CDA R3 Proposal - Subject Enhancements

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Submitted by: Sondra Renly	Revision date: Dec 3, 2008
Submitted date: Dec 3, 2008	Change request ID: <<Change Request ID>>

Issue

IBM Research has been working with HL7v3 CDA R2 for public health laboratory reporting. Through this process three recommendations have been documented on the report Subject. These are listed below.

Recommendation

• We would like to enter one or more subject IDs, type II, under relatedSubject.
• We would like relatedSubject CE to be changed to CD to support qualifiers.
• We would like greater support for veterinary subject data.

Rationale

• In public health reporting two types of reports contain a subject. First, a subject only report where the sample originates from a non-human source such as animal, food, or the environment. Second, a combined patient and subject report exists in the scenario of rabies testing where the result is relevant to the bitten patient but the sample originates from the animal. In both of these cases it is important that we provide ID(s) for the subject.

• In public health food borne illness reporting samples of "Chicken" can be either from an animal source or a food source. The use of qualifier helps us distinguish between the two.

<subject>
  <relatedSubject>
    <code code="226955001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Chicken">
      <qualifier>
        <name code="105590001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Substance"/>
        <value code="39866004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Animal"/>
      </qualifier>
    </code>
    <addr>...</addr>
  </relatedSubject>
</subject>

<subject>
  <relatedSubject>
    <code code="226955001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Chicken">
      <qualifier>
        <name code="105590001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Substance"/>
        <value code="255620007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Food"/>
      </qualifier>
    </code>
    <addr>...</addr>
  </relatedSubject>
</subject>

• Additional data elements are needed to support veterinary use cases. We would like to capture:
  • “id” unbounded - supports medical record number, ear or neck tag number, tattoo number, brand number
  • “code” - species
  • “code” – breed
  • “code” - color (may be a qualifier to breed?)
  • “name” – animal name
  • “adminGenderCode” – gender (male, female, castrated, spayed)
  • “birthTime” - age
  • “associatedEntity?” – owner (person/organization)
  • “associatedEntity?” – trainer (person/organization)

Discussion

SDWG 08/10/09: We need to widen the modeling for subject participation beyond "human" and should consider including all living and non-living entities. We should consider an additional type of identifier ("ident") for non-interoperable identification, typically associated with the role. We should review the public health entity for the use of multiple roles and entities and role-based associations. These need to be reviewed for both the clinical statements and the CDA header.

Recommended Action Items

Here is a possible schema for relatedSubject. We are open to feedback.

<xs:complexType name="POCD_MT000040.RelatedSubject">
  <xs:sequence>
    <xs:element name="realmCode" type="CS" minOccurs="0" maxOccurs="unbounded"/>
    <xs:element name="typeId" type="POCD_MT000040.InfrastructureRoot.typeId" minOccurs="0"/>
    <xs:element name="templateId" type="II" minOccurs="0" maxOccurs="unbounded"/>
    <xs:element name="id" type="II" minOccurs="0" maxOccurs="unbounded"/>
    <xs:element name="code" type="CD" minOccurs="0"/>
    <xs:element name="name" type="??" minOccurs="0" maxOccurs="unbounded"/>
    <xs:element name="speciesCode" type="CD" minOccurs="0"/>
    <xs:element name="breedCode" type="CD" minOccurs="0"/>
    <xs:element name="administrativeGenderCode" type="CE" minOccurs="0"/>
    <xs:element name="birthTime" type="TS" minOccurs="0"/>
    <xs:element name="addr" type="AD" minOccurs="0" maxOccurs="unbounded"/>
    <xs:element name="telecom" type="TEL" minOccurs="0" maxOccurs="unbounded"/>
    <xs:element name="subject" type="POCD_MT000040.SubjectPerson" minOccurs="0"/>
    <xs:element name="associatedEntity" type="POCD_MT000040.AssociatedEntity" minOccurs="0"/>
  </xs:sequence>
  <xs:attribute name="nullFlavor" type="NullFlavor" use="optional"/>
  <xs:attribute name="classCode" type="x_DocumentSubject" use="optional" default="PRS"/>
</xs:complexType>

Resolution

April 6, 2010 SDWG: Agree with the need for more expressive subject participant to support public health requirements. (See also Austin's proposals). opposed: 0; abstain: 0; approve: 9.