IHE Educational Workshop

1
Cross Enterprise Sharing ofMedical Summaries
(XDS-MS)

• IHE Educational Workshop
• Keith W. Boone, Dictaphone Corporation
• Patient Care Coordination TC Co-chair

2
Presenter

• Keith W. Boone
• Sr. Consulting Engineer, Dictaphone Corporation
• Co Chair, IHE Patient Care Coordination TC
• Member, IHE IT Infrastructure Technical Committee
• Editor, HL7 Care Record Summaries Implementation
  Guide
• Member, HL7 Structured Documents TC
• Keith.Boone_at_dictaphone.com

3
Outline

• XDS-MS Profile Transactions
• XDS
• NAV
• ATNA
• Quick Overviews
• HL7 CDA Release 2.0
• HL7 Care Record Summary
• IHE Medical Summaries Content Profile

4
Cross-Enterprise Sharing of Medical Summaries
(XDS-MS)
The Cross-Enterprise Sharing of Medical Summaries
Integration Profile solves the problem of
transferring summary patient information between
providers in different clinical settings.
5
Transactions
Patient Identity Source
Patient Identity Feed ITI-8 ?
Document Registry
Query Registry ITI-16 ?
Document Consumer
Notification Receiver
? Register Document Set ITI-14
Provide RegisterDocument Set ITI-15 ?
Document Repository
Retrieve Document ITI-17 ?
DocumentSource
Notification Sender
Send Notification ITI-25 ?
Receive Notification ITI-26 ?
Receive Acknowledgement ITI-28 ?
Send Acknowledgement ITI-27 ?
6
XDS Transactions

• Sender
• Provide and Register Document Set
• Register Document Set
• Receiver
• Query Registry
• Retrieve Document

7
XDS Provide and Register Document Set

• Must include a Medical Summary
• May include other clinical documents
• Log the export (see ATNA and ITI-20)

8
XDS Register Document Set
9
NAV Send Notification

• Create MIME multipart/mixed message
• Text instructions
• Notification attachment

10
multipart/mixed Message

• From pseudouser_at_bogus.site
• Sender pseudouser_at_bogus.site
• Message-ID lt12345678-1234-5678-0ABC-DEF012345678_at_
  1.3.6.1.4.1.21367.2005.1.1gt
• Subject Notification of Document Availability
• MIME-Version 1.0
• Content-Type multipart/mixed boundary'boundary'
  
• --boundary
• Content-Type text/plain charsetus-ascii
• Instructions to the user as to the use of this
  e-mail message.
• To acknowledge receipt of this message, please
  click on the following link
• mailtopseudouser_at_bogus.site?subjectXDS20Acknowl
  egement3A20signatureIDbodyOK
• --boundary
• Content-Type application/xml charsetUTF-8
• Content-Disposition attachment
  filename'IHEXDSNAV-UUID.xml'
• ltSignature Id"signatureID" xmlns"http//www.w3.o
  rg/2000/09/xmldsig"gt
• lt/Signaturegt
• --boundary--

11
Notification Attachment
ltSignature Id"signatureID" xmlns"http//www.w3.o
rg/2000/09/xmldsig"gt ltSignedInfogt ltCanonicaliz
ationMethod Algorithm"http//www.w3.org/TR/2001/R
EC-xml-c14n-20010315WithComments" /gt
ltSignatureMethod Algorithm"urniheitidsgnos
ig" /gt ltReference URI"IHEManifest"
Type"http//www.w3.org/2000/09/xmldsigManifest"gt
ltDigestMethod Algorithm"http//www.w3.org/200
0/09/xmldsigsha1" /gt ltDigestValuegtbase64Diges
tValuelt/DigestValuegt lt/Referencegt lt/SignedInfo
gt ltSignatureValuegtbase64SignatureValuelt/Signature
Valuegt ltObjectgt ltSignaturePropertiesgt ltSign
atureProperty Id"recommendedRegistry"
target"signatureID" gthttp//registryServer/re
gistryBaseURLlt/SignaturePropertygt
ltSignatureProperty Id"sendAcknowledgementTo"
target"signatureID" gtpseudouser_at_bogus.sitelt/S
ignaturePropertygt lt/SignaturePropertiesgt ltMan
ifest Id"IHEManifest"gt lt!-- this is document
A, read it first  --gt ltReference
URIurniheitixdsregistryxxxx-xxxx"gt ltDige
stMethod Algorithm"http//www.w3.org/2000/09/xmld
sigsha1" /gt ltDigestValuegtbase64DigestValuelt/D
igestValuegt lt/Referencegt lt/Manifestgt lt/Object
gt lt/Signaturegt
12
NAV Receive Notification

• Receive e-mail message
• Verify Attachment
• Extract Document UUIDs

13
XDS Query Registry

• Use GetDocument query to obtain document metadata
• SELECT doc.id
• FROM ExtrinsicObject doc
• WHERE doc.id IN (list of ids)

14
XDS Retrieve Document

• Retrieve the Medical Summary
• Most recent document whose document type is one
  of the following LOINC codes
• HTTP GET on the URI
• Log the import (see ATNA and ITI-20)

15
ATNA Record Audit Event

• Type of Log
• BSD Syslog
• Reliable Syslog
• Format of Log Message
• IHE Provisional Format
• RFC-3881

16
BSD Syslog (RFC-3164)

• lt(0-191)gt Aug 30 090000 aegeus Hello World!
• Priority A value from 0 to 191
• Timestamp MMM DD hhmmss
• Hostname First part of DNS name, or IP address.
• The rest is the message, and should conform to
  one of the two logging options.

17
ATNA Log Format(RFC-3881)

• See the RFC
• http//www.faqs.org/rfcs/rfc3881.html

18
CDA Basics

• Dates and Times
• Identifiers
• Codes
• Names
• Addresses
• Phone Numbers
• People
• Organizations

19
Dates and Times

• lteffectiveTime value'200503292244110500'/gt
• lteffectiveTimegt
• ltlow value'200503292244110500'/gt
• lthigh value'200503292244110500'/gt
• lt/effectiveTimegt
• HL7 Date Time Values
• CCYYMMDDHHMMSS(Z(-HHMM))
• Century
• Year
• Month
• Day
• Hour
• Minute
• Second
• Time Zone

20
Identifiers

• ltid extension'12345678' root'1.3.6.4.1.4.1.2835'
  /gt
• root Identifies the namespace.
• extension Provides the identifier.
• Roots are typically ISO Object Identifiers,
  otherwise known as OIDs, but may also be a GUID.
• An OID is an assigned value. Someone has to give
  you a root OID. Then you can make your own, or
  give OIDs to others.
• If your root OID is X, then you can assign X.1
  through X.somereallybignumber to yourself or
  others.

21
Codes

• ltcode code'59058001' displayName'General
  Physician'
• codeSystem'1.3.6.4.1.4.1.2835' codeSystemName
  'SNOMED CT'
• /gt
• code Provides the code value.
• displayName A human readable name.
• codeSystem Identify the coding system used.
• codeSystemName As above, but for humans.
• Not all coded values require the specification of
  codeSystem, especially when it is already known.
• Values used for human readability are optional.

22
Names

• Organizational Names
• ltnamegtGood Health Cliniclt/namegt
• Personal Names
• ltnamegt
• ltprefixgtMr.lt/prefixgt
• ltgivengtKeithlt/givengt
• ltgivengtW.lt/givengt
• ltfamilygtBoonelt/familygt
• ltsuffixgtSr.lt/suffixgt
• lt/namegt

23
Addresses

• ltaddrgt
• ltstreetAddressLinegt21 North
  Avelt/streetAddressLinegt
• ltstreetAddressLinegtSuite 142lt/streetAddressLi
  negt
• ltcitygtBurlingtonlt/citygt
• ltstategtMAlt/stategt
• ltpostalCodegt01803lt/postalCodegt
• ltcountrygtUSAlt/countrygt
• lt/addrgt
• Repeat streetAddressLine if needed.

24
Phone Numbers

• lttelecom value"tel[phone]" use"WP"/gt
• value - The telephone number, as a URL
• use - One of a restricted set of values
• HP - Home Phone
• HV - Vacation Home
• WP - Work Phone
• AS - Answering Service
• EC - Emergency Contact
• PG - Pager
• MC - Mobile

25
People

• ltpersongt
• ltnamegt
• ltprefixgtMr.lt/prefixgt
• ltgivengtKeithlt/givengt
• ltgivengtW.lt/givengt
• ltfamilygtBoonelt/familygt
• ltsuffixgtSr.lt/suffixgt
• lt/namegt
• lt/persongt

26
Organizations

• ltorganizationgt
• ltid extension"1" root"1.3.6.4.1.4.1.2835.3"/gt
  
• ltnamegtGood Health Cliniclt/namegt
• lttelecom value"tel[phone]" use"WP"/gt
• ltaddrgt
• ltstreetAddressLinegt21 North
  Avelt/streetAddressLinegt
• ltcitygtBurlingtonlt/citygt ltstategtMAlt/stategt
• ltpostalCodegt01803lt/postalCodegt
• ltcountrygtUSAlt/countrygt
• lt/addrgt
• lt/organizationgt

27
Reading Schematron

• Schema is a collection of patterns.
• Patterns contain one or more rules with a
  context.
• Rules assert that a test has passed.
• Failures issue diagnostics
• Now you can read the Schema

28
Sample Schema Rule
Schema is a collection of patterns.

• ltschema xmlns"http//www.ascc.net/xml/schematron"
  gt
• lttitlegtSample Schematron schemalt/titlegtltns
  prefix"cda" uri"urnhl7 orgv3" /gt
• ltpattern name'ClinicalDocument'
  seeSample.htmClinicalDocument'gt
• ltpgtThis schema applies to CDA Release 2.0
  documents.lt/pgt
• ltrule id'cda root' context'/'gt
• ltassert diagnostics"CNF 1" test'selfcdaCli
  nicalDocument'gt
• The root of a Care Record Summary must be a
  ClinicalDocument
• element from the ltemphgturnhl7 org v3lt/emphgt
  namespace.
• lt/assertgt
• lt/rulegt
• lt/patterngt
• ltdiagnosticsgt
• ltdiagnostic idCNF 1gt
• Ensure the appropriate namespace declaration
  exists.
• The root element must be ClinicalDocument.
• lt/diagnosticgt
• lt/diagnosticsgt

29
An Example

• In this example, we will create a CDA Instance
  that provides the following information in a Care
  Record Summary
• Ellen Ross is a 45 year old female who sprained
  her ankle by slipping on ice. She was treated in
  the ER and the next day goes to see Dr. Bernard
  Wiseman Sr., her PCP, who creates a referral for
  her to see Dr. Phil Green, an orthopedist.
• In 1994, she and her husband filed a number of
  legal documents regarding their advanced
  directives for healthcare. Her father had a
  history of alcohol abuse and died of liver
  cancer. She quit smoking in 1996, and has 1-2
  drinks per week. Her prior medical history is
  significant for cholecystitis which occurred
  during a difficult pregnancy. Her gall bladder
  was removed after delivery. She is presently on
  Indomethacin, and was given Tylenol 3 for the
  ankle sprain. She is allergic to Penicillin but
  similar drugs are OK. She had the usual run of
  pediatric immunizations. An X-Ray of her ankle
  was done in the ER.

30
Steps in Creating the CDA Instance

• Describe the Document
• Describe the Participants
• Patient ? Author(s)
• Data Entry Personnel ? Informant(s)
• Custodian ? Intended Recipient(s)
• Authenticator(s) ? Legal Authenticator(s)
• Other Participant(s)
• Describe the event the document is about
• Describe the encounter
• Provide the Human Readable Content
• Describe Problems, Medications and Allergies

31
Describe the Document

• ltClinicalDocument xmlns"urnhl7-orgv3"
  xmlnscrs"urnhl7-orgcrs" gt
• ltrealmCode code"US" /gt
• lttypeId extension"POCD_HD000040"
  root"2.16.840.1.113883.1.3" /gt
• lttemplateId extension"IMPL_CDAR2_LEVEL1
  2REF_US_I2_2005SEP"
• root"2.16.840.1.113883.10" /gt
• ltid extension"999021" root"1.3.6.4.1.4.1.2835.2
  " /gt
• ltcode code"34133-9"
• codeSystem"2.16.840.1.113883.6.1
• codeSystemName"LOINC"
• displayName"SUMMARIZATION OF EPISODE NOTE" /gt
• lttitlegtGood Health Clinic Care Record
  Summarylt/titlegt
• lteffectiveTime value"200503292244110500" /gt
• ltconfidentialityCode code"N" codeSystem"2.16.84
  0.1.113883.5.25" /gt
• ltlanguageCode code"en US" /gt
• ltsetId extension"999021" root"1.3.6.4.1.4.1.283
  5.1" /gt
• ltversionNumber value"1" /gt

32
Patient

• ltrecordTargetgt
• ltpatientRolegt
• ltid extension"12345" root"2.16.840.1.113883.3
  .933"/gt
• ltaddrgt
• ltstreetAddressLinegt17 Daws Rd.lt/streetAddressLi
  negt
• ltcitygtBlue Belllt/citygt
• ltstategtMAlt/stategt
• ltpostalCodegt02368lt/postalCodegt
• ltcountrygtUSAlt/countrygt
• lt/addrgt
• lttelecom value"tel[phone]" use"HP"/gt
• ltpatientgt
• ltnamegt
• ltprefixgtMrs.lt/prefixgt
• ltgivengtEllenlt/givengt
• ltfamilygtRosslt/familygt
• lt/namegt
• ltadministrativeGenderCode code"F"
  codeSystem"2.16.840.1.113883.5.1"/gt
• ltbirthTime value"19600127"/gt

33
Patient (cont.)

• ?
• ltproviderOrganizationgt
• ltid extension"M345" root"2.16.840.1.113883.3.
  933"/gt
• ltnamegtGood Health Cliniclt/namegt
• lttelecom value"tel[phone]" use"WP"/gt
• ltaddrgt
• ltstreetAddressLinegt21 North
  Avelt/streetAddressLinegt
• ltcitygtBurlingtonlt/citygt
• ltstategtMAlt/stategt
• ltpostalCodegt01803lt/postalCodegt
• ltcountrygtUSAlt/countrygt
• lt/addrgt
• lt/providerOrganizationgt
• lt/patientRolegt
• lt/recordTargetgt

34
Authors

• ltauthorgt
• lttime value"200503292244110500"/gt
• ltassignedAuthorgt
• ltid extension"1" root"1.3.6.4.1.4.1.2835.1"/gt
  
• ltaddrgt
• ltstreetAddressLinegt21 North
  Avelt/streetAddressLinegt
• ltcitygtBurlingtonlt/citygt
• ltstategtMAlt/stategt
• ltpostalCodegt01803lt/postalCodegt
• ltcountrygtUSAlt/countrygt
• lt/addrgt
• lttelecom value"tel[phone]" use"WP"/gt
• ltassignedPersongt
  OR ltassignedAuthoringDevicegt
• ltnamegt ltsoftwareNamegt
• ltprefixgtDr.lt/prefixgt Good Health Clinic
  System v1.0
• ltgivengtBernardlt/givengt lt/softwareNamegt
• ltfamilygtWisemanlt/familygt lt/assignedAuthorin
  gDevicegt
• ltsuffixgtSr.lt/suffixgt
• lt/namegt

35
Data Entry Personnel

• ltdataEnterergt
• lttime value"200503292224510500"/gt ltassignedE
  ntitygt ltid extension"2" root"1.3.6.4.1.4.1.28
  35.2"/gt ltassignedPersongt
• ltnamegt ltprefixgtMrs.lt/prefixgt ltgivengt
  Bernicelt/givengt ltfamilygtWisemanlt/familygt
  lt/namegt lt/assignedPersongt lt/assignedEntitygt
  lt/dataEnterergt

36
Informants

• ltinformantgt ltrelatedEntity classCode"PRS"gt
  ltcode code"MTH" codeSystem"2.16.840.1.113883.5.1
  11"/gt ltrelatedPersongt ltnamegt ltprefixgtM
  rs.lt/prefixgt ltgivengtAbigaillt/givengt ltfam
  ilygtRuthlt/familygt lt/namegt lt/relatedPersongt
  lt/relatedEntitygt lt/informantgt

37
Custodian

• ltcustodiangt
• ltassignedCustodiangt
• ltrepresentedCustodianOrganizationgt
• ltid extension"1" root"1.3.6.4.1.4.1.2835.3"/gt
  
• ltnamegtGood Health Cliniclt/namegt
• lttelecom value"tel[phone]" use"WP"/gt
• ltaddrgt
• ltstreetAddressLinegt21 North
  Avelt/streetAddressLinegt
• ltcitygtBurlingtonlt/citygt ltstategtMAlt/stategt
• ltpostalCodegt01803lt/postalCodegt
• ltcountrygtUSAlt/countrygt
• lt/addrgt
• lt/representedCustodianOrganizationgt
• lt/assignedCustodiangt
• lt/custodiangt

38
Information Recipient(s)

• ltinformationRecipientgt
• ltintendedRecipientgt
• ltid extension"4" root"1.3.6.4.1.4.1.2835.2"/gt
• ltaddrgt
• ltstreetAddressLinegt21 North Avelt/streetAddressL
  inegt
• ltcitygtBurlingtonlt/citygt
• ltstategtMAlt/stategt
• ltpostalCodegt01803lt/postalCodegt
• ltcountrygtUSAlt/countrygt
• lt/addrgt
• lttelecom value"tel[phone]" use"WP"/gt
• ltinformationRecipientgt
• ltnamegt
• ltprefixgtDr.lt/prefixgt
• ltgivengtPhillt/givengt
• ltfamilygtGreenlt/familygt
• lt/namegt
• lt/informationRecipientgt
• ltreceivedOrganizationgt

39
Authenticators

• ltlegalAuthenticatorgt OR ltauthenticatorgt
• lttime value"200503292245120500"/gt
• ltsignatureCode code"S"/gt
• ltassignedEntitygt
• ltid extension"1" root"1.3.6.4.1.4.1.2835.1"/gt
  
• ltaddrgt
• ltstreetAddressLinegt21 North
  Avelt/streetAddressLinegt
• ltcitygtBurlingtonlt/citygt
• ltstategtMAlt/stategt
• ltpostalCodegt01803lt/postalCodegt
• ltcountrygtUSAlt/countrygt
• lt/addrgt
• lttelecom value"tel[phone]" use"WP"/gt
• ltassignedPersongt
• ltnamegt
• ltprefixgtDr.lt/prefixgt
• ltgivengtBernardlt/givengt
• ltfamilygtWisemanlt/familygt
• ltsuffixgtSr.lt/suffixgt

40
Participants

• ltparticipant typeCode"HLD"gt lttimegt ltlow
  value"20050101"/gt lthigh value"20051231"/gt lt
  /timegt ltassociatedEntity classCode"POLHOLD"gt
• ltid extension"123456789"
  root"00000000-0000-0000-0000 000000000000"/gt lt
  code code"PHFAMDEP" codeSystem"2.16.840.1.113883
  .5.1095"/gt
• ltaddrgtI assume youve figured this out by
  nowlt/addrgt
• lttelecom value"tel[phone]" use"WP"/gt
• ltassociatedPersongt
• ltnamegtThis toolt/namegt
• ltcrsasPatientRelationship classCode'PRS'gt
• ltcode code'MTH' codeSystem'2.16.840.1.11388
  3.5.111'/gt
• lt/crsasPatientRelationshipgt
• lt/associatedPersongt
• ltscopingOrganizationgt
• ltnamegtGood Health Insurance Companylt/namegt
• lttelecom value"tel[phone]" use"WP"/gt
• ltaddrgtAnd thislt/addrgt
• lt/scopingOrganizationgt
• lt/associatedEntitygt
• lt/participantgt

41
The Service Event

• ltdocumentationOfgt
• ltserviceEvent classCode"PCPR"gt
• lteffectiveTimegt
• ltlow value"19600127"/gt
• lthigh value"20050329"/gt
• lt/effectiveTimegt
• ltperformer typeCode"PRF"gt
• ltfunctionCode code"PCP" codeSystem"2.16.840.1
  .113883.5.88"/gt
• lttimegt
• ltlow value"1998"/gt
• lthigh value"2005"/gt
• lt/timegt
• ltassignedEntitygt
• ltid extension"1" root"1.3.6.4.1.4.1.2835.1"/
  gt
• ltcode code"59058001" codeSystem"2.16.840.1.1
  13883.6.96"
• codeSystemName"SNOMED CT"
  displayName"General Physician"/gt
• ltaddrgtlt/addrgt
• lttelecom value"tel[phone]" use"WP"/gt
• ltassignedPersongt

42
The Encounter

• ltcomponentOfgt
• ltencompassingEncountergt
• ltid extension"9937012" root"1.3.6.4.1.4.1.2835
  .12"/gt
• ltcode code"99213"
• codeSystem"2.16.840.1.113883.6.12"
• displayName"Evaluation and Managment"
• codeSystemName"CPT-4"
• /gt
• lteffectiveTimegt
• ltlow value"20050329"/gt
• lthigh value"20050329"/gt
• lt/effectiveTimegt
• ltdischargeDispositionCode code"01"
• codeSystem"2.16.840.1.113883.6.21"
• displayName"Routine Discharge"
• codeSystemName"UB92"
• /gt
• lt/encompassingEncountergt
• lt/componentOfgt

43
Level 2 Basic Content

• Paragraphs
• ltparagraphgtAnkle Sprain.lt/paragraphgt
• Lists
• ltlistgtltitemgtCholecystectomylt/itemgt
• ltitemgtCesarian Sectionlt/itemgt
• lt/listgt
• Tables
• lttable border"1"gt
• lttheadgt
• lttrgt ltthgtDatelt/thgtltthgtHeightlt/thgtltthgtWeightlt/th
  gtltthgtTemperaturelt/thgt
• ltthgtBPlt/thgtltthgtPulselt/thgtltthgtRespirationlt/thgt
  ltthgtO2lt/thgt
• lt/trgt
• lt/theadgt
• lttbodygt
• lttrgtltthgt3/28/2005lt/thgtltthgt5'9"lt/thgtltthgt215
  lbs.lt/thgtltthgt98.7 Flt/thgt
• ltthgt120/80lt/thgtltthgt68lt/thgtltthgt16lt/thgtltthgt99lt
  /thgt
• lt/trgt
• lt/tbodygt
• lt/tablegt

44
Level 2 Section Structure

• ltcomponentgt
• ltsectiongt
• ltcode code"X-RFVCC"
• codeSystem"2.16.840.1.113883.6.1"
• /gt
• lttitlegtReason for Visit/Chief Complaintlt/titlegt
• lttextgt OR ltcomponentgt
• ?
• lt/textgt lt/componentgt
• lt/sectiongt
• lt/componentgt

45
Level 2 Body Structure

• ltstructuredBodygt
• lttemplateId
• extension"IMPL_CDAR2_LEVEL1-2REF_US_I2_2005SEP"
  
• root"2.16.840.1.113883.10"
• /gt
• ltcomponentgt
• ?
• lt/componentgt
• ?
• ltstructuredBodygt

46
Level 2 Narrative Text

• ltcomponentgt
• ltsectiongt
• ltcode code"X-RFR"
• codeSystem"2.16.840.1.113883.6.1"/gt
• lttitlegtReason for Referrallt/titlegt
• lttextgt
• ltparagraphgtFollow-up care for Ankle Sprain
• lt/paragraphgt
• lt/textgt
• lt/sectiongt
• lt/componentgt

47
Level 2 List

• ltsectiongt
• ltcode code"10160-0"
• codeSystem"2.16.840.1.113883.6.1"/gt
• lttitlegtMedicationslt/titlegt
• lttextgt
• ltlistgt
• ltitemgt Indomethacin, 50mg bid with food,
• 12/10/2003 - presentlt/itemgt
• ltitemgt Acetaminophen with codeine, 3 1-2
  tablets
• for pain as needed, 03/28/2005lt/itemgt
• lt/listgt
• lt/textgt
• lt/sectiongt

48
Level 2 Tables

• ltcomponentgt
• ltsectiongt
• ltcode code"29274-8" codeSystem"2.16.840.1.1138
  83.6.1"/gt
• lttitlegtVital Signslt/titlegt
• lttextgt
• lttable border"1"gt
• lttheadgt
• lttrgt ltthgtDatelt/thgtltthgtHeightlt/thgtltthgtWeightlt/
  thgtltthgtTemperaturelt/thgt
• ltthgtBPlt/thgtltthgtPulselt/thgtltthgtRespirationlt/t
  hgtltthgtO2lt/thgt
• lt/trgt
• lt/theadgt
• lttbodygt
• lttrgt ltthgt3/28/2005lt/thgtltthgt5'9"lt/thgtltthgt215
  lbs.lt/thgtltthgt98.7 Flt/thgt
• ltthgt120/80lt/thgtltthgt68lt/thgtltthgt16lt/thgtltthgt99
  lt/thgt
• lt/trgt
• lt/tbodygt
• lt/tablegt
• lt/textgt
• lt/sectiongt

49
Level 3 Conditions

• ltcomponent xmlns"urnhl7-orgv3"gt
• ltsectiongt
• ltcode code"11450-4" codeSystem"2.16.840.1.1138
  83.6.1" /gt
• lttitlegtConditionslt/titlegt
• lttextgt
• lttable border"1"gt
• lttheadgt
• lttrgtltthgtSeveritylt/thgtltthgtProblemlt/thgtltthgtDate
  lt/thgt
• ltthgtStatuslt/thgtltthgtCommentslt/thgt
• lt/trgt
• lt/theadgt
• lttbodygt
• lttrgtlttd ID"severity-2"gtSeverelt/tdgt
• lttd ID"problem-1"gtAnkle Sprainlt/tdgt
• lttdgt3/28/2005lt/tdgtlttdgtCurrentlt/tdgt
• lttd ID"comment-2"gtSlipped on ice and
  felllt/tdgt
• lt/trgt
• lt/tbodygt
• lt/tablegt

50
Level 3 Condition Entry

• ltentrygt
• ltobservation classCode"COND" moodCode"EVN"gt
• ltid root"6a2fa88d-4174-4909-aece-db44b60a3aba"
  /gt
• lt!-- How determined (CPT/LOINC/SNOMED
  Procedures, etc.) --gt
• ltcode code"" codeSystem"Any"
  codeSystemName"Any" /gt
• ltstatusCode code"active" /gtlt!-- Computed from
  Status column --gt
• lt!-- The interval of time the condition event
  occurred,
• computed from date column --gt
• lteffectiveTimegtltlow value"20050328"
  /gtlt/effectiveTimegt
• lt!-- What (ICD-9, ICD-10, SNOMED, MEDCIN, et
  cetera) --gt
• ltvalue xsitype"CV" code"44465007"
• codeSystem"2.16.840.1.113883.6.96
• codeSystemName"SNOMED CT"gt
• ltoriginalText mediaType"text/xml"gt
• lt!-- problem in column 2 --gt
• ltreference value"problem-1" /gt
• lt/originalTextgt
• lt/valuegt
• lt!-- Severity 0..1 --gt

51
Level 3 Condition Severity
lt!-- Severity --gt ltentryRelationship
typeCode"SUBJ" inversionInd"true"gt ltobservation
classCode"OBS" moodCode"EVN"gt ltcode
code"SEV" /gt ltstatusCode code"completed" /gt
ltvalue xsitype"CV" code"TBD"
codeSystem"TBD" codeSystemName"SeverityObser
vation"gt ltoriginalText mediaType"text/xml"gt
lt!-- pointer to severity in column 1 --gt
ltreference value"severity-2"
/gt lt/originalTextgt lt/valuegt lt/observationgt lt
/entryRelationshipgt
52
Level 3 Condition Comments

• lt!-- Annotation --gt
• ltentryRelationship typeCode"SUBJ"
  inversionInd"true"gt
• ltobservation classCode"OBS" moodCode"EVN"gt
• ltcode code"COMMENT"
• codeSystem"2.16.840.1.113883.5.112"
• codeSystemName"ActCode" /gt
• lttext mediaType"text/xml"gt
• lt!-- pointer to comments in last column --gt
• ltreference value"comment-2" /gt
• lt/textgt
• ltstatusCode code"completed" /gt
• lt/observationgt
• lt/entryRelationshipgt

53
Level 3 Allergies

• ltcomponentgt
• ltsectiongt
• ltcode code"10155-0" codeSystem"2.16.840.1.1138
  83.6.1" /gt
• lttitlegtAllergies and Adverse Reactionslt/titlegt
• lttextgt
• lttable border"1"gt
• lttheadgt
• lttrgtltthgtAllergenlt/thgtltthgtReactionlt/thgt
• ltthgtSeveritylt/thgtltthgtOnsetlt/thgtltthgtCommentslt
  /thgt
• lt/trgt
• lt/theadgt
• lttbodygt
• lttrgtlttd ID"allergen-1"gtPenicillinlt/tdgt
• lttd ID"reaction-1"gtHiveslt/tdgt
• lttd ID"severity-1"gtSeverelt/tdgtlttdgt11/2004lt/
  tdgt
• lttd ID"comment-1"gtAmoxicillin is OKlt/tdgt
• lt/trgt
• lt/tbodygt
• lt/tablegt

54
Level 3 Allergy Entry

• ltentrygt
• ltobservation classCode"COND" moodCode"EVN"gt
• ltid root"dc6d49d1-9371-40bb-9507-90ca93e181a6"
  /gt
• lt!-- Express the kind of allergy or intolerance
  --gt
• ltcode code"Allergy" codeSystem"TBD
• codeSystemName"ObservationAllergyCode" /gt
• ltstatusCode code"active" /gt
• lt!-- The time the condition event occurred --gt
• lteffectiveTime value"200411" /gt
• ltvalue xsitype"CV" code"TBD"
• codeSystem"TBD"
• codeSystemName"IntoleranceAgentValue"gt
• ltoriginalText mediaType"text/xml"gt
• ltreference value"allergen-1" /gt
• lt/originalTextgt
• lt/valuegt
• lt!-- Reactions 0..N --gt
• lt!-- Severity 0..1 --gt
• lt!-- Comments 0..1 --gt

55
Level 3 Reactions

• ltentryRelationship typeCode"SPRT"gt
• ltobservation classCode"OBS" moodCode"EVN"gt
• ltcode code"RXNASSESS" /gt
• lt!-- reactions --gt
• ltentryRelationship typeCode"REFR"gt
• ltobservation classCode"OBS" moodCode"EVN"gt
• ltid root"369bb3eb-c7f6-4e5e-9c44-96c6bcbb8a3d
  " /gt
• ltcode code"DX" /gt
• ltstatusCode code"completed" /gt
• ltvalue xsitype"CV" code"247472004"
• displayName "Hives"
• codeSystem"2.16.840.1.113883.6.96"
• codeSystemName"SNOMED CT"gt
• ltoriginalText mediaType"text/xml"gt
• ltreference value"reaction-1" /gt
• lt/originalTextgt
• lt/valuegt
• lt/observationgt
• lt/entryRelationshipgt

56
Level 3 Medications

• ltcomponentgt
• ltsectiongt
• ltcode code"10160-0" codeSystem"2.16.840.1.1138
  83.6.1" /gt
• lttitlegtMedicationslt/titlegt
• lttextgt
• lttable border"1"gt
• lttheadgt
• lttrgtltthgtMedicationlt/thgtltthgtDoselt/thgtltthgtDatelt
  /thgtlt/trgt
• lt/theadgt
• lttbodygt
• lttr ID"med-1"gt
• lttd ID"medication-1"gtAcetaminophen with
  codeinelt/tdgt
• lttdgtltcontent ID"strength-1"gt3lt/contentgt
• ltcontent ID"dose-1"gt1-2 tabletslt/contentgt
  
• ltcontent ID"route-1"gtPOlt/contentgt
• ltcontent ID"frequency-1"gtevery four
  hourslt/contentgt
• ltcontent ID"instruct-1"gtfor pain as
  neededlt/contentgt
• lt/tdgtlttdgt03/28/2005 - 4/6/2005lt/tdgt
• lt/trgt

57
Level 3 Medication Entry

• ltentrygt
• ltsubstanceAdministration classCode"SBADM"
  moodCode"EVN"gt
• lt!-- could also be moodCode RQO --gt
• ltid root"af30c55f-afa7-44f1-9fbb-caab0e994a72"
  /gt
• ltcode code"377261001"
• codeSystem"2.16.840.1.113883.6.96"
• codeSystemName"SNOMED CT"gt
• lt!-- just the medication name --gt
• ltoriginalText mediaType"text/xml"gt
• ltreference value"medication-1" /gt
• lt/originalTextgt
• lt/codegt
• lt!-- The whole sig (thing) --gt
• lttext mediaType"text/xml"gt
• ltreference value"med-1" /gt
• lt/textgt
• ltstatusCode code"active" /gt

58
Level 3 Start, Stop and Frequency
lteffective_time xsitype"SXPR_TS" operator"I"
gt ltcomp xsitype"IVL_TS"gtlt!-- start and stop
--gt ltlow value"20050328" /gt lthigh
value"20050405" /gt lt/compgt ltcomp
xsitype"PIVL_TS"gtlt!-- frequency --gt ltperiod
value"4" unit"h" institutionSpecifiedfalse"
/gt lt/compgt lt/effective_timegt
59
Level 3 Route
ltrouteCode code"PO" codeSystem"2.16.840.1.113
883.5.112" codeSystemName"RouteOfAdministration
"gt ltoriginalText mediaType"text/xml"gt ltreferen
ce value"route" /gt lt/originalTextgt lt/routeCode
gt
60
Level 3 Dose
ltdoseQuantitygt ltlow value"1" unit"tablet"gt ltt
ranslationgt ltoriginalText mediaType"text/xml"gt
ltreference value"dose-1" /gt
lt/originalTextgt lt/translationgt lt/lowgt lthig
h value"2" unit"tablet"gt lttranslationgt ltori
ginalText mediaType"text/xml"gt ltreference
value"dose-1" /gt lt/originalTextgt lt/transla
tiongt lt/highgt lt/doseQuantitygt
61
Level 3 Stuff
ltconsumable typeCode"CSM"/gt lt!--
Instructions --gt ltentryRelationship
typeCode"SUBJ" inversionInd"true"gt ltobservati
on classCode"OBS" moodCode"EVN"gt ltcode
code"INSTRUCT" codeSystem"2.16.840.1.113883
.5.112" codeSystemName"ActCode" /gt
lttextgtltreference value"instruct-1"
/gtlt/textgt ltstatusCodegtcompletedlt/statusCodegt
lt/observationgt lt/entryRelationshipgt lt/subst
anceAdministrationgt lt/entrygt
62
Level 3 References

• ltcomponentgt
• ltsectiongt
• ltcode code"X-SS" codeSystem"2.16.840.1.113883.
  6.1" /gt
• lttitlegtRelated Reportslt/titlegt
• lttextgt
• lttable border"1"gt
• lttheadgt
• lttrgtltthgtStudylt/thgtltthgtSummarylt/thgtltthgtDatelt/t
  hgt
• lt/trgt
• lt/theadgt
• lttbodygt
• lttrgt
• lttd ID"study-1"gtX-Ray Study - Left
  Anklelt/tdgt
• lttdgtNo Fracturelt/tdgt
• lttdgt3/28/2005lt/tdgt
• lt/trgt
• lt/tbodygt
• lt/tablegt
• lt/textgt

63
Level 3 Reference Entry

• ltentrygt
• ltact classCode"ACT" moodCode"EVN"gt
• ltid root"6b55d2e7-78f1-49a4-bb18-ace4c9b6e1f1"
  /gt
• lt!-- Document type Code for the type of service
  that
• the reference document is documentation of
  --gt
• ltcode code"24541-5" codeSystem"2.16.840.1.113
  883.6.1
• codeSystemName"LOINC
• displayName"X-RAY ANKLE, STUDY" /gt
• ltreference typeCode"REFR"gt
• ltexternalDocument classCode"DOC"
  moodCode"EVN"gt
• ltid extension"999020" root"1.3.6.4.1.4.1.283
  5.2" /gt
• ltcodegt
• ltoriginalText mediaType"text/xml"gt
• ltreference value"study-1" /gt
• lt/originalTextgt
• lt/codegt
• ltsetId root"999019" extension"1.3.6.4.1.4.1.
  2835.2" /gt
• ltversionNumber value"1" /gt
• lt/externalDocumentgt

64
Final Result
65
Questions

• ?

66
References

• Care Record Summary
• http//www.hl7.org/Library/Committees/structure/c
  rs.zip
• CDA Release 2.0
• http//www.hl7.org/Edition2005/html/infrastructur
  e/cda/cda.htm
• XML
• http//www.w3.org/TR/xml
• XSLT
• http//www.w3.org/TR/xslt
• XHTML
• http//www.w3.org/TR/xhtml-modularization/
• Schematron
• http//www.schematron.com/
• http//xml.ascc.net/resource/schematron/schematro
  n.html