Pre-procedure History and Physical (PPHP)

1. Pre-procedure History and Physical (PPHP) IHE Development Team Workshop 2006 IHE Patient Care Coordination Education Dan Russler, MD, co-chair PCC Technical Committee

2. Pre-procedure History and Physical • H&P documentation required prior to procedure that is designed to assess: • Procedure Risk • Anesthesia Risk • Factors influencing procedure after-care decisions • Desired outcomes • Minimize injury during procedure • Optimize procedure after-care

3. Pre-procedure History and PhysicalScope • To identify the required and optional PPHP document content templates including: • CDA Document Header • CDA Document Type(s) • CDA Section Types • CDA Entry Types

4. Pre-procedure History and PhysicalValue Proposition • A procedure risk assessment must be present and evaluated by the operative and after-care teams before the patient is allowed to have the procedure. Missing information is frequently a reason for canceling the procedure for the day, which leads to expensive underutilization of resources and dissatisfied patients. Further, incomplete information about the patient’s clinical or home status may create a situation where a procedure is performed that ultimately results in an injury, inadequate aftercare or other undesirable outcome.

5. Pre-procedure History and PhysicalKey Technical Properties • PPHP Profile inherits specifications required for other IHE PCC Medical Documents • PPHP Profile follows documentation practices for all IHE PCC Medical Documents • PPHP Profile emphasizes re-usability of CDA template identifiers in order to reduce un-necessary variability in IHE Content Profiles

6. Pre-procedure History and PhysicalStandards Used • IHE Medical Document Content Profiles • HL7 Reference Information Model ANSI Standard • HL7 CDA R2 ANSI Standard • HL7 Care Provision Domain DSTU (in process) • Implementation Guides • HL7 Care Record Summary CDA R2 Implementation Guide (in process) • HL7/ASTM Continuity of Care Document Implementation Guide (in process)