IPS NoInfos section

Introduction

The group has discussed the best way to express the absence of information about the content of a specific section (e.g.; no available data about allergies, I don't know anything about drug treatment for this patient ...), as well as the best way to express that the content is known absent (e.g.; at the best of my knowledge I'm not aware about allergies for this patient)

Existing templates evaluated seem to propose different approaches for this.

This need mainly applies to mandatory sections.

The solution should be the same for all sections.

Cases to be covered

1. No info about allergies/intolerances ; No allergies/intolerances
2. No info about drugs ; No current drug treatment
3. No info about problems ; No current problem
4. No info about procedures ; No history of procedure
5. No info about medical devices, implants ; No current implant
6. No info about immunizations ; No history of immunization

Solution Selected

The information about the absence of information should be coveyed through the coded element that also conveys the main information (e.g. the type of allergy) (decision of the 2017-02-22 call)

see below for details

Rational for the choice

• Facilitate the work of implementers
• Solution independent of the underlying syntax (e.g.; CDA or FHIR), which facilitates the mapping to FHIR resources

With this approach we aim to provide implementers with a common way to access information about a specific topic (e.g. allergies) independently of the fact they are looking for a positive assertion, known absent or no availability of data.

Issue to be resolved

• Identify for each case suitable codes for asserting no info and known absent. The table below summarize the current status (to be updated)

Section	No Infos	Known Absent
Allergies/intolerances	concept to be created in HL7 Int extension, with these defining characteristics: FSN: "Allergic disposition not known (situation)" Hierarchy: 413350009 |Finding with explicit context (situation)| Associated finding = 609328004 |Allergic disposition (disorder)| Temporal context = 410589000 |All times past (qualifier value)| Subject relationship = 410604004 |Subject of record (person)| Finding context = 261665006 |Unknown (qualifier value)|	716186003 |No known allergy (situation)| (this code or any combination of its descendants)
Medications	concept to be created in HL7 Int extension, with these defining characteristics: FSN: "Drug treatment not known (situation)" Hierarchy: 129125009 |Procedure with explicit context (situation)| Associated procedure = 416608005 |Drug therapy (procedure)| Temporal context = 410512000 |Current or specified time (qualifier value)| Subject relationship = 410604004 |Subject of record (person)| Procedure context = 261665006 |Unknown (qualifier value)|	concept to be created in HL7 Int extension, with these defining characteristics: FSN: "No drug treatment (situation)" Hierarchy: 129125009 |Procedure with explicit context (situation)| Associated procedure = 416608005 |Drug therapy (procedure)| Temporal context = 410512000 |Current or specified time (qualifier value)| Subject relationship = 410604004 |Subject of record (person)| Procedure context = 385660001 |Not done (qualifier value)|
Problems	concept to be created in HL7 Int extension, with these defining characteristics: FSN: "History of problems not known (situation)" Hierarchy: 413350009 |Finding with explicit context (situation)| Associated finding = 404684003 |Clinical finding (finding)| Temporal context = 410589000 |All times past (qualifier value)| Subject relationship = 410604004 |Subject of record (person)| Finding context = 261665006 |Unknown (qualifier value)|	160245001 |No current problems or disability (situation)|
Procedures	concept to be created in HL7 Int extension, with these defining characteristics: FSN: "History of procedures not known (situation)" Hierarchy: 129125009 |Procedure with explicit context (situation)| Associated procedure = 71388002 |Procedure (procedure)| Temporal context = 410589000 |All times past (qualifier value)| Subject relationship = 410604004 |Subject of record (person)| Procedure context = 261665006 |Unknown (qualifier value)|	416128008 |No history of procedure (situation)|
Medical devices, implants	concept to be created in HL7 Int extension with these defining characteristics: FSN: "Presence of implanted device not known (situation)" Associated finding = 397578001 |Device in situ (finding) Temporal context = 410512000 |Current or specified time (qualifier value)| Subject relationship = 410604004 |Subject of record (person)| Finding context = 261665006 |Unknown (qualifier value)|	concept to be created in HL7 Int extension with these defining characteristics: FSN: "No implant in situ (situation)" Associated finding = 397578001 |Device in situ (finding)| Temporal context = current or specified time Subject relationship = subject of the record Finding context = known absent
Immunizations	concept to be created in HL7 Int extension, with these defining characteristics: FSN: "History of immunizations not known (situation)" Hierarchy: 129125009 |Procedure with explicit context (situation)| Associated procedure = 127785005 |Administration of substance to produce immunity, either active or passive (procedure)| Temporal context = 410589000 |All times past (qualifier value)| Subject relationship = 410604004 |Subject of record (person)| Procedure context = 261665006 |Unknown (qualifier value)|	401179006 |No previous immunizations (situation)|

To Do

• Search for possible candidates in existing code systems -> done
• Define the missing codes to be added -> done
• Evaluate the request to have an HL7 extension in SNOMED CT -> done
• In case, add the missing codes in this extension

Options evaluated

Nullflavored section

• This seems to be the C-CDA suggested approach. The section are nullflavore with "NI" and only the text is present

  <section nullFlavor="NI">  <title> </text></section>

Pros:

1. Simple to model and common for all the sections

Cons:

1. Doubts on the actual semantic of this approach
2. implementers should look to different elements / attributes to get the right information about an element

Coded element

• The coded element that conveys the main information (e.g. the type of allergy) is used also for indicating that there are no info about it.

Pros:

1. Implementers access to the same element / attribute to get positive and "no infos" data

Cons:

1. Codes are not always available for all the cases (how to deal with these cases ?)
2. the approved C-CDA example for known absent uses the negationInd

Nullflavored entry

• The single nullflavored entry is provided.

   <section > <…> <entry> <act nullFlavor="NI">  <..> </section>

note: the act calls is used here only as example. the nullflavored element is the root elelent of the clincial statement (e.g. observation, supply,...)

Pros:

1. Simple to model and common for all the sections

Cons:

1. implementers should look to different elements / attributes to get the right information about an element

Comments

Kai Heitmann 2017-02-21 opinion: I doubt that a section is feasible to convey NO INFORMATION in a coded way AT ALL. I consider a section as a coded and labelled TEXT, not more. So the only thing I can convey is "No allergies" or "אין אלרגיות" (sorry for the Hebraic :-) in the section about allergies. If I want to code that no allergies are stated that needs to go into an entry.