiology Implant and Explant Procedure reports intended for adult cardiac procedures. However the aim is to provide an extensible framework to allow for the addition of further report templates in future (e.g., general cardiac imaging procedures like Echocardiography, cardiac CT, MR, or Nuclear Medicine Imaging).

Benefits

This profile provides a library of templates for various type of cardiac procedure notes, which is easily extensible to address additional cardiac procedures. It uses coded structured data elements (based on various NCDR cardiac registries), which enable computer processing as well as patient based longitudinal or population based analysis.

It re-uses the distribution and structuring work from the XDS ( ITI domain), Medical summaries (PCC domain), and the HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, Release 2.1 DSTU (C-CDA) for exchangeable procedure notes (HL7/IHE).

This implementation guide was modeled using the toolkit ArtDecor toolkit, which eases modeling and provides tools for comprehensive validation and testing.

Details

The Cardiac Procedure Note(CPN) Profile specifies the content structure for a clinical report for Cardiac Procedure Notes. Such exams include:

  • Diagnostic Cath and PCI procedures
  • Structural Heart interventions
  • Electrophysiology implant and explant procedures.

It provides a library of templates, so that it can easily be extended to support additional cardiac procedures


The CPN Profile specifies the use of an HL7 Clinical Document Architecture (CDA) format for the report. This format supports both the human readable narrative historically used for clinical reports, as well as a substantial set of discrete data elements that may be used for longitudinal or population analysis or other computer processing.

The Cardiac Procedure Note (CPN) is a content profile – as such it is agnostic with respect to the workflow or data exchange mechanism in which the data is produced and handled. It is intended to be deployed, for example, in the Displayable Reports (DRPT) workflow profile for in-patient environments, or the Cross-Enterprise Document Sharing (XDS) profile to propagate the content across organizational boundaries.

The aim is to enable collection and distribution of the most clinically-relevant discrete data on the cardiac catheterization procedures common in cardiology. The usage of the discrete data is three-fold:

  1. To enable individual cardiac procedures to be more easily shared and used between care givers and systems
  2. To enable population-based outcomes-based research on procedure effectiveness
  3. To provide the ability to interact with data registries for data exchange.

Systems Affected

The CPN profile is a content profile, which defines the content of a Cardiac Procedure Note. The means of interchanging the report is not detailed in this profile but addressed in other profiles like DRPT, XDS or PDI. In general two types of systems would be relevant: A reporting workstation, Cardiovascular Information System or an Image Analysis workstation which creates a report and distributes it via one of the mechanism mentioned above. A workstation or system which is receiving and displaying the report. This could be an EMR System or any type of reporting workstation

Actors & Transactions:

CIRC ACT Trans.jpg

Specification

Profile Status: Trial Implementation

Documents:

Computable Specifications:

Underlying Standards:

  • HL7
  • HL7 CDA Release 2.0
  • HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, Release 2.1

See Also

Related Profiles

As a content integration profile CRC provides the payload for any of the exchange mechanisms of the following profiles


This page is based on the Profile Overview Template