Functional Status Assessment: A Important Factor in the Emerging Standard Continuity of Care Document

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Functional Status Assessment: A Important Factor in the Emerging Standard Continuity of Care Document

Consumers are seeking new methods to enable sharing of health information between providers to improve patient safety and quality. The U.S. population is both mobile and aging which creates a compelling argument for the ability to transmit key data elements between health care providers and other designated agencies or individuals that provide timely and relevant information when needed. Functional status or the ability for a person to manage daily routines is a critical wellness factor that cannot be discerned from either diagnoses or problem lists. Functional assessments measure a person's need for care, monitor changes over time and serve as an indicator for the presence and severity of disease.

The ASTM (American Society for Testing and Materials) CCR is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. The primary use case for the CCR is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient. (HL7, 2006)

The CDA is a document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange. From its inception, CDA has supported the ability to represent professional society recommendations, national clinical practice guidelines, and standardized data sets. From the perspective of CDA, the CCR is a standardized data set that can be used to constrain CDA specifically for summary documents.The resulting specification, known as the Continuity of Care Document (CCD), is developed as a collaborative effort between ASTM and HL7 (HL7,2006)

There are a number of different methods and terminologies currently used as tools to measure functional status components that include vision and hearing, mobility, continence, nutrition, mental status (cognitive and affect), home environment, social support, and activities of daily living. By design the ASTM Continuity of Care Record does not allow for user-configurable fields or local differences in implementation so the information will be understood by senders and receivers and should enable electronic transport between health care settings and locations. This makes the emerging CCD standard data set useful for a variety of circumstances, including natural disasters or other catastrophic events that separate people from their normal health care network and support systems.

Collection of functional status assessment using standard methods allows monitoring for changes in quality of life and abilities/disabilities that affect patient care decisions.