EHR Interop - CDA R3 - Audit Events

Submitted by: HL7 EHR Interoperability WG - Gary Dickinson Revision date: 1 October 2009

Submitted date: 1 October 2009 Change request ID: <<Change Request ID>>

Issue

Allow Lifecycle Event Audits in CDA R3 Instances

Recommendation

As per HL7 EHR Lifecycle Model DSTU - include all lifecycle event audits in CDA R3 instances.

• DRAFT Evidence of EHR Lifecycle Events in support of CDA Release 3 Formal Proposal (incomplete), revised 13 Apr 2010

Rationale

To ensure document architecture fully enables records management and evidentiary support requirements, track all document lifecycle events. Excerpted from HL7 EHR Lifecycle Model the following audit/trace points are identified...

Event ID/Point in Lifecycle

1/Originate and Retain/Persist Record

2.1/Amend Record Content

2.2/Translate Record Content

3.1/Verify Record Content

3.2/Ensure/Attest Record as Complete

3.3/Ensure/Attest Record as Accurate

4/Access/View Record Content

5.1/Transmit and/or Disclose Record(s) – Original and Amendment(s)

5.2/Transmit and/or Disclose Record – Most Recent Amendment

6.1/Receive and Retain/Persist Record(s) – from external source

6.2/Receive Record(s) – from external source – no persistence (NO AUDIT)

7.1/De-identify or Alias Record(s)

7.2/Re-identify Record(s)

8/Converge Record(s)

9/Archive Record(s)

10/Destroy or Identify Record(s) as Missing

11/Deprecate Record(s)

Resolution

April 13, 2010: For those not covered by CDA R2, they align more closely with medical records domain and functionality we'd like to see in document management systems / v2/v3 medical records messages. Suggest bringing this forward as medical records proposals (to SDWG), and consider doing such work in collaboration with EHR WG. Opposed: 0; Abstain: 0; In favor: 8.