Confidentiality code support in ClinicalStatement choices

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Return to SDTC page; Return to CDA R3 Formal Proposals page.

Submitted by: Ioana Singureanu Revision date: 12/1/2009
Submitted date: 11/17/2009 Change request ID: <<Change Request ID>>

Issue

Currently there is no way to specify the confidentiality and sensitivity of a act, observation, procedure, etc. choice in a ClinicalStatement. This information is often required in specifying the Consent Directive or Privacy Policy.

Severity:High

High: The workaround is an ambiguous use of "Precondition" in place of a security indicator. CBCC WG Wiki


Recommendation

  • Add "confidentialityCode" property to the classes avaialable as choices in POCD_MT000040.Entry (clinicalStatement)

Rationale

Needed for Consent Directive representations.

Discussion

The item was introduced during the SDWG meeting - Nov. 17th, 2009. This proposal would replace the current workaround using "Precondition": <precondition typeCode="PRCN">

<criterion classCode="OBS" moodCode="EVN.CRT">

</criterion>
</precondition>

with this RIM-based attribute:

<confidentialityCode code="N"/>

Recommended Action Items

Resolution

April 13, 2010 SDWG: Comes along with decision to use RIM as right side of CDA R3 (therefore approved). Opposed: 0; Abstain: 0; In favor: 7.