NHIN Content Payload
HITSP C32 and Other
Content Components
Omar Bouhaddou (VA contractor)
David Katz (SSA)
Shane Rossman (SSA)
Copyright 2009. All Rights Reserved.
Objectives of this session
• Understand what content payload is exchanged over the NHIN,
in particular the patient health summary record (HITSP C32)
• Gain familiarity with useful tools to create, validate, and display
HITSP content components (e.g., C32)
• Learn about the relationship between the content exchanged
over the NHIN, CCD and CCR, HL7 CDA and the RIM
• Learn about SSA and VA experience with information exchange
over the NHIN. This year, each agency is engaging into a limited
production release.
2
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Outline
Introduction
HITSP standards and useful tools
Introduction to Clinical Document Architecture
SSA use case
Break
VA use case
Q&A
3
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HITSP Standards & Useful Tools
Omar Bouhaddou (VA Contractor)
4
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Standards Support of
Health Information Exchange
HL7 = CDA
ASTM = CCR
CDA + CCR = CCD
HITSP + CCD = C32
Secure
Interoperable
EHR
Value
Cases
Standards
Organizations
Prioritizing
Business
Needs
Consumer
Empowerment
Use Case
5
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Emergency
Responder
EHR
Use Case
NHIN
Consumer
Access to
Clinical Care
Use Case
Medication
Management
Use Case
Useful Tools
• HITSP website
• NHIN trial implementation
content workgroup
• C32 creation tools (e.g.,
Kaiser ‘spreadsheet’, Mitre
Laika)
• C32 validation tools (e.g.,
NIST CDA validator, Laika2)
• C32 display style sheets
6
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HITSP Web Portal
http://www.hitsp.org/
Interoperability Specifications
7
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HITSP Interoperability Specifications –
IS 01
Specific Standards
for Each IS:
TP=Transaction Packages
T=Transactions
C=Components
TN=Technical Notes
Content Components
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HITSP Interoperability Specifications –
IS 04
Specific Standards
for Each IS:
TP=Transaction Packages
T=Transactions
C=Components
TN=Technical Notes
Content Components e.g., C32
9
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HITSP Interoperability Specifications –
IS 03
Content Components e.g., C32
10
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HITSP Interoperability Specifications –
C32 use
List of the
Interoperability
Specifications that
refer to the C32
11
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HITSP Interoperability Specifications –
C37 use
List of the
Interoperability
Specifications that
refer to the C37
12
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HITSP C32
13
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HITSP C48 Encounter Document
14
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C48 Data Elements
Randomized data linker
Diagnosis/Injury Code
Encounter date/time
Diagnosis type (Problem Code)
Date of Birth
Diagnosis date/time
Age
Discharge disposition
Gender
Patient class (Outpatient, Inpatient, ER)
Zip
Date and time onset of Illness
State
Chief Complaint
Date/Time of Message
Temperature
--------------------------------------------------
Blood Pressure
Patient Identification
Pulse/Heart rate
Admit time/date
Extended triage notes
Discharge time/date
15
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HITSP C83
C28 C32 C38 C48
C83
16
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C78 C84
C80
HITSP C83 (data elements)
C83 Contains All
Content Modules
Used in Several
C Constructs
17
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HITSP C80 (vocabularies)
Vocabularies References from C83
18
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RxNorm for Medication Names
Overview of C32
• 17 data modules
– Demographics, language, support, provider, insurance, allergy, condition,
medications, pregnancy, information source, comments, advance
directive, immunization, vital signs, results, encounter, procedure
• Constraints
– Required/required if known/ optional
– Repeating constraints
– Terminology constraints
• 155 data elements
• 48 data elements with a HITSP-specified value set
• 58 required data elements
• 16 that are both required and have a HITSP-specified value set
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HITSP C32 Data Modules
REQUIRED (R) - MUST
•
Personal Information
•
Information Source
REQUIRED IF KNOWN (R2) –
SHOULD
•
Language Spoken
•
Support
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OPTIONAL (O) - MAY
• Healthcare Provider
• Insurance Provider
• Allergies and Drug Sensitivity
• Condition
• Medications
• Pregnancy
• Comments
• Advance Directives
• Immunizations
• Vital Signs
• Results
• Procedures
• Encounters
20
NHIN Trial Implementation
Content Workgroup
Content Specifications
Narrative in Word doc
21
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Content Specifications
Data elements in Excel
NHIN C32 Minimum Data Set
Personal Information
Language Spoken
Support
Healthcare Provider
Insurance Provider
Allergies and Drug Sensitivity
Condition
Medications
Pregnancy
Information Source
Comments
Advance Directives
Immunizations
Vital Signs
Results
Encounters
22
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Content modules in
Minimum Data Set
22
NHIN Content Specifications:
Spreadsheet - http://healthit.hhs.gov/
23
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NHIN Content Specifications:
Word document - http://healthit.hhs.gov
NHIN Trial Implementation further constrained HITSP C32
24
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Creating test C32 documents
There are at least 3 methods:
1. Kaiser Permanente (KP) method
using a spreadsheet as an input
2. Laika tool from Mitre/NIST
3. Modifying an existing C32
25
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Creating Test C32 documents
Kaiser Permanente Tool
URL
Select content
modules
Upload input
spreadsheet
Assemble C32
26
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Creating Test C32 documents
Kaiser Permanente Tool
(input spreadsheet)
Data element IDs
XML tags
Patient values
27
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Laika C32 Template page
C32 content
modules
C32 data
elements
Patient data
28
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Laika Library page
Library of
created C32
documents
29
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Laika Dashboard
Passed/failed
status of C32
documents
30
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Modifying a Sample C32 XML File
Using a Text/XML Editor
<?xml version="1.0" encoding="UTF-8" standalone="no"?><?xml-stylesheet type="text/xsl" href="CCD.xsl"?>
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3
http://xreg2.nist.gov:8080/hitspValidation/schema/cdar2c32/infrastructure/cda/C32_CDA.xsd">
<!--
********************************************************
CDA Header
********************************************************
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root="2.16.840.1.113883.10.20.1"/>
<!-- CCD v1.0 Templates Root -->
<templateId root="2.16.840.1.113883.3.88.11.32.1"/>
<!-- HITSP/C32 Registration and Medication Template -->
<id root="6858a017-39c1-4153-bbd4-eaedac72a0e7"/>
<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" displayName="Summarization of episode note"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<!-- DOCUMENT LANGUAGE -->
<languageCommunication>
<templateId root="2.16.840.1.113883.3.88.11.32.2"/>
<languageCode code="en-US" displayName="United States"/>
</languageCommunication>
<!-- PERSON INFORMATION CONTENT MODULE, REQUIRED -->
<!-- 1.01 DOCUMENT TIMESTAMP, REQUIRED -->
<effectiveTime value="20090128000000-0000"/>
<recordTarget>
<patientRole>
<!-- Root OID: http://www.oid-info.com/get/1.3.6.1.4.1.26580 -->
<!-- 1.02 PERSON ID, REQUIRED -->
<id extension="500000007" root="2.16.840.1.113883.3.200"/>
<!-- 1.03 PERSON ADDRESS-HOME PERMANENT, REQUIRED -->
<addr use="HP">
<streetAddressLine>221 Testview Road</streetAddressLine>
<city>Quantico</city>
<state>VA</state>
<country>US</country>
<postalCode>22134</postalCode>
</addr>
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Copyright 2009. All Rights Reserved.
-->
NIST CDA Validation Tool
http://xreg2.nist.gov/cda -validation/
Upload xml file
Specify error
returns
Specify CDA
construct to be
validated
(e.g., C32, C37)
32
Copyright 2009. All Rights Reserved.
NIST CDA Validation Tool
The
validation
results are
posted.
No errors.
33
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XML Schema Definition (XSD)
The structural schema
(XSD) for C32 is the schema
for CDA.
The C32 restriction is
defined by the schematron
template rules.
34
Copyright 2009. All Rights Reserved.
XSD Content Rules
Here is the actual XML document for the Personal
information.
Employee Information
SSN
Name
DateOfBirth
EmployeeType
Salary
<?xml version="1.0" ?>
- <Employees xmlns="http://www.abccorp.com"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="http://www.abccorp.com/employee.xsd">
- <Employee>
Here is the XML Schema for the above Information
<SSN>737333333</SSN>
<Name>ED HARRIS</Name>
<DateOfBirth>1960-01-01</DateOfBirth>
<EmployeeType>FULLTIME</EmployeeType>
<xsd:schema xmlns:xsd="http://www.w3.org/2001/XMLSchema">
<xsd:element name="Employee"
minOccurs="0"
<Salary>4000</Salary>
maxOccurs="unbounded">
</Employee>
</Employees>
<xsd:complexType>
<xsd:sequence>
<xsd:element name="SSN="xsd:string>
<xsd:element name="Name" type="xsd:string"/>
<xsd:element name="DateOfBirth" type="xsd:date"/>
<xsd:element name="EmployeeType" type="xsd:string"/>
<xsd:element name="Salary" type="xsd:long"/>
</xsd:sequence>
</xsd:complexType>
</xsd:element>
</xsd:schema>
35
Copyright 2009. All Rights Reserved.
Display of a C32
XML
+
XSLT
=
36
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Introduction to Clinical Document Architecture
David Katz (SSA)
37
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Introduction to Clinical Document
Architecture (CDA)
Objectives:
Clinical Document Architecture Fundamentals:
• What is CDA? How does CDA relate to Continuity of Care Document and
HITSP C32/C83? Why is it important to learn and understand?
• What are the characteristics of a CDA document?
• What comprises a CDA document?
Useful Information:
• Where can I find copies of discussed specifications?
• Where can I go for help with standards questions?
• What in the HL7 v3 standard is important to know to further my
understanding of CDA?
38
Copyright 2009. All Rights Reserved.
What is Clinical Document
Architecture?
The official definition:
The HL7 Clinical Document Architecture
(CDA) is a document markup standard
that specifies the structure and
semantics of “clinical documents” for
the purpose of exchange.
HL7 Clinical Document
Architecture, Release 2.0
39
Copyright 2009. All Rights Reserved.
We’re all
CDA experts
now, right?
XML and CDA
XML “document” (file)
<?xml version="1.0" encoding="utf-8"?>
<document>
<tag1>Information</tag1>
<tag2 tag2DataPresent=“false”></tag2>
</document>
Clinical Document Architecture
<?xml version="1.0" encoding="utf-8"?>
<?xml-stylesheet type="text/xsl" href="CCD.xsl"?>
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc"
xmlns:sdtc="urn:hl7-org:sdtc" xmlns:cda="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3">
…
</ClinicalDocument>
40
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Continuity of Care Document
HITSP C32/C83
CDA
+
CCR
=
Continuity of
Care Record
Clinical Document
Architecture
CCD
Continuity of Care
Document
C32
+
CCD
=
“Summary Documents Using
HL7 Continuity of Care
Document (CCD) Component”
C83
“CDA Content Modules
Component”
41
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Constraints on CDA
CCD
42
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Why Understand CDA?
XML Request For
Medical/Clinical Information
XML Received
Medical/Clinical Payload
43
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CCD
What If…
I want to add more ingredients?
44
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More Than A Recipe
45
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What If…
I want additional content?
Content
Requirement
Content
Requirement
46
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CCD Cookbook:
Adding Encounter Location
CONF-471: An encounter activity MAY contain one or more
location participations.
CONF-472: A location participation (templateId 2.16.840.1.113883.10.20.1.45)
SHALL be represented with the participant participation.
CONF-473: The value for “participant / @typeCode” in a location participation SHALL be “LOC”
2.16.840.1.113883.5.90 ParticipationType STATIC.
CONF-474: A location participation SHALL contain exactly one participant / participantRole.
CONF-475: The value for “participant / participantRole / @classCode” in a location participation SHALL be
“SDLOC” “Service delivery location” 2.16.840.1.113883.5.110 RoleClass STATIC.
CONF-476: Participant / participantRole in a location participation MAY contain exactly one participant /
participantRole / code.
CONF-477: The value for “participant / participantRole / code” in a location participation SHOULD be selected from
ValueSet 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType 2.16.840.1.113883.5.111 RoleCode
DYNAMIC.
CONF-478: Participant / participantRole in a location participation MAY contain exactly one participant /
participantRole / playingEntity.
CONF-479: The value for “participant / participantRole / playingEntity / @classCode” in a location participation
SHALL be “PLC” “Place” 2.16.840.1.113883.5.41 EntityClass STATIC.
47
Copyright 2009. All Rights Reserved.
More Than Instructions
HL7 Clinical Document Architecture, Release 2.0
ANSI/HL7 CDA, R2-2005
HL7 Clinical Document Architecture, Release 2
4/21/2005
48
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The Six CDA Characteristics
1
Persistence
4
Context
2
Stewardship
5
Wholeness
3
Potential for
Authentication
6
Human
Readability
49
Copyright 2009. All Rights Reserved.
CDA Components (XML Perspective)
<ClinicalDocument>
…
DOCUMENT
HEADER
<StructuredBody>
<component><section>
<text>...</text>
<entry>
<observation>...</observation>
</entry>
<entry>
<observation>...</observation>
</entry>
</section></component>
<component>...</component>
</StructuredBody>
</ClinicalDocument>
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BODY
SECTIONS
NARRATIVE TEXT
ENTRIES
CDA Fields
HL7 RIM defines the fields used in CDA.
…
<section>
<templateId root="2.16.840.1.113883.10.20.1.12"/>
<text>Cholecystectomy was performed by Dr. Smith…</text>
<entry>
<procedure classCode=“PROC" moodCode=“EVN">
<code code="38102005" codeSystem=“2.16.840.1.113883.6.96”
codeSystemName=“SNOMED CT" displayName="Cholecystectomy"/>
</procedure>
</entry>
</section>
…
51
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CDA Field Values
Field values are defined by standard terminologies.
…
<section>
<templateId root="2.16.840.1.113883.10.20.1.12"/>
<text>Cholecystectomy was performed by Dr. Smith…</text>
<entry>
<procedure classCode=“PROC" moodCode=“EVN">
<code code="38102005" codeSystem=“2.16.840.1.113883.6.96”
codeSystemName=“SNOMED CT" displayName="Cholecystectomy"/>
</procedure>
</entry>
</section>
…
52
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Is This Legal?
<ClinicalDocument>
<documentationOf>…</documentationOf>
<author>…</author>
<recordTarget>…</recordTarget>
…
<component>
<StructuredBody>
<section>…</section>
</StructuredBody>
<component>
</ClinicalDocument>
53
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Clinical Document Architecture
Refined Message Information Model
(R-MIM)
54
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How to Read the CDA R-MIM
<ClinicalDocument classCode=“DOCCLIN”
moodCode=“EVN”>
<id>…</id>…
<component>
<StructuredBody>
<component>
<Section>…</Section>
</component>
</StructuredBody>
</component>
</ClinicalDocument>
55
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Understanding Classes in the
CDA R-MIM
text: ED [0..1]
• text = attribute (XML element) name.
• ED = data type (Encapsulated Data).
• [1..1] = cardinality, attribute may
appear once or not at all. .
code*: CD CWE [0..1] <= ObservationType
•
•
•
•
•
code* = attribute (XML element) name.
CD = data type (Concept Descriptor).
CWE = code strength, “Coded With Extensions”.
[1..1] = cardinality, attribute must appear once but not more than once.
ObservationType = vocabulary domain
56
Copyright 2009. All Rights Reserved.
Templates and Object Identifiers
(OIDs)
How does the processing system know what standard a XML file is
declaring conformance to?
<?xml version="1.0" encoding="utf-8"?>
<?xml-stylesheet type="text/xsl" href="CCD.xsl"?>
<ClinicalDocument ..">
<realmCode code="UV" />
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
<templateId root=" 2.16.840.1.113883.10.20.1 " />
<templateId root=" 2.16.840.1.113883.3.88.11.32.1 " />
<id root="6858a017-39c1-4153-bbd4-eaedac72a0e7" />
<code code="34133-9" displayName="Summarization of episode note"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<title>Continuity of Care Document</title>
…
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Data Types and Vocabulary Domains
58
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About Data Types
code*: CD CWE [1..1] <= ObservationType
Data types are the basic
building blocks of attributes.
They define the structural
format of the data carried in
the attribute and influence the
set of allowable values an
attribute may assume…
- HL7 v3 Specification
59
Copyright 2009. All Rights Reserved.
Data Types in the CDA R-MIM:
Implementation Technology Specification
code*: CD CWE [1..1] <= ObservationType
<!-- type CD -->
<x nullFlavor = (NI | OTH | NINF | PINF | UNK | ASKU | NAV | NASK | TRC | MSK | NA | NP)
code = ST
codeSystem = UID
codeSystemName = ST
codeSystemVersion = ST
displayName = ST >
Content: ( originalText, qualifier*, translation* )
</x>
<code
code=“57054005”
codeSystem=“2.16.840.1.113883.6.96”
codeSystemName=“SNOMED CT”
displayName=“Acute myocardial infarction ” >
<translation
code=“410.90”
codeSystem=“2.16.840.1.113883.6.2”
codeSystemName=“ICD9 CM”
displayName=“Acute myocardial infarction, unspecified site, episode of care unspecified ” />
</code>
60
Copyright 2009. All Rights Reserved.
Vocabulary Domains and the RIM
Modern health care communications and data storage makes heavy use of encoded information.
In HL7, this is referred to as vocabulary. The HL7 standards define several different type of
objects that implement various characteristics of vocabulary. Whereas other elements of the HL7
standards are primarily concerned with structure, vocabulary deals with content.
ActStatus
[2.16.840.1.113883.5.14]
Codes representing the defined possible states of an Act, as defined by the Act class state machine.
Lvl- Typ
Concept Code
Head Codedefined Value Set
Print Name
Definition
0-S
normal
ActStatusNormal
normal
Encompasses the expected states of an Act, but excludes "nullified" and "obsolete"
which represent unusual terminal states for the life-cycle.
1-L
. aborted
. ActStatusAborted
aborted
The Act has been terminated prior to the originally intended completion.
1-L
. active
. ActStatusActive
active
The Act can be performed or is being performed
1-L
. cancelled
. ActStatusCancelled
cancelled
The Act has been abandoned before activation.
1-L
. completed
. ActStatusCompleted
completed
An Act that has terminated normally after all of its constituents have been
performed.
statusCode: CS CNE [0..1] <= ActStatus
61
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In Summary
• C32/C83 constrain the Continuity of Care Document that constrains Clinical
Document Architecture.
• CDA inherits classes and attributes from the HL7 RIM
• CDA R-MIM dictates the cardinality of CDA classes, attributes allowed in
those classes, and the data type of those attributes.
• Data types define the structural format of the data carried in the attribute and
influence the set of allowable values an attribute may assume
• Some class attributes may require data from specified HL7 vocabulary
domains.
• Template identifiers can be used to signify conformance to a specified
standard and its sections.
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Copyright 2009. All Rights Reserved.
Useful Information
• CDA documentation
– http://www.hl7.org
– HL7 membership required
• CCD Documentation
– http://www.hl7.org
– HL7 membership required
• HITSP Specifications
– http://www.hitsp.org/
• HL7 Listserv
– http://lists.hl7.org/read/
– ccd and strucdoc forums
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• Important Sections in the HL7 v3
Standard
– Clinical Document Architecture Domain
– XML Implementation Technology Specification
- Data Types
– HL7 Vocabulary
SSA Use Case
Shane Rossman (SSA)
64
Copyright 2009. All Rights Reserved.
Social Security Administration
Use Case
Test
Connectivity
Identify Content
Producer
Confirm Content
Consumer
Develop
Content (XML)
Develop XSLT
Test Content
65
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Healthcare
Partner
Content Modules
• Problems
– Information on relevant clinical problems
– ICD 9
• Results
– Current and relevant historical result observations
• Procedures
– Coded entries indicating a procedure performed on a patient
– How to display procedure narrative and procedure location
• Encounters
– Contains information describing the patient history of encounters
– How to display encounter narrative
66
Copyright 2009. All Rights Reserved.
Problem Section - XPATH
OID
Oject Identifier
component/section/templateId/@root
Text reference
67
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ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelation
ship/observation/reference/@ value
Problem Section - XPATH
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.11"></templateId>
<code code="11450-4" displayName="Problem list" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" />
<title>Problem list</title>
<text><content ID="prob-1"></content></text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27" />
<id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7" />
<code nullFlavor="UNK" />
<performer typeCode="PRF">
<time>
<low value="20060601" />
<high value="20080924" />
</time>
<assignedEntity>
<id root="78AAAA11-B890-49dc-B716-5EC0027B3982" extension="ProviderID" />
<code code="280000000X" displayName="Hospitals" codeSystem="2.16.840.1.113883.6.101"
codeSystemName="ProviderCodes" />
<addr use="WP">
<streetAddressLine>145 Applecross Road</streetAddressLine>
<streetAddressLine></streetAddressLine>
<city>Southern Pines</city>
<state>NC</state>
<postalCode>28388</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr. </prefix>
<given>Shirley</given>
<family>Jordan</family>
</name>
</assignedPerson>
68
Copyright 2009. All Rights Reserved.
Problem Section – XML cont.
<representedOrganization>
<name>Test Health Center</name>
</representedOrganization>
<sdtc:patient xmlns:sdtc="urn:hl7-org:sdtc">
<sdtc:id root="78A155555-ZZ23-49dc-B716-5EC0027B3983" extension="33445566" />
</sdtc:patient>
</assignedEntity>
</performer>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28" />
<id root="ab1791b0-5c71-11db-b0de-0800200c9a66" />
<code code="282291009" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED
CT"></code>
<originalText>
<reference value="#prob-1" />
</originalText>
<statusCode code="completed" />
<effectiveTime>
<low value="20080915" />
<high nullFlavor="UNK" />
</effectiveTime>
<value xsi:type="CD" code=“486.0" displayName=“Lobar pneumonia with influenza "
codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9" xmlns:xsi="http://www.w3.org/2001/XMLScheMDinstance" />
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<!--20.1.50 = problem status observation 20.1.57 = conforMDnt status observation-->
<templateId root="2.16.840.1.113883.10.20.1.50"></templateId>
<code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<statusCode code="completed" />
<value xsi:type="CD" code="55561003" displayName="Active" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" xmlns:xsi="http://www.w3.org/2001/XMLScheMD-instance" />
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
69
Copyright 2009. All Rights Reserved.
Problem Section - Display
Prob List
Date
Type
Code #
Problem
September 15, 2008
Diagnosis
(486.0)
Lobar pneumonia with influenza Active
Dr. Shirley Jordan
September 10, 2008
Symptom
(114.0)
Pneumonia
Dr. Shirley Jordan
70
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Status Provider
Active
Results Section - XML
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.14"/>
<code code="30954-2" displayName="Relevant diagnostic tests and/or laboratory data"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Results</title>
<text>
<content ID="lab-1">LDL</content>
<content ID="lab-2">BG Bruce</content>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="57d07056-bd97-4c90-891d-eb716d3170c8"/>
<code code="2093-3" displayName="Cholesterol" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<originalText>
<reference value="#lab-1"/>
</originalText>
<statusCode code="completed"/>
<effectiveTime>
<low value="20080820"/>
</effectiveTime>
<value xsi:type="PQ" value=“71" unit="mg/dL"/>
<interpretationCode code="N" displayName="Normal" codeSystem="2.16.840.1.113883.5.83" codeSystemName="Observation
Interpretation"/>
</entry>
</section>
</component>
71
Copyright 2009. All Rights Reserved.
Results Section - XML
Results
Date
Test
August 20, 2008
Result Value
Interpretation
LDL
71 mg/dL
Normal
August 20, 2008
BG Bruce
86 mg/dL
Normal
August 20, 2008
WBC
4.4 10*3/uL
Normal
August 20, 2008
HGB
13.9 g/dL
Normal
72
Copyright 2009. All Rights Reserved.
Ref Range
Procedures Section - XML
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.12" />
<!-- CCD Procedures section template -->
<code code="47519-4" displayName="History of procedures" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" />
<text>
<content ID="proc-1">Dialysis Clinic Inc NEW MARKET, MD 02222 MEDICAL RECORDS
DEPARTMENT *****OPERATIVE REPORT ********* Signed by: Sohen, Henry
Patient: Snow,
Jane Report Date: 11/05/2008 A case is reported of a patient with long-standing, severe airflow
obstruction requiring long-term nebulizer therapy developing a facial dermatitis in the area bounded
by the nebulizer mask. The facial dermatitis seems to be the result of the combined irritancy of the
nebulizer solutions and moisture, and prophylactic measures are suggested for patients requiring
long-term nebulizer therapy.
The patient tolerated the procedure well and was taken to the recovery room in satisfactory and
stable condition. John Smith, MD 022222 I certify that I was present in compliance with HCFA
regulations. Dictated by John Smith, MD Signed electronically by: Dr. John Smith on Thu Nov 05,
2008 10:47 AM</content>
</text>
<code code=" 56251003 " displayName="Nebulizer therapy“ codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT">
<Text>
<reference value="#proc-1" />
</Text>
</code>
<effectiveTime>
<low value=“20081109”>
<high value=“20081109”>
</effectiveTime>
73
Copyright 2009. All Rights Reserved.
Procedures Section - Display
PROCEDURES
Date
Code#
Procedure
November 9, 2008
(56251003)
Nebulizer Therapy
November 9, 2008
Operative Report For Procedure:
Nebulizer therapy
Dialysis Clinic Inc NEW MARKET, MD 02222 MEDICAL RECORDS DEPARTMENT *****OPERATIVE REPORT ********* Signed by: Sohen,
Henry Patient: Snow, Jane Report Date: 11/05/2008 A case is reported of a patient with long-standing, severe airflow obstruction
requiring long-term nebulizer therapy developing a facial dermatitis in the area bounded by the nebulizer mask. The facial dermatitis
seems to be the result of the combined irritancy of the nebulizer solutions and moisture, and prophylactic measures are suggested
for patients requiring long-term nebulizer therapy. The patient tolerated the procedure well and was taken to the recovery room in
satisfactory and stable condition. John Smith, MD 022222 I certify that I was present in compliance with HCFA regulations. Dictated
by John Smith, MD Signed electronically by: Dr. John Smith on Thu Nov 12, 2008 10:47 AM
74
Copyright 2009. All Rights Reserved.
Encounters Section - XML
<section>
<templateId root="2.16.840.1.113883.10.20.1.3"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
<title>Encounters</title>
<text>
<content ID="note-1">Name: SNOW, JANE
Admitted: 01/15/2009~MR#222222222 DOB: 03/29/1975~Account #:000111111111 Age: 33~
Consultant: SYDNEY MANNER, NP Location: 7W 729 A~~CONSULTATION REPORT~~DATE of CONSULTATION: 01/16/2009~REFERRING
PHYSICIAN:~~~REFERRING PHYSICIAN:Sohen, Harry, MD~~~~PRIMARY CARE PHYSICIAN: Bradley Mouse, MD~~PSYCHIATRIST: Sue
Green, MD~~HISTORY OF PRESENT ILLNESS: This is a 33-year-old white female who~apparently has long-standing
psychiatric issues with panic attacks and~depression, posttraumatic stress disorder…
<br/><br/> Name: SNOW, JANE
Service Date: DOB: 03/29/1975
<br/><br/></content>
<content ID="note-2"> <br/><br/></content></text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.17"/>
<templateId root="2.16.840.1.113883.10.20.1.21"/>
<id root="8e6184b6-2321-4800-97e5-ccb487a104ff"/>
<code code="EMER" codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7 ActCode" displayName="Emergency"/>
<effectiveTime>
<low value="20080910"/>
<high nullFlavor="UNK"/>
</effectiveTime>
75
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SSA Lessons Learned
<code code="IMP" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" displayName="Inpatient encounter">
<Text><reference value="#note-1"/></Text>
</code>
<effectiveTime>
<low value="20090115"/>
<high value="20090120"/>
</effectiveTime>
<performer typeCode="PRF">
<assignedEntity>
<id extension="d6d7fb89-afb2-4903-9dc1-841875289e0d" root="2.16.840.1.113883.4.6.1013905751"/>
<code code="280000000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="ProviderCodes"
displayName="Hospitals"/><addr/>
<assignedPerson>
<name><family>MANNER</family><given>SYDNEY</given></name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.3.xxx"/>
<name>Test Hospital</name>
</representedOrganization>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<templateId root="2.16.840.1.113883.10.20.1.45"/>
<participantRole classCode="SDLOC">
<code code="PC" codeSystem="2.16.840.1.113883.5.111"
codeSystemName="RoleCode" displayName="Primary Care Clinic"/>
<addr use="WP"/>
<playingEntity classCode="PLC">
<name>Test Hospital</name>
76
Copyright 2009. All Rights Reserved.
Encounters Section Display
Encounter List
#
Date
1 January 15, 2009
2 August 08, 2008
Type of Encounter
Provider Name
Facility
Inpt. Encounter
Sydney Manner
Test Hospital
ER
Harry Sohen
Simple Clinic
Encounter Details
Encounter # 1 Inpatient encounter at Test Hospital
Date: January 15, 2009
Name: SNOW, JANE I Admitted: 01/15/2009~MR #: 222222222 DOB: 03/29/1975~Account #: 000111111111 Age: 33~Consultant:
SYDNEY MANNER, NP Location: 7W 729 A~~CONSULTATION REPORT~~DATE OF CONSULTATION: 01/16/2009~REFERRING
PHYSICIAN:~~~REFERRING PHYSICIAN: Sohen, Harry, MD~~PRIMARY CARE PHYSICIAN: Bradley Mouse,
MD~~PSYCHIATRIST: Sue Green, MD~~HISTORY OF PRESENT ILLNESS: This is a 33-year-old white female who~apparently has
long-standing psychiatric issues with panic attacks and~depression, posttraumatic stress disorder…
Name: SNOW, JANE
Service Date: DOB: 03/29/1975…
Encounter # 2 Emergency Room at Simple Clinic
Date: August 8, 2008
The medical source did not provide any encounter information for this date. Please review other sections of this HIT MER document for
information for this date.
77
Copyright 2009. All Rights Reserved.
SSA Lessons Learned
Identify Content
Validation of the Content
Communication and Quick turnaround
Confirm Content
Remember the Details
78
Copyright 2009. All Rights Reserved.
Break
79
Copyright 2009. All Rights Reserved.
VA Use Case
Omar Bouhaddou (VA contractor)
80
Copyright 2009. All Rights Reserved.
Overview of VA Business Case
• Estimated 3 out of 4 veteran patients receive care from both VA
and non-VA providers (2005 VA/Medicare Data Match and 2007 VHA Enrollee Survey)
• Many requests for VA records from the private sector
• Executive Order 13335 – (April 27, 2004)
• Announces commitment to the promotion of health IT & widespread
adoption of interoperable EHRs within 10 years
• Executive Order 13410 (Aug 22, 2006)
– shall utilize, where available, health information technology systems
and products that meet recognized interoperability standards.
81
Copyright 2009. All Rights Reserved.
NHIN solution components
Agency
Systems
Existing
VistA
82
Copyright 2009. All Rights Reserved.
Adapter
Under
development
At VA
Gateway
Federal Agencies shared
development of NHIN
CONNECT Gateway, now
available in public domain
NHIN
VA NHIN components
NHIN WS
Protocols
HTTPS
VistAWeb
NHIN-C Gateway
Entity/Adapter
WS
XSPA SOAP
VistAWeb Server
NHIN
WS
RPC/HL7
MSG
VA MPI
RPC
VA NHIN Gateway Adapter
Subsystem
RPC
Preferences and
Policy Subsystem
VistA
83
Copyright 2009. All Rights Reserved.
VistA
Terminology
Editing System
Data
Extraction
& Assembly
of a C32
Data Extract Method from your EHR
Do you have one, multiple or none?
– One Method:
• Determine which C32 data elements can be populated
• Determine how to handle unavailable data elements
– Multiple Methods:
• Determine data sources for the C32 data content
• Pick method(s) that provides best coverage for C32
– No Existing Method:
• Need one
How well defined are the data extracted so that you can
map them reliably to the C32 data elements?
84
Copyright 2009. All Rights Reserved.
C32 – Personal information
PATIENT INFORMATION EVENT ENTRY
R/N
Person ID
R/N
Person Address <streetAdressLine>, 4 max
R/Y
Person Address
<city>
R/Y
Person Address
<state>
R/Y
Person Address
<country>
Person Address
<postal code>
O/Y-for US Addresses
R/Y-for
R/Y
Person Phone/Email/URL
R/Y
PERSONAL INFORMATION
Person Name - Legal
<prefix>
O/Y
Person Name -Legal <given> (first)
R/Y
Person Name - Legal
O/Y
<given>(middle)
Person Name -Legal
Person Name -Legal
<family>
<suffix>
R/Y
O/Y
Person Name -Alias/Former
O/Y
Person Name -Alias/Former
O/Y
Person Name
O/Y
Person Name
O/Y
Person Name
O/Y
Gender
R/N
Person Date of Birth
R/N
Marital Status
R2/
Religious Affiliation
O/N
Race
O/Y
Ethnicity
O/N
85
Copyright 2009. All Rights Reserved.
non-US addresses
C32 - Personal Information
• Person name
– First name, middle initial, last name, suffix
(provide any, in required syntax)
• Address (required)
– Home, Work, Vacation (At least 1 is required)
– Provide any details available (#, street, city,
state, zip, country)
• Phone/email/URL
– At least 1 is required using format specified
86
Copyright 2009. All Rights Reserved.
C32 – Contact Module
SUPPORT
R2/Y
Date
R/N
CONTACT
R2/Y
3.02
Contact Type
R/N
contactType
3.03
Contact Relationship
R2/N
relationshipType
relationshipDisplay
3.04
Contact Address
R2/Y
homeAddressLine
homeCity
homeState
homeCountry
homePostal
workAddressLine
workCity
workState
workCountry
workPostal
3.05
Contact Phone/Email/URL
R2/Y
homePhone
workPhone
3.06
Contact Name
R/Y
nameGiven
nameMiddle
nameFamily
nameSuffix
3.01
87
Copyright 2009. All Rights Reserved.
date
contactDisplay
C32 – Allergy Module
HITSP/C32
Opt/Rep
BHIE-RDV
VistA File #
VistA Field #
ADVERSE EVENT ENTRY
R2/Y
Adverse Event Date
R2/N
4^ Verification Date/Time
120.8-PATIENT ALLERGIES/
20-VERIFICATION DATE/TIME
Adverse Event Type
R/N
3^ Allergy Type
120.8-PATIENT ALLERGIES/
3.1-ALLERGY TYPE
Alert type code
O/N
PRODUCT
R2/Y
Product Free-Text
R/N
2^ Allergy Reactant
120.8-PATIENT ALLERGIES/
.02-REACTANT
Product Coded
R2/N
120.8-PATIENT ALLERGIES/
1 GMR ALLERGY (value that points
to a reference table)
REACTION
O/Y
Reaction Free-Text
R2/N
Patient Allergies 120.8
10 REACTIONS (Multiple-120.81), 1
OTHER REACTION
Reaction Coded
R2/N
Patient Allergies 120.8
11 REACTIONS (Multiple-120.81), 1
OTHER REACTION
SEVERITY
R2/N
Severity Free-Text
R2/N
Adverse Reaction Reporting File
#120.85
14.5 Severity
Severity Coded
R2/N
Adverse Reaction Reporting File
#120.85
14.5 Severity
Allergy Status
O/N
88
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C32 – Medication Module 1/4
HITSP/C32
Opt/
Rep
BHIE-RDV
VistA File #
14^ Detail
PRESCRIPTION (#52)/SIG1
(#10.2)
VistA Field #
ADMINISTRATION
INFORMATION EVENT ENTRY
R2/Y
Free Text Sig
O/N
Indicate Medication Stopped
O/N
Administration Timing
O/Y
Frequency
O/Y
PRESCRIPTION #52
113 MEDICATION INSTRUCTIONS (Multiple),
7 SCHEDULE
Interval
O/Y
PRESCRIPTION #52
113 MEDICATION INSTRUCTIONS (Multiple),
7 SCHEDULE
Duration
O/Y
PRESCRIPTION #52
113 MEDICATION INSTRUCTIONS (Multiple),
7 SCHEDULE
Route
O/Y
PRESCRIPTION #52
113 MEDICATION INSTRUCTIONS (Multiple),
7 SCHEDULE
Dose
O/Y
PRESCRIPTION #52
113 MEDICATION INSTRUCTIONS (Multiple),
7 SCHEDULE
Site
O/Y
Dose Restriction
O/Y
PRESCRIPTION #52
7 QTY
Product Form
O/N
PRESCRIPTION #52
3 NOUN
Delivery Method
O/Y
PRESCRIPTION #52
8 VERB
89
Copyright 2009. All Rights Reserved.
No known match?? (cancel
date in VistA?)
C32 – Medication Module 2/4
HITSP/C32
Opt/
Rep
BHIE-RDV
VistA File #
VistA Field #
2^ Drug Name
PRESCRIPTION #52
6 DRUG
MEDICATION INFORMATION
R/Y
Coded Product Name
R2/Y
Coded Brand Name
R2/Y
Free Text Product Name
R/N
Free Text Brand Name
R2/N
PRESCRIPTION #52
6.5-TRADE NAME, if null use PRODUCT FILE/ PRINT
NAME
Drug Manufacturer
O/N
PRESCRIPTION #52
28 MANUFACTURER (original fill)
52 REFILL (Multiple), 12 MANUFACTURER
60 PARTIAL (FILL) DATE, 2 MANUFACTURER
Product Concentration
R2/N
50.68-PRODUCT
2-STRENGTH + 3-UNITS, if these fields are null
then use 52-PRESCRIPTION/113-MEDICATION
INSTRUCTION (multiple) .01-DOSAGE ORDERED
Type of Medication
R2/N
50.67-NDC/UPN
10-OTX/RX INDICATOR
Status of Medication
R2/N
PRESCRIPTION #52
100 STATUS
Indication
O/Y
Patient Instructions
O/N
PRESCRIPTION #52
114 PATIENT INSTRUCTIONS
Adverse Reaction Report #120.85
10 REACTIONS (Multiple),
.01 REACTION (MP120.83) [points to the
SIGN/SYMPTOMS File #120.83]
1 OTHER REACTION (F) [If reaction not found in
(120.83) file, free text will be here]
Reaction
O/N
Vehicle
O/Y
Dose Indicator
O/Y
90
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5^ Status
C32 – Medication Module 3/4
HITSP/C32
Opt/
Rep
ORDER INFORMATION
R2/Y
Order Number
Fills
VistA File #
VistA Field #
R2/N
PRESCRIPTION #52
39.3 PLACER ORDER #
O/N
PRESCRIPTION #52
9 # OF REFILLS
R2/N
6^ Quantity
(NOTE: RDV does not
provide Unit Of
Measure)
PRESCRIPTION #52
7 QTY
Order Expiration Date/Time
R2/N
7^ Exp/Cancel Date
(NOTE: RDV does not
provide time, date only,
may have to provide a
default time)
PRESCRIPTION #52
26-EXPIRATION DATE OR
26.1 CANCEL DATE
Order Date/Time
O/N
PRESCRIPTION #52
1 ISSUE DATE
Ordering Provider
O/N
PRESCRIPTION #52
4 PROVIDER
Fulfillment Instructions
O/N
PRESCRIPTION #52
39 PROVIDER COMMENTS
(Multiple), .01 PROVIDER
COMMENTS
Quantity Ordered
[Qty + Unit of measure]
91
Copyright 2009. All Rights Reserved.
BHIE-RDV
11^ Provider
C32 – Medication Module 4/4
HITSP/C32
Opt/
Rep
Fulfillment History
O/Y
Prescription Number
R2/N
Provider
(Pharmacy that provided the
dispense)
O/N
Location
O/N
Dispense Date
O/N
Quantity Dispensed
R2/N
Fill number
(Total counts of fills allowed for
the prescription - stays constant)
R2/N
Fill Status
92
Copyright 2009. All Rights Reserved.
O/N
BHIE-RDV
VistA File #
VistA Field #
4^ RX #
PRESCRIPTION #52
.01 RX #
PRESCRIPTION #52
20 DIVISION (Points to the OUTPATIENT
SITE File #59, .01 NAME)
PRESCRIPTION #52
20 DIVISION (Points to the OUTPATIENT
SITE File #59:
.02 MAILING FRANK STREET ADDRESS
.05 MAILING FRANK ZIP+4 CODE
.07 MAILING FRANK CITY
.08 MAILING FRANK STATE)
PRESCRIPTION #52
101 LAST DISPENSED DATE
PRESCRIPTION #52
113 MEDICATION INSTRUCTIONS
(Multiple),
1 DISPENSE UNITS PER DOSE (numeric)
2 UNITS (Points to the Drug Units file
#50.607)
See comments.
9^ Last Fill Date
No known match OR
Candidate Match = 52PRESCRIPTION/400-CMOP
Event (multiple) 3-Status
C32 – Problem List Module
HITSP/C32
Opt/
Rep
PROBLEM ENTRY
R2/Y
Problem Date
R2/N
Problem Type
R2/N
Problem Name
R/N
Problem Code
O/N
BHIE-RDV
VistA File #
VistA Field #
4^ Date of Onset for
<low> element = onset
date
9000011-PROBLEM
LIST
Problem Date (Low) maps to.13
DATE OF ONSET
Problem Date (high) maps to
1.07 DATE RESOLVED
3^ Provider Narrative
#9000011-PROBLEM
LIST/
1.01 PROBLEM (Points to
EXPRESSIONS File #757.01)
PROBLEM LIST
#9000011
.01 DIAGNOSIS (Points to
ICD DIAGNOSIS File #80)
PROBLEM LIST
#9000011
.12 Status (A=Active, I=Inactive)
9000011-PROBLEM/
1.05-RESPONSIBLE PROVIDER
pointer to 200-NEW
PERSON/.01-NAME
Problem Status
Treating Provider
93
Copyright 2009. All Rights Reserved.
O/Y
6^Provider
C32 – Information Source Module
• NHIN Specification for the Exchange of Summary Patient Record – Appendix A
• Source of Information at Document Level
– “Each clinical document must have an author element at the ClinicalDocument
level that attributes the source of the information in the document as a whole.”
– Organization OID and Organization Name
– Registered in HL7 OID Repository
• Source of Information at the Entry Level
– “indicates the source of information for the information within that element only,
overriding the author at the document or any other higher level”
– More specific location/facility within your organization
– Still represented as an OID and OID name
94
Copyright 2009. All Rights Reserved.
C32 coverage - statistics
Current
extract
method
(RDV)
EHR (VistA)
Average over 10
NHIE
Participants
89 (59%)
Can provide
39 (26%)
109 (72%)
Can provide (and it’s Required)
18 (40%)
31 (69%)
Cannot provide
113 (74%)
43 (28%)
63 (41%)
152
152
152
TOTAL number of data elements
95
Copyright 2009. All Rights Reserved.
C32 – Terminology Translation
48 data elements need HITSP terminologies
Priority given to:
Minimum Data Set (6 modules)
Required, Required if known, and Optional
Data available from sources
Data needed for decision support (e.g., Drug-drug interactions)
96
Copyright 2009. All Rights Reserved.
NHIN requirements for value sets
(continued)
• When translation is performed to obtain a HITSP-specified code, the
original code must be sent too
– e.g., if translate from ICD-9 to SNOMED, then send ICD-9 code too
<value xsi:type=”CD” code=”40275004” codeSystem=”2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Contact dermatitis">
<translation code="692.9" codeSystem="2.16.840.1.113883.6.2"
codeSystemName="ICD9CM" displayName="DERMATITIS NOS"/>
</value>
• If HITSP codes are not available, supply local codes along with
terminology identifier
<value xsi:type=”CD” nullFlavor=”OTH”>
<originalText>dermatitis nos</originalText>
</value>
97
Copyright 2009. All Rights Reserved.
C32 Required Data with HITSP
Specified Terminology
C32 id
Data element
Req/Repeat
Terminology specified
Person Information Module
1.06
Gender
R/N
HL7 Administrative Gender Codes
R/N
HL7 Role Class
R/N
SNOMED CT Subset
Support Module
3.02
Contact Type
Allergy/Drug Sensitivity Module
6.02
Adverse Event Type
98
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C32 ‘R2’ and ‘O’ data with HITSP
Specified Terminology
C32
id
Data element
Req/Repeat
Terminology specified
Person Information Module
1.08
Marital Status
R2/
HL7 MaritalStatus code set
1.09
Religious Affiliation
O/N
HL7 ReligiousAffiliation code set
1.10
Race
O/Y
CDC Race and Ethnicity Codes
1.11
Ethnicity
O/N
CDC Race and Ethnicity Codes
R2/N
HL7 Role Code
R2/N
National Uniform Claim Committee Provider Codes
Support Module
3.03
Contact Relationship
Healthcare Provider Module
4.04
Provider Type
Allergy/Drug Sensitivity Module
6.04
Product Coded
R2/N
UNII for Food and substance allergies, or RxNorm when to medications, or NDF-RT when to classes of
medications.
NHIN Coop Extension: UNII & SNOMED CT
Substance Hierarchy for substance allergy.
6.08
Severity Coded
R2/N
Subset of SNOMED CT Preferred Terms for Severity (concept 272141005)
99
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C32 ‘R2’ and ‘O’ data with HITSP
Specified Terminology (cont.)
Condition Module
7.04
Problem Code
7.04.1
Problem Status
O/N
Use VA/KP Problem List Subset of SNOMED CT, and shall be terms that descend from the clinical
finding (404684003) concept. NHIN recommended ICD-9. Note: Many ICD-9-CM concepts are
already incorporated into SNOMED CT.
SNOMED CT (by NHIN)
Medication (Rx & Non-Rx) Module
8.07
Route
O/Y
FDA route of administration
8.08
Dose
O/Y
Unit attribute shall be coded using Unified Code for Units of Measure (UCUM), and should contain the
preferred name of the presentation units within braces { } using the units of presentation from
the NCI Thesaurus.
8.11
Product Form
O/N
Shall have a value drawn from dosage form - FDA dosage form – source NCI Thesaurus
8.13
Coded Product Name
R2/Y
UNII, NDF-RT, RxNorm, or NDC
8.19
Type of Medication
R2/N
code derived from a limited set of values SNOMED CT
8.20
Status of Medication
R2/N
SNOMED CT
8.23
Reaction
O/N
VA/KP Problem List Subset of SNOMED CT, and shall be terms that descend from the clinical finding
(404684003) concep
8.28
Quantity Ordered
[Qty + Unit of
measure]
R2/N
If other than administration units (e.g., a volume of liquid or mass of substance) units shall be recorded
using the Unified Code for Units of Measure. The unit attribute should contain the preferred
name of the presentation units within braces { } using
8.38
Quantity Dispensed
R2/N
If other than administration units (e.g., a volume of liquid or mass of substance) units shall be recorded
using the Unified Code for Units of Measure. The unit attribute should contain the preferred
name of the presentation units within braces { } using
8.40
Fill Status
O/N
Shall contain a code derived from a limited set of values HL7 ActStatusNormal (Completed, Aborted)
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C32 ‘R2’ and ‘O’ data with HITSP
Specified Terminology (cont.)
Vital Sign Module
14.03
Result Type (Vital signs)
R/N
HITSP: LOINC (value set in C80 v1.0) NHIN:SNOMED CT
CCD: also allows any value from LOINC, SNOMED CT, OR CPT-4.
14.04
Result Status
R2/N
HL7 ActStatus, Value Set Name=ResultStatus
Results Module
15.03
Result Type
R/N
C32: Should be selected from LOINC or SNOMED CT
NHIN: SNOMED CT
15.04
Result Status
R2/N
HL7 ActStatus, Value Set Name=ResultStatus
15.05
Result Value
R/N
Unified Code for Units of Measure (UCUM) for units of measure
15.06
Result Interpretation
O/N
HL7 Result Normalcy Status (C80 v1.0) or should it be HL7 ObservationInterpretation (see tab on this spreadsheet)?
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Role of the Payload in Testing your
NHIN Core Services
Test data – scripting stories and
creating test C32 documents
Metadata (e.g., date range, creation date)
Document hash code
Persistence of documents
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Story script - excerpt
Query
date range
Salient previous
medical history
Treatment
Well child care
and childhood
immunizations
---
Immunization
schedule
Well child visits
immunizations
Joseph visited a
friend in Kingsport,
Tennessee, where
he received care for
a sports accident
from a CareSpark
provider.
serious fall while
riding a
skateboard with
his friend
(injured right
ankle)
(NMHIC,
IHS)
12/12/1976
– 1/1/ 1992
NMHIC: Past
immunization, well
visits, penicillin
allergy
After evaluating the patient and
after reviewing an x-ray of the
right foot, the physician on duty
determined that Joseph had a
mild right ankle sprain. The
physician bandaged the sprained
right foot and ankle. The
physician prescribed ibuprofen
600 mg to be taken every 8
hours for 5 days. Rest,
compress ankle. Records will be
available to future health
encounters.
Joseph enlisted in
the US Marine Corps
and was stationed at
the Marine Corps
Base Quantico in
Virginia.
Before
deployment
however, Joseph
required a predeployment
health evaluation
(NMHIC,
IHS,
CareSpark)
12/12/1976
to 6/1/2007
NMHIC: childhood
immunizations and a
Penicillin allergy
CareSpark:
skateboarding injury
in Kingsport (sprains
right ankle)
previous medical history and
current physical examination
results have met the deployment
criteria
Age
Background
Reason for visit
NMHIC
0-6
Joseph had a
healthy and fairly
typical childhood
with his well child
care provided by an
NMHIC provider
CareSpark
16
DoD
18
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Test Patients Shared Matrix
Gender
Marital
Status
Use Case
19990627
M
S
Core Services
Schnur
19560813
F
W
Core Services
Henry
Penia
20060524
M
S
Core Services
Patient 4
Anna
Rooney
19640501
F
D
Core Services
Patient 5
Oscar
Penia
19390727
M
W
Core Services
Patient 6
Salma
Fletcher
19431110
F
M
Core Services
Patient 7
Jordy
LaForge
19231114
M
D
Core Services
Patient 8
Judie
Snow
19471229
UN
S
Core Services
Patient 9
Audrey
Kim
19800314
F
M
Core Services
Patient 10
William
Ozzie
19761212
M
M
Core Services
S.No
First Name
Last Name
Patient 1
Gallow
Younger
Patient 2
Anna
Patient 3
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DOB
(mm/dd/yyyy)
C32 Metadata includes
• FindDocument
– Patient ID
– Class code
• summarization of episode note ‘34133-9’
– Class code scheme
• LOINC OID=2.16.840.1.113883.6.1
– Service start time & stop time
• RetrieveDocument
– Patient ID
– Home community ID and Document ID
– Hash code, size, …
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C32 Hash Code
C32 must be generated upon query
Hash code calculated upon query and sent with metadata
Requester uses hash code to validate retrieved document
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Persisted documents
Responder must persist retrieved
documents for a given period of
time for auditing purposes
(i.e., archive file)
Document ID, Retrieve date,
User data
Documents queried but not
retrieved can be discarded
(i.e., cache file)
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Summary
Agency
Systems
Existing
VistA
Agency
Systems
Display
C32
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Adapter
Extract data and
Create C32 xml
Persist
Adapter
Pass Thru
Gateway
Outbound
NHIN
Send C32 xml
Gateway
Receive C32 xml
Inbound
NHIN
Source Data -> C32 XML
NHIE Adapter
NHIE Gateway
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First
Name
Last
Name
MI
Gender
Suffix
Language
John
Halamka
D
male
MD
English
C32 XML --> HTML Display
NHIE Gateway
NHIE Viewer
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Lessons Learned
•
Standards information difficult
to access
•
– Cascading references
•
– Versioning issues is still work in
progress
Mapping work requires EHR
and HITSP/CCD expertise
– If source data is not well
documented, then expect a lot
of detective work
– Map to APIs not to source files
and fields (the case of data
‘entered in error’)
– Need XML knowledge
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Maintenance challenges
– Need to establish strong
interface agreements with
source systems
•
Users impact
– Integrated views, data ranges,
sorting, filters, etc.
•
Semantic Interoperability
– Viewable data, semantically
processable data, then
semantic interoperability when
decision support is ready
CONNECT Seminar
Presentations are Available
for Download Online at
http://www.connectopensource.org
CONTACTS:
Omar.Bouhaddou@va.gov
David.Katz@ssa.gov
Shannon.P.Rossman@ssa.gov
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