ToC+Implementation+Guidance+Approach

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toc The Transitions of Care (ToC) Implementation Guide was created through the following five step approach:

Step 1: Define Use Case Constructs
Key constructs were identified as part of the use case of the Transition of Care Initiative as essential outputs that enable patient transition of care. The use case utilized the following approach:
 * Identify key scenarios and user stories to define the scope of the transitions of care.
 * Identify actors and roles involved at each scenario and story.
 * Conduct interviews and create process diagrams to depict the activities involved in each scenario and user story.
 * Identify key constructs used and their components.

Step 2a: Define Critical Clinical Data Elements
After the constructs were identified, the CIM workgroup, as part of the S&I Framework, began to identify key data elements to include in each construct. The superset of data elements are contained in the Clinical Information Model. Refer to the following approach when creating the CIM model:
 * Identify CIM core data elements and assess detailed information, such as descriptions and examples.
 * Classify data elements.
 * Map priority content to be included in the transitions of care to the CIM to find common semantics to create a harmonized CIM.

Step 2b: Identify Standard Used
In parallel with defining the CIM model, the Standards Analysis workgroup, as part of the S&I Framework, began to analyze the standards to meet the requirements for Meaningful Use. The general consensus supported that the Clinical Document Architecture (CDA) is the candidate standard recommended for standardizing care transitions due to the following advantages:
 * There is a strong base of implementers in the healthcare community with an existing knowledge of CDA and its application to care transitions.
 * CDA is able to accommodate the identified exchange content on all three levels of system capabilities.
 * CDA has a support of model-based standards and development environment, such as the usage of Model-Drive Health Tools (MDHT) and the Template Database (Tdb) to generate artifacts such as models and user guides at the entry, section, and document level templates.
 * CDA tools, such as MDHT and Tdb, support testing functionality and NIST maintains a suite of CDA test profiles.
 * CDA is a well documented standard with numerous sources of information and education available to implementers.

Step 3: Map CDA Standard to Clinical Data Elements
After the CIM Model and the CDA recommendation are complete, there will be a cross-walk that aligns the existing CDA standard to the data elements contained in the CIM Model to ensure consistency and completeness. Any gaps identified will be resolved as needed.

Step 4: Create and Package Implementation Guide
The complete validation of the CDA standard to CIM Model signifies that the key constructs used to facilitate the clinical transitions of care can be generated. This implementation guide provides instructions and guidance for EHR vendors and developers on implementing the exchange of clinical information. =Current Progress= As of August 2011, several major components of this implementation approach have been completed:
 * Tooling Support for CDA has been developed using MDHT and Trifolia as options. A draft roadmap is now being developed.
 * Draft guidance has been developed in support of the S&I Framework Transitions of Care Use Case, which will be piloted and tested through the TOC Pilots Workgroup. Further work on the TOC implementation guidance is ongoing, including automation of implementation guide development, supporting API, and supporting UML models.
 * [[file:ToC Implementation Guidance_Version 1.6_DRAFT.docx]]
 * A roadmap to support greenCDA as an implementation path has been developed
 * Work has begun on development of the CCR-CDA transformation service as part of the TOC Reference Implementation.
 * A draft CIM has been developed and is available for review. Further work on the TOC CIM is ongoing (current version is 1.3)

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