Tuesday, February 5, 2019

History of the Concern Act in CCDA

This particular post results from questions on the HL7 Structured Documents workgroup's e-mail list.  It basically boils down to a question of why the Condition and Allergy observations have an Act structure wrapping the Observation related to the Condition or Allergy that is described within.

The answers are below:
  1. What were the intended semantics associated with the effectiveTime on the concern act?
    This is the time that the reported problem became the concern of the provider.
  2. What were the semantics of the author on the concern act as opposed to the semantics of the author on the Problem Observation?
    One provider can be concerned about an observation made by another provider.  The author of the concern is basically the person saying, this is an issue I need to track.
  3. What were the semantics of the Priority Preference on the concern act as opposed to the semantics of the Priority Preference on the Problem Observation?
    Again, this is related to the distinction between the "concern" and the "condition".  A low priority problem for the patient (e.g., a minor twinge in their tooth), might be a high priority concern for the patient's dentist.
  4. How was the design of the Problem Concern intend to be used relative to representing “the patient’s problem list”? 
    The provider's problem list for the patient can be viewed as the provider's record of the concerns they have regarding the health of the patient.

General Background

In 2005, shortly after CDA was introduced, HL7 and IHE collaborated on a joint project to develop templates to exchange a care record summary.  HL7 was to to work on level 1 and 2 templates (documents and sections), and IHE was to work on Level 3 templates (entries) to enable the exchange of of this data (you might recall that ASTM was building the CCR around this time as well).  I was the editor for both the HL7 and IHE documents (and later the editor for the HITSP C32, and one of many editors for CCD and later C-CDA).

Involved in this project also from the HL7 and IHE sides was Dan Russler, cochair of the Patient Care workgroup at the time in HL7, and alongside me, of the IHE Patient Care Coordination Workgroup.  Dan brought extensive knowledge of V3 structures and vocabulary that HL7 had been developing in Patient Care to the project, and I was the go to person for mapping this to CDA.  The project had been cooked up by leadership of HL7 and IHE to basically try to get something done on care record exchange, because some of the IHE sponsors who had also been engaged with the CCR project were getting tired of it getting bogged down in ASTM.  Also involved from the HL7 and IHE sides was Larry McKnight, a physician from Siemens.

In HL7, we based a lot of our work on the Vancouver Island Health Authority's e-Medical Summary, developed for CDA Release 2.0 in 2004 (before CDA Release 2.0 had even finished publication).  That organization was the first organization to use Schematron for validation in CDA documents, something that continues to this day, 15 years later.  But the eMS didn't really get into details for level 3 templates for problems, meds and allergies (our key areas of concern in this project).  Fortunately, the HL7 Patient Care group had been working on vocabulary and modeling to describe Concerns about a patient.

If you look at the changes to CCD over time, you will see in C-CDA 1.1 that the Problem Concern Act uses CONCERN from ActClass in Act.code.  This is because it couldn't be used in Act.class because CONCERN hadn't been an accepted V3 vocabulary term at the time CDA R2 was completed.  This resulted in part from long running debates over the semantics of the CONCERN Act, which didn't finally get resolved until 2014 and later after the third and final push to complete this work.

The Problem Concern Act in C-CDA is the representation in CDA of the semantics of a Health Concern, which is distinct from the underlying problem that causes the concern.  Concern is about provider awareness of a problem, while the problem observation is directly related to the problem itself.  Consider this: I have Cervicular Radiculopathy again, but this time in my left arm.  I told my physician about it on January 19th, but had symptoms going back to a week before, and I was examined on the 22nd.  So, the concern about my nerve pain should be dated 1/19, or perhaps 1/22 after he evaluated me, but the problem itself should have a start date somewhere around 1/11.  When this problem is resolved (say in a few more weeks), it can be marked in the problem observation with regard to the date is was resolved, and in the concern act when that resolution is reported to my provider (which will likely be after that).

The health concern itself can change over time, and acts as a wrapper around the relevant data: When I originally had the problem, we could have included not just the physician observation, but also subsequent diagnostic test data, the treatment plan and evaluation.  All of this development of the Health Concern act evolves from the Problem Oriented Medical Record pioneered by Dr. Larry Weed.


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