This page was inspired by Grahame Grieve. Simply post a comment with your question or topic suggestion below. I'll either answer it in a followup comment, or write a post on it.
[Note: Due to increases in spamming on other pages, your comment may not be published immediately. Don't worry, I'll accept all comments so long as they aren't spam, and if I cannot answer it, I'll let you know. One benefit of this new approach is that it should encourage me to answer your questions sooner!]
The rules are simple:
[Note: Due to increases in spamming on other pages, your comment may not be published immediately. Don't worry, I'll accept all comments so long as they aren't spam, and if I cannot answer it, I'll let you know. One benefit of this new approach is that it should encourage me to answer your questions sooner!]
The rules are simple:
- Topics I'll cover include anything in the Tag cloud to the right...
(Please do not ask me questions about my employer's products. While I may sometimes be the right person to answer these, this blog is not related to my employment, and isn't the proper channel to ask or respond to those questions. If uncertain, you can always contact me directly).
(Also don't ask me questions about Meaningful Use certification (e.g., how to pass a test). I'm not an authority there, and while I can tell you what is correct in the standard, I don't want to give bad advice about certification). - All questions and suggestions posted are subject to this Blog's Policies.
- If I don't know or cannot otherwise answer your question, I'll let you know.
- Questions are not necessarily answered or addressed in the order received. Note, the SLA here is when I can get to it, which is probably not what you are looking for. However, I do encourage other readers to answer when possible.
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After reading Grahame's book, where he describes that in a CCD all information to authorize, bill, contact and collect from a payer should be in the payer section: would the medicare identifier for a hospital go in there, or be in the provider organization under clinicaldocument?
ReplyDeleteDear Kieth, in you blog post from March (http://motorcycleguy.blogspot.com/2017/03/diagnostic-imaging-reports-in-ccd.html) you mentioned the issue of e1 containing a diagnostic image report in the body of the document. I've encountered this issue and was wondering if you'd found a resolution, or could point me to someone who may help resolve this? Thanks!
ReplyDeleteHello Kieth,
ReplyDeleteI am struggling in understanding the differences between XDR/XDM and XDS(.b). All I know is below:
XDR: SOAP based post over HTTPS. This will be under HISP Direct protocol.
XDM: SOAP based post over SMTP. This will be under HISP Direct protocol.
XDS: SOAP based post over HTTPS using SAML as and Mutual TLS for encryption.
In healthcare industry, What approach is more acceptable? XDS.b or XDR?
XDR and XDM are used for messaging, and supported by the Direct protocol. Most every EHR in the US supports the Direct protocol in some way, most often through XDM and SMTP (though XDR is also used to some extent). NOTE: XDM is NOT SOAP based.
DeleteXDS.b is widely used with HIE systems, and is likely the preferred approach for HIE connections.
All are widely acceptable, the question is, what is your specific use case, and then you can get a better answer.
Hello,
ReplyDeleteOn the Fhir coverage resource, what type indicates "Medicare" and what type indicates "Medicaid"? Also is there an easy way of identifying if the payor is a private party like "Aetna"?
Codes used to identify coverage vary according to jurisdiction, but most are commonly based on Federal claims standards to identify type of payer.
DeleteMay payers (like Aetna) act in both public and private interactions (e.g., they handle some kinds of Medicare processing), so there isn't an easy way to distinguish between them.
Please explain how SNOMED can provide hierarchy and ontology coding
ReplyDeleteI'd suggest starting here: What is SNOMED CT?
DeleteUsing a Google search, I came across your blog post for 04/27/2010 concerning Advance Directives in a CCD. You mentioned the advance directive content should not be included in a CCD, and indeed, the Advance Directive Observation Template (2.16.840.1.113883.10.20.22.4.48) did not allow for a value element. However, there has since been a 2015-08-01 update to this template requires a value element. I've seen many sample CCD's, including in HL7 documentation, that have a value element here describing the advance directive content. Is your old blog post now obsolete, and advance directive content can and should be summarized in the value element?
ReplyDeleteSummarized as to type, perhaps, but not in more detail. The challenge is that an advance directive can be VERY specific, but the summary not. For example, a no intubation order may be for a specific time period, but that would not be captured in a summary, and thus anything more than the type of content contains can result in a misapplication of the patient's intent.
DeleteWith zero knowledge at all, how long will it take for a person to learn HL7 Messaging?...Thanks in advance
ReplyDeleteA junior developer given the first four or five chapters of HL7 V2 could learn the basics on their own well enough to craft a functional ADT message in a couple of weeks. Lab inbound would take about a month. Orders outbound could take a couple of months. V3 message requires training, and at least a quarter to het something working... 6 months to conformance for anything usefull. FHIR? Give them a week with it.
DeleteHi Keith - I'm trying to track down the differences between the HL7 QRDA CAT III and CMS QRDA CAT III standard for 2018 reporting. I believe that payer is expressed differently, but I'm not really finding a good comparison of the two on line.
ReplyDeleteQuestions -
Is payer the only difference that you know of?
If not, do you know of a good resource for me to learn more?
thanks very much,
Laura
regarding dates and timestamps -
ReplyDeleteunless time is clearly irrelevant, keep as datetime datattype, and convert on the fly, e.g., convert(date,DateCreated)='2018-04-09'
I would be keeping as both for efficiency, which is about as good as converting on the fly, because the additional storage is small and cheap.
DeleteAny good places to find a complete list of typeCodes, classCodes, and moodCodes?
ReplyDeleteYou might try: the HL7 Version 3 Normative Edition if you are a member, or you can download from if not.
DeleteHi,
ReplyDeleteI want to understand the main difference between CDA/CCDA/CCD/C32. I understand that CDA is a schema, CCD is a document, CCDA can have sections from CCD and other documents also and I don't know C32. And there are multiple releases for each one. Can you give me a little deeper insight into them? And what are the identifying elements for each one. I heard all of them serve same purpose, do they?
Please educate me on this?
Thank You.
See the various "Moving from" posts in https://motorcycleguy.blogspot.com/p/my-favorites.html
DeleteGood afternoon Keith,
ReplyDeleteWe are struggling to get clarification on the CCD. In 2014 Edition certification we have creted one consolidated CCD (xml) which included discharge summary and SOC. Based on the certification company we are being told with 2015 Edition we need to generate at least 3 different xml document with different templates.
I cannot get a good answer from any resources I have. What is your take on this.
I appreciate your feedback.
Paul, your certifier is most certainly right, and is a good resource to trust. In 2014, you had to show compliance with CCDA. In 2015 you have to go further. You can find the test procedures here: 2015 Edition Test Methods
DeleteHi Keith,
ReplyDeleteI met you at a conference in Phoenix 2017. You provided a presentation on FHIR.
I’m teaching a master’s level class in Data Management and FHIR is currently being discussed. Is it still relevant and a cutting-edge technology?
Thanks, Jill Snider
Absolutely! Just have a look at the increasing frequency of posts which mention FHIR on this blog.
DeleteHi Keith,
ReplyDeleteHow do you represent a phone number with an extension in a R2.1 CCDA
Thanks
tel:+1-999-999-9999;ext=111
DeleteSee extension at https://tools.ietf.org/html/rfc3966#page-5
DeleteThis is more than a bar bet, but do non-CCD documents contain the LOINC code 34133-9? I thought the LOINC code 34133-9 and template ID 2.16.840.1.113883.10.10.20.22.1.2 of 2.16.840.1.113883.10.10.20.22.1.1 togethr defined a Continuity of Care Document. There is a disagreement on our team about this. We need a referee and an expert, hence I contacted you!
ReplyDeleteThere is absolutely no requirement that this LOINC be only used on CCD documents. The HL7 Care Record Summary predates (and is the direct antecedant) the CCD and could use this code. The likelyhood is small, but does exist and there are some non-CCD Summary of Episode Notes out there using this. If you said NOT just CCD, you win the bet, otherwise you are buying the next round.
DeleteWell, I'm out a couple bucks! I hope there's a cheap beer night somewhere in Atlanta!
ReplyDeletethanks!
As a follow-up, is a CCD only identified with templateIDs then? (still some lingering discussion) Would these two template IDs (2.16.840.1.113883.10.10.20.22.1.2 or 2.16.840.1.113883.10.10.20.22.1.1) then be used as only identifying CCDs? I did read your blog where you state (i edited a bit):
ReplyDeleteIdentifies document as a CCDA Release 2.1 or later
Indicates document is backwards compatible with CCDA Release 1.1
If only one templateId where root="2.16.840.1.113883.10.20.22.1.1" and no extension (like extension="2015-08-01")
The document (CCDA 1.1) hasn't been uplifted to CCDA 2.1 yet
templateId where root="2.16.840.1.113883.10.20.22.1.1" but extension="2014-06-09"
The document (CCDA 2. won't be backwards compatible with CCDA 1.1
(I have your CDA book too, but I couldn't find the answer to this question. If it's in there, can you please let me know?)
It's not in there, the book was written in 2010 and published in early 2011. Given my focus on FHIR these days, a second edition (even though needed) probably isn't going to happen any time soon.
DeleteCCD has a document type as well as a template ID. Generally you can use a combination of templateId and ClinicalDocument/code to identify which of the CCDA document types is present.
DeleteHi Keith - After reading chapter 6, I decided to try wrapping a base64 encoded pdf in a CDA document. Are there any tools out there that will let me test my work? Thanks!
ReplyDeleteYou might look into IHE Mesa testing tools, but I haven't had to do any IHE validation of CDA wrapped PDFs in some time, so I don't know what is available.
DeleteWhat should a FHIR response look like when no information is available? For instance, if the query is for a patient's medications and the patient does not have any medications, what should the response be? I was told to use a Bundle but we do not use List Resources. Thank you!
ReplyDeleteA query that has no matching data will always return an empty Bundle. (A query that has matching data will return a Bundle with the first set of matching entries.) The use of List doesn't really come into it.
DeleteThank you!
DeleteHi Keith,
ReplyDeleteI'm struggling with standards to submit vital signs tagged as recorded via telemonitored device. As we move towards this type of healthcare, is there any standard way to code this? jprusik@hixny.org Thank you!
The Continua guidelines contain some of what you are looking for.
DeleteWe are in the process of adding the ability for our HISP to include an endpoint for XDR both to receive XDR messages and convert them to SMTP to send via Direct Messaging as well as to receive SMTP Direct Messages and convert them to XDR for delivery to the edge systems. I am seeking resources that define the specifications for both as well as instructions, examples, perhaps "bare metal" implementations for how to set up and configure an XDR endpoint. Specifically, for now, I am seeking information that will enable me to create a test endpoint that I can use to test via the Edge Testing Tool for XDR Test Cases at https://ttpedge.sitenv.org/ttp/#/certification/certh2
ReplyDeleteI have found the IHE IT Infrastructure TEchnical Framework documents, such as the Volume 1 doc at http://www.ihe.net/uploadedFiles/Documents/ITI/IHE_ITI_TF_Vol1.pdf
I have also found other resources.
https://wiki.ihe.net/index.php/Main_Page
https://wiki.ihe.net/index.php/Cross-enterprise_Document_Reliable_Interchange
http://wiki.directproject.org/XDR+and+XDM+for+Direct+Messaging
http://wiki.directproject.org/XDR+and+XDM+for+Direct+Messaging+Working+Version
I found articles that mention training videos for using the ETT with links; but, the links are no longer valid. I have found these and others. But, looking through these resources, what I cannot seem to find is something that spells out the whole specification. What is required in the SOAP+XDR, for example? What can be submitted to the Edge Testing Tool? Are there any sample, open source or binary implementations that are downloadable from which we can build our own, just as we did for Direct Messaging via SMTP?
Any assistance you can provide is much appreciated.
Hi Keith,
ReplyDeleteHow can I get quality data model(QDM) elements from EHR's raw data to calculate eCQM? I know EHR can export data using standards like CDA and FHIR by HL7. But how to extract QDM elements from these standards?
Your help would be appreciated.
Regards
This one is going to require a longer answer. Look for a post on the topic soon.
DeleteThanks. Looking forward to it.
Deleteand also can you please point me to the right direction(some basic terms to look for or github repository). I'm currently working on a project and I need to do this ASAP.
DeleteThanks again
Hi Keith,
ReplyDeleteI want to extract QDM elements from ccda templates and I know for QDM elements there is one to one mapping with CCDA templates to generate QRDA-I. But I’m unable to map the template ids given in the implementation guide (last appendix) with the samples provided.
>>QRDA IG : https://drive.google.com/open?id=1HEcyA4gqpNVJ56_CtyC1Ri_PJ1PiOinX
>>CCDA samples : github.com/chb/sample_ccdas
Can you please help me with this? Am I missing something?
Regards
Hi Keith,
ReplyDeleteI'd be interested to get your general perspectives on using a C-CDA document as a mechanism to bill a payer for services. These standards were developed for sharing clinical information between entities and I want to know if you can imagine any (un)intended consequences to using them for payment purposes. Also, if you're familiar with any real-world examples of providers submitting C-CDA documents to a payer for reimbursement, could you share?
Hi Keith, I have some questions about FHIR Provenance. The specs say that the version of the resource should be included. I don't understand how a resource (let's say allergies) would have a version. A CDA could get generated and then re-generated so now there is a new version but a FHIR resource...aren't we just providing the data at a particular point in time? Or are we expected to actually assign a version number to the allergy list every time a change is made to it? Or...Is that referring to the FHIR version (DSTU2 or FHIR Release #4)? Or possibly the maturity level of a resource? (I am so confused!) In addition, I am not clear on when the Provenance resource should be used. Some resources actually refer to it but many do not. I would really appreciate any help that you can provide with the exception of referring me back to the FHIR specs...I have read, and re-read, and read again...still don't understand:( Thanks!
ReplyDeleteDear Keith
ReplyDeleteI have been involved in all the Danish CDA profiles that MedCom has implemented in Denmark since 2014 and is wondering why the PostalAddressUse code CONF is not a part of the HL7 xml-schemas.
For instance in CDAR2_IG_CCDA_CLINNOTES_R1_DSTU2.1_2015AUG_Vol2_2017NOVwith_errata.pdf CONF is described in Table 518: PostalAddressUse, but in the corresponding voc.xsd CONF is not present.
Do you know why this is the case, I’ve not been able to find any information about it or any xml schemas containing the CONF code, but maybe I’ve searched in the wrong places.
In MedCom we are now working on a national Personal Data Card CDA and need a way to tell if an address is confidential, it would be obvious to use CONF.
By the way Morten Bruun-Rasmussen, Mediq.dk suggested that I took contact to you.
Thanks in advance.
Kind Regards
Michael Due Madsen
Specialconsultant, MBA
MedCom, Forskerparken 10, 5230 Odense M
Office: (+45) 65 43 20 30 Mobile: (+45) 23 46 53 56
mdm@medcom.dk, medcom.dk
Keith,
ReplyDeleteThank you in advance for any guidance you can offer on this HL7 CCDA specs.
We are evaluating the Problem Type section which is a Shall statement under Problem Observation and Family History.
The exact text is as follows.
"SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC (CONF:1198-9045).
a. If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC, then it SHALL have at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 DYNAMIC (CONF:1198-32950) (CONF:1198-32950)."
We are debating if we must allow a provider to select the SnoMeds and LOINC codes called out in the HL7 specs for Problem Type versus hard-coding to an acceptable value.
Since it is a SHOULD binding for both the SNOMEDCT and LOINC translation our interpretation is that we can hard-code these values. Thus we do not need to allow a provider to select from a list when entering information in to an EHR.
We are also curious on any guidance related to the word "translation" that is called out under the LOINC section in the Implementation Guide.
Can somebody point me to the latest C-CDA to FHIR mapping?
ReplyDeleteI am looking for C-CDA R2.1 to FHIR4.0 mapping.
http://build.fhir.org/ig/HL7/ccda-on-fhir/
DeleteWe are working towards creating a tool that displays HL7 spec in a structured way (like an XML/JSON) for creating some sustainable documentation and mapping purposes. For this purpose I would like to know if HL7 has any open source structured version of the standard PDF spec that is published. Any guidance to HL7 published or any other tool will be great. Not looking for an an entire interface engine
ReplyDeleteHello Keith. What would be few implementation challenges we could facewhile we implement PIX/PDQ and MHD/WIA IHE profiles with respect to image sharing?
ReplyDelete