Add ServiceEvent Participant Information

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See CDA R3 Formal Proposals for instructions on using this form. Failure to adhere to these instructions may result in delays. Editing of formal proposals is restricted to the submitter and SDTC co-chairs. Other changes will be undone. Comments can be captured in the associated discussion page.


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(An announcement of this proposal must be submitted to the Structured Documents list to be formally submitted.)


Submitted by: <<Helmut Koenig>> Revision date: <<Revision Date>>
Submitted date: <<October 23, 2009>> Change request ID: <<Change Request ID>>

Issue

While CDA R2 allows for providing information on the referring physician in the context of an encounter (encounterParticipant associated with EncompassingEncounter), inclusion of information on the physician who ordered or requested a specific service (e.g. imaging study) is not possible in the document header (ServiceEvent has only an associated performer participation).

Recommendation

  • Add referrer participation to ServiceEvent in the CDA R3 header which allows to capture information on the person having referred the subject of the service to the performer. In the context of ServiceEvent that would typically be the physician ordering or requesting the service.

Rationale

The RSNA Reporting Committee (refer to Kahn et al. "Towards Best Practices in Radiology Reporting", Radiology 2009; 252: 852-856) requires information on the referring physician of imaging studies as part of the administrative information. This is different from the referring physician information in the context of an encounter or visit that is already covered by the CDA R2 header.

Discussion

Recommended Action Items

Resolution

Feb 9, 2010 SDWG teleconference: We need to assert a 0..* fulfills relationship between serviceEvent and Order (retaining the existing fulfills relationship). We need to add 0..* author participant to Order. abstain: 0; opposed: 0; in favor: 6