Convert your FHIR JSON -> XML and back here. The CDA Book is sometimes listed for Kindle here and it is also SHIPPING from Amazon! See here for Errata.

Thursday, February 7, 2013

2012 Answers Archive

Periodically, I archive the answers from Ask me a Question.  Below are the answers from 2012:

  1. Anonymous: On Q1, I see there is a placeholder page here 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.
  2. 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.
  3. 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.
  4. Lou, see my second ever post. Transcription is unstructured data. C32 and C83 are structured data.

    1. 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.

      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.)
    2. 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.
  5. 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.

    1. Douglas,

      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.
  6. Keith-

    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.

  7. Hi Keith,

    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.


    1. 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>
    2. Whoops, codeSystemName is missing an = after it. I think you get the idea.
    3. Hi Keith,

      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,
    4. 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.

  8. 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.

    1. 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.
  9. 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?

    Any help would be greatly appreciated.


    1. 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
  10. 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).

    1. Thank you for your quick response.

      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.


  11. Hi Keith,

    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,

    1. 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.
  12. Hello Keith

    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 ?

    "cervicovaginal cytology result" = "112662005 ^ Low-grade squamous intraepithelial lesion (morphologic abnormality) ^ SNOMED CT"
    "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

  13. 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).
  14. Hi Keith,

    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?


    1. 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.
  15. Hi Keith,

    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?


    1. 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.
  16. What is the difference between CCD 1.0 and 1.1? You have mentioned these in table comparing the Stage 1 and 2 Meaningful Use standards.
  17. 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?

  18. 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?

    1. 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...
  19. 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.

    1. 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:
    2. 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.
    3. 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.
  20. Keith,

    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.

    1. 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.
  21. I want a sample CCD document. Can you pls send it?


    1. You can find sample CCD documents in the download packages for the NIST CDA Validator (see )
  22. Are you aware of another validation tools available today for the CCDA
  23. Hello Keith,

    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?

    1. x_EncounterParticipant also includes REF for Referrer.
    2. As I answered elsewhere, x_EncounterParticipant also allows for REF, to identify the referring physician.
  24. Hi Keith,

    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.

    1. 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.
  25. Hi, Keith.

    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



    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.

  26. Ooops. Look like the XML didn't come through. Substituting...

    [observationMedia classCode="OBS" moodCode="EVN" ID="Hgb-A1C"]
    [id root="C06E4A43-13AB-4A5D-8A72-ABF887D915CD"/]
    [value xsi:type="ED"
    representation="B64"][reference value="images/Glucose-Metformin.jpg"/][/value]


    [observationMedia classCode="OBS" moodCode="EVN" ID="Hgb-A1C"]
    [id root="C06E4A43-13AB-4A5D-8A72-ABF887D915CD"/]
    [value xsi:type="ED"

    1. 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 and for some pointers.
  27. 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#.


    1. 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

      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.
    2. Thankyou very much for the quick response.
      Will look into what you have suggested
  28. Hi Keith,

    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 ?


    1. 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.
  29. Keith,

    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 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.

    1. 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.
    2. 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.
  30. Keith,

    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 ( 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.

    1. See my response to the comment above.
  31. 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?

    1. Peter,

      It would be good to make that comment on the IHE PCC eReferral profile that is presently out for public comment.
  32. 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?

    1. See conformance statement 7438 under Medication Supply Order.
    2. Thanks. What is the performer (CONF 7522) represent?
  33. Hi Keith,

    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?

    1. For discussions on consolidation, I'd sign up for the HL7 Structured Documents Workgroup list serve (see top right), or the S&I Framework Transitions of Care Implementation Guidance Workgroup.

      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.
  34. 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 =, codeSystemName = IHEActCode?

    1. 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).
  35. 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.

    Warm Regards,

    1. For Stage 1, the applicable criteria are found in: §170.304(i). Related criteria are §170.304(f) and §170.304(h).

      For Stage 2, the proposed criteria are found in: §170.314(b). To see the citations for the standards, check out this page.
    2. 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.

      Warm Regards,
    3. 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).
  36. Hi Keith,

    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?


    1. 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.
  37. ,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?

    Thanks Andrew W.

    1. I'm not aware of any particular deployments, but you can see who has implemented and tested at connectathon here
  38. I see you have a host of HQMF posts... but I didn't see a definition and introduction to what "H" "Q" "M" "F" means...
  39. Hi Keith,

    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

    1. 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 ;-)
  40. 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?
  41. 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?
  42. Hi Keith-

    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!
  43. Hi Keith,

    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!
  44. 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:

    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

    1. 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.
  45. Keith,

    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,

  46. Keith,

    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. for medications) are well implemented but other standards for entries i.e. 2.16.840.1.113883. 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.


    - Rich

    1. 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.
  47. 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


    1. 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.
    2. 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?
  48. Hey Keith,

    On page 73 of the HITSP C83 documentation (, 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?

    1. I was able to find the information I'm looking for here:

      ..although I'm not sure if this is the latest copy of this specification or the best one to use.
    2. This page from NIST contains some downloadable samples which might help. See the first link.
  49. Hi Keith,

    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 ?


    1. 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.
  50. Hi Keith,

    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.


    1. 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:

      <code nullFlavor='NI'>
      <originalText><reference value='#free-text-problem-1'/></orginalText>
    2. Awesome .. did not know this.
  51. 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?

    1. They should go into the Functional Status section found in the CCDA 1.1 specification.
  52. Hi Keith,

    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.

    1. 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.
  53. Hi Keith,

    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.

    1. CCDA describes an extension element to support the recording of multiple race codes.
  54. Hello Keith,

    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

    1. 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.
  55. 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?

    1. While it won't hurt to send the additional information, it doesn't help anything either.
  56. 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).
  57. 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).

    1. Yes. Look carefully at the definition of Encounter Diagnosis:
      Both here:
      and here:
      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 and subequently see 45 CFR 162.1002), and the latter is SNOMED CT (see )

      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.
  58. 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.

    1. 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.
  59. 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.
  60. Hi, is there any direction on being able to include Blood Bank Products or tests on the CCDA?

    1. 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.
  61. 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?

    1. 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.
  62. Hi Keith,

    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>

    1. 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.
    2. 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?
    3. 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
    4. 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.
  63. 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.

    1. Thanks for your info. I have certainly bookmarked the QH website.

      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.
    2. 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.
  64. Hi Keith,

    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.

    1. 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.
  65. 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.

    Appreciate your help.

    Warm Regards,
  66. 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.
  67. 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:

    <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" />
  68. 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
  69. Hello Keith:

    I would like to know on the various interoperability challenges/issues faced while integrating the HC products with external entities in HCIT.
  70. Hello Keith,

    Does the Meaningful Use Stage 2 final rule have a requirement that EHRs must be able to import QRDA Category 1 documents?
  71. hi, what is the terminology and value set for CG pedigree that was defined in the meaningful use stage 2?
  72. Keith,
    The NIST XDS Test Facility is no longer available. Is there a replacement or another service for XDS testing?
  73. 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.


    1. 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.
  74. Hi Keith,
    Does the top validation tool at
    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