2015-2016 Ask Me a Question Archive

  1. Following on from the above question, if we want to use a different value set for Social History Observation than the one that is defined (as Should) in the template, we specify compliance w/ that template and then a new template ID for the new value set? Or do we define a completely new template ID?
    Thank you.


    1. If you use a different value set, you are still conformant to the existing template ID, so no new template ID is needed there. Yes, your value set should be associated with an identifier, but it is NOT a template ID.
  2. §170.314(e)(2) Clinical summary (ambulatory) for this criteria we have included all the data item which they have mentioned to include as minimum.. but how user will test by excluding the items.. in my system we are displaying common data as by default and allow rest of the items to exclude if they want.. is this correct to pass this criteria?


    1. Sorry, I'm neither ONC nor NIST, so I cannot answer that question authoritatively. What you suggest sounds right though.
  3. Hi,
    I am currently reading trough the IHE XDS.b specifications. Could be that this question is already answered, but I couldn't find it in the archive.
    I am wondering for which purpose a SubmissionSet is required?
    SubmissionSets can carry DocumentEntries and Folders. It is used to perform ITI 41 and 42 (for XDS.b). But if I want to read data from the repository, I am just asking for single documents. In ITI-43 it is not specified that I can ask for a SubmissionSet.
    So why do I have to put documents/folders in to a SubmissionSet to put them in the repository and registry. It doesn't make sense to me.



    1. SubmissionSet is used to identify everything that was issued in the XDS transaction. You can include multiple documents, folders, et cetera, in a single submissionSet. Even if all you are doing is addressing a single document, submissionSet is necessary to capture certain data specific to the transaction (such as the source system doing the submission, and the reason for the submission).
  4. Hi,

    I am currently researching what the current CCD version is for Meaningful Use 2. Information I am looking for are the section list (required/optional) and the code sets that need to be utilized for each coded item within each Section (ie: Problem: SNOMED CT / ICD-9-CM).



    1. The version of the CCD that you want for 2014 Certification (used for both stage 1 and stage 2) is found in the HL7 Consolidated CDA (C-CDA) version 1.1 Draft Standard for Trial Use. However, if you are certifying product, you need to look at the NIST test scripts, because they have more requirements than are found in C-CDA.
  5. Hi Motorcycle Guy,

    What does JASON stand for?



    1. JSON (JavaScript Object Notation) http://json.org/
    2. Jason is a popular name for a male.
    3. Are you referring to JSON, or JASON (group/project at MITRE), and the recently released AHRQ report on "Data for Individual Health"?
  6. Hello Keith, I'm considering getting the CDA book, but noticed that it was published prior to CCDA. Is the current edition still relevant for some new to CDA and CCDA? Is there a updated edition planned anytime soon?


    1. It covers CDA, not C-CDA. However, most of what you need to understand C-CDA is described in the book. No, I haven't planned an update yet, probably after I finish my degree.
  7. I am having great difficulty with displaying a "middle name" with the CDA style sheet.

    Documentation suggests:

    but the middle name, Martin, will not display.
    The CDA scheme does not have a node for "middle names", just "given" and "family"
    Any help would be greatly appreciated.


    1. The second occurrence of tag represents middle name.
      Try the adding Martin as value for second tag under recordTarget/patientRole/patient/name/
  8. Hi,

    Do we have a comprehensive guide for implementation of HITSP C32 document?
    I specifically need the template id's and the conformance specifications as to which tag is mandatory or optional for C32 document.
    I tried to refer the guide for CDA (CDAR2_IG_IHE_CONSOL_R1_DSTU_2011DEC) but it is not of much help.
    Any reference to C32 implementation would be helpful.


    1. You can find the HITSP C32 specifications (you will also need C80 [vocabulary] and C83 [sections and entries] at http://www.hitsp.org
  9. Hi Keith,
    Could you please explain
    in which cases CCDA CCD should be used and in which cases CCDA Summary Of Care Record
    according to MU requirements.
    Thanks in advance.


    1. The version of CCDA has 9 document types, one of which includes the CCD version 1.1. Of these, all are acceptable for Meaningful Use 2014 Certification EXCEPT the Unstructured Document. For Stage 2 incentives, you could use any of these to generate the the summary of care record requirement by Stage 2.
  10. Hi Keith,

    I'm having a little trouble deciding which template identifiers to use for problems, meds, allergy, etc sections for XDS-MS Referral/Discharge summary documents.

    For example, in table of the IHE Patient Care Coordination Technical Framework documentation (http://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_TF_Vol2.pdf), it specifies using as an OID for an Active Problems section. However, in section 2.3.1 of the same document, it states, "At present, the PCC Technical Framework uses only one base standard, CDA Release 2.0", which makes me think that I should instead use the OIDs listed in the CDA R2 specifcations (e.g. 2.16.840.1.113883. for an Active Problems section).

    When I generate my documents like this though, they fail on the NIST validator (http://cda-validation.nist.gov/cda-validation/validation.html), with error messages like:
    Error: A(n) Referral Summary must contain Active Problems.
    Context /ClinicalDocument[1]
    Test .//cda:templateId[@root = ""]

    If you could shed some light on this, I would be eternally grateful.

    Thanks very much for your time,


    1. Kyle, IHE uses an older version of the specifications that Meaningful Use, because it is still the only INTERNATIONAL specification supporting these exchanges. C-CDA itself is designed to meet US requirements, but many other countries have different requirements. So if you are testing for Meaningful Use, you should be using the C-CDA templates, but if you want International support, you should use the IHE PCC work. We are still trying to figure out how to solve this problem jointly with HL7. Now that there is a joint workgroup, we'll be taking up that issue Stay tuned.
  11. Hi Keith,

    I would like to know about your views on treating FHIR schema as a data model that can store any kind of Clinical/Administrative/Financial data, i.e., a kind of data warehouse model rather than a repository. Please let me know your thoughts.

    Many thanks,


    1. Data models and standards are often closely related. If your tooling can read the standard and automatically build a data model, then you are probably in good shape. But once you ship, you are probably frozen in that state, whereas the DSTU could still change. In general, I tell people that they should look at a separation of concerns, make sure you have the functionality necessary, but don't simply ape the way it is done in a different layer.
  12. Hi Keith,

    Sorry if these were asked before. I looked around, but could not find clear answers.

    I am researching an area related to an App we are developing on iPad/iPhone and Android. The app allows patients to obtain patient education material while they are within the healthcare settings. We record in the App the fact that the patient was provided with that patient education.

    My questions: Is there a standard that allows the loading of that knowledge (for example: ‘patient John Doe viewed drug education guide for Amoxicillin’) from the App into an EHR used in the same healthcare settings? If the standard exists, does the data need to be loaded as individual records or can it be loaded in a list or table as a weekly/monthly batch?

    The idea behind the loading of this information to the EHR is simple: Doctors may use our App to help themselves reach the meaningful use 'Patient-Specific Education resources' measure goal.

    Thanks in advance for your help!


    1. There's a very draft resource in the FHIR spec called Communication (http://hl7-fhir.github.io/communication.html) that I think will likely evolve into something suitable for this purpose, but it's a bit rough around the edges and may or may not make it into DSTU2. Feedback would certainly be welcome. (You can use the "Request a Change" link at the bottom.)
    2. There's a template for this somewhere in C-CDA as I recall, See the Instructions template in CCDA. You might ask the HL7 Structured Documents examples task force for an example of this.
  13. Keith,

    I have a client and development team that are having issues using the CDA R2 extensions, e.g. sdtc:birthtime and getting it by NIST/Lantana validation. They seem to have the correct namespaces within the xml but something is missing or incorrect. They have followed the examples provided in the CCDA R1.1 package but still hare having no luck. As an example:


    Any help is appreciated,

    Doug DeShazo
  14. I am searching spec or sample on how to put diagnostic codes and modifier code associated with a procedure in the procedure section of a C-CDA file. Can we include them?


    1. A code for diagnosis would go on a problem concern. If you wanted to indicate that a particular problem was the reason for the procedure, you could do that in CDA through the use of an entryRelationship element using a typeCode of RSON (Reason). IHE's Procedure template illustrates how this can be done.

      For procedure modifier codes, I'm assuming you are talking about CPT codes with modifiers. There are a couple of ways that you could handle modifiers, but since they are part of the CPT-4 coding system (and also part of HCPCS), just append them to the code as you would normally (e.g., 73090-26 for Professional Component only of an X-ray of the forearm).
  15. Keith,

    Apologies if this is posted twice. My developers are having issues with using the extensions to CDA R2 when building a CCD (CCDA). NIST keeps telling them it is expecting one of urn:hl7....and they are having difficulties determining the issue. They have the namespace declared and seem to be following the CCDA examples the July 2012 zip package. NIST returns this:

    cvc-complex-type.2.4.a: Invalid content was found starting with element 'sdtc:birthTime'. One of '{"urn:hl7-org:v3":name}' is expected.".




    1. Hmm, it sounds as if the use of sdtc:birthtime is appearing in the wrong place in your document, or inside the wrong structure. It may also be that the NIST validator is not properly configured to allow extensions to be used other than where they are necessary for meaningful use. In which case, your document is still valid, it's just that the NIST validator doesn't correctly interpret it so. I'd need to see the XML to be sure.
    2. Thanks so much for the quick reply. I'm thinking it might be both of your suggestions. It's being used in guardian and informant and I'm not sure why they coded it that way. This is the structure with some of the tags removed:

      guardian classCode="GUARD"
      code displayName="mother"
      guardianPerson classCode="PSN" determinerCode="INSTANCE"
      sdtc:birthTime value="19731103"

      Thanks again
    3. Ok, so here is what is going on:
      The CCDA specification only defines the use of the sdtc:birthTime extension on participant/participantRole/playingEntity.

      That DOESN'T make your CCDA invalid, even for use with Meaningful Use, because, according to the standard, extensions are allowed, and Meaningful Use doesn't forbid them either. And furthermore, sdtc:birthTime is specified by Structured Document thus:

      The element allows for the birth date of any person to be recorded. The purpose of this extension is to allow the recording of the subscriber or member of a health plan in cases where the health plan eligibility system has different information on file than the provider does for the patient.

      That doesn't limit it to just that participant element, but allows it to be used for any RIM class describing a person. However, the CCDA specification doesn't include it in the modified schema for all persons because it is only specified in that guide for some use cases.

      Thus, what I'd recommend is to take out the use of it for Meaningful Use testing. Meanwhile, I'd also suggest you discuss with the testing folk.

      The challenge for the validation tool is that it may even strip extensions it doesn't know about, but since it knows about stdc:birthTime, it doesn't strip it from places where it MAY be used in CCDA, but hasn't been recommended by that specification.
  16. I'm looking to understand if it is an accepted practice to modify the CDA style sheet. One of our customers is asking for patient identifying information to be repeated on every page of the CCD when it is printed. What would be your recommendation in handling this request?


    1. The CDA stylesheet is NOT part of the standard. Vendors and other implementers routinely modify the stylesheet. Often, they create a patient identity banner at the top of the page to capture patient identifying information, and then make the narrative portion of the document appear in a div or other HTML block element with a vertical scroll bar, so that the patient identity is always present.
  17. Hi Keith,
    We are designing a way to transfer a patient between two systems (databases) by using transition of care of C-CDA, To transfer procedure, allergy, problem, and medication well and sync automatically, we are thinking to include a global unique identifier (GUID), entry system name, last update system name and last update date time stamp with each item. So the receiver can match, process (update and import) them more automatically. Does the C-CDA standard allow these extra info to be included? If yes, how to include them? Thanks for your help


    1. Every act in CDA can have an identifier, so you can certainly include a global unique identifier. As for entry system name, last update system name, and last update time stamp, my suggestion would be to include a generalized element where participant.time was the time of last update, and the participantRole.device contained the last update system name. As for the entry system name, that's probably a bit more difficult, but could probably be handled using another participant in a similar fashion.

      The key however, is simply to use the same GUID in the act identifier all the time when you exchange the information. This is the principle upon which the IHE RECON profile is built. All the extra stuff is basically overkill.
  18. Very sorry to bother your, just one more question: Does C-CDA generation (clinical summary etc.) in MU stage 2 requires that encounter diagnosis must be coded or mapped in SNOMED CT. ICD-10 is not acceptable for encounter diagnosis in CCDA documents? In other words if for billing purpose we are using ICD-10 then for encounter diagnosis to be included in C-CDA documents do we need to convert them in SNOMED CT?


    1. If you want to conform to the Meaningful Use requirements, you must do what they say. Yes, you must used SNOMED CT. I think you just answered your own question.
  19. Hi Keith,

    I have a question about C-CDA. We have a clinic note for each patient encounter. It is in a free text format. I would like to include it in a C-CDA. Can I do this?


    1. The short answer is yes. The point of CDA is to support exchange of patient visit documentation.

      The long answer is that the clinical note and your C-CDA should really be the same thing. The "free text" note that you speak of is a Level 1 CDA document. For meaningful use, you need to move up to Level 3.

      The human readable content of your clinical note should include somewhere the text found in the clinic note. You will be challenged figuring out how to do that, because as you will find, the human readable text is probably broken up into several sections, and each of those sections will be found in a different place in the CCDA.
  20. Hello Keith.
    MU2 Interoperability certification question.
    There are a bunch of CCD templates listed below.
    OUR EHR system can process (compile, transmit, receive, parse) Consolidation 2013 CCD.
    Do we need to be able to process all of them to get MU2 certified?
    Best, Vadim.
    1. CDA R2 2007:
    templateId 2.16.840.1.113883.10.20.1
    2. Consolidation 2013:
    templateId 2.16.840.1.113883.
    3. Consolidation V2 2014:
    templateId 2.16.840.1.113883.


    1. For Meaningful Use, you must be able to create a CCDA (pick one of the eight allowed), display CCR, HITSP C32, and CCDA, and incorporate CCDA documents.
  21. What is the difference between a Summary of Care Record and a Summarization of Episode Note? There seem to be too many misnomers with regard to the naming convention of these documents. I would have expected a Summ of Episode to be information about a solitary Episode but that doesn't seem to be the case. Thanks in advance. -John


    1. Define "episode" (I spent a whole blog post on it) and you've got the answer to your question. A briefer answer is here.
  22. Hi Keith! We discussed this a while back privately but I thought I'd pose it again here publicly. You've written before about how CDA documents are to be signed (optionally): http://motorcycleguy.blogspot.com/2011/09/security-masking-and-legal-signatures.html

    We now face an issue where C-CDA will be an incredible format for submitting charts to insurers, both public and private, for many purposes including quality measurement and risk adjustment. However, in other CMS regulation that predated ARRA and HITECH, and C-CDA for that matter, they only cite physical signatures (and go so far as to describe medical notes printed on stationery but not signed).

    So: what's the easiest way for providers to embed a verifiable digital signature that not only identifies the signer, but may also prove the authenticity of the document?


    1. Well... Right now there are three different ways to sign a document or exchange transaction digitally as described in the standards proposed for 2015 Certification just released. That problem seems to be on its way to being solved thrice over.
  23. Hi Keith, I have worked on MU since 2011, have worked with Quality Health Network (QHN), and am on a HIMSS Committee to respond to the Interoperability Standards Advisory. I appreciate your opinion on the CCDA 1.1 v 2.0. I read your blotspot, and wonder if we may contact you for further information? I tried the email link, however it did not work (operator/computer error?). Thank you very much, Pam Foyster
  24. Hi Keith,

    I'd like to generate a new template, is there a tool can help in this, other than MDHT?
  25. Could you please let me know if we have any concept of Patient Merge with CDA (As it is historic information I am under assumption that we don't have it), I am new to CDA and tried looking different websites and could not find an answer. If so how and where do we send/receive this information. I would also want to know if we use ADT^A40 event for patient merege if the patient (MPI) is being duplicated within community or do we use ADT^Â24 and ADT^Â27 (link and unlink events).

    Thanks in advance!!


    1. HL7 Version two trigger events and CDA can be used together within a single system. How you do that is completely up to you. With regard to how patients are merged, there are two different ways that systems do that, merge (North America typically uses this) and link/unlink which is often more used in Europe. Pick one, or use both (some systems support both).
  26. Keith,

    I have a question about the use code attribute for the TEL datatype. HL7 v3 has the codes defined, one of which is MC for cell phone or mobile contact. IHE has made that attribute required but in their mapping from HL7 v2 to v3 they only address home and business. Do you know if the conformance requirement extends to the other use codes that the Vocabulary Standard defines? This would be a PIX feed. (ITI-44) Our PIX Manager doesn't like it without the use code attribute on all phone numbers.




    1. Doug,
      Mobile is an attribute on a slightly different axis from home/business. PIX maps V2 which only supports home and business numbers to V3, which has use codes to differentiate these two numbers. I suspect that while IHE doesn't have other mappings, that many PIX V3 managers could support other use codes.
  27. Looking for a blog/book/pointers that will benefit the newcomer to Healthcare IT/and standards. Thanks in advance,
  28. how to encript the CCDA xml file. Data present in xml or xml file password protected


    1. There are a lot of different ways, but the preferred way would be to use encryption in the transport (SMIME for SMTP, TLS for HTTP). If you are encrypting the XML file itself on local storage, you could use a variety of encryption tools. What are you trying to do?
  29. Keith,

    My development team is asking about the handling of required CCD sections (CCDA) and MU. There are times when there is no data to go in those sections when the CCD is constructed. They would like to simply add the section, title, but not the entry level xml. My understanding is that for MU, we are at Level 3 and the entry level code is required, even if we have to use nullFlavor to indicate 'NI', etc. Is that correct or can we remove entry level xml from the required sections?



    1. As I recall, the proper way to handle empty sections is to use nullFlavor on the section, and eliminate the entries. Check out the work of the CDA Example Task Force
  30. Good afternoon. I am trying to understand CCDs vs CCDAs, especially when it comes to displaying medications. Is there anything in the standards (right term?) that define what medications should or should not be listed for a patient? e.g., all, active only, any without a stop date, etc. Is the purpose of a CCD significantly different from a CCDA such that it would cause a different subset of medications to be listed?

    A bit of context....we are receiving CCDA files and are being told that medications that are "hidden" by an EMR user because no longer active cannot be distinguished from those that are active. Therefore, all medications without a stop date come across in the CCDA. However, in the products CCD file it only lists the active medications, excluding those that are "hidden" without stop dates.

    Any information is helpful to this novice CCD/CCDA user.


    1. With regard to CCD and CCDA, the latter is simply an extension of the former. I would expect no differences in the medications being displayed. In the example you gave, clearly there's an implementation difference in how the CCD and CCDA are generated, but there need not be according to either standard. In fact, CCDA 1.1 included an updated CCD.

      The issue of what medications should come across is not actually defined in CCD or CCDA. However, this is the focus of the Relevant and Pertinent project that is just starting up.
  31. Hi Keith,

    I was wondering if you could comment on ICD-10 compliance and the use of ICD codes as translation codes in the CCDA. Do translation codes also have to be ICD-10 compliant? Example: Client is sending ICD-9 as a translation code now, do they need to change that to ICD-10 codes to observe the ICD compliance? My main question: Does compliance even apply to CCDs and Translation codes?? Thanks so much, John P.


    1. ICD-10 will be required for use in HIPAA designated transactions (claims and other transactions). Right now, CDA is NOT required to be used in those transactions. For Meaningful Use Stage 3, I believe that ICD-10 will be the required vocabulary for diagnosis, but for all other cases, it would be SNOMED CT. For procedures, we'd be talking SNOMED-CT again in CDA, with optional support for ICD-10-PCS.

      I'd recommend translation to ICD-10-CM, but presently, little requires it. esMD may require use of ICD-10-CM and ICD-10-PCS in that specification. You'd need to look at it once it is published.
  32. Morning Keith,

    I recently came across a document that had only one type of CDA tag, the birthTime tag, annotated with an xmlns attribute (). For some reason, this doesn't agree with our parser and breaks it.

    I've also tried validating these documents on the NIST validator (http://cda-validation.nist.gov/cda-validation/validation.html) which yields "cvc-complex-type.2.4.a: Invalid content was found starting with element 'birthTime'. One of '{"urn:hl7-org:v3":name, "urn:hl7-org:v3":desc}' is expected."

    As far as I know, there's nothing wrong with explicitly specifying the xml namespace within a tag as long as it's the correct one.


    1. There's a lot of missing information in this particular problem, but let me see if I can disentangle it from your query. The birthTime shows up in only one place in CDA, in he patient element. According to the error message you are getting however, the parser is looking at a playingEntity element. So, you must be dealing with an extension, where birthTime was added to playingEntity (this is often done to handle family history data). Extensions are legal in CDA, but are NOT present in the XML Schema. You have to remove them before validating against the CDA Schema. See Validating CDA Documents in this blog for more details.
  33. Sorry if this is a re-post - not sure this was posted successfully earlier.

    Hello Kieth,

    I need to specify a global note section for my lab section. I already have note sections for each result.

    Below is how my result looks like -

    lab result - component appears under component/section/entry typeCode="DRIV".

    Where should I specify the global comments?
    ToHV.xslt is picked up the global note and attach a 'common' element at the end if we provide the note like below directly under entry typeCode="DRIV" in lab section.


    But then it's not a valid CCDA.
    Please let know how I should provide global note for the entire lab results section.
  34. Hi Keith
    I have been going through CDA Framework for Questionnaire Assessments, DSTU. It talks in detail about CARE Assessment Framework.

    My question was, is it that only data specified in CARE framework (value sets/questions/codes) are only allowed for passing on to another system?

    I assume not, like let’s say some EMR has recorded Fall Risk Assessment and a care management solution has recorded HRA, they should be able to send each question and its response and a final score perhaps in this template, while creating an outbound CCD right?


    1. I'll refer you to the project description, which explains that this is a framework applicable to any sort of questionnaire. Yes, it uses CARE as an example, but is not focused on just that instrument.
  35. Hi, can you please explain the differences between Basic Patient Privacy Consent, Access Consent Policy, and Differed Patient Discovery. Thanks.
  36. Hi Keith, in your opinion, what constitutes reuse of a template? If the constraints of the existing template are loosened/tightened, additional constraints added, mandatory constraints removed - is this still considered "reuse" (with all the benefits of reuse)? Thank you.
  37. Hi Keith, is there any benefit of reuse, when a C-CDA template has been modified by loosening/tightening constraints, adding constraints, removing constraints or should we define a new template? Thank you.
  38. Healthcare provider often have codes that aren't part of existing value sets. For example suppose a provider has a code for race that is mixed for black and white BW. This would be an extension to the existing codes. But there are cases where overrides can occur the provider uses M to mean female for gender (extreme example). The problems are
    1. How to share information with other providers when these use non-standard values?
    2. Should a SVS be created for them?
    3. How is any CDA export going to pass validation with these values?
  39. The code system for these local codes will be different from the code system that is suggested by CDA, or required (e.g., by Meaningful Use). Validation according to the CDA standard can check conformance to the CDA model, but cannot check vocabulary conformance without an external resource that supports validation of code values, such as SVS.
  40. Hi Keith,

    Quick question. Is there any reason that anyone would ever want to use the HL7 V3 data type 'REAL' as opposed to just using 'PQ' data type when filling out Values for results in the result observation section (2.16.840.1.113883. I don't see the purpose of this data type- was hoping you could shed some light on the need for that? Thanks!
  41. Not that I can think of.
  42. Given that json is strictly a data/record oriented format with many limitations, how does the inclusion of it justify the additional cost/complexity increase?


    1. JSON is as capable as XML, with much lower implementation costs. An XML parser should be about the level of a senior (In college) project. JSON is at the level of a high school project. The value of JSON is. In the platforms it enables.
  43. Where can we find Patient Account number (PID 18) and Visit Number (PV1-19) in a HL7 CCD or CCDA.


    1. PID-18 is just another kind of patient identifier and might appear in patientRole/id. PV1-19 should appear in encompassingEncounter/id. This and many other Version 2 to CDS mapping questions are addressed in Chapter 17 of The CDA Book.
  44. Noobie Alert: Our VNA vendor can supply XDS Rep/Reg, and we would like to get our feet wet with (non-DICOM) pathology images. Looking for an XDS document source product we can test with our VNA, that would collect metadata from Epic for labeling and upload. Can anyone help me get started?
  45. Hi,
    I need to parse xds.b and get the document and metadata. I don't have to implement the registry or repository. How do i achieve this? Can I do this using DOM or will it be heavy on memory?
  46. Hi Keith,
    My use case is to parse ITI 41,44,45,51 &18 and get the metadata and CDA document (if any in that transaction). Could you please help identify a framework for the parsing of documents.


    1. If you are looking for a framework, I'm assuming you mean you are probably meaning some sort of code that would help you to translate CDA content into transactions used with Provide and Register (41), Patient Identity Feed V3 (44), PIX V3 Query (45), Multi-patient stored query (51), and Registry Stored Query (18). Three things come to mind for developing such a framework: Open Health ToolsModel Driven Health Tools, and Chapter 17 of the CDA Book. You might also check out section 4.1 in Volume 2 of the PCC Technical Framework. Most open source work in this area is a bit moldy at this stage.
  47. Hello Keith,
    Do you have any updates or information on Windows XP no longer being HIPPA compliant? I have several used digital systems in the field with XP, and want to make sure I am getting the correct information to my customers. Thanks in advance!
  48. Hi Keith,

    Right now I am working on a CCDA for a Dialysis Provider and we are trying to record Vascular Accesses in it but are a bit stuck.
    Specifically, while it looks like we can put our Dialyzers and Catheters in the Medical Equiptment section we can't put in certain information such as the Heparin we administers timing (halftime or hourly) and the method administered (bolus or infusion) .

    We are also having issues with mapping the insertion date (when created) vs the first use date (matured and used as access) and end date (no longer used) vs removal date (didn't mature or surgically closed) for our fistulas. I am not not even sure which section these would go under but I'm thinking we should use the Plan Of Care section for that.

    What are your thoughts? Thanks for all your blog posts so far, they've helped a ton!


    1. Heparin is a drug, and its administration would be recorded using a SubstanceAdministration entry. Insertion of a catheter or surgical closure would be recorded as separate Procedure entries associated with the device. Dates of use would be represented as the interval of time associated with the device's participation in the patient's dialysis. Dialysis procedures themselves might be represented by a Procedure entry, but a patient will be dialyzed numerous times, and you'd probably rather not repeat the details of the device each time they are dialyzed. I'd represent this using an episode of care described using PCPR (Provision of Care) in an Act, which had as components the procedures describing the insertion of devices, removal/surgical closure of them, the uses of them (via procedures) with references to the device used via participations. The modeling for this is rather complex, and so yes, I think you'd probably put a large bit of this under plan of care.
  49. Hi Keith,
    Should the PROBLEMS section of a CCDA have the two templateID ( 2.16.840.1.113883. and 2.16.840.1.113883. or just one would suffice? In your article entitled "Moving on from HITSP C32: The CCDA Problems and Allergies Section" you listed the new CCDA templateID's for the PROBLEMS section.
  50. Hi Keith,
    It appears that FHIR has provided a great way to translate/map codes across systems using the CONCEPT MAP resource. I'm fairly new to the challenges associated with Patient Matching/Mapping, but it seems as if this could also be solved in a generic way through the concept map. Did you envision that this may be used in addition to the Link Property of the patient, or would Link replace the need for a valueset/concept map for this resource?

    We were thinking that local Patient Ids could be collected in the Value Sets and mapped/unmapped as needed in the concept map.(this would allow us to translate Ids across an interface)

    Alternately, I suppose we could just walk the link property to achieve the same.

    Thanks a lot!


    1. Entity Identity Mapping and Concept Mapping are very different things. I wouldn't try to repurpose ConceptMap for supporting MPI uses.
  51. We are looking to add the STS Risk Score to the Indications of a Procedure Report for CCL. First, is this permitted and if so, is there an XML example?
  52. Hi Keith,

    Is there a quick and easy way to know where 2016 NCQA HEDIS measures are intended to be captured in the consolidated CDA 1.1 specification? One example would be where is PHQ-9, or patient health questionnaire, scores intended to be placed?

    Thank you.
  53. Where would you put the data for some several dozen measures in the C-CDA? Since HEDIS provides comprehensive guidelines for general care, and C-CDA documents support comprehensive documentation of such care, the short answer is everywhere. I think you probably want to clarify your question.


    1. This answer is actually very helpful, I was looking for a crosswalk of sorts that would break down the measures and where they are kept in C-CDA when it wasn't straightforward. To clarify, NCQA's 2016 HEDIS measures mention the utilization of PHQ-9 scores, is this intended to be in a CCD, or a C-CDA document?
    2. Are the status code values applicable to all types ofdata or only medications?

      For example, for these records, how do I interpret the second row of data?
      A smoker because the Non-Smoker is No Longer Active?
      Or for these types of records, do I ignore the Status Code?

      Thanks, Jim

      TOBACCO USE 55561003 Active
      NON SMOKER/NO TOBACCO USE 73425007 No Longer Active <<---
      TOBACCO ** MU ** 55561003 Active
      NON SMOKER/NO TOBACCO USE 55561003 Active
      TOBACCO USE 73425007 No Longer Active
  54. Hi, I' am new to CDA and health standards in general. I want to know if there is a CDA template which can be used only to report substances administered by a nurse or should I made my own template? I want something like "Substances Administration Report" document.

  55. Hi, I' am new to CDA and health standards in general. I want to know if there is a CDA template which can be used only to report substances administered by a nurse or should I made my own template? I want something like "Substances Administration Report" document.

  56. I have created a java application using Openhealthtools to send documents to a registry. When I call the same application using a WebApp, the document's soap headers are not populated. I would like to know if there are any configurations to be done since the webapp runs in tomcat7
  57. Hey Folks,
    It was just recently discovered that when you combine CCDA parsing with an ITI-57 transaction that there is a huge clinical risk here. Because if we parse discrete data from the CCDA and put that into a clinical database and then the client sends an ITI-57 to deprecate that document, what happens to the parsed data then? How can it be tied back to originating source? Has anyone tackled this issue yet?? Just curious??

    Thank you!
  58. Hi,

    I've been trying to find a way to reliably map FHIR encounter class (inpatient, outpatient, emergency, ambulatory) with CCDA documents (ambulatory summary, clinical summary, etc) across multiple EHRs. The only way I've thought to differentiate this is through the document title, which won't be uniform for documents across different EHRs. Is there a template id or some other indicator I'm missing that more easily shows what encounter class a CCDA would fall into? Thanks!
  59. Hi everyone,

    Is there a particular reason for changing the order of segments NK1 and NTE in the PID group for an ORU message from v2.4 to 2.5?

  60. Hi there,

    Is there a particular reason for which the order of the NK1 and NTE segments in the PID group for an ORU message got changed?

    Thanks in advance
  61. We are starting to bring in CCDAs from practices via provide and register. Our vendor requires ADT for the patient record portion. We were going to do ADT feeds plus CCDA but I suggested that we create (between the EMR and our vendor) an ADT from the information provided in the CCDA, so we eliminate an interface.

    1. Do know what the data gap is between an ADT and CCDA? I know one EMR vendor said an ADT will have Next of Kin and Guarantor but CCDA won't.
    2. Any other shortcomings you see with my approach that I'm missign?

  62. Keith,

    Is there anywhere within the HL7 standards (v2.x) that requires or defines the version of HL7 that shall be used in a general ACK?

    Thanks in advance,
  63. Hi,
    I am looking for the detailed steps to convert FHIR to CCD. Could you please help.
  64. I'm reading through the S&I Framework ToC Companion Guide to C-CDA for MU2 (CDA_SIFRAME_CCG2CCDA_R1_I1_2014SEP), Section 3.3.2 Table 10 and see that recordTarget/patientRole/id is listed as mandatory (SHALL), however it is not highlighted in red as being required for MU2 conformance. I have run a C-CDA ToC XML sample that completely removed the id field through the C-CDA R1.1 / ONC 2014 Edition S&CC Validator (https://sitenv.org/c-cda-validator) for ToC Ambulatory Summary 170.314(b)(2) and the validator did not flag this entire missing element with an error, warning, or even informational.

    Question...is the id element actually optional in this case? Or is there a bug with the validator? How should I be reading this particular document if there are elements that are listed as SHALL but are not marked in red? Do we re-interpret non-red elements as optional?
  65. I'm reading through the S&I Framework ToC Companion Guide to C-CDA for MU2 (CDA_SIFRAME_CCG2CCDA_R1_I1_2014SEP), Section 3.3.2 Table 10 and see that recordTarget/patientRole/id is listed as mandatory (SHALL), however it is not highlighted in red as being required for MU2 conformance. I have run a C-CDA ToC XML sample that completely removed the id field through the C-CDA R1.1 / ONC 2014 Edition S&CC Validator (https://sitenv.org/c-cda-validator) for ToC Ambulatory Summary 170.314(b)(2) and the validator did not flag this entire missing element with an error, warning, or even informational.

    Question...is the id element actually optional in this case? Or is there a bug with the validator? How should I be reading this particular document if there are elements that are listed as SHALL but are not marked in red? Do we re-interpret non-red elements as optional?

    May Terry, Medical Informatics Lead, Flatiron Health


    1. May,
      The TOC Guide is advisory, so it's shall statements are not essential for Meaningful Use. I think this element is "shall" from the TOC guide perspective, but not from the MU perspective.

  66. Are there any issues with data modeling in fhir server? such as problem or methology and so on.. I can't find it.. so please help me :)
  67. Hi Keith

    I am relatively new to the standards and HL7 and I had a couple of questions:

    1. The HL7 specification talks about Product detail country segment which is part of the summary product experience report. But I am not able to identify if the medical devices are required to send the SUR or if it is optional. How do I see if an message is optional or required? And in any case, do you know if medical devices are required to send the Product detail country segment?
    2. This is slightly beyond spec by related: In some cases medical devices are serially connected to a monitor which in turn forwards the data to an Information system as you know. I know the monitor strips out some data and forwards the rest. When it comes to HL7 do you know if the manufacturer and brand information can be stripped off or are they mandatory?

  68. Hi Keith,

    I work for an HIE and I'm new to both CDA and HL7. I've completed associate training for the Rhapsody interface engine. Our team is trying to convert incoming CDA's to outgoing HL7 ADT messages through Rhapsody. What would be the correct schema to use for mapping the incoming CDA. Would any of your books help us in our quest? Has this work been done and would it be available for HIE use? Lot's of dumb questions but I have to start somewhere.

    Thanks for your help,
  69. Hi Keith,

    I work for an HIE and I'm new to both CDA and HL7. I've completed associate training for the Rhapsody interface engine. Our team is trying to convert incoming CDA's to outgoing HL7 ADT messages through Rhapsody. What would be the correct schema to use for mapping the incoming CDA. Would any of your books help us in our quest? Has this work been done and would it be available for HIE use? Lot's of dumb questions but I have to start somewhere.

    Thanks for your help,
  70. Hello,

    I'm new to HL7 and CDA. Looking for any help I can get for converting CDAs to HL7 ADTs through the Rhapsody interface engine. Also looking for any good resources for completing this work. Any help at all would be greatly appreciated.

  71. Hello. I'm a physician and am wondering how a CDA would handle a correction to an entry. Example:

    Let's say I have the following note on Mary Grant:

    Chief complaint: Diarrhea x 3 weeks. No weight loss or rectal bleeding.

    Meds, allergies, physical exam, family hx, results, immunizations,plan of care, etc all entered.

    Note is then signed.

    Ok, this can create a valid CDA.

    Now, the next day, in rereading the note, I realize that I made a mistake. Mary in fact had a 12 lb weight loss over the past 3 weeks since the diarrhea started.

    On a paper chart, I would add an addendum: "Error above: Pt actually had a 12 lb weight loss over the past three weeks. - PKW"

    On my current EHR, I also add an addendum. It would be marked:

    Addendum added on 8/12/15 at 4:30 pm by Peter K Wayne, MD:
    Pt actually had a 12 lb weight loss over the past three weeks.

    Do you have any idea how this would be handled in a CDA? Note an addendum need not just be for the chief complaint, it could be for the physical exam, plan of care, family history -- anywhere a mistake could be made. Would this go into the Comment template?

    Thanks for your thoughts on this.

    - Peter Wayne
  72. Hi!
    I'm trying hard to find some Results section narrative examples (discrete entries could help as well) especially with Microbiology and Anatomic Pathology results in CDA vR2.1 documents. I have tried all the Standards sites - HL7, NIST, etc. but none seem to have them. Could you please help in finding some examples?
    Thanks much!
    - Sue
  73. Hello Keith,

    I could not find answer for below question on the blog.

    Question:- Why do we have subcomponents for Namespace ID under components.
    Version: HL7 Version 2.x

    ex: Role person (ROL-4) has components and sub-components.

    Assigning facility has " & & " as sub-components, followed by "Subcomponents for Namespace ID (CWE)" which is not part of components for Role person, however it is sub-component of "Assigning Authority". would like to know why do we have Namespace ID as component, it itself is a sub-component of a component. This is avaialble for other fields under different chanpters

    Components: ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

    Subcomponents for Family Name (FN): & & & &

    Subcomponents for Source Table (CWE): & & & & & & & & & & & & & & & & & & & & &

    Subcomponents for Assigning Authority (HD): & &

    Subcomponents for Namespace ID (CWE): & & & & & & & & & & & & & & & & & & & & &

    Subcomponents for Assigning Facility (HD): & &

    Subcomponents for Namespace ID (CWE): & & & & & & & & & & & & & & & & & & & & &

    Subcomponents for Name Context (CWE): & & & & & & & & & & & & & & & & & & & & &

    Subcomponents for Assigning Jurisdiction (CWE): & & & & & & & & & & & & & & & & & & & & &

    Subcomponents for Assigning Agency or Department (CWE): & & & & & & & & & & & & & & & & & & & & &

    Thank you for your time.

  74. Hi Keith,

    Im working on a validation engine for QFDD / QRD with some national extensions. As far as I can tell, it looks like noone else has ever bothered to write the schematrons matching the rules stated in the drafts. Would you happen to have knowledge of any authored schematrons that regards the QFDD / QRD drafts?
  75. Hi Keith (and others),

    I'm doing some investigation into MU3 CCDA validation requirements (as I'm sure many others are) and am wondering if you are aware of any 3rd party, licensable/commercial products?

    There are obviously several online testing tools, but as we are a commercial EMR vendor we obviously cant be using these web tools to verify real patient CCDA's. We'd love, however, to find some sort of product that we could incorporate into our product to do this work for us.

    I've done some cursory searching but there seems to be an absence of this kind of commercial tool. I cant imagine that all these HIE or health informatics companies are all rolling their own custom tools that all do the same thing but that seems to be the case(?)...

    Are there any known commercial/licensable products out there that you (or others) are aware of?

  76. Hi Keith,

    Last week I took my daughter to her pediatrician, and noticed the computers in the exam rooms were still running Windows XP. As an IT professional, this made me a bit nervous. Not knowing anything about HIPPA rules concerning technology, maybe you can shed some light on it. Is it still ok for Windows XP to be used? Even if it is, should I send a note to the clinic's business manager expressing my concern? Thanks!


    1. It is certainly a risk, as XP is no longer being maintained by Microsoft, however, there are other mitigations for that risk that could be in place that you aren't aware of. You should certainly send a note to the business manager. For this specific issue, see also my post here: http://motorcycleguy.blogspot.com/2014/02/hipaa-bullshit-about-windows-xp.html

      Given the date today, the risks for using XP are probably much higher than they were 3 years ago.
  77. Keith,

    Is using 'middle" a valid use of qualifier? Or more specifically, can 'middle' be used in place of 'IN' or is 'IN' required? Though in reading your book you use 'initial'.

    Thank you,

    Doug DeShazo


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