CDAR2_IG_PHCASERPT_R2_STU_2016JUN_Vol1
HL7 CDA® R2 Implementation Guide: Public Health Case Report, Release 2 – US Realm the Electronic Initial Case Report (eICR) Standard for Trial Use June 2016 Volume 1 – Introductory Material Publication of this standard for trial use and comment has been approved by Health Level Seven International (HL7). This draft standard is not an accredited American National Standard. The comment period for use of this draft standard shall end 24 months from the date of publication. Suggestions for revision should be submitted at http://www.hl7.org/dstucomments/index.cfm. Following this 24 month evaluation period, this draft standard, revised as necessary, will be submitted to a normative ballot in preparation for approval by ANSI as an American National Standard. Implementations of this draft standard shall be viable throughout the normative ballot process and for up to six months after publication of the relevant normative standard.
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Acknowledgements This guide was produced and developed through a collaborative effort of the Centers for Disease Control and Prevention (CDC), Council of State and Territorial Epidemiologist (CSTE), the Association of State and Territorial Health Officials (ASTHO), the Association of Public Health Laboratories (APHL), CGI Federal, public health surveillance practitioners, EHR vendors, and the HL7 Public Health and Emergency Response (PHER) Work Group for an electronic initial case report (Public Health Case Report). A list of Problem List (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:15408). or 2. SHALL contain exactly one [1..1] effectiveTime/@value (CONF:5256).
Figure 4: Allowed nullFlavors When Element is Required (with xml examples) 1. SHALL contain at least one [1..*] id
2. SHALL contain exactly one [1..1] code 3. SHALL contain exactly one [1..1] effectiveTime
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New Grading system Spiculated mass grade 5
Figure 5: nullFlavor Not Allowed on Element (with XML example) 1. SHALL contain exactly one [1..1] targetSiteCode (CONF:1169-32487) a. b.
This targetSiteCode SHALL contain exactly one [1..1] @code (CONF:1169-32488) This targetSiteCode ab contain exactly one [1..1] @codeSystem (CONF:1169-33182)
3.2.4 If a sender wants to state that a piece of information is unknown, this is an example of how an author can record a section that contains “No Information”. This is an exceptional case and does not cover 'No Known' scenarios (see below). Figure 6: No Information for Problem List PROBLEMS No Information
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3.2.5 If the sender wants to state “no known”, a negationInd can be used on the corresponding act (substanceAdministration, Procedure, etc.) Previously Continuity of Care Document (CCD), Intergrating the Healthcare Enterprise (IHE), and the Healthcare Information Technology Standards Panel (HITSP) recommended using specific codes to assert no known content, for example 160244002 No known allergies or 160245001 No current problems or disability. Specific codes are still allowed; however, use of these codes is not recommended. 3.2.6 The next example illustrates additional nuances of representing information that is a negative assertion, where for example, it is not the case that the patient has an allergy or it is not the case that a patient takes a medication. The phrases "no known allergies" or "no known medications" are typically associated with this type of negative assertion. Figure 7: No Known Medications Example No known medications
3.3 Use of vocabulary standards Value set bindings adhere to HL7 Vocabulary Working Group best practices, and include both a conformance verb (SHALL , SHOULD , MAY, etc.) and an indication of DYNAMIC vs. STATIC binding. The use of SHALL requires that the component be valued with a member from the cited value set; however, in every case any HL7 "null" value such as other (OTH) or unknown (UNK) may be used. DYNAMIC binding means that the allowed values bind to the most current version of the value set. STATIC binding means that the allowed values of the value set are bound to a specifc version of a value set. If a STATIC binding is specified, a date SHALL be included to indicate the value set version. Figure 8: Vocabulary bindings are specified as a reference to the value set name followed by the value set OID; for example: This patient SHALL contain exactly one Page 28 HL7 CDA R2 IG: Public Health Case Report R2 (eICR) – US Realm Vol 1 © 2016 Health Level Seven International. All rights reserved. June 2016
[1..1] administrativeGenderCode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) urn:oid:2.16.840.1.113883.1.11.1 DYNAMIC (CONF:1198-6394). Value sets specifications are included in the section entitled “Value Sets In This Guide”(Section 9, Volume 2). Each value set includes a value set member list including the code, code system name, and print name for each member of the value set. The name of the value set, along with its OID is included in the table header.
Example from Volume 2: Table 1: Administrative Gender (HL7 V3) Value Set: Administrative Gender (HL7 V3) urn:oid:2.16.840.1.113883.1.11.1 Administrative Gender based upon HL7 V3 vocabulary. This value set contains only male, female and undifferentiated concepts. Value Set Source: http://www.hl7.org/documentcenter/public/standards/vocabulary/vocabulary_tables/infrastructure/vocabula ry/vocabulary.html Code
Code System
Code System OID
Print Name
F
AdministrativeGender
urn:oid:2.16.840.1.113883.5.1
Female
M
AdministrativeGender
urn:oid:2.16.840.1.113883.5.1
Male
UN
AdministrativeGender
urn:oid:2.16.840.1.113883.5.1
Undifferentiated
3.4 CSTE Identified Data Requirements Table 3 below contains a set of data element requirements proposed by the CSTE and used to map data for this standard. The following sections contain reference tables and graphics of the data model used in this document. CSTE ELEMENT NAME Date of the Report
Report Submission Date/Time
Sending Application Provider ID
CSTE DESCRIPTION The date on which the reporting party (e.g., physician, nurse practitioner, physician assistant, etc.), completes collection of minimum data for the eICR The date and time at which the EHR system sends the eICR data to the jurisdictional public health agency or designee The name of the sending application Identification code for the care provider (e.g., NPI)
RATIONALE / JUSTIFICATION Used to assess timelines of eICR data provisioning, and other quality assurance tasks
Used to ensure timeliness of report and to identify time lags between date of the report and when the EHR sends the report Used to ensure quality and integrity of eICR data Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.
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CSTE ELEMENT NAME Provider Name
CSTE DESCRIPTION The first and last name of the healthcare provider
Provider Phone
The provider's phone number with area code
Provider Fax
The provider's fax number with area code
Provider Email
The provider's email address
Provider Facility/Office Name
The provider facility's full name, not necessarily where care was provided to patient
Provider Address
The geographical location or mailing address of the provider's office or facility. Address must include street address, office or suite number (if applicable), city or town, state, and zip code Identification code for the facility (e.g., Facility NPI)
Facility ID Number
Facility Name
The facility's name
RATIONALE / JUSTIFICATION Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. Necessary to obtain additional info during case follow-up phase or to submit supplemental information If secure email is available; used for sharing secure links to health data if allowed by state regulations Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.
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CSTE ELEMENT NAME Facility Type
Facility Phone
Facility Address
Patient ID Number
Patient Name
Parent/Guardian Name
Patient or Parent/Guardian Phone Patient or Parent/Guardian Email Street Address
CSTE DESCRIPTION The type of facility where patient received or is receiving healthcare for the reportable condition (e.g., hospital, ambulatory, urgent care, etc.) The facility's phone number with area code
The mailing address for the facility where patient received or is receiving healthcare for the reportable condition. Must include street address, city/town, county, state, and zip code Patient social security number, medical record number, or other identifying value as required or allowed under jurisdictional laws governing health data exchange All names for the patient, including legal names and aliases. Must include the name type (i.e., legal or alias), first name, middle name, and last name All names for the patient’s parent or guardian, including legal names and aliases (if patient age is < 18 years). Must include name type (i.e., legal or alias), first name, middle name, and last name All phone numbers and phone number types for the patient or parent/guardian The email address for the patient or the patient’s parent/guardian. All addresses for the patient, including current and residential addresses. Must include street address, apartment or suite number, city or town, county, state, zip code, and country
RATIONALE / JUSTIFICATION Used to determine the type of care setting in which patient is receiving care for the reportable condition Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc. Identification and contact; jurisdictions may select which they can receive based on laws governing public health data exchange Identification and contact
For appropriate contact with minors
Contact Patient
Contact Patient Case Assignment, analysis and visualization, matching
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CSTE ELEMENT NAME Birth Date
CSTE DESCRIPTION The patient's date of birth
Patient Sex Race Ethnicity Preferred Language Occupation
The patient's biological sex (not gender) The patient's race The patient's ethnicity The patient's preferred language The patient's occupation
Pregnant
The patient's pregnancy status
Visit Date/Time
Date and time of the provider's most recent encounter with the patient regarding the reportable condition
Admission Date/Time
Date and time when the patient was admitted to the treatment facility; e.g., hospital
History of Present Illness
Physician’s narrative of the history of the reportable event. Hopefully a place where we can get information such as travel, contacts, etc. if captured
Reason for Visit
Provider’s interpretation for the patient’s visit for the reportable event
Date of Onset
The date of symptoms for the reportable event
RATIONALE / JUSTIFICATION Appropriate identification, appropriate identification of minors, risk; Necessary to determine patient age; matching electronic laboratory reports (ELR) Demographic reporting Demographic reporting Demographic reporting Communication with Patient Identification of potential risk, transmission risk Appropriate treatment, followup, appropriate for scoring/risk ascertainment Defines when the individual may have been ill; a point in time to which can link other potential cases of reportable event; necessary to ensure follow-up within key time frames/helps triage priority follow-up and ensure control measures are implemented in a timely way Key for epidemiologic investigation - important to know if hospitalized for severity of condition and to triage priority follow-up Indicator of reportable condition - most important descriptor of condition/ epidemiologic information - supports epidemiologic investigation ; epidemiologic relevant information Indicator of reportable condition - most important descriptor of condition/ epidemiologic information - supports epidemiologic investigation Helps determine possible exposure and illness- calculate incubation period
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CSTE ELEMENT NAME Symptoms (list)
CSTE DESCRIPTION List of patient symptoms (structured) for the reportable event
Laboratory Order Code
Ordered tests for the patient during the encounter Identifier for the laboratory order from the encounter
Placer Order Number
Diagnoses
Date of Diagnosis
The healthcare provider's diagnoses of the patient's health condition (all) The date of provider diagnosis
Medications Administered (list)
List of medications administered for the reportable event
Death Date
The patient's date of death
Patient Class
Whether patient is outpatient, inpatient, emergency, urgent care
RATIONALE / JUSTIFICATION We know if clinical symptoms signify a case of PH importance confirm the need for PH follow up Some lab test orders are reportable for suspected cases Potential value to linking electronic laboratory reports (ELR) to eICR Would include something that is potentially reportable We want to know when they're diagnosed; integral to epidemiological investigation To find treatments that were prescribed; prophylaxis; we know if they've already been treated, lower on the list for PH (priority) Patient follow-up and epidemiological purposes
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3.5 eICR Data Model Figure 9. The eICR Data Model documents the important data that support clinical care and public health for an electronic initial public health case report.
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3.6 Mapping of data elements to Data Model (Table 4)
ELEMENT NAME Date of the Report Provider ID Provider Name Provider Phone Provider Fax Provider Email Provider Facility/Office Name Provider Address Facility ID Number Facility Name Facility Type Facility Phone Facility Address Facility Fax Patient ID Number Patient Name Parent/Guardian Name Patient Phone Patient Email Parent/Guardian Phone Parent/Guardian Email Street Address Birth Date Patient Sex Race Ethnicity Preferred Language Occupation Pregnant Visit Date/Time Admission Date/Time Hospital Unit Discharge Date History of Present Illness Reason for Visit Date of Onset Symptoms (list) Laboratory Order Code Filler Order Number Laboratory Results Diagnoses Date of Diagnosis Medications Administered (list) Immunization Status Death Date Patient Class
Class Name IntialPublicHealthCaseReport Provider Provider Provider Provider Provider ProviderFacility ProviderFacility CareDeliveryFacility CareDeliveryOrganization CareDeliveryFacilityUnit CareDeliveryOrganization CareDeliveryFacility CareDeliveryOrganization Patient Patient PatientGuardian Patient Patient PatientGuardian PatientGuardian Patient Patient Patient Patient Patient Patient Patient Patient PatientEncounter PatientEncounter CareDeliveryFacilityUnit PatientEncounter PatientEncounter PatientEncounter ReportableCondition ReportableConditionSymptom LaboratoryObservation LaboratoryObservation LaboratoryObservationResult EncounterDiagnosis EncounterDiagnosis AdministeredMedication ImmunizationActivity Patient PatientEncounter
Class Attribute Name effectiveDate identifier name telecomAddress telecomAddress telecomAddress Name postalAddress Identifier Name typeCode telecomAddress postalAddress telecomAddress Identifier Name Name telecomAddress telecomAddress telecomAddress telecomAddress postalAddress birthDate sexCode raceCode ethnicityCode preferredLanguage occupationCode isPregnantIndicator startDateTime startDateTime typeCode endDateTime presentIllnessHistoryText EncounterReason onsetDate typeCode typeCode identifier value typeCode effectiveDate medicationTypeCode vaccineTypeCode deathDate typeCode
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3.7 eICR Template Hierarchy (Figure 10)
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3.8 Mapping of elements to IG Templates (Table 5) Data Element
IG Template
IG Constraint (Conformance Identifier)
Date of the Report Provider ID
US Realm Header (V3)
(CONF:1198-5256)
eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document
(CONF:2218-8)
eICR Initial Public Health Case Report Document
(CONF:2218-26)
eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document US Realm Header (V3)
(CONF:2218-27)
US Realm Header (V3)
(CONF:1198-5268)
US Realm Header (V3)
(CONF:1198-5284)
US Realm Header (V3)
(CONF:1198-5280)
US Realm Header (V3)
(CONF:1198-5280)
Provider Name Provider Phone Provider Fax Provider Email Provider Facility/Offic e Name Provider Address Facility ID Number Facility Name Facility Type Facility Phone Facility FAX Facility Address Patient Class Patient ID Number Patient Name Patient Phone Patient Email
Note
This data element can repeat.
(CONF:2218-25) (CONF:2218-24) (CONF:2218-24) (CONF:2218-24)
URL.scheme = ‘tel:’. This data element can repeat. URL.scheme = ‘tel:’. This data element can repeat. URL.scheme = ‘mailto:’. This data element can repeat.
(CONF:2218-13) (CONF:2218-33) (CONF:2218-14) (CONF:2218-34) (CONF:2218-34) (CONF:2218-32)
URL.scheme = ‘tel:’. This data element can repeat. URL.scheme = ‘tel:’. This data element can repeat. This data element can repeat.
(CONF:2218-4) This data element can repeat. This data element can repeat. URL.scheme = ‘tel:’. This data element can repeat. URL.scheme = ‘mailto:’. This data element can repeat.
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Data Element
IG Template
IG Constraint (Conformance Identifier)
Note
Parent/Guar dian Name Parent/Guar dian Phone Parent/Guar dian Email
US Realm Header (V3)
(CONF:1198-5386)
US Realm Header (V3)
(CONF:1198-5382)
US Realm Header (V3)
(CONF:1198-5382)
Street Address Birth Date
US Realm Header (V3)
(CONF:1198-5271)
This data element can repeat. URL.scheme = ‘tel:’. This data element can repeat. URL.scheme = ‘mailto:’. This data element can repeat. This data element can repeat.
US Realm Header (V3)
(CONF:1198-5298)
Patient Sex
US Realm Header (V3)
(CONF:1198-6394)
Race
US Realm Header (V3)
(CONF:1198-5322), (CONF:1198-7263)
This data element can repeat.
Ethnicity
US Realm Header (V3)
(CONF:1198-5323), (CONF:1198-32901).
This data element can repeat.
Preferred Language Occupation
US Realm Header (V3)
(CONF:1198-5407)
Social History Observation (V3)
(CONF:1198-8559)
Pregnant
Problem Observation (V3)
(CONF:1198-9058)
This data element can repeat. Observation.code = SCTID: 14679004 This data element can repeat. During the DSTU period, the use of the Problems Observation template to indicate pregnancy is being evaluated. The recommended SNOMED value codes are '60001007' Not pregnant (finding), and '77386006' Patient currently pregnant (finding).
Hospital Unit
eICR Initial Public Health Case Report Document
(CONF:2218-14)
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Data Element
IG Template
IG Constraint (Conformance Identifier)
Note
Visit Date/Time Admission Date/Time Discharge Date/Time History of Present Illness
eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document eICR Initial Public Health Case Report Document History of Present Illness Section
(CONF:2218-20)
For outpatient encounters
(CONF:2218-20)
For Inpatient encounters
(CONF:2218-21)
For Inpatient encounters
(CONF:81-7851)
Reason for Visit
Reason for Visit Section
(CONF:81-7839)
Date of Onset Symptoms (list) Lab Order Code Laboratory Results
Problem Observation (V3)
(CONF:1198-15603)
Problem Observation (V3)
(CONF:1198-9058)
Result Organizer (V3)
(CONF:1198-7128)
Result Observation (V3)
(CONF:1198-7133), (CONF:1198-7143)
Filler Order Number Diagnoses
Result Organizer (V3)
(CONF:1198-7127)
Problem Observation (V3)
(CONF:1198-9058)
Date of Diagnosis Medications Administered (list) Death Date
Encounter Activity (V3)
(CONF:1198-8715)
Medication Information (V2)
(CONF:1098-7412)
This data element can repeat within the text element of this narrative only template. This data element can repeat within the text element of this narrative only template. This data element can repeat. This data element can repeat. This data element can repeat. Laboratory results require both an observation code and an observation value. This data element can repeat. This data element can repeat. Observation.code = LOINC: 29308-4. This data element can repeat. This data element can repeat. This data element can repeat.
eICR Initial Public Health Case Report Document Immunizations Section (entries required) (V3)
(CONF:1198-106)
Immunizatio n Status
(CONF:2218-149)
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Appendix A — Extensions to CDA R2 Where there is a need to communicate information for which there is no suitable representation in CDA R2, extensions to CDA R2 have been developed. These extensions are described above in the context of the section where they are used. This section serves to summarize the extensions and provide implementation guidance. Extensions created for this guide include: sdtc:raceCode
The raceCode extension allows for multiple races to be reported for a patient. sdtc:ethnicGroupCode The ethnicGroupCode extension allows for additional ethnicity groups for the recordTarget or subjectPerson. sdtc:deceasedInd The deceasedIndextension (= “true” or “false”) in the family history organizer on the related subject is used inside to indicate if a family member is deceased. sdtc:deceasedTime The deceasedTime extension in the family history organizer on the related subject allows for reporting the date and time a family member died. sdtc:dischargeDispositionCode The dischargeDispositionCode extension allows the provider to record a discharge disposition in an encounter activity. sdtc:signatureText The signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 Implementation Guide for CDA® Release 2: Digital Signatures and Delegation of Rights, Release 1. To resolve issues that need to be addressed by extension, the developers of this guide chose to approach extensions as follows: • An extension is a collection of element or attribute declarations and rules for their application to the CDA Release 2.0. • All extensions are optional. An extension may be used, but need not be under this guide. • A single namespace for all extension elements or attributes that may be used by this guide will be defined. • The namespace for extensions created by the HL7 Structured Documents Working Group (formerly Structured Documents Technical Committee) shall be urn:hl7-org:sdtc. • This namespace shall be used as the namespace for any extension elements or attributes that are defined by this implementation guide. • Each extension element shall use the same HL7 vocabularies and data types used by CDA Release 2.0. Page 40 HL7 CDA R2 IG: Public Health Case Report R2 (eICR) – US Realm Vol 1 © 2016 Health Level Seven International. All rights reserved. June 2016
• Each extension element shall use the same conventions for order and naming as is used by the current HL7 tooling. An extension element shall appear in the XML where the expected RIM element of the same name would have appeared
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