September 14, 2022
Texas Health Services Authority hosts a multi-disciplinary, vendor agnostic collaborative supporting interoperability in Texas. The Collaborative serves to address challenges with timely, trusted data exchange across multiple public and private healthcare venues, public health, and vendor platforms.
The Collaborative C-CDA Standardization Work-Group consisting of clinicians, IT analysts, EHR vendors and national networks developed a Discharge C-CDA Minimum Data-Set. The C-CDA Standardization Work-Group leveraged the experience of clinicians to identify needs, received feedback from a community survey (119 respondents) and vetted technology ability with vendor community.
The Collaborative Members agreed to support the Discharge C-CDA Minimum Data-Set Content and to share with their respective organizations and EHR vendors.
It is recognized that this is not perfect but a beginning. Clinicians can query for additional information when needed – this recommendation is to meet the majority of clinician needs. The list is organized by priority of content. Each organization is asked to work with their EHR vendor and information technology teams to send and receive the Discharge C-CDA Content.
Organizations receiving the Discharge C-CDA can use a style sheet to display content.
Discharge C-CDA Minimum Data-Set Content
1. Discharge Summary Narrative (aka Hospital Course)
2. Discharge Medications
3. Allergies
4. Admission Diagnosis
5. Discharge Diagnosis
6. Procedures: including Interventional Radiology, Cardiac Cath, operative procedures
7. Diagnostic Imaging – Advanced imaging for example: MRI, CT, PET, Nuclear Imaging, Ultrasound, Echo, & Venous Doppler
8. Laboratory – Recommend first and last laboratory result for every test. On rare tests – they are only done once so would be included (ANA Rheumatoid)
9. Consultations
10. Assessment & Plan (includes future orders for follow-up with PCP and diagnostic tests)
11. Problem List
Please contact: info@THSA.org for additional information.