Thursday, January 12, 2017

What version of CCDA Document is this?

This is a question I get internally and externally all the time.  The answer is pretty straightforward. Look at the templateId elements underneath the <ClinicalDocument> element.  There will be at least two and possibly more.

If you see: <templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
you can be sure this document is a CCDA Release 2.1 or later.  It will also bear:
<templateId root="2.16.840.1.113883.10.20.22.1.1"/> indicating that it is backwards compatible with CCDA Release 1.1.  

If you only have one templateId where root="2.16.840.1.113883.10.20.22.1.1" and there is no extension (like extension="2015-08-01"), you have a CCDA 1.1 that hasn't been uplifted to CCDA 2.1 yet.

If you have a templateId where root="2.16.840.1.113883.10.20.22.1.1" but extension="2014-06-09then you have CCDA 2.0 and it won't be backwards compatible with CCDA 1.1.

Now, what if you have a templateId with 2.16.840.1.113883.10.20.1?  Well, now were talking old-school CCD, first edition.  It's a fine thing that has mellowed with age.

What you really want to see is <Composition> or <Bundle> as your first element, in which case you might be dealing with CDA or CCDA on FHIR.

It's all very confusing, but not really.

Each of them provides a core set of data about the patient, and for every single one of them, it's pretty much the same set of elements.  Those you might call a Continuity of Care Record.  There are a lot of ways to write the XML, but in the end, the data is essentially the same.

   Keith

P.S.  Thanks to Corey Spears for taking up the challenge of answering this question on the Structured Docments workgroup.  I'd already half written this post when he responded.

6 comments:

  1. If the clinical document has templateId root="2.16.840.1.113883.10.20.22.1.1"
    and templateId root="2.16.840.1.113883.10.20.22.1.2"
    would that be CCDA 1.1?

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    Replies
    1. Yes. But it could also be CCDA 2.1 if it has the CCDA 2.1 templateId, because ALL CCDA 2.1 templates are backwards compatible with CCDA 1.1.

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    2. I should have said: All CDA 2.1 documents that have a corresponding CCDA 1.1 document are backwards compatible.

      Delete
  2. Hi... what does the templateId 2.16.840.1.113883.10.20.22.1.4 mean? It is listed underneath 2.16.840.1.113883.10.20.22.1.1 with not "extension" attribute so I am sure it is CCDA 1.1 but I wanted to check whether 2.16.840.1.113883.10.20.22.1.4 means something...

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  3. 2.16.840.1.113883.10.20.22.1.4 is a Consultation Note. So what you have there is a Consultation Note Document in C-CDA R1.1 format.

    ReplyDelete
  4. Hello, the blog posts talks about templateId's that end with 1.1, but what if you have a 1.2 extensions like below?




    Does the 1.2 indicate this is v2.1?

    ReplyDelete