Medical Summaries Profile

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

• Content Creator
• Content Consumer

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