PCC TF-1/XDS-MS

Cross-Enterprise Sharing of Medical Summaries (XDS-MS) Integration Profile

Scope and Purpose

Patient, clinician, industry and governmental demands for improved healthcare quality have created increased focus to make patient healthcare information interoperability across disparate systems a reality.

A solution for interoperability is, however, not a simple undertaking. Unstructured textual data forms remains the predominate mechanism for information exchange among health care providers, and a good majority of data needed by physicians and other health care providers to make good clinical decisions is embedded in this free text. Efficient and effective interoperability therefore begins by identifying the most relevant documents and the most relevant sections within those documents.

By their nature, Medical Summaries form a class of clinical documents that contain the most relevant portions of this information. As the name would indicate they have the purpose of summarizing, both abstracting the most important pieces of information from the EMR and recording free-text summaries at the time of medical summary creation. Operationally, they are commonly created at points in time of transfers of care from one provider to another or from one setting to another.

Patient transfers and, therefore, the summary documents that accompany these transfers can be categorized into 3 primary types: Episodic, Collaborative, or Permanent. These categories are important because they represent a breadth of use case scenarios for Medical Summaries. For example, summaries for collaborative transfers of care such as referral notes have a focused objective for providing the most relevant information about the patient intended for a specific provider. Collaborative summaries have a general audience that is generated as an artifact since they also provide the most relevant spot to obtain information about specific classes of patient problems that the patient has.

By contrast, episodic summaries have the primary purpose of highlighting the most relevant details of focused periods of time in a patient history. Examples include discharge summaries or history and physicals. Episodic summaries are written for a broad audience by intent.

Permanent transfers have yet a third purpose of summarizing the entirety of a patient's medical history and therefore covers a broader range of patient problems. The audience may be focused (as in a transfer to a new provider) or general (as in a discharge from the military).

The challenge is to identify the clinically relevant documents (and data elements those documents contain) that are used in typical "transfer of care" scenarios and then to provide interoperability standards to promote ease in transmission of those documents (and data elements). The Cross-Enterprise Sharing of Medical Summary (XDS-MS) Integration Profile facilitates this by defining the appropriate standards for document transmission and a minimum set of "record entries" that should be forwarded or made available to subsequent care provider(s) during specific transfer of care scenarios. In addition, this integration profile needs to define the utilization requirements/options for the receiving entity in order to ensure that the "care context" of the sending entity is appropriately maintained following the information transfer.

Process Flow

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.

Because the Collaborative care transfers and Episodic Care transfers differ significantly, these two use cases are defined. Users or implementers of this Integration Profile are offered options in the support of either of these two use cases. Permanent Care Summaries also differ significantly. However their use is less frequent; so this use case was deferred for future work.

Use Case 1: Ambulatory Specialist Referral

This use case involves a "collaborative" transfer of care for the referral of a patient from a primary care provider (PCP) to a specialist. This use case is a central component of an "e-referral" process, which typically requires an appropriate level of agreement/collaboration between the two parties prior to the actual transfer of clinical information being initiated.

The preconditions assume a PCP sees a patient in his office. The PCP has talked to the patient and performed an examination, and has decided to refer the patient to a specialist. An assumption is made that the PCP has an EMR system with capability to write notes and manage data elements. The specific data elements managed by the PCP's EMR are expected to be the source for the information used in creating the medical summary document related to this transfer of care. A variety of EMR implementations and usage by clinicians may result in some variability in the content of the medical summary.

The detailed content of the medical summary to support this use case will be detailed as part of the document content profile specification (See PCC TF-2: 5.4.1.3).

Steps to identify the specialist and obtain insurance preauthorization have been placed out of scope for this Integration Profile.

Post conditions include the specialist physician receiving the notification of referral, locating the documents (via the Document Registry), retrieving the Documents and viewing them and optionally importing data. Import assumes the specialist with an EMR system with the capability for managing those discrete data elements.

Use Case 2: Acute Care Discharge to Ambulatory Care Environment

This use case involves an episodic transfer of care in the form of a patient discharge from a hospital to home. The attending physician in the hospital generates a discharge summary document that is used by the hospital record keeping and billing abstraction. The attending physician in the hospital may or may not also be serving as the ambulatory PCP. If not, a copy of this record is sent to the PCP as well as other specialist providers that will have ambulatory follow-up care.

The events of the use case involve creation of the discharge summary, sharing it, and notifying other providers such as the PCP's office and the surgeon's office.

The post conditions include the receipt and viewing of the discharge summary with optional import into the ambulatory EMR system.

The detailed content of the medical summary to support this use case will be detailed as part of the document content profile specification (See PCC TF-2: 5.4.1.4).

Note that the two use cases above use the same set of transactions and differs only in the content of the Medical Summary. A process flow for these use cases using XDS and NAV is listed in Figure 3.2 1. Other process flows are possible using XDM and/or XDR.

Use Case Process Flow Diagram