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Carequality is proud to announce the final product of the Joint Document Content Work Group. As you may know, Carequality has convened a group of subject matter experts (many of whom are from our Implementer community) to discuss document content issues. The Document Content Workgroup was created with the goal of identifying guidelines for document content that would yield the highest impact on document quality while minimizing the development burden on our Implementers. In January of 2018, the group was expanded to include members of CommonWell and re-branded as the Joint Document Content Work Group (JDCWG).

On June 7th of this year, the Work Group released their final detailed recommendations. The JDCWG’s recommendations include, but are not limited to, the ones highlighted in this post. We encourage you to review the full document.

Clinician participation in the group was vital, and the docs advocated strongly for the inclusion of clinical notes in the data set available.  The group decided that the most effective way to ensure access to notes was to recommend that our Implementers support Encounter Summary Documents in addition to Patient Summary Documents. The group came to a consensus on definitions of Encounter Summaries and Patient Summary Documents that combine the traditional definition along with the how they can be practically used in the field:

Encounter Summary: A clinician authored collection of information specific to a single patient interaction with a clinician, care team or hospitalization

Patient Summary Documents: The most current information available from the sending system across multiple encounters

Encounter Summary Documents should be based upon the C-CDA template for Progress Note (Outpatient/Ambulatory) or Discharge Summary (Inpatient/Hospital). These information exchange documents were selected because they are the most generic encounter-level templates currently available.

The group participated in a lot of lively debate about how information such as medication and problem lists, that are not always tracked at an encounter level, should be handled in Encounter Summary Documents.  The conclusion was that Implementers should only include information that was validated during the encounter, specifically:

Problems – Include those addressed during the encounter as Encounter Diagnoses

Allergies – Include only if the system can recreate the active Allergy list at the time of encounter, including those recorded in prior encounters.

Medications – Include only if the system can recreate Medications at time of encounter.

Immunizations – Include immunizations given during the encounter.

The group acknowledged that this approach may result in an Encounter Summary document containing only a subset of the ONC Common Clinical Data Set.

The Joint Document Content Work Group felt strongly that documents provided in response to a query, should respect the scope of the document query parameters.  In other words, you should get what you actually asked for.

As previously mentioned, the JDCWG was a collaborative effort, creating recommendations for both Carequality and CommonWell, and potentially the industry as a whole. Our next step within the Carequality community will be to decide how to incorporate these recommendations into Carequality’s document requirements, and how best to advance their adoption by Implementers. This process is already underway and our community of Implementers, along with the public, will be updated as progress is made.

We would like to thank all of the members of the Joint Document Content Work Group for their diligent work. Your contributions to advancing the quality of clinical documents will have a lasting impact on the Carequality community. Please stay tuned to our blog and social media for more news about how you can participate in future workgroups related to this issue and others!