Beginning next month, the medical informatics community will get an opportunity to vote on proposed standards for a minimum set of data needed to assure continuity of care when patients move between care delivery settings.
Balloting on what is being called the Continuity of Care Record tentatively is scheduled to open in mid-January, according to ASTM International, a West Conshohocken, Pa.-based standards-setting organization.
ASTM, the Massachusetts Medical Society, the Healthcare Information and Management Systems Society and the American Academy of Family Physicians last week published a draft proposal based on input from a November meeting and other public comments.
The groups will issue a final version of the Continuity of Care Record plan shortly before the balloting period opens, according to ASTM.
From the current draft, the proposal outlines seven classes of mandatory data elements:
- Document identifiers regarding the clinicians a patient is referred from and to;
- Patient-identifying information;
- Patient insurance and financial information, including eligibility for coverage;
- Advanced directives, such as "do not resuscitate" orders, living wills and powers of attorney;
- Patient health status, including medical history, current medications, vital signs, allergies and other data critical to any treatment regimen;
- Care documentation, with some detail on each medical encounter or examination for the patient; and
- Care plan recommendation, a free-text entry section.
Participants say the CCR is but one part of a comprehensive electronic medical record, for which HIMSS and standards-setting organization Health Level Seven are developing technical specifications.