Anonymous: On Q1,
I see there is a placeholder page here
https://developer.connectopensource.org/display/CONNECTWIKI/Release+3.3
but no details. I suspect that if you were
participating, you might be able to get more details.
With regard to readyness for prime-time, I'm not
qualified to comment, since I don't used it. I
believe that several state HIE's and agencies are
using it, but it depends on what you mean by
"real". These are all good questions.
Hi Keith, I'm
looking for some solid examples of Pathology and
Radiology Text reports that have been published in the
clinical statements of a CDA HITSP C32 CCD. I cannot
seem to find any updates to the HL7 CDAR1A1S0004R021
Clinical Reports Document that would help our engineers.
The HITSP C83, while helpful, does not address how one
should deal with a transcription as a result.
Keith: I would be
interested in your comments on the HHS/VA Blue Button
initiative and their choice of a very simple ASCII text
document format -- essentially a succession of 'tag:
value' pairs on successive lines. They explain their
motivation quite clearly, but it occurs to me that the
effort is promising (for the intended use cases)
precisely because of the standardization that HL7 has
been driving behind the scenes. That is, the tag sets
and value formats (and vocabularies) will have a fairly
high level of consistency across organizations right out
of the box because of their prior work on adopting a
variety of standards internally, and especially HL7
standards.
In
this connection, I might mention the work
being done by one of the major players in
automated medical transcription, Nuance
Communications, to bridge the gaps at issue
here — verbal dictation to
transcription output (unstructured text) to
structured clinical data. Their emphasis is
now on the second gap. They are partnering
with IBM on the Watson project, specifically
for applications to healthcare, largely
because they bring this kind of expertise
and interest to the table.
I'm quite familiar with the original
product line from that division, as I used
to work for Dictaphone many years ago.
Natural Language processing and CDA are
pretty good fits, as I've mentioned previously.
VA has also done quite a bit of work using
NLP and CDA, and M*Modal also has a product
that supports it.
Keith, can a
custom, though registered with HL7, OID be used in the
templateId element to further define a result entry in
the result component of the CCD? My understanding is
that the "new" templateId is still declaring
conformance to the component
itself.
You can certainly add a
template ID to assert application of
additional business rules, but you will also
need to use any of the required templateIds
to ensure conformance. IHE and HITSP did
just this with the CCD.
I'm a student in the Health IT
certificate program. I have an assignment to interview
someone who has had a bad experience with
interoperability and then analyze how standards could
have improved that experience.
May I please
have your permission to use your post "HITsm T1: To
what extent should patient involvement influence the
advancement of HIE?" as the interview portion? I
would quote directly and attribute.
Thanks,
I've got a question about how I
represent a non-numeric value for a lab result in the
C32. All of the examples and documentation I have only
shows how to display numeric values in the observation
template:
But let's say I have a
result for Appearance of urine output that has a value
of YELLOW. How do I represent that? Which xsi type
should I be using in this case? My apologies if this has
been answered before, I just can't find an example
of it anywhere.
Mike, in this case, its either a code, in
which case xsi:type would be CD, and
you'd use this form (and an appropriate
code system, such as SNOMED):
<value
xsi:type='CD'
code='263935005'
codeSystem='2.16.840.1.113883.6.96'
codeSystemName'SNOMED CT'
displayName='Yellow'/>
Or,
it is a string (no code), in which case, you
would use this form:
<value
xsi:type='ST'>YELLOW</value>
I have a followup question
for you. I have some lab results in our
system that came back with numeric data but
the uom was never sent with it. The
validation requirements for a PQ value
require the unit attribute to be present,
and it can't just be left blank. In this
particular case is there an unknown UCUM
unit that I can use (I couldn't find one
in my search) like UNK or should I be
sending that value as ST instead of
PQ?
If you don't have the
units, and you know it is a numeric result,
the first thing to do is insist that they
send you the units, which you could then
translate using this table.
If
you cannot get them to fix their broken
interface, then I would report the value
using the ST data type like
this:
Hello - I was
referred to you by W. Ted Klein. Our hospital is in the
process of trying to implement Meditech’s CCD
(Continuity Care Document) module to meet our meaningful
stage 1 requirements. Meditech needs an OID number from
us, but unfortunately we have not had a lot of
experience with this. I have read that there are
sometimes several identifier numbers that hospitals
already have, such as a provider number, all of which we
have. Do we have to have this separate HL7 OID number in
order to meet the ARRA requirement? I am not sure if you
will have the answer to this, but you may be able to
direct me to someone else. I have read over the OID
website, but I am still not sure exactly how to
determine if we already have an HL7 OID number, and if
not how to get one.
Thank you for your help.
I
had already routed Ted's e-mail to me to
the right person within your Vendor
organization. I believe you should be
getting a response from them shortly.
I'll be putting together a longer post
to address the general details for
ARRA/HITECH and the need for OIDs in the
next day or two.
I'm working
on a third-party patient portal that is meant to
interoperate with multiple PMS/EHR systems. This portal
will support patient self registration forms including,
but not limited to, patient demographics, next of kin,
guarantor, insurance, medical history, social history,
current medications, and chief complaints. In fact, it
must be flexible enough to handle questions required for
specific specialties and so on. The current strategy is
to generate a CDA file for import by the other
system.
Is there a document type or template
available for delivering all of this information in a
singe file? Could you direct me to resources and
examples that are similar to this? Is there a problem
with presenting patient-provided data as
fact?
Healthy diets will contain foods from all
food groups, and most of the foods you eat
will come from fresh fruits and
vegetables.Healthy diet plans encourage
nutriment and energetic lifestyle choices.Hypnotherapy Chelmsford
Everything you
just mentioned except "chief complaints" is
supported in the HL7 CCD. If by "chief
complaints" you mean the problem list as I suspect,
that is supported as well. If you are looking for a
specification for use in the US, see the HITSP C32 (see the Payers section
for Insurance details). Internationally, try the IHE XPHR profile (which C32 is
based on).
By "chief
complaints," I meant the reason the
patient is giving for his/her visit that
day. I would also need to deliver responses
to any specific questions a physician might
want to have the patient
answer.
What is your recommendation for how to
include radiology and microbiology results into the C32?
All of the examples I have seen show diagnostic lab
results with quantitative data. But our microbiology and
radiology results come back as long narratives that are
not directly tied (like our regular labs via loinc) to
our orders. Just wondering what would be a good way of
me going about adding those results to the results
section, since a single result may be connected to
multiple test orders, and that the data is just a long
narrative rather than quantitative
results.
First of all, C32 is a summary, not a
detailed report. So in the results section,
you could include a result that summarizes
the details. For reference, see my second post which was
the reason I started this blog in the first
place. If you want to communicate the
details, send the complete report in the
appropriate document type, which isn't,
in either of the cases that you mentioned, a
C32. I expect to see more document types
supported in Stage 2, and at least one that
supports radiology.
I'm working on clinical valuesets
for a decision support system project, using SNOMED and
HL7 CDA.
When I have to choose a code for a possible
Observation.value, does this code need to include some
information about the observation identifier
("observation.code") itself ?
As our system will
probably structure our electronic medical record
database, maybe it's important to do with the more
complete observation.value code ?
But for others
values without such complete pre-coordinated code, it
would signify doing post-coordinated code such as
"28899001 : 418775008 = 416107004 ^ | squamous cell
carcinoma | : | | finding method | = | cervical cytology
test | ^ SNOMED CT " debatable and difficult to
implement....
...or just do the more complete way
when an existing pre-coordinated code permit it
?
Thanks a lot for your response
(sorry for
my bad english)
Few EHR
applications today are capable of supporting complex
SNOMED CT Post-coordination that you just described. The
best that you can work with across the most number of
systems is to be able to apply a code to the question
and the answer. If code is the question, value is the
answer. When working with CDA, you might get a little
more complicated, because things like observation have a
methodCode (which is the method by which the observation
was made = Finding method).
something that I find lacking in the CCD
arena (HITSP C32 or just plain HL7 CCD) is examples of
real world uses that are actually in play and have had
some sensible analysis of assumptions - e.g. duplicate
detection for allergies or results from multiple CCD
sources, binding of clinical events to the presentation
of a CCD - e.g. a discharge summary, a referral, a
longitudinal patient healthcare record.
Do you
know of public discussions anywhere involving people
actually using CCD in anger? or alternatively and
lessons you have overheard that would be useful to
share?
I
don't know of "public
discussions", but CCD is certainly
being used "in anger" as you put
it in several Beacon programs, e.g., for
care management. Details aren't
available, but overviews of what is being
done are being shared through the Beacon
program.
thanks for your opinion on real world
uses. I have another question about update modes in CCD
documents. It seems to be difficult to figure out what
update mode to use in CCD for specific acts without a
clear understanding of the business process that
produced the CCD.
For example, if I get an
on-demand CCD from Source A for Patient X - say doc1 -
that has a set of allergies for a patient, and then
later I ask for another on-demand CCD from Source A for
Patient X, but this time there are two allergies
missing, how should I interpret those records that are
now missing? Looking at act attributes I'd expect
the two missing ones to still be present but with a
status code of "added in error". And because
this is a snapshot, not a cumulative update record, then
those "added in error" records would need to
exist for all time now from that source. Alternatively a
"amendment" could be published for that
document, but since this is a generated document, and
perhaps pulled by a consumer, there is nothing to
indicate that there is an amendment - unless one
inspected an XDS registry entry - perhaps. Amendments
don't seem to make sense for on-demand documents,
since their I thought their document id was supposed to
remain constant.
Do I really trust a source
system to publish records with a record status of
"added in error"? I don't know - it does
not seem to be something that is required by
CCD.
Alternatively, for a particular source, I
could set allergies that are now missing to a record
status of unknown - since there is nothing really to
qualify them now as active or inactive or added in error
etc.
The same question applies to other
sections of CCD.
Is there a recommendation
somewhere on how to interpret updates - especially
on-demand documents?
You
are right that "Added in Error" is
not something that CCD requires a system to
report on. But it doesn't prevent that
from being done either. This was the point
behind the IHE Reconciliation
profile.
Hi Keith,
I
currently try to make use of RFID-Tags to automatically
identify persons for telemonitoring purposes. A simple
mapping mechanism (PID to RFID) won't do. I would
rather find a way to save the RFID within the
patient's EHR and then search for the patient by
RFID using PDQ. Is there a way to do so?
I see last week
you posted links to the new IHE specifications related
to importing/reconciling images. I am trying to locate
what I believe exists similar to that for the common
data sets in the CCD/CDA documents (i.e home meds,
allergies, etc.) Have you posted anything related to the
guidance for importing/incporprating/reconciling that
data from an IHE specification standpoint?
What
are your toughts on this in correlation to
the Stage 2 idea of
"incorporating" data from a
summary of care record? This obviously wasnt
called out in the certification criteria at
all - and typically nothing gets added per
se between the interim anf final... so you
anticipate they will leave it pretty generic
in teh way of how one would implement import
essentially but just define data elements
that need to be imported? I know - it's
somewhat of a guess at this point...
Keith,
Thanks for the CDA book, I've found it
very helpful in my journey in creating CCD and CDA
documents. I have a question for you about medication
effectiveTime. I have a couple scenarios I haven't
been able to figure out how to create.
The
first is timings such as 5 times a day or 3 times a
week. For 5 times a day it doesn't work out into an
even number of hours so i'm not exactly sure how to
handle that. I could break it down into minutes but that
feels wrong to me.
The second issue I have is a
timing that is expressed as 'while awake'. An
'EIVL_TS' effectiveTime with an offset seems
like the most likely scenario but the only applicable
'EIVL_TS' code that seems to work would be
'HS' with an offset. But as you pointed out in
your book there is no implied direction for the 'the
hour of sleep' offset.
Any help or insight
into these problems would be greatly appreciated.
I
work with Dave: I asked this same question
on Stack Exchange's Healthcare IT site.
As of now it hasn't been answered yet.
Here's the link:
http://healthcareit.stackexchange.com/questions/912/how-to-specify-medication-timing-like-5-times-a-day-or-3-times-a-week
On
your first question: 5 times per day could
be represented as every 4.8 hours, and three
times per week could be represented as every
56 hours. You certainly can use decimal
representations in , as it is of the PQ data
type.
The more detailed challenge
about simplicity of representation has been
addressed in datatypes release 2.0, which
will be supported in the CDA Release
3.
With respect to the "While
Awake" issue, the EIVL_TS data type
uses the CS data type, which means that you
cannot express anything not in the code set.
I'd implement that as an annotation in
the SIG.
Thanks for the quick reply. I thought about
doing the 4.8 hours and the 56 hours
solution but for some reason it felt off to
specify 3 times a week in hours. But if it
works then i'll go with it.
I'm confused on what you mean
by expressing "While Awake" as an
annotation in the SIG, would you mind being
a little more specific?
I really
appreciate all your help, the CDA can be a
little overwhelming at times.
My organization follows the standard
CCD pattern. For one of our current implementations, we
were discussing a small change in the results section of
the CCD (described as follows).
Our product
provides an acknowledge option for the Clinicians to
review the lab results. What we want to do is to include
the lab results information in CCD only upon
acknowledgement and not immediately upon their
availability. Can we make this change? Or do you see any
issues with this? Really appreciate your inputs.
Thanks.
CCD
says to include relevant and pertinent data
in it. It doesn't say what IS relevant
and pertinent, as that is clinical
judgement. So you certainly could do
this.
We have a question regarding the way you have
presented requirements for meaningful use in one of your
spreadsheets labelled 'MUSCR-2.xls'. There are
two requirements we are trying to understand how to
implement and have following questions:
1. the
referring or transitioning provider's name and
contact information
For this rule, your
suggested implementation is to use an
ecompassingEncounter/responsible party. However in
looking at the encompassingEncounter we find that this
section uses encounterParticipant,
typeCode="ATND" must always be set.
typeCode="ATND" is for attending physician.
How would we use this typeCode and provide information
for referring physician?
Is the
encounterParticipant not required and if so how would we
differentiate who the referring physician vs who an
attending physician is?
I am currently working in a EHR company.
Looking forward to work on core HL7 Standards and
HIE's and Interoperability. Currently i am working
on Point to point Lab and Custom(Pa)Interface between
various Health care Organizations. I am looking forward
to work with GE Healthcare and have applied in various
sectors but i am not finding proper path on how i can
apply in exact Domain. I am located in India. I did
attended your Webinar on Meaningful Use Stage
2.
Let me know on what would be the best way to
approach from over here.
Send
me an e-mail using the contact me link, so
that I can hook you up with the right folks.
Please provide me with details on what you
are trying to do.
I’ve been struggling a bit with
CDA particularly this notion of packaging all the
contents of a CDA document so that it can be rendered by
any recipient, images especially (see CDA R2 section
1.2.3). The problem comes down to two parts: how to
represent the image in the CDA document so that the
image is IN the document rather than be a reference to a
file and how transform that it into HTML that can be
rendered by common browser rendering
engines.
(1) Content—I started by
changing something like
to
/9j/4AAQSkZJRgABAQ…….
This seems like the way to do it based on
my reading of your book and the XML ITS, but I
can’t find any examples. I did note that Figure
6.1 from your book did not use a “value”
element, but instead embedded the base 64 encoding
directly in the “observationMedia”
element—that confused me.
(2)
Rendering—This is actually a two part problem. The
first, has to do with what the HTML would look like and
second the use of the generic style sheet provided with
CCDA. In the first case I thought, that I could simply
use data URI, but it has a number of problems: not
supported by all browsers and IE8 (a necessity for me)
severely limits the encoding length. I’ve tried
fooling around with getting MIME to work, but just
can’t seem to make it happen.
In the
second case, the generic (presumably non-normative style
sheets) won’t convert the above encoding.
It’s very telling that the one provided with the
CCDA DSTU doesn’t even transform PNG content, much
less embedded base 64 encoded images.
I’m
planning on embedding my own custom style sheet for the
type of content I’m producing, but I’m aware
that all content should be renderable with a generic
style sheet (see again, CDA R2 section 1.2.3). The
problem is that there’s no normative way for me to
ensure this.
I’m really stuck here and
definitely would appreciate some guidance and some
examples.
Packaging a CDA and Rendering it from
within a browser is something I tried a
while back. You could use the data: URL
format with B64 encoded data, but it only
works well in Opera and Safari. IE has
handicapped it for some formats. See
http://motorcycleguy.blogspot.com/2010/11/frustrated-by-lack-of-standards-support.html
and
http://motorcycleguy.blogspot.com/2010/11/progress-report-on-self-displaying-cda.html
for some pointers.
Would really
appreciate if you can clarify my questions.It is very
urgent
I have been assigned a project whose
requirement is to convert files in other formats to XML
files that conform with the specifications in ( HITSP
Summary Documents Using HL7 Continuity of Care Document
(CCD) Component).
I would like to know how to proceed.
1)How do I get the XML schema files for HITSP? Are
they readily available or do I need to generate
them.
2) What is the process to follow, i.e how to
convert the file to the XML standard, how do I
validate?
Are there any tools available etc.I need
to do coding in C#.
You
need the XML Schema for CDA if you want to
validate against Schema, but that
doesn't cover all the constraints in the
HITSP C32 (they aren't
"schemifiable", see
http://motorcycleguy.blogspot.com/2011/03/why-there-is-no-w3c-schema-for-ccd.html).
To
check those constraints, you want to use the
NIST
Validator
On how to convert the
files to XML, it depends on the format
they've started in. If it's an XML
format, I recommend XSLT. If it's HL7
Version 2, check out chapter 17 of The CDA™
Booke.
In terms of tooling,
there are plenty of open source tools in
Java, but I'm not aware of any
that support C#. MDHT
has code generation capabilities that could
generate C# that would support the C32, but
the project has nobody with time and
experience in C# to create the generator.
You could start there.
The HL7 OID registry doesn't seem to
contain all the templates OIDs used in the different
Implmentation guides. Are there specific rules that to
govern the decision to register vs not register OIDs in
HL7 OID registry ? Should we register only Document
Templates and not the other template types (Header,
Section, Entry) ? Should the different countries
register their Template OIDs under their own Country
OIDs (for example in Canada, register template OID
within HL7 Canada 2.16.840.1.113883.2.20.xxx)
?
Ideally, all templates would be registered
in the OID Registry. Unfortunately, the
infrastructure doesn't make it easy to
register a batch of OIDs. With regard to how
you get OIDs to register a template, what
you suggest (to use a country specific OID)
makes sense for national programs.
That's what HITSP did years ago when it
created a number of templates for use in the
US.
I have had an observation about the
Administered Medications section in the CCD that my
organization provides to the patient. Irrespective of
what the order status is (in progress or discontinued or
cancelled or completed), we always display the status as
completed. Is this correct?
I have referred to
this link
http://wiki.ihe.net/index.php?title=CDA_Entry_Content_Modules#Development_Only_14
and even that says all the orders should have a status
"Completed".
The status of all
elements must be "completed". The act has
either occurred, or the request or order has been
placed.
I do not understand why we have to
display such an order status for an in-progress or
discontinued item. Am I missing something here? Please
help.
statusCode in an act describes the status
of the act (with respect to the mood it is
recorded in). In a document, this is almost
always completed, because the act (ordering,
intent or event) has been completed. That
status code is part of the RIM, and deals
with the act state machine. Moving beyond
the Act class state machine, you can record
the status of the med (e.g., discontinued,
active) using a different structure.
That's more often what folks want for
medication status.
Thanks for the reply. I have a follow-up
question though.
There are 2
sections in the CCD. The status in
"Medications" section displays as
Active or Inactive While the status in
"Administered Medications" section
is always "Completed". So, are we
saying that this is correct? Please
help.
Should the Administered Medications
section in CCD always show the order status as
completed? (I have observed that even the in-progress/
discontinued items are displayed as completed). And the
link
(http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.4.7)
also says that 'all elements must be
"completed". The act has either occurred, or
the request or order has been placed.' Am I missing
something here? Please help. Thanks.
NZ is moving to
CDA for discharge summaries and looking at adopting XDW.
I an attempting to get my head around using XDW. The use
case I have is that a discharging clinician creates a
discharge summary and discharges back to the GP he
creates a task for the GP to accept the transfer. The GP
refuses because it is not their patient do the task is
not completed. All that is fine but we have a
requirement to attach a reason for the refusal. If the
XDW contains no information what do we do with the
reason?
Thanks
Peter
C32 v2.5/C83
v2.0 Medication section (Table 2-12, HITSP/C83 version
2.0) has the concept of a “Ordering
Provider” (8.31). I’m having a difficult
time matching this up to a similar concept in the
“"CDA Consolidation (December, 2011)".
There is a performer (CONF 7522) for the medication
section in the Consolidation CDA (CCDA), but there is
not much for a definition in the specification. Are
these equivalent or is there another concept in the CCDA
that would match up to the “Ordering
Provider” (8.31) for C83?
Your site is a great help. What other
resources are there, like discussion groups, on the web
that focus on implementation questions for the "CDA
Consolidation (December, 2011)" and/or MU2?
The SDWG list
serve doesn't focus on CDA
Consolidation, but there are some
discussions on it there (including on
current ballot reconciliation), and you can
certainly ask implementation questions
there. The S&I Framework project is
developing guidance, but that is still a
work in progress.
In the
“CDA Consolidation (December, 2011)”, Table
167: Instructions Constaints Overview the code (CONF
7394) element is now a SNOMED code. What would be the
SNOMED equivalent to the previous C83v2.0 code of code=
PINSTRUCT, codeSystem = 1.3.6.1.4.1.19376.1.5.3.2,
codeSystemName = IHEActCode?
The
closest I can find would be something like
"Instructions from the Pharmacy"
(423201001). Others could be appropriate
depending on the type of patient
instructions. Typically, this field was
meant for instructions like "take with
food", which would often be instruction
coming from the pharmacy (and perhaps also
the provider).
Hi Keith,
In
case of Physicians with more than 50% of patient
population at Ambulatory Surgery Centers, is it
mandatory for the Ambulatory Surgery Centers to have a
Certified EHR technology to capture & send required
data to Physician's office EMR to enable physician
to apply for MU. If yes, what would be the necessary
modular certification criteria's that apply for the
ASC to be able to capture send the information to
Physician Office EMR.
Hi
Keith,
Thank you for your reply. One
follow up question though is, if the ASC
wants to share images that were taken during
a particular procedure with the physician,
are there any applicable standards to share
the same with the Physicians EMR ?
Appreciate your help in this regard.
On
sharing images with the EMR, there are a
couple of ways that you can do this. From a
specialist's perspective, where the EMR
is designed for specialist use, you'd
want to look at IHE's Image Enabled Office
profile.
That capability unlikely
to be available on non-specialist's EHR
system. What you can do in that case is send
an ORU message with a link to the image from
a web-enabled viewing application (e.g., a
WADO URL).
For Encounters in a History of
Encounters section in HITSP C32 2.5 documents, what
would be your recommendation for conveying:
1. the
specialty in which an encounter was performed - e.g.
cardiology, general medicine
2. the discharge
diagnosis
I don't see these concepts
referenced in any of the HITSP C83, IHE PPC profile, or
HL7 CCD, so I gather we should drop back to a CDA R2
recommendation?
for
discharge diagnosis I was thinking of
something like:
under problems
section
entry/act[problem]/entryRelationship/encounter
with the identifier of the encounter for
which this problem was
established
entry/act[problem]/problemTypeCode
= diagnosis
I also considered an
entryRelationship[@typeCode='SUBJ']
directly on the encounter with a problem
observation, but I am not sure the statement
made by this is obvious.
,Keith, I am now
working with a really innovative multispecialty practice
and we were looking through IHE and ran across the Care
Plan spec. Are you aware of anyone using the spec? IHE
PPOC?
I have a question on the MDM^T02 HL7
messages, we are using MDMs with a CCD payload to
populate our XDSb repository and we do patient discovery
of the MDMs(no ADT feeds). Our current implementation
handles MDM^t02/MDM^t09 , is there a way to do
Merges(like A40, A36) using MDM^t02/T09? Any input is
greatly appreciated. Thanks
Yes,
there is a way to do a merge. Just process
the ADT^A40 or ADT^A36 messages. Oh wait,
did you want to use the MDM messages to do
patient ID management? Sorry, no. That's
what ADT messages are for ;-)
Hi
Keith,
Our company provides DICOM archive and study
viewing services for several hundred G.P.-s and doctors
from the many hospitals. We are planning to go XDS with
all the bells and whistles but so far the problem is
that all hospitals are completely separate and have no
XDS. But first (any day now)
I need to publish a
tender for DICOM web viewer software but I'm not
really sure what to ask for.
One thing is the user
authentication - I would like to all the user logins to
be handled by hospitals so that we all users from one
hospital use one login to vew the DICOM studes and
reports (then we have to handle only the GP-s that work
privately).
I'm planning to requre XDS.b
Document Consumer conformance but can XDR help with use
auth or should I go for XUA? And where does LDAP user
auth/directory stand in XUA?
Hi Keith
-
Being a standards-kinda-guy, I was wondering if
you would happen to know if there exists any good
document templates for writing all them custom HL7
interface specifications that we as HL7 vendors tend to
do?
Quick background of what I am trying to do...
I'm trying to parse the HL7 medication RXO or RXE to
extract the medication code and name and store that into
our exchange repository, also parsing CCD ang store it
into our exchange repository.
When it comes to
CCD generation, I am not sure what is the best way to
determine if that medication code and name parse from
HL7 can be specified in either CCD Medication Coded
Product Name or Coded Branded Name. Also when parsing
out the Coded Product Name and Coded Branded name from
CCD, which code would fit to send out in an HL7 RXO\RXE
Give code. Would a terminology service be needed to
address this different use cases?
I have your
CDA book and I really find it helpful the mapping it
provided for Labs between HL7 messages and
CDA.
In the CDA
Consolidated Rel 1 use for ARRA Stage 2, the Allergy
reaction requires a coded value (CONF 7335).
Unfortunately, we have quite a bit of data that is not
coded and we believe is important to include. By using
the Lantana Validation Tool, we have found the following
two options will work:
Option 1 seems bad to me
because this does not contain a valid snomed in the code
attribute. Option 2 seem more in line with the CDA
policies. Are either of these options acceptable for
ARRA Stage 2, or is there other better options for
this?
Neither of the forms you show are
acceptable. The Lantana Validator
doesn't check for valid SNOMED
codes
The CD data type allows this
form:
<code
nullFlavor='UNK'><orginalText>hives
on arm</code>
Or better
yet:
<text>...<content
id='reaction1'>hives on
arm</content>...
...
<code
nullFlavor='UNK'><orginalText><reference
value="#reaction1/></orginalText></code>
In
terms of what is acceptable for Stage 2, I
suspect that either of the formulations I
show will work, but we don't have either
the rule or the test suites from NIST as of
yet.
I'm hoping you might have some
input for my organization. (if this has posted twice
forgive me)
We need to include an annotated
comment for an observation result in our C32 CCD. We are
using the Comment Module to include this comment that
corresponds to a NTE segment from an HL7 v2.x result. We
would like to include this at the observation or OBX
level within the structured xml of the CCD. Including
this comment at the section or component level seems to
work but when moved to attempt to have it associate with
the observation result itself is proving a bit difficult
for development.
I'm trying to appreciate what is
"standard" and what is variable among CCDs. In
my experience, the section template headers (
i.e.
2.16.840.1.113883.3.88.11.83.112 for
medications) are well implemented but other standards
for entries i.e. 2.16.840.1.113883.3.88.11.83.14 for
(Vital Signs ) are not. It seems that the world has
decided to accept one level of granularity at the
section level and then abandoned this concept at the
entry / leaf level. I have accepted this as the current
state of the world.
My question is about
intra-product variability. For example, if company X
delivers product Y that is installed at facility A and
facility B, will the format for a CCD from facility A
and B follow the same intra-section format? Will the
table structure that contains the actual data look the
same between these installations or will it
differ?
If this is more appropriate for the
website, let me know and I'll post it so that others
will have a chance to follow.
Usually, the CCD's
produced by the same EHR system will have
the same capabilities. However, those
capabilities are often configurable, which
means that you might not always get the same
set of sections. Also, code (e.g., SNOMED
vs. ICD) use can vary between different
sites. It really depends on the EHR, and the
amount of customization that it enables. In
general though, you can expect limited
variation "intra-section"
variation when you've controlled for the
EHR variable.
Hi
Keith,
I'm working on the CDA Release2 and Have
a question on the validation being done by the Lantana
Validator tool. I'm referring to the
1)
PDF
"CDAR2_IG_IHE_CONSOL_R1_DSTU_2011DEC.pdf"
2)
page 227 "Hospital Discharge Instructions
Section" and
3) table on page 228 "Figure
103: Hospital discharge instructions section
example".
My understanding is that
unstructured part of these section that is content of
the "section/text" are not being validated.
But, for this section, the content inside the
"section/text" is being validated and if I
have any other HTML tag, the Lantana validator errors
out.
What do you think about these,
1) Do
we need a validation for the HTML content of the this
section “Hospital Discharge Instructions
Section”?
2) Should Lanatana be validating
this HMTL section? or
not
I
don't know the details of what you are
putting in your section/text, however, given
the number of times you mention HTML, I
suspect that is your problem. CDA uses
it's own XML in section/text, not
HTML.
Thanks for your response.I mean HTML tags
in XML, sorry about that. I'm able to
get these done for other CDA sections
though, this is only section where the
content of section/text is being validated,
should it be validated?
On page 73 of the HITSP C83
documentation
(www.hitsp.org/Handlers/HitspFileServer.aspx?FileGuid=c21d785a-1dac-4fc6-b806-8ca3143f1cf3),
there's an example of a Results section, but it
doesn't seem to cover the full entry. It just starts
at the result's 'observation' tag instead of
the tag directly under the 'entry' tag like the
other.
Is there anywhere I can see what tags
belong above it?
I
was able to find the information I'm
looking for here:
http://www.ihe.net/Technical_Framework/upload/IHE_PCC_Suppl_CDA_Content_Modules_Rev2-1_TI_2011-09-02.pdf
..although
I'm not sure if this is the latest copy
of this specification or the best one to
use.
We have a need to use some DT R2 in our
CDA documents. will this make our documents not CDA R2
compliant even if we add the new data types in
datatypes-base schema file using the extension tag ?
You
can add extension elements or attributes to
support Data Types Release 2.0. You should
look at what Data Types Release 1.1 did, and
add the new attributes using an extension
namespace. However, note, that most
implementations will ignore these, or even
fail to parse since the extensions won't
be in their schema. However, the documents
will be CDA R2 compliant (according to the
standard) if you add an extension
namespace.
Running into some trouble when trying to
export a CCD from a patient chart from a meaningful use
certified EHR. The EHR allows me to free text problems,
allergies and medications but this means that there are
no codes associated with them. When I export the CCD, it
requires me to have codes like ICD 9 or RxNorm. Is it
allowed to NOT have codes associated with these
problems, med and just populate the "Display
Name" in the CCD, or is there some generic
"user generated" code I could use for all of
these items?
Would love to get advice on how
to export user generated free text clinical data into
the meaningful use CCD.
It's allowable to NOT have codes (e.g.,
H5N1 didn't have a code at first, nor
did SARS or Legionaire's disease when
they were initially discovered as
illnesses). To do that, you generate a code
element referencing the free text like
this:
Hi Keith,
My question concerns the Consolidated CCD in
Meaningful Use Stage 2. The "Transition in
Care" and "Data Portability" CCD
requirements (per the Final Rules) include Activities of
Daily Living, Cognitive Status, and Disability Status.
Do you have any guidance on where to place this
information in the CCD and what data elements should be
included?
Not
necessarily. The MU Requirements are a
little more stringent than the HITSP C32
V2.5. Having said that, NIST does provide an
online validation tool that validates
against the MU requirements.
With the need to collect race as a
multiple, how does that need to be represented in the
CCDA? It's currently listed with the constraint of
only 1. Is this a case where the Final Rule requiring
this to be multiple supersedes the CCDA
constraint?
My dev team is working through the QRDA
Category I specs for CQM esubmission as required for MU
2014 certification. I have been tasked with finding the
answer to this question: "Is QRDA I a
"dump" of the patient visit record?".
No,
it's not really a dump of the patient
visit record. Instead, it is a dump of data
relevant to a particular quality measure or
quality measure set over a period of time,
containing data suitable for computing the
quality measure.
Thank you
Keith-so please let me give a more specific example so
that I know that I am on the right page. If measure NQF
XXX is looking for a patient on aspirin and that patient
is also on lipitor and plavix and digoxin. Can we send
the lipitor, plavix and dig along with the aspirin?
Is it your
understanding that when EHR data is printed, copied, and
queried the info needs to be tracked in the audit log? I
recall under MU Stage 1 (2011 Edition) that printing was
included in the Proposed Rule but then specically
dropped in the Final Rule. The Proposed and Final Rules
for MU Stage 2 (2014 Edition) didn't mention the
addition of print, copy, query but did reference the
ASTM E2147-01(2009) standard.
For the first
specific capability related to actions involving
electronic health information, we
have required that
the data elements specified in sections 7.2 through 7.4,
7.6, and 7.7 of ASTM E2147-01(2009) be
captured.
7.6 Type of Action (additions,
deletions, changes, queries, print,
copy)—Specifies inquiry, any changes made (with
pointer to original data state), and a delete
specification (with a pointer to deleted
information).
Keith - This
blog is awsome; thanks for doing it.
Question: the
ONC Stage 2 final rule seems to indicate that ICD-10 is
the required vocabulary for Encounter Diagnosis. That
would require that an EH attesting for 2014 would need
to be live on ICD-10 prior to the 2014 implementation
date since they report on the FY. Is that accurate or
have I missed something (I
hope).
Jim
james.r.herbert@kp.org
Hi. I have been
researching CCD and CCDA specs and regarding non-med
allergies, there appears to be a conflict for the coding
standard between UNII and SNOMED-CT. Do you know if this
has been settled? Is there significant risk with just
going with SNOMED-CT? Thanks.
I'm not sure what you mean by conflict?
UNII is to describe allergens, SNOMED-CT
types of allergies (food, drug,
environment). These are different. With
regard to significant risk, there are
challenges using any single controlled
vocabulary to cover the allergy space, as
none are complete. This is why CCD and CCDA
used a variety of value sets to describe
allergens.
Hi. I have been
researching a complete CCDA sample but I had no luck so
far. The ones that I have found or created based on the
guide failed the validation tool. Is there anywhere that
we can find full sample of CCDA for Clinical Office
Visit Summary? Thanks.
It
isn't prohibited, so you could include
them, but the area hasn't been delved
into by HL7 Structured Documents. So the
answer is yes, but if you are going to ask
me next how this would be done, my answer is
I don't know.
Hi. I have been
reading about 2012 PQRS Medicare EHR Incentive Pilot
program and wanted to confirm my understanding. Simply
put
EPs have 2 options:
1. EHR Data Submission
Vendor-Based Reporting Option ->
Submit
existing CQMs for MU stage 1 in XML format + PQRS
Measures in QRDA Category 1 format(DSVs submit on behalf
of EPs through a certified EHR)
2. Direct EHR-based
through Vendor-based Data Submission Reporting Option
-> Submit CQMs for MU Stage 1 QRDA category 1 format
+ PQRS Measures in QRDA 1 category format(EPs submit the
data through a certified EHR)
Is there anything else
that I need to understand?
I
have to spend a bit more time with the PQRS
regulations, but so far, that's my
understanding. This post might also be
helpful to see how these standards relate to
Meaningful Use.
I am having trouble finding examples of
embedding image data in lab results observations in CCD.
Is it possible to use the following as a value in a
result observation?
If
you want to include an image in a CDA
document, you would use the observationMedia
element as an entry (or a component of
another entry). The value element in
observationMedia would be represented as you
have shown above.
So,
for example, if we were translating the
equivalent of an ORU/ORC+OBR into a results
organizer, any OBXs that had ED type data
would be represented by an observationMedia
element inside a component element of the
organizer?
It
also seems, according to your CDA book, that
ED is a perfectly valid type for the value
element of an observation, which was my
first analysis of the situation. Is there a
reason why we would use observationMedia
over this? What I prefer about being able to
use an observation element is that I can
represent the test the image is a result for
using the observation/code
To
your first response, that sounds right,
I'd have to look at it to be
sure.
To your second one: It is
perfectly valid to use ED in Observation.
ObservationMedia is purpose designed to
support this use case, whereas Observation
is the more general approach (and would be
indistinguishable from a RIM
perspective).
The critical point is
in the definition of the renderMultimedia
tag that is used in the narrative with
observationMedia:
The
<renderMultiMedia> element ...
contains a required referencedObject
attribute (of type XML IDREFS), the values
of which must equal the XML ID value(s) of
ObservationMedia or
RegionOfInterest CDA entries within
the same document.
Hi Keith-
I
am reviewing the Query Format (HQMF) Implementation
Guidance v0.5 and trying to match up with the finalized
eCQMs that we downloaded last week. I see from the
document appendix no work is planned on Greening the
HQMF until 2013. Is there any more specific timeline on
that? What is the best way to stay in tune with
that?
Thanks for your guidance.
Zero. The standards for MU2 have already
been identified, and standards for quality
measure definition were not included. NQF or
the subsequent maintainer of the Measure
Authoring tool could choose to use HQMF
Release 2.0 when it becomes available, but
substantial work will be needed. I'm
told that MITRE has done some testing of a
transform from the old form to the new form
and been somewhat successful.
I am really interested to know if you
have come across the ability to extract CCD information
into a database through an automated solution. If you
can point to a source that would be great. Thanks.
There are plenty of commercial solutions
that do that, and a number of integrators
and interface engines who would support your
efforts. But what I think you mean is
something that would make it easier for you
to role your own code. For that, check into
MDHT for reading CCD
documents. You'll still have to do the
database back-end.
Hello Keith,
I am trying to figure out how the following
abbreviations are connected - NQF's QDM, HQMF,
eMeasures, Query Health, QRDA, QDM based QRDAs,
others.
Rather than individual definitions, I
am a bit in the dark around how each of these are
interconnected.
Kieth:
In
the Lab Results section of the CDA document, the
validator (the one available online on the NIST
website), requires us to provide the procedure along
with the battery->Test Results collection. Is there
documentation that you can help me point to that could
further describe the requirements for the procedure
section? We are not sure if a procedure refers to a CPT
or the specimen collection procedure.
Second
question:
The sample documents that I've seen
refers to SNOMED CT codes in the battery & procedure
sections of the document.. Is it allowed to provide the
lab order codes (belonging to the Labs that we interact
with) in place of the SNOMED CT codes? If it is allowed,
what coding system should be specified? Thanks in
advance.
Your examples
for "How to say no" and "Smells like I
dunno" are great models for building the empty
entries required by CCD when no records exist for these
sections. In particular, it's nice to have decent
"generic" codes documented SOMEWHERE out there
to use (like 413477004 - Allergen or 410942007 - Drug or
Medication).
However, now that CCDA requires
RxNorm for meds/allergies (or NDF/UNII), do you know of
any equivalent "generic" code in these
systems? I hate to do the following just to pass
validation:
Hello
Keith:
Can you share how the patient identification
type (whether it is an SSN, Clinic Generated Id, MRN
etc.) be represented in the CDA patient header?
Thank you
Hello
Keith,
for MU Stage 1, CDA entries with codes(level
3) was required for Allergies, Medication, Labs, Patient
Problems.. What additional sections need to have
entries(level 3) for MU stage 2 when generating c-CDA?
It's not clear from the final rule. Also, other than
the above 4 sections, what others need to be parsed for
MU Stage 2.
You'll still need to be able to
"parse" problems, allergies, meds
and labs to incorporate them into the EHR.
There's other data that you might also
want to use, but no "incorporate"
clause that requires you to do much more
than display it.
With regard to
what you need to put into your C-CDA,
it's the common data set (defined in the
rule) plus a few other things. For that, I
suggest you have a look at the testing procedures.
Hi
Keith,
Does the top validation tool at
http://xreg2.nist.gov/cda-validation/validation.html
---------------
Name:
CDA R2
Description: HL7 CDA R2 (with no
extensions)
---------------
test the latest
consolidated CDA (CCDA) corresponding to the Dec 2001
implementation guide?
Thank you
Lou.Lunetta@acs-inc.com
From Nuance's website, see Clinical Language Understanding (CLU™) and the resource links in the navigation sidebar. Among those, see the linked article by Nuance's director of medical informatics, The problem with problem lists (November 2010).
(NOTE: I have no connection with Nuance.)
douglas.deshazo@acs-inc.com
You can certainly add a template ID to assert application of additional business rules, but you will also need to use any of the required templateIds to ensure conformance. IHE and HITSP did just this with the CCD.
I'm a student in the Health IT certificate program. I have an assignment to interview someone who has had a bad experience with interoperability and then analyze how standards could have improved that experience.
May I please have your permission to use your post "HITsm T1: To what extent should patient involvement influence the advancement of HIE?" as the interview portion? I would quote directly and attribute.
Thanks,
Brian
I've got a question about how I represent a non-numeric value for a lab result in the C32. All of the examples and documentation I have only shows how to display numeric values in the observation template:
But let's say I have a result for Appearance of urine output that has a value of YELLOW. How do I represent that? Which xsi type should I be using in this case? My apologies if this has been answered before, I just can't find an example of it anywhere.
Thanks,
Mike
<value xsi:type='CD' code='263935005' codeSystem='2.16.840.1.113883.6.96' codeSystemName'SNOMED CT' displayName='Yellow'/>
Or, it is a string (no code), in which case, you would use this form:
<value xsi:type='ST'>YELLOW</value>
I have a followup question for you. I have some lab results in our system that came back with numeric data but the uom was never sent with it. The validation requirements for a PQ value require the unit attribute to be present, and it can't just be left blank. In this particular case is there an unknown UCUM unit that I can use (I couldn't find one in my search) like UNK or should I be sending that value as ST instead of PQ?
Thanks again,
Mike
If you don't have the units, and you know it is a numeric result, the first thing to do is insist that they send you the units, which you could then translate using this table.
If you cannot get them to fix their broken interface, then I would report the value using the ST data type like this:
<value xsi:type='ST'>5</value>
There is no "unknown" unit in UCUM.
Keith
Thank you for your help.
Is there a document type or template available for delivering all of this information in a singe file? Could you direct me to resources and examples that are similar to this? Is there a problem with presenting patient-provided data as fact?
Any help would be greatly appreciated.
Regards,
Bill
By "chief complaints," I meant the reason the patient is giving for his/her visit that day. I would also need to deliver responses to any specific questions a physician might want to have the patient answer.
Regards,
Bill
What is your recommendation for how to include radiology and microbiology results into the C32? All of the examples I have seen show diagnostic lab results with quantitative data. But our microbiology and radiology results come back as long narratives that are not directly tied (like our regular labs via loinc) to our orders. Just wondering what would be a good way of me going about adding those results to the results section, since a single result may be connected to multiple test orders, and that the data is just a long narrative rather than quantitative results.
Thanks again,
Mike
I'm working on clinical valuesets for a decision support system project, using SNOMED and HL7 CDA.
When I have to choose a code for a possible Observation.value, does this code need to include some information about the observation identifier ("observation.code") itself ?
Exemple:
"cervicovaginal cytology result" = "112662005 ^ Low-grade squamous intraepithelial lesion (morphologic abnormality) ^ SNOMED CT"
Or
"cervicovaginal cytology result" = " 416030007 ^ Cervicovaginal cytology: Low grade squamous intraepithelial lesion (finding) ^ SNOMED CT
As our system will probably structure our electronic medical record database, maybe it's important to do with the more complete observation.value code ?
But for others values without such complete pre-coordinated code, it would signify doing post-coordinated code such as "28899001 : 418775008 = 416107004 ^ | squamous cell carcinoma | : | | finding method | = | cervical cytology test | ^ SNOMED CT " debatable and difficult to implement....
...or just do the more complete way when an existing pre-coordinated code permit it ?
Thanks a lot for your response
(sorry for my bad english)
Meilleures salutations
EJ
something that I find lacking in the CCD arena (HITSP C32 or just plain HL7 CCD) is examples of real world uses that are actually in play and have had some sensible analysis of assumptions - e.g. duplicate detection for allergies or results from multiple CCD sources, binding of clinical events to the presentation of a CCD - e.g. a discharge summary, a referral, a longitudinal patient healthcare record.
Do you know of public discussions anywhere involving people actually using CCD in anger? or alternatively and lessons you have overheard that would be useful to share?
cheers
Matt
thanks for your opinion on real world uses. I have another question about update modes in CCD documents. It seems to be difficult to figure out what update mode to use in CCD for specific acts without a clear understanding of the business process that produced the CCD.
For example, if I get an on-demand CCD from Source A for Patient X - say doc1 - that has a set of allergies for a patient, and then later I ask for another on-demand CCD from Source A for Patient X, but this time there are two allergies missing, how should I interpret those records that are now missing? Looking at act attributes I'd expect the two missing ones to still be present but with a status code of "added in error". And because this is a snapshot, not a cumulative update record, then those "added in error" records would need to exist for all time now from that source. Alternatively a "amendment" could be published for that document, but since this is a generated document, and perhaps pulled by a consumer, there is nothing to indicate that there is an amendment - unless one inspected an XDS registry entry - perhaps. Amendments don't seem to make sense for on-demand documents, since their I thought their document id was supposed to remain constant.
Do I really trust a source system to publish records with a record status of "added in error"? I don't know - it does not seem to be something that is required by CCD.
Alternatively, for a particular source, I could set allergies that are now missing to a record status of unknown - since there is nothing really to qualify them now as active or inactive or added in error etc.
The same question applies to other sections of CCD.
Is there a recommendation somewhere on how to interpret updates - especially on-demand documents?
cheers
Matt
I currently try to make use of RFID-Tags to automatically identify persons for telemonitoring purposes. A simple mapping mechanism (PID to RFID) won't do. I would rather find a way to save the RFID within the patient's EHR and then search for the patient by RFID using PDQ. Is there a way to do so?
Regards,
Emmanuel
Thanks for the CDA book, I've found it very helpful in my journey in creating CCD and CDA documents. I have a question for you about medication effectiveTime. I have a couple scenarios I haven't been able to figure out how to create.
The first is timings such as 5 times a day or 3 times a week. For 5 times a day it doesn't work out into an even number of hours so i'm not exactly sure how to handle that. I could break it down into minutes but that feels wrong to me.
The second issue I have is a timing that is expressed as 'while awake'. An 'EIVL_TS' effectiveTime with an offset seems like the most likely scenario but the only applicable 'EIVL_TS' code that seems to work would be 'HS' with an offset. But as you pointed out in your book there is no implied direction for the 'the hour of sleep' offset.
Any help or insight into these problems would be greatly appreciated.
The more detailed challenge about simplicity of representation has been addressed in datatypes release 2.0, which will be supported in the CDA Release 3.
With respect to the "While Awake" issue, the EIVL_TS data type uses the CS data type, which means that you cannot express anything not in the code set. I'd implement that as an annotation in the SIG.
I'm confused on what you mean by expressing "While Awake" as an annotation in the SIG, would you mind being a little more specific?
I really appreciate all your help, the CDA can be a little overwhelming at times.
My organization follows the standard CCD pattern. For one of our current implementations, we were discussing a small change in the results section of the CCD (described as follows).
Our product provides an acknowledge option for the Clinicians to review the lab results. What we want to do is to include the lab results information in CCD only upon acknowledgement and not immediately upon their availability. Can we make this change? Or do you see any issues with this? Really appreciate your inputs. Thanks.
Thanks
We have a question regarding the way you have presented requirements for meaningful use in one of your spreadsheets labelled 'MUSCR-2.xls'. There are two requirements we are trying to understand how to implement and have following questions:
1. the referring or transitioning provider's name and contact information
For this rule, your suggested implementation is to use an ecompassingEncounter/responsible party. However in looking at the encompassingEncounter we find that this section uses encounterParticipant, typeCode="ATND" must always be set. typeCode="ATND" is for attending physician. How would we use this typeCode and provide information for referring physician?
Is the encounterParticipant not required and if so how would we differentiate who the referring physician vs who an attending physician is?
I am currently working in a EHR company. Looking forward to work on core HL7 Standards and HIE's and Interoperability. Currently i am working on Point to point Lab and Custom(Pa)Interface between various Health care Organizations. I am looking forward to work with GE Healthcare and have applied in various sectors but i am not finding proper path on how i can apply in exact Domain. I am located in India. I did attended your Webinar on Meaningful Use Stage 2.
Let me know on what would be the best way to approach from over here.
Your help is greatly appreciated.
Thank You.
I’ve been struggling a bit with CDA particularly this notion of packaging all the contents of a CDA document so that it can be rendered by any recipient, images especially (see CDA R2 section 1.2.3). The problem comes down to two parts: how to represent the image in the CDA document so that the image is IN the document rather than be a reference to a file and how transform that it into HTML that can be rendered by common browser rendering engines.
(1) Content—I started by changing something like
to
/9j/4AAQSkZJRgABAQ…….
This seems like the way to do it based on my reading of your book and the XML ITS, but I can’t find any examples. I did note that Figure 6.1 from your book did not use a “value” element, but instead embedded the base 64 encoding directly in the “observationMedia” element—that confused me.
(2) Rendering—This is actually a two part problem. The first, has to do with what the HTML would look like and second the use of the generic style sheet provided with CCDA. In the first case I thought, that I could simply use data URI, but it has a number of problems: not supported by all browsers and IE8 (a necessity for me) severely limits the encoding length. I’ve tried fooling around with getting MIME to work, but just can’t seem to make it happen.
In the second case, the generic (presumably non-normative style sheets) won’t convert the above encoding. It’s very telling that the one provided with the CCDA DSTU doesn’t even transform PNG content, much less embedded base 64 encoded images.
I’m planning on embedding my own custom style sheet for the type of content I’m producing, but I’m aware that all content should be renderable with a generic style sheet (see again, CDA R2 section 1.2.3). The problem is that there’s no normative way for me to ensure this.
I’m really stuck here and definitely would appreciate some guidance and some examples.
Regards,
Geoff
[entry]
[observationMedia classCode="OBS" moodCode="EVN" ID="Hgb-A1C"]
[id root="C06E4A43-13AB-4A5D-8A72-ABF887D915CD"/]
[value xsi:type="ED"
mediaType="image/jpeg"
representation="B64"][reference value="images/Glucose-Metformin.jpg"/][/value]
[/observationMedia]
[/entry]
to
[entry]
[observationMedia classCode="OBS" moodCode="EVN" ID="Hgb-A1C"]
[id root="C06E4A43-13AB-4A5D-8A72-ABF887D915CD"/]
[value xsi:type="ED"
mediaType="image/jpeg"
representation="B64"]/9j/4AAQSkZJRgABAQ…….[/value]
[/observationMedia]
[/entry]
I have been assigned a project whose requirement is to convert files in other formats to XML files that conform with the specifications in ( HITSP Summary Documents Using HL7 Continuity of Care Document (CCD) Component).
I would like to know how to proceed.
1)How do I get the XML schema files for HITSP? Are they readily available or do I need to generate them.
2) What is the process to follow, i.e how to convert the file to the XML standard, how do I validate?
Are there any tools available etc.I need to do coding in C#.
Thankyou.
To check those constraints, you want to use the NIST Validator
On how to convert the files to XML, it depends on the format they've started in. If it's an XML format, I recommend XSLT. If it's HL7 Version 2, check out chapter 17 of The CDA™ Booke.
In terms of tooling, there are plenty of open source tools in Java, but I'm not aware of any that support C#. MDHT has code generation capabilities that could generate C# that would support the C32, but the project has nobody with time and experience in C# to create the generator. You could start there.
Will look into what you have suggested
The HL7 OID registry doesn't seem to contain all the templates OIDs used in the different Implmentation guides. Are there specific rules that to govern the decision to register vs not register OIDs in HL7 OID registry ? Should we register only Document Templates and not the other template types (Header, Section, Entry) ? Should the different countries register their Template OIDs under their own Country OIDs (for example in Canada, register template OID within HL7 Canada 2.16.840.1.113883.2.20.xxx) ?
Thanks
Adel
I have had an observation about the Administered Medications section in the CCD that my organization provides to the patient. Irrespective of what the order status is (in progress or discontinued or cancelled or completed), we always display the status as completed. Is this correct?
I have referred to this link http://wiki.ihe.net/index.php?title=CDA_Entry_Content_Modules#Development_Only_14 and even that says all the orders should have a status "Completed".
The status of all elements must be "completed". The act has either occurred, or the request or order has been placed.
I do not understand why we have to display such an order status for an in-progress or discontinued item. Am I missing something here? Please help.
There are 2 sections in the CCD. The status in "Medications" section displays as Active or Inactive While the status in "Administered Medications" section is always "Completed". So, are we saying that this is correct? Please help.
Should the Administered Medications section in CCD always show the order status as completed? (I have observed that even the in-progress/ discontinued items are displayed as completed). And the link (http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.4.7) also says that 'all elements must be "completed". The act has either occurred, or the request or order has been placed.' Am I missing something here? Please help. Thanks.
Thanks
Peter
It would be good to make that comment on the IHE PCC eReferral profile that is presently out for public comment.
Your site is a great help. What other resources are there, like discussion groups, on the web that focus on implementation questions for the "CDA Consolidation (December, 2011)" and/or MU2?
The SDWG list serve doesn't focus on CDA Consolidation, but there are some discussions on it there (including on current ballot reconciliation), and you can certainly ask implementation questions there. The S&I Framework project is developing guidance, but that is still a work in progress.
In case of Physicians with more than 50% of patient population at Ambulatory Surgery Centers, is it mandatory for the Ambulatory Surgery Centers to have a Certified EHR technology to capture & send required data to Physician's office EMR to enable physician to apply for MU. If yes, what would be the necessary modular certification criteria's that apply for the ASC to be able to capture send the information to Physician Office EMR.
Warm Regards,
Shyam
For Stage 2, the proposed criteria are found in: §170.314(b). To see the citations for the standards, check out this page.
Thank you for your reply. One follow up question though is, if the ASC wants to share images that were taken during a particular procedure with the physician, are there any applicable standards to share the same with the Physicians EMR ? Appreciate your help in this regard.
Warm Regards,
Shyam
That capability unlikely to be available on non-specialist's EHR system. What you can do in that case is send an ORU message with a link to the image from a web-enabled viewing application (e.g., a WADO URL).
For Encounters in a History of Encounters section in HITSP C32 2.5 documents, what would be your recommendation for conveying:
1. the specialty in which an encounter was performed - e.g. cardiology, general medicine
2. the discharge diagnosis
I don't see these concepts referenced in any of the HITSP C83, IHE PPC profile, or HL7 CCD, so I gather we should drop back to a CDA R2 recommendation?
cheers
Matt
under problems section
entry/act[problem]/entryRelationship/encounter with the identifier of the encounter for which this problem was established
entry/act[problem]/problemTypeCode = diagnosis
I also considered an entryRelationship[@typeCode='SUBJ'] directly on the encounter with a problem observation, but I am not sure the statement made by this is obvious.
Thanks Andrew W.
I have a question on the MDM^T02 HL7 messages, we are using MDMs with a CCD payload to populate our XDSb repository and we do patient discovery of the MDMs(no ADT feeds). Our current implementation handles MDM^t02/MDM^t09 , is there a way to do Merges(like A40, A36) using MDM^t02/T09? Any input is greatly appreciated. Thanks
Our company provides DICOM archive and study viewing services for several hundred G.P.-s and doctors from the many hospitals. We are planning to go XDS with all the bells and whistles but so far the problem is that all hospitals are completely separate and have no XDS. But first (any day now)
I need to publish a tender for DICOM web viewer software but I'm not really sure what to ask for.
One thing is the user authentication - I would like to all the user logins to be handled by hospitals so that we all users from one hospital use one login to vew the DICOM studes and reports (then we have to handle only the GP-s that work privately).
I'm planning to requre XDS.b Document Consumer conformance but can XDR help with use auth or should I go for XUA? And where does LDAP user auth/directory stand in XUA?
Being a standards-kinda-guy, I was wondering if you would happen to know if there exists any good document templates for writing all them custom HL7 interface specifications that we as HL7 vendors tend to do?
I'm curious if you know of a CCDA XSLT that is available online? Could you point me to it if you know where I can find an good XSLT example?
Thanks very much!
Quick background of what I am trying to do... I'm trying to parse the HL7 medication RXO or RXE to extract the medication code and name and store that into our exchange repository, also parsing CCD ang store it into our exchange repository.
When it comes to CCD generation, I am not sure what is the best way to determine if that medication code and name parse from HL7 can be specified in either CCD Medication Coded Product Name or Coded Branded Name. Also when parsing out the Coded Product Name and Coded Branded name from CCD, which code would fit to send out in an HL7 RXO\RXE Give code. Would a terminology service be needed to address this different use cases?
I have your CDA book and I really find it helpful the mapping it provided for Labs between HL7 messages and CDA.
Thank you!
1) <value xsi:type="CD" code="UNK" codeSystem="2.16.840.1.113883.6.96" displayName="Hives"/>
2) <value xsi:type="ST">hives on arm</value>
Option 1 seems bad to me because this does not contain a valid snomed in the code attribute. Option 2 seem more in line with the CDA policies. Are either of these options acceptable for ARRA Stage 2, or is there other better options for this?
Thank you
The CD data type allows this form:
<code nullFlavor='UNK'><orginalText>hives on arm</code>
Or better yet:
<text>...<content id='reaction1'>hives on arm</content>...
...
<code nullFlavor='UNK'><orginalText><reference value="#reaction1/></orginalText></code>
In terms of what is acceptable for Stage 2, I suspect that either of the formulations I show will work, but we don't have either the rule or the test suites from NIST as of yet.
I'm hoping you might have some input for my organization. (if this has posted twice forgive me)
We need to include an annotated comment for an observation result in our C32 CCD. We are using the Comment Module to include this comment that corresponds to a NTE segment from an HL7 v2.x result. We would like to include this at the observation or OBX level within the structured xml of the CCD. Including this comment at the section or component level seems to work but when moved to attempt to have it associate with the observation result itself is proving a bit difficult for development.
Thank you,
Doug
Love your website - what a great resource!
I'm trying to appreciate what is "standard" and what is variable among CCDs. In my experience, the section template headers ( i.e.
2.16.840.1.113883.3.88.11.83.112 for medications) are well implemented but other standards for entries i.e. 2.16.840.1.113883.3.88.11.83.14 for (Vital Signs ) are not. It seems that the world has decided to accept one level of granularity at the section level and then abandoned this concept at the entry / leaf level. I have accepted this as the current state of the world.
My question is about intra-product variability. For example, if company X delivers product Y that is installed at facility A and facility B, will the format for a CCD from facility A and B follow the same intra-section format? Will the table structure that contains the actual data look the same between these installations or will it differ?
If this is more appropriate for the website, let me know and I'll post it so that others will have a chance to follow.
Best,
- Rich
Usually, the CCD's produced by the same EHR system will have the same capabilities. However, those capabilities are often configurable, which means that you might not always get the same set of sections. Also, code (e.g., SNOMED vs. ICD) use can vary between different sites. It really depends on the EHR, and the amount of customization that it enables. In general though, you can expect limited variation "intra-section" variation when you've controlled for the EHR variable.
I'm working on the CDA Release2 and Have a question on the validation being done by the Lantana Validator tool. I'm referring to the
1) PDF "CDAR2_IG_IHE_CONSOL_R1_DSTU_2011DEC.pdf"
2) page 227 "Hospital Discharge Instructions Section" and
3) table on page 228 "Figure 103: Hospital discharge instructions section example".
My understanding is that unstructured part of these section that is content of the "section/text" are not being validated. But, for this section, the content inside the "section/text" is being validated and if I have any other HTML tag, the Lantana validator errors out.
What do you think about these,
1) Do we need a validation for the HTML content of the this section “Hospital Discharge Instructions Section”?
2) Should Lanatana be validating this HMTL section? or not
Thanks,
Sandeep
On page 73 of the HITSP C83 documentation (www.hitsp.org/Handlers/HitspFileServer.aspx?FileGuid=c21d785a-1dac-4fc6-b806-8ca3143f1cf3), there's an example of a Results section, but it doesn't seem to cover the full entry. It just starts at the result's 'observation' tag instead of the tag directly under the 'entry' tag like the other.
Is there anywhere I can see what tags belong above it?
..although I'm not sure if this is the latest copy of this specification or the best one to use.
We have a need to use some DT R2 in our CDA documents. will this make our documents not CDA R2 compliant even if we add the new data types in datatypes-base schema file using the extension tag ?
Thanks
Adel
Running into some trouble when trying to export a CCD from a patient chart from a meaningful use certified EHR. The EHR allows me to free text problems, allergies and medications but this means that there are no codes associated with them. When I export the CCD, it requires me to have codes like ICD 9 or RxNorm. Is it allowed to NOT have codes associated with these problems, med and just populate the "Display Name" in the CCD, or is there some generic "user generated" code I could use for all of these items?
Would love to get advice on how to export user generated free text clinical data into the meaningful use CCD.
Thanks!
<code nullFlavor='NI'>
<originalText><reference value='#free-text-problem-1'/></orginalText>
</code>
My question concerns the Consolidated CCD in Meaningful Use Stage 2. The "Transition in Care" and "Data Portability" CCD requirements (per the Final Rules) include Activities of Daily Living, Cognitive Status, and Disability Status. Do you have any guidance on where to place this information in the CCD and what data elements should be included?
Will CCD that is C32 v2.5 MU version pass validation if using HITSP/C32 v2.5 Summary Documents Using HL7 CCD (using HITSP/C83 v2.0) to validate?
Thanks in advance.
With the need to collect race as a multiple, how does that need to be represented in the CCDA? It's currently listed with the constraint of only 1. Is this a case where the Final Rule requiring this to be multiple supersedes the CCDA constraint?
Thank you.
My dev team is working through the QRDA Category I specs for CQM esubmission as required for MU 2014 certification. I have been tasked with finding the answer to this question: "Is QRDA I a "dump" of the patient visit record?".
Thank you
For the first specific capability related to actions involving electronic health information, we
have required that the data elements specified in sections 7.2 through 7.4, 7.6, and 7.7 of ASTM E2147-01(2009) be captured.
7.6 Type of Action (additions, deletions, changes, queries, print, copy)—Specifies inquiry, any changes made (with pointer to original data state), and a delete specification (with a pointer to deleted information).
Question: the ONC Stage 2 final rule seems to indicate that ICD-10 is the required vocabulary for Encounter Diagnosis. That would require that an EH attesting for 2014 would need to be live on ICD-10 prior to the 2014 implementation date since they report on the FY. Is that accurate or have I missed something (I hope).
Jim
james.r.herbert@kp.org
Both here: http://www.federalregister.gov/a/2012-20982/p-1538
and here: http://www.federalregister.gov/a/2012-20982/p-1562
it describes encounter diagnosis as:
The standard specified in § 170.207(i) or, at a minimum, the version of the standard specified § 170.207(a)(3)
The former is ICD-10-CM (see http://www.federalregister.gov/a/2012-20982/p-1372 and subequently see 45 CFR 162.1002), and the latter is SNOMED CT (see http://www.federalregister.gov/a/2012-20982/p-1351 )
So your choices are use SNOMED-CT, or use ICD-10-CM. I'd go with the former, since you already have to use SNOMED-CT for problems.
EPs have 2 options:
1. EHR Data Submission Vendor-Based Reporting Option ->
Submit existing CQMs for MU stage 1 in XML format + PQRS Measures in QRDA Category 1 format(DSVs submit on behalf of EPs through a certified EHR)
2. Direct EHR-based through Vendor-based Data Submission Reporting Option -> Submit CQMs for MU Stage 1 QRDA category 1 format + PQRS Measures in QRDA 1 category format(EPs submit the data through a certified EHR)
Is there anything else that I need to understand?
I am having trouble finding examples of embedding image data in lab results observations in CCD. Is it possible to use the following as a value in a result observation?
<value xsi:type="ED" mediaType="image/jpeg" representation="B64">the data</value>
To your second one: It is perfectly valid to use ED in Observation. ObservationMedia is purpose designed to support this use case, whereas Observation is the more general approach (and would be indistinguishable from a RIM perspective).
The critical point is in the definition of the renderMultimedia tag that is used in the narrative with observationMedia:
The <renderMultiMedia> element ... contains a required referencedObject attribute (of type XML IDREFS), the values of which must equal the XML ID value(s) of ObservationMedia or RegionOfInterest CDA entries within the same document.
I am reviewing the Query Format (HQMF) Implementation Guidance v0.5 and trying to match up with the finalized eCQMs that we downloaded last week. I see from the document appendix no work is planned on Greening the HQMF until 2013. Is there any more specific timeline on that? What is the best way to stay in tune with that?
Thanks for your guidance.
What are the chances of the easier to read HQMF version becoming the standard for MU2 eMeasures?
Thanks and great post on the abbreviation soup and clearing that all up.
I am really interested to know if you have come across the ability to extract CCD information into a database through an automated solution. If you can point to a source that would be great. Thanks.
I am trying to figure out how the following abbreviations are connected - NQF's QDM, HQMF, eMeasures, Query Health, QRDA, QDM based QRDAs, others.
Rather than individual definitions, I am a bit in the dark around how each of these are interconnected.
Appreciate your help.
Warm Regards,
Shyam
In the Lab Results section of the CDA document, the validator (the one available online on the NIST website), requires us to provide the procedure along with the battery->Test Results collection. Is there documentation that you can help me point to that could further describe the requirements for the procedure section? We are not sure if a procedure refers to a CPT or the specimen collection procedure.
Second question:
The sample documents that I've seen refers to SNOMED CT codes in the battery & procedure sections of the document.. Is it allowed to provide the lab order codes (belonging to the Labs that we interact with) in place of the SNOMED CT codes? If it is allowed, what coding system should be specified? Thanks in advance.
However, now that CCDA requires RxNorm for meds/allergies (or NDF/UNII), do you know of any equivalent "generic" code in these systems? I hate to do the following just to pass validation:
<code codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" nullFlavor="UNK">
<translation code="413477004" codeSystem="2.16.840.1.113883.6.96" displayName="Allergen or Pseudoallergen" />
</code>
Can you share how the patient identification type (whether it is an SSN, Clinic Generated Id, MRN etc.) be represented in the CDA patient header?
Thank you
I would like to know on the various interoperability challenges/issues faced while integrating the HC products with external entities in HCIT.
Does the Meaningful Use Stage 2 final rule have a requirement that EHRs must be able to import QRDA Category 1 documents?
thanks
Orna
The NIST XDS Test Facility is no longer available. Is there a replacement or another service for XDS testing?
for MU Stage 1, CDA entries with codes(level 3) was required for Allergies, Medication, Labs, Patient Problems.. What additional sections need to have entries(level 3) for MU stage 2 when generating c-CDA? It's not clear from the final rule. Also, other than the above 4 sections, what others need to be parsed for MU Stage 2.
Thanks,
-sri
With regard to what you need to put into your C-CDA, it's the common data set (defined in the rule) plus a few other things. For that, I suggest you have a look at the testing procedures.
Does the top validation tool at http://xreg2.nist.gov/cda-validation/validation.html
---------------
Name: CDA R2
Description: HL7 CDA R2 (with no extensions)
---------------
test the latest consolidated CDA (CCDA) corresponding to the Dec 2001 implementation guide?
Thank you