MEDICAL RECORD SIG MINUTES - SPRING 1993 MEETING The Medical Record Special Interest Group (SIG) met on Thursday afternoon May 20, 1993. The group reviewed and approved the agenda for the meeting. Co-Chairman Wayne Tracy explained to the group that discussions were held with the Technical Steering Committee regarding the possibility of the SIG becoming a Committee. Wayne reviewed the history of this effort and the goals and objectives of becoming a committee. After development of the committee mission statement (see attached), a motion was made that the SIG request sanction as a committee. The motion carried eight in favor, three abstentions. John Quinn agreed to take the request forward to the Steering and Executive committees for approval. The four task force groups formed at the January 1993 meeting provided status reports on their progress: Consent Task Force: John Doolittle reviewed the Kaiser consent manual with the group and will pursue getting approval from Kaiser to use the documents within the subgroup and HL7. It was decided that SIG members will gather examples of other consent forms before the September meeting to identify any which may not be included in the Kaiser manual. Wayne Tracy reviewed the message segment development which he has done related to consents. Anyone interested in this work-in-progress should contact Wayne at Cerner Corporation. It was decided that Advance Directives should be addressed as part of the Consent Task Force at the September meeting. Message Review Task Force: Individuals from SMS reported that they had mapped the SMS medical record system to the HL7 2.2 messages and identified that some components were missing from the 2.2 specification. It was decided that these would be attached to the SIG minutes and that many of them could be handled by other chapters. Several are to be forwarded to the ADT Technical Committee. It was decided that at the September meeting it will be discussed as to whether or not to collapse the four identified segments into one classification segment. Security/Confidentiality Task Force: The draft of the ASTM security and confidentiality document was discussed. It was generally felt that the document was vague and lacked representation of such things as the Freedom of Information Act. It was decided that Wayne Tracy and Cindy Miller will draft a response to ASTM for review at the September meeting. Wayne will review with John Quinn whether this can be an "official" HL7 response to ASTM. Attestation Task Force: Due to limited time, the group briefly reviewed sample attestation forms. A packet of these will be made available to any interested parties prior to the September meeting. Interested parties can obtain copies of these attestation packets from Cindy Miller through TDS Healthcare Systems Corp. Additional discussion will be held in September as to how to proceed in this area. NEW BUSINESS The issue of where Utilization Management issues fall within HL7 was raised. It was decided that this issue will be discussed in greater detail at the September meeting to analyze the possibility of message segments in this area. It was decided that if the Executive Committe approves the request for the SIG to become a Committee that the attendance lists from the January and May 1993 meetings would be merged and would be used in lieu of Technical Committee preference sheets. Cindy Miller will take responsibility for merging these lists and forwarding them to the HL7 Administrative office. It was decided that there is sufficient work to warrant a full day of meetings at the September plenary meeting. The group decided that the full day should be held on Thursday. Wayne Tracy agreed to write a SIG history document outlining the issues discussed and resolved for new attendees to the group. This will be reviewed at the September meeting. The meeting was adjourned at 4:00 p.m. Minutes submitted by Cynthia Miller, RRA Minutes verbally approved by Wayne Tracy MEDICAL RECORD SIG ATTENDEES - MAY 1993 Cynthia Miller - Chair Joun O'Brien AHIMA Representative Emory University Wayne Tracy - Co-Chair Kathy Blyler Cerner Corporation SMS Jay Margolis Jo Comstock SMS Kaiser Permanente Art Ammann John Doolittle IBM Kaiser Permanente Elaine Lips, RRA Tom Dean Elacor Resources Group Bell Atlantic Lynda Hernandez Arden Forney Medicus ASTM John Quinn E&Y SEPTEMBER 1993 HL7 PLENARY MEETING MEDICAL RECORD AGENDA THURSDAY - ALL DAY o Review and Approval of Agenda Items o Old Business - Review SIG Status Wayne Tracy - Review of SIG History Document Wayne Tracy - Utilization Management Segments Cindy Miller o Task Force Reports - Consent Task Force - Message Review Task Force - Security/Confidentiality Task Force Review of ASTM Response - Attesatation Task Force o New Business INFORMATION MANAGEMENT (MEDICAL RECORDS) COMMITTEE Mission Statement The objective of the Information Management Technical Committee is to contribute work to the HL7 Working Group from the perspective of the Information Management or Medical Records Department. The committee is comprised of individuals representing vendors of information systems (computer based systems), information management professionals (RRAs - Registered Records Administrators), and other interested parties. The work of the technical committee includes the review of existing and proposed messages in order to provide insight and advise as to the conformance of the message content to existing medical records requirements and practice. To provide formal feedback to other technical committees with suggested modifications where appropriate. The Information Management technical committee has a major objective. The objective is the construction of messages which can be communicated to and from systems which serve the needs of the Information Management Department of healthcare organizations. Such systems may exist as discreet stand-alone departmental systems or as a set of applications or functions within a larger more functionally expansive system such as an HIS. Initially, the following subject areas will be reviewed for potential message construction: - Consents, both procedural and information release - Advance Directives or Living Wills - Durable Power of Attorney for Healthcare Decisions - Medical Record/Chart Tracking - Management of Information Release - Attestations - Utilization Management In addition, this committee will act as a liaison with other organizations such as AHIMA, CPRI, ASTM, and other HL7 technical committees or HL7 special interest groups concerning other related issues such as confidentiality, security, and access to medical records both in paper and electronic form. The committee will formulate recommendations to the HL7 technical committee where appropriate.