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CDA R2 Implementation Guide for Procedure Notes

CDA R2 Implementation Guide for Procedure Notes. Judith R. Logan, MD Department of Medical Informatics & Clinical Epidemiology Oregon Health & Science University. Quality in Documentation. Documentation. Quality Measurement. Quality in Research. Research. Significant issues.

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CDA R2 Implementation Guide for Procedure Notes

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  1. CDA R2 Implementation Guide for Procedure Notes Judith R. Logan, MD Department of Medical Informatics & Clinical Epidemiology Oregon Health & Science University

  2. Quality in Documentation Documentation Quality Measurement Quality in Research Research

  3. Significant issues • What is a procedure? • How to be consistent with other IGs • How to specify coding systems in a universal realm IG • How to select sections that are general enough for all types of procedures yet specific enough to be useful • Can clinical content from the CCD be suggested when that is a US-realm standard?

  4. Where now? • Continue work with the ASGE Quality Committee to develop an implementation for one or more types of endoscopic procedures • Develop clinical content which can be used for quality reporting/quality measure specification as well as documentation and in research • Merge this work with the vocabulary/ontology work that is occurring in parallel

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