Who Writes Clinical Notes?

This question was the fundamental question being addressed in a recent Structured Documents Workgroup meeting.  At the root of it is whether or not a patient authored note belongs, or doesn't belong in the CDA Consolidation Guide as it is further developed by HL7.  One of the reasons for concern is that at present, HL7 published documents are the fundamental unit of "standardization" (and in fact, this is true for just about every SDO).  While we need better ways of publishing this content, others, such as ANSI and ISO, and regulators which reference HL7 standards are still referring to these standards by the name of the publication.  If patient authored notes become part of the CDA Consolidation standard, it becomes much easier to cite (or in this case, re-cite) them in ongoing regulatory efforts.

One of the challenges of course, is that this also expands what CDA Consolidation is, and certainly expands the efforts for the next ballot cycle on the CDA Consolidation guide.  At issue here, I believe is a need to incorporate some work developed by one part of the community that is competing with the need of other members of that same community to meet a more restricted set of goals.  I'm quite sensitive to this tension, and I often fuss myself about the crazy schedules that SD sets for itself.

Structured Documents spent quite a bit of time discussing this last year.  In September, we established the following principles for inclusion in the CDA Consolidation product (or product family, it still isn't clear which this is).  This was the agreed upon outcome:

Scope of Consolidation: “CDA templates at entry, section and document level applied in primary clinical information records and for exchange supporting continuity of care.”

Criteria for Inclusion:

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