Cath Report Content

Summary

This profile provides an HL7 CDA Implementation Guide for a Cardiac Cath/PCI Report, derived from the Procedure Note specifications as defined in the IHE Health Story Consolidation, Release 1. The content is based on the ACC NCDR Cath/PCI version 4.4 data set

Benefits

Clinically-relevant Cath Lab data is the key value proposition of this profile. The approach is to:

1. reuse 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 1 DSTU (C-CDA) for exchangeable procedure notes (HL7/IHE)
2. extend it through adding and codifying the ACC-NCDR Cath/PCI dataset and the ACC NCDR Cath/PCI version 4.4 to clinical data standards like ICD9/10,Snomed and LOINC
3. evaluate it as it applies to the work in progress by the ACC and AHA to create an “ACCF-AHA Cardiac Cath Reporting – Report template”

Details

The Cardiac Cath Report Content (CRC) Profile specifies the content structure for a clinical report of a Cardiac Cath imaging exam, recorded in a DICOM Study. Such exams include:

• Diagnostic Cath
• Angiography
• PCI

Not included in the scope of this profile are electrophysiology procedures, and non-cardiology procedures (e.g., peripheral angiography). Pediatric Cath cases are also excluded.

The CRC 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.

Cath Report Content (CRC) is a content profile – 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 Cath/PCI 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 CRC profile is a content profile, which defines the content of a Cardiac Cath Report. 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:

Specification

Profile Status: Trial Implementation

Documents:

• CRC Supplement

Underlying Standards:

• HL7
• HL7 CDA Release 2.0
• HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, Release 1

See Also

Related Profiles

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

• Displayable Reports (DRPT) for the creation, exchange and management of cardiac imaging reports within an enterprise
• Portable Data for Imaging (PDI) for storage and exchange of cardiac imaging Reports on exchangeable media
• Cross Enterprise Document Sharing (XDS) for storage and retrieval of cardiac imaging reports in a cross enterprise setting

This page is based on the Profile Overview Template