@@ Line 1: / Line 1: @@
-<noinclude>
+#redirect [[PCC TF-1/FSA]]
-{{|Title Page|
-Domain=Patient Care Coordination|
-Volume=Cross-Enterprise Sharing of Medical Summaries (XDS-MS) Integration Profile|
-Revision=2.0|
-Year=2006-2007|
-Status=Draft}}
-{{|:PCC TF-1/Header}}
-</noinclude>
-==Functional Status Assessment (FSA) Integration Profile==
-===Scope and Purpose===
-==Profile Abstract==
-The Functional Status Assessment Profile (FSA) supports the handoff of assessment information between practictioners during transfers of care by defining the Functional Status Assessment option on the XDS-MS and XPHR profiles.
-The Institute of Medicine has determined that the highest risk for medical errors occurs during the handoffs of patient care between practitioners, cross-enterprise or intra-enterprise. Continuity of care requires provision of assessments to be available to the receiving practitioner for critical decision making. The transfer of physician documentation provides much of the medical/physiologic condition information. Transfer of nursing documentation provides human response (psychological, social, emotional, physiological and spiritual) of patient/family to changing conditions.  Both types of documentation support continuity of patient care as each patient moves through the continuum. This profile demonstrates the collection and exchange of standardized assessment information as it is exchanged across a variety of residential and care provision settings.
-==Glossary==
-; Term : Definition
-'''IHE Functional Status Assessments Profile Glossary of Terms'''
-'''IHE Integration Profiles''' describe the solution to a specific integration problem, and document the system roles, standards and design details for implementors to develop systems that cooperate to address that problem. IHE Profiles are a convenient way for implementors and users to be sure they're talking about the same solution without having to restate the many technical details that ensure actual interoperability.
-'''Continuity of Care Record (CCR):'''  A core data set of the most relevant administrative, demographic, and clinical information facts about a patient’s healthcare, covering one or more encounters. The CCR is Designation E2369-05 of the ASTM (American Society for Testing and Materials, International). More information is available from [http://www.astm.org].
-'''Continuity of Care Document(CCD):'''  An HL7 Clinical Document Architecture (CDA) implementation alternative to ASTM ADJE2369 for institutions or organizations committed to HL7 standards.  This specification was developed as a collaborative effort between ASTM and HL7. More information is available from [http://www.HL7.org].
-'''Clinical Document Architecture (CDA):''' A document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange. From the perspective of CDA the CCR is a standardized data set that can be used to constrain CDS specifically for summary documents. More information is available from [http://www.HL7.org].
-'''Logical Observation Identifiers Names and Codes( LOINC®)''' A database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical code for use in clinical care, outcomes management, and research.  LOINC® codes (sometimes in combination with SNOMED-CT codes are used to encode functional status assessments to facilitated health information exchange.  Additional information found at [http://www.regenstrief.org/medinformatics/loinc/].
-'''Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT®):''' A comprehensive clinical terminology, originally created by the College of American Pathologists (CAP) and, as of April 2007, owned, maintained, and distributed by the International Health Terminology Standards Development Organisation (IHTSDO), a non-for-profit association in Denmark. The CAP continues to support SNOMED CT operations under contract to the IHTSDO and provides SNOMED-related products and services as a licensee of the terminology. More information available from [http://www.ihtsdo.org/] or the United States National Library of Medicine at
-[http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html]
-=Volume I=
-<pre>Add the following bullet to the list of profiles</pre>
-* {{{1}}} - {{{3}}}
-===Dependencies===
-<pre>Add the following row(s) to the list of dependencies</pre>
-{|style='background-color:#7f7f7f;' align='center' border='1' cellspacing='0'
-!Integration Profile
-!Dependency
-!Dependency Type
-!Purpose
-|- style='background-color:#ffffff;' align='center'
-|Functional Status Assessment
-|XDS-MS
-|
-|
-|-
-|}
-==Functional Status Assessment==
-The Functional Status Assessment Profile (FSA) supports the handoff of assessment information between practictioners during transfers of care.
-In the context of the Continuity of Care Document, the functional status describes the patient’s status of normal functioning at the time the document was created.
-Functional status includes information concerning:
-* Ambulatory ability
-* Mental status or competency
-* Activities of Daily Living (ADL’s) including bathing, dressing, feeding, grooming
-* Home/living situation having an effect on the health status of the patient
-* Ability to care for self
-* Social activity, including issues with social cognition, participation with friends and acquaintances other than family members
-* Occupation activity, including activities partly or directly related to working, housework or volunteering, family and home responsibilities or activities related to home and family
-* Communication ability, including issues with speech, writing or cognition required for communication
-* Perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance
-The Institute of Medicine has determined that the highest risk for medical errors occurs during the handoffs of patient care between practitioners, cross-enterprise or intra-enterprise. Continuity of care requires provision of assessments to be available to the receiving practitioner for critical decision making. The transfer of physician documentation provides much of the medical/physiologic condition information. Transfer of nursing documentation provides human response (psychological, social, emotional, physiological and spiritual) of patient/family to changing conditions.  Both types of documentation support continuity of patient care as each patient moves through the continuum. This profile demonstrates the collection and exchange of standardized assessment information as it is exchanged across a variety of residential and care provision settings.
-=== Options ===
-This integration profile supplement adds the following two options to the {{ILink|Functional Status Assessments (FSA) Integration Profile Supplement|Cross Enterprise Sharing of Medical Summaries (XDS-MS) Integration Profile}}, and to the {{ILink|Functional Status Assessments (FSA) Integration Profile Supplement|Exchange of Personal Health Record Content (XPHR) Integration Profile}}.
-{|align='center' border='1' cellspacing='0'
-|-bgcolor='#D9D9D9'
-!Actor
-!Option
-|+{{{1}}} Options
-|- align='center'
-|Content Consumer||Functional Status Option
-|- align='center'
-|Content Creator||Functional Status Option
-|}
-==== Functional Status Option ====
-A Content Consumer Actor implementing the Functional Status Option of this profile supplement shall be able to view and consume coded functional status information sent in the functional status section of a Medical Summary or XPHR Extract.
-A Content Creator Actor implementing the Functional Status Option of this profile supplement shall be able to create a coded functional status section that contains at least one of the optional functional status assessments in a Medical Summary or XPHR Extract.
-This option has the effect of adding the Functional Assessments data element as a required data element in the XPHR Extract, Referral or Discharge Summary content modules.
-{{Note|How should we handle this profile?  Should the coded functional status section be added to XDS-MS and XPHR as conditionally required (when the Functional Status Option is declared on the actor), or should this profile be published on its own.|For Public Comment}}
-=== Content Modules ===
-Content modules describe the content of a payload found in an IHE transaction. Content profiles are transaction neutral. They do not have dependencies upon the transaction that they appear in.
-==== Coded Functional Status Assessment ====
-The coded functional status assessment section contains one or more subsections that included coded functional status assessment information.  This is a section content profile that is intended to be used in Medical Summaries of various type, including those described in the XDS Medical Summaries profile, and the XPHR profile.  The subsections that are defined by this content profile are further described below.
-===== Pain Scale =====
-Using the Pain Scale (Numeric Pain Scale, a Patient rates his/her pain from 0 to 10 (or 5 or 20), with 0 representing no pain and 10 (or 5 or 20) representing the worst possible pain.  This scale is used for age 5 years and older and is the preferred pain scale for many older healthy adults. Reliable and valid per Herr & Garland, 2001; Ho et al, 1996; Price et al, 1994.
-This content profile describes how a Pain Scale assessment is reported in a CDA Document.
-[[Media:LOINC-PainAssessmentPanel.pdf]]:  A 13 Item Pain Scale
-[[Media:LOINC-PainVisualAnalogScale.pdf]]:  The Visual Analog Pain Scale.  Responses can be an integer, ratio, real number, or range and may optionally include relational operators from the set <=, <, >, and >=.
-===== Geriatric Depression Panel =====
-While there are many instruments available to measure depression, the Geriatric Depression Scale (GDS), first created by Yesavage et al., (Stanford University) has been tested and used extensively with the older population. It is a brief questionnaire in which participants are asked to respond to the 30 questions by answering yes or no in reference to how they felt on the day of administration. Scores of 0 - 9 are considered normal, 10 - 19 indicate mild depression and 20 - 30 indicate severe depression. The GDS may be used with healthy, medically ill and mild to moderately cognitively impaired older adults. It has been extensively used in community, acute and long-term care settings. As for evidence-based research the GDS was found to have 92% sensitivity and 89% specificity when evaluated against diagnostic criteria per the Hartford Institute for Geriatric Nursing. The validity and reliability of the tool have been supported through both clinical practice and research. More information is available from [http://www.stanford.edu/~yesavage/GDS.html].
-This content profile illustrates how to record the Geriatric Depression Panel within a CDA document.
-===== Braden Score =====
-The Braden Scale is a summated rating scale made up of six subscales scored from 1-3 or 4, for total scores that range from 6-23. The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levers of risk for pressure ulcer development. Reliability and validity research found at [http://www.bradenscale.com/bibliography.htm] [[Media:Braden.pdf]]
-This content profile illustrates how to record the Braden Score within a CDA document.
-===== Minimum Data Set =====
-The '''Minimum Data Set for Long Term Care Version 2.0 (MDS 2.0)''' is a federally mandated (in the United States) standard assessment form.  This instrument is specified by the Centers for Medicare and Medicaid Services, and requires nursing facilities to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity. Section G Physical Functioning and Structural Problems are included in this demonstration project.  More information is found at[http://www.cms.hhs.gov/MinimumDataSets20/].
-[[Media:SectionG_MDS20.pdf]]
-'''Outcomes and Assessment Information Set (OASIS):'''  A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs in the United States.  More information is available from
-[http://www.cms.hhs.gov/OASIS/].
-=== Process Flow ===
-[[Image:seq.jpg|frame|center|Functional Status Assessment Process Flow]]
-More text about process flow
-== Actor Definitions ==
-; Actor : Definition
-== Transaction Definitions ==
-; Transaction : Definition
-=Volume II=
-===Functional Status Assessment Content===
-==== Standards ====
-; [http://www.hl7.org/v3ballot/html/infrastructure/cda.htm CDAR2] : Clinical Document Architecture, Release 2, 2005 HL7
-; [http://www.hl7.org/documentcenter/public/standards/informative/crs.zip CRS] : Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm), 2006, HL7.
-; [http://www.hl7.org/Library/Committees/structure/CCD%2E01Dec2006%2EDRAFT%2Ezip CCD] : ASTM/HL7 Continuity of Care Document (Draft)
-; [http://www.regenstrief.org/medinformatics/loinc/ LOINC] : Logical Observation Identifiers Names and Codes
-; [http://www.snomed.org SNOMED] : Systemized Nomenclature for Medicine
-==== LOINC Codes for Selected Instruments ====
-[[Media:LOINCified Braden Scale.pdf]]
-[[Media:LOINCified Geriatric Depression Scale - 30 Item.pdf]]
-[[Media:LOINCified MDS.pdf]]
-Details about the Nursing Home Minimum Data Set (MDS), which must be completed by Nursing Homes, can be found [http://www.cms.hhs.gov/MinimumDataSets20/045_MDSApplicability.asp#TopOfPage here]
-[[Media:LOINCified OASIS.pdf]]
-Details about the Outcome and Assessment Information Set (OASIS), which must be completed by Home Health Agencies, can be found [http://www.cms.hhs.gov/OASIS/02_Background.asp#TopOfPage here]
-==== Semantic Mapping of Contents of LOINC-ified Instruments to SNOMED Concepts ====
-[[Media:LOINCified MDS to SNOMED Mappings.xls]]
-This mapping was funded by DHHS/ASPE (The Office of the Assistant to the Secretary for Planning and Evaluation within the Department of Health and Human Services)
-The plan is for these mappings to be loaded to the UMLS' Metathesaurus.  Although these mappings have been validated by MDS experts, they have not been validated by SNOMED experts.  The expectation is that these mappings will continue to be validated and updated by appropriate stakeholders.
-[[Media:SNOMED_Braden_Mapping.pdf]]
-[[Media:Geriatric_Depression_Scale20070518.pdf]]
-[[Media:SNOMED_Pain_NRS_Mapping.pdf]]
-==== Data Element Index ====
-{| cellspacing=0 border=1 align='center'
-!style='background-color:#cfcfcf' |Data Elements
-!style='background-color:#cfcfcf' |Other Reference
-!style='background-color:#cfcfcf' |LOINC Section or CDA Element
-|+ FSA Data Elements
-|-
-|Numerical Pain Rating Scale|| ||
-|-
-|Braden Scale|| ||
-|-
-|MDS Section G|| ||
-|-
-|Geriatric Depression Scale|| ||
-|}
-==== Document Specification ====
-{| cellspacing=0 border=1 align='center'
-! style='background-color:#cfcfcf'|Data Element
-! style='background-color:#cfcfcf'|Opt
-!  style='background-color:#cfcfcf'|Section
-! style='background-color:#cfcfcf' |Template ID
-|+ {{{1}}} Constraints
-|-
-|Numerical Pain Rating Scale||R|| || 1.3.6.1.4.1.19376.1.5.3.1.3.X
-|-
-|Braden Scale||R|| || 1.3.6.1.4.1.19376.1.5.3.1.3.Y
-|-
-|MDS Section G||R|| || 1.3.6.1.4.1.19376.1.5.3.1.3.Z
-|-
-|Geriatric Depression Scale||R|| || 1.3.6.1.4.1.19376.1.5.3.1.3.Q
-|}
-[[Category:Patient Care Coordination]]
-[[Category:Draft Profile Supplement]]

Difference between revisions of "Functional Status Assessments (FSA) Integration Profile Supplement"

Latest revision as of 15:53, 14 June 2007

Navigation menu

Search