Business and Legal Requirements

A Patient Summary-CA Solution should provide the ability to manage the versioning, storage, preservation, destruction, and archiving of Patient Summaries produced and consumed by authorized users of the system in accordance to jurisdictional policies.

A Patient Summary-CA Solution should provide a health care provider with the option to review and sign-off the Patient Summary content before it is made available to PS-CA Consumers.

Note: If the health care provider determines that changes are required to the Patient Summary prior to sign-off, the HCP will make the updates in the patient's chart. If the changes affect the Patient Summary content, a new Patient Summary will be created for review/sign-off by the HCP.

A Patient Summary-CA Solution shall provide a healthcare provider with the ability to invalidate a Patient Summary if they determine it was entered in error or is invalid as required by jurisdictional policy.

A Patient Summary-CA Solution should adhere to data retention policies set by local/jurisdictional policies and system requirements.

A Patient Summary-CA Solution shall provide the ability for an authorized PS consumer (e.g. authorized health care provider) to ascertain the provenance (PS-CA author, producer, date and subject of care) of a current and historical PS.

A Patient Summary-CA Solution may provide the ability to extract and save discrete data from a Patient Summary based on a request by an authorized system user.

A PS-CA Author should reasonably ensure that the health information contained in a Patient Summary-CA is accurate, sufficiently complete and up to date to meet the specified clinical purpose.

A Patient Summary-CA Solution should be able to comply with a legal hold from an authorized entity based on jurisdictional policies.

*Note: Legal hold policies prevent deletion of any electronically stored information on the PS-CA that may be imminent for a legal case.

A Patient Summary-CA Solution should be able to omit or mask data in a PS-CA in compliance with local/jurisdictional privacy policies.

A Patient Summary-CA Solution shall have the ability to produce a Patient Summary in compliance with a subject of care's consent directives in accordance to local/jurisdictional standards and/or policies.

Note: For example, local/jurisdictional standards may include associating consent directives with PHI in the Patient Summary which cover concepts of maintaining association, processing consent directives, blocking transmission of PHI in Patient summary where consent directives are violated or no exception of a disclosure is outlined by law or by jurisdictional policy, and notifications to requesters when data is blocked due to consent directives.

A Patient Summary-CA Solution shall limit the sharing of health information to what is clinically necessary and sufficient, in accordance with governing legislation and the Patient Summary-CA specification.

Note: For example, the clinician will have the ability to create the PS-CA with a subset of the data domains defined within the PS-CA Interoperability Specifications.

A Patient Summary-CA Solution shall have the ability to indicate or make the PS-CA Consumer (e.g. a healthcare provider) aware that information about the subject of care has been omitted or masked based on a consent directives and jurisdictional policies.

A Patient Summary-CA Solution shall provide the Patient/Subject of Care a right of access to their Patient Summary based on jurisdictional policies and legislative provisions.

A Patient Summary-CA Solution shall limit access to only authorized PS-CA Producers and PS-CA Consumers.