Surrogate EHR Environment (SEE) Transfer of - (S&I) Framework

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    Surrogate EHR Environment (SEE)

    Transfer of Care Implementation Guide, Release 1.1

    March 2013

    Prepared by Lantana Consulting Group


    The Massachusetts Technology Collaborative

    RFP No. 2013-MeHI-03

    ? 2013 Lantana Consulting Group

    All rights reserved.

    Page 2CDA Transfer of Care Implementation Guide, R1

    ? 2013 Health Level Seven International. All rights reserved.May 2013

Lantana Consulting Group

    PO Box 177

    East Thetford, VT 05043

    Liora Alschuler

    Chief Executive Officer

    liora.alschuler@lantanagroup.comBob Dolin, MD, FACP

    President and Chief Medical Officerbob.dolin@lantanagroup.comJohn Baker

    Software Architect and Engineerjohn.baker@lantanagroup.comGaye Dolin

    Chief Information Analystgaye.dolin@lantanagroup.comSarah Gaunt

    Information Analyst

    sarah.gaunt@lantanagroup.comRick Geimer

    Chief Technology Officer rick.geimer@lantanagroup.comZabrina Gonzaga

    Information Analyst

    zabrina.gonzaga@lantanagroup.comMeenaxi Gosai

    Engineering Quality Assurancemeenaxi.gosai@lantanagroup.comRuss Hamm

    Terminology Analyst

    Implementation GuideSEE Transfer of Care Implementation Guide, Release 1.1Page 3

    ? 2013 Lantana Consulting GroupMarch 2013

Todd Hibbs


    todd.hibbs@lantanagroup.comAngelo Kastroulis

    Software Engineer

    angelo.kastroulis@lantanagroup.comGeorge Koromia

    Information Analyst

    george.koromia@lantanagroup.comSean McIlvenna

    IT Manager, Senior Software Architectsean.mcilvenna@lantanagroup.comCarlos Muentes

    Software Development Engineercarlos.muentes@lantanagroup.comMike Tushan

    Project Manager

    mike.tushan@lantanagroup.comDiana Wright

    Technical Editor

    Page 4CDA Transfer of Care Implementation Guide, R1

    ? 2013 Health Level Seven International. All rights reserved.May 2013


    This guide was developed through the joint efforts of the Massachusetts Health Information Exchange (MASS HIE), participants in the Improving Massachusetts Post-Acute Care Transfers (IMPACT) project, the Massachusetts Long-Term and Post-Acute Care (MASS LTPAC) community, and Lantana Consulting Group. It was produced under a project sponsored by the Massachusetts Technology Collaborative.

    The co-editors appreciate the support and collaboration of Dr. Lawrence Garber, Medical Director for Informatics at the Reliant Medical Group, Dr. Terrence O’Malley, Medical Director for Non-Acute Care Services at Partners HealthCare, Massachusetts General Hospital, and the Longitudinal Coordination of Care (LCC) Long Term Post-Acute Care (LTPAC) Transition Sub-Workgroup of the Standards and Interoperability (S&I) Framework.

    The conformance requirements included here for review were generated from the Trifolia Workbench template repository—developed initially for the Centers for Disease Control and 1Prevention (CDC) and released by Lantana Consulting Group under an open source license.This guide uses content from Health Level Seven ( HL7 and Health Level

    Seven are registered trademarks of Health Level Seven International. Use of this material is governed by HL7's IP Compliance Policy (

    ? This guide contains content from SNOMED CT( SNOMED

    CT is a registered trademark of the International Health Terminology Standard Development Organisation (IHTSDO).

    ?This guide contains content from LOINC ( The LOINC table, LOINC codes,

    and LOINC panels and forms file are copyright ? 1995-2012, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and available at no cost under the license at

    1?Lantana Consulting Group, Trifolia Workbench.

Revision History

    RevDateBy WhomChanges

    R 1.02/22/13Non-balloted IG created for The Massachusetts Technology


    R 1.13/8/131. Added more text in Open and Closed Templates section with

    2 new example figures.

    2. Added a new chapter 2 “Questionnaire Assessment

    Framework” — Include Model of Use vs. Model of Meaning

    3. Changed name from “Transfer Summary Document” to

    “Transfer of Care Document” for templateId

    2.16.840.1.113883. and modified constraints.

    4. Removed Patient Data Section template

    5. Added value set tables

    6. Added and updated references to implementation guides

    7. Removed empty appendices





    The Massachusetts Long-Term and Post-Acute Care (MASS LTPAC) providers play an important

    role when a patient is transitioned between a skilled nursing facility and hospital or when a

    patient is sent home for home health services. The Massachusetts Health Information Exchange

    (MASS HIE) is an avenue for exchanging critical MASS LTPAC data between these settings. The

    MASS LTPAC community identified critical data elements for a transfer in care during the

    Improving Massachusetts Post-Acute Care Transfers (IMPACT) project. The approximately 480

    IMPACT data elements were mapped to 20 existing Clinical Document Architecture (CDA)

    template sections to build this Surrogate EHR Environment (SEE) Transfer of Care

    Implementation Guide.


    This document describes constraints on the CDA header and body elements for the Transfer of

    Care Document from the IMPACT data elements identified by MASS LTPAC providers. A

    Transfer of Care Document standardizes critical information for exchange when a patient moves

    from a LTPAC setting to a hospital or to a home healthcare setting, as well as for reuse in quality

    measurement, public health assessment, research, and reimbursement processes.

    This implementation guide (IG) has not been through the Health Level Seven (HL7) balloting and

    publishing process nor been accepted by any national group. It provides a standardized means to

    exchange critical information identified in the IMPACT data set among LTPAC providers in the

    MASS HIE community.


    The audiences for this implementation guide are the architects, developers, and implementers of

    healthcare information technology (HIT) systems in the MASS HIE who wish to create or

    process a Transfer of Care Document according to this specification. This is guide is intended to 2provide guidance to implementers of the Surrogate EHR Environment (SEE) tool.

    Business analysts and policy managers in the MASS HIE community can also benefit from a

    basic understanding of the use of CDA templates across multiple implementation use cases.


    The approach taken here is consistent with balloted implementation guides for CDA. These

    publications view the ultimate implementation specification as a series of layered constraints.

    CDA itself is a set of constraints on the HL7 Reference Information Model (RIM) defined in the

    CDA Release 2 (CDA R2) Refined Message Information Model (RMIM). Implementation guides

    such as this add constraints to CDA through conformance statements that further define and

    restrict the sequence and cardinality of CDA objects and the vocabulary sets for coded elements.

    2?MeHI, “LAND and SEE architecture” web page.


    This implementation guide is a conformance profile, as described in the “Refinement and 3Localization” section of the HL7 Version 3 Interoperability Standards. The base standard for this 4implementation guide is the HL7 Clinical Document Architecture, Release 2.0. As defined in that

    document, this implementation guide is both an annotation profile and a localization profile. It

    does not describe every aspect of CDA.

    Development of this implementation guide included a review and analysis of the IMPACT data

    elements in relation to existing templates in the HL7 Implementation Guide for CDA? Release 2: 5IHE Health Story Consolidation, Release 1.1 - US Realm (Consolidated CDA or C-CDA) which 6is the standard referenced in the final rules for Stage 1 Meaningful Use. This standard includes

    exchanges that comply with the Health Information Technology for Economic and Clinical 7Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009.

    Additional analysis included previously balloted clinical exchange standards and published

    guides which contained similar LTPAC data elements such as the Framework for Questionnaire 89Assessments , Long-Term Post-Acute Care (LTPAC) Summary, and HL7 Implementation Guide 10for CDA? R2: Quality Reporting Document Architecture, DSTU Release 2 (QRDA).

    Mapping IMPACT data elements to C-CDA and LTPAC Summary templates allowed for reuse of

    these existing templates. Establishment of reusable templates through standards development

    organizations promotes the templates for future inclusion in Meaningful Use. This

    implementation guide also contains further guidance for elements that did not map to C-CDA

    templates. These remaining data elements were mapped to CDA question answer pattern entry

    templates. Further details on the differences between the modeling styles are explained in the

    Model of Use vs. Model of Meaning Section.

    3?HL7 Refinement, Constraint and Localization.

    4?HL7 CDA R2,

    5?HL7 IHE Health Story Consolidation.


    6?HHS, HIT Standards (Meaningful Use, Stage 1).


    7?ARRA 2009.

    8?HL7 CDA Framework for Questionnaire Assessments, DSTU Release 2.

    9?HL7 CDA Long-Term Post-Acute Care Summary, DSTU Release 1.

    10?HL7 CDA QRDA.

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