Medical Summaries Profile

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Cross-Enterprise Sharing of Medical Summaries (XDS-MS) defines the content sections for Discharge Summaries and Referral Notes.


Summary

The Cross-Enterprise Sharing of Medical Summaries profile provides a mechanism to automate the sharing process between care providers of Medical Summaries, a class of clinical documents that contain the most relevant portions of information about the patient intended for a specific provider or a broad range of potential providers in different settings. Patient transfers and, therefore, the summary documents that accompany these transfers can be categorized into 3 primary types: Episodic, Collaborative, or Permanent. Medical Summaries are commonly created and consumed by electronic medical record systems at points in time of one of these types of transfers of care. For example, a referral note is a medical summary used for a collaborative transfer of care whereby a discharge summary is a medical summary reflecting an episodic transfer.

It uses HL7 Clinical Document Architecture (CDA) Release 2 and Care Record Summary as its base standard and constrains this to level 3 encoding for medications, allergies and problem lists.

The Cross-Enterprise Sharing of Medical Summaries Integration Profile solves the problem of transferring summary patient information between providers in different clinical settings.

Benefits

  • Leverage Clinical Documents ontology
    • A common mechanism for transfer of encoded clinical data embedded in documents
  • Enhances Clinical Documents criteria for key use cases:
    • Inpatient to Primary Care Provider
    • Primary Care Provider to Specialist

Details

The basic process flow supported by XDS-MS mirrors current manual practices: someone gathers the appropriate documents from the patient medical record, copies them, packages them up with a cover letter explaining the reason the information is being sent, and then ships the package to the receiving provider. This is often accompanied by a telephone call from the sending provider to the receiving provider that indicates that such information is forthcoming.

Systems Affected

EHR Systems

Actors

PCC Share Content Diagram.png

Transactions

See Also

Profile Status: Final Text

The Patient Care Coordination Framework is the official master document for this Profile.

Document Sharing

This page is based on the Profile Template