CDA R3 Proposal - Append, Edit, Correct 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 we identified a hole in consistent machine markup for reports that are appended, edited, and corrected. These are frequent operations in the laboratory report setting. In some situations it may be sufficient to document in a comment what has changed between document versions, but policies and regulations can require greater documentation such as entire previous result documentation accompanying a new, updated result.

In conjunction with the IHE Lab Committee, we have identified the following use cases for CDA R3 work as we have not identified solutions in the current CDA R2:

• Use Case 1 – A laboratory report was issued on the wrong patient. Today two documents will be issued. For the correct patient, a new laboratory report shall be approved. For the wrong patient, the specification to represent the error in the CDA document and negate content has been left for future work.

• Use Case 2 – A laboratory report was issued with incomplete or incorrect non-result data, defined as the information found in the CDA Header or Specimen, such as the collection date and time. The results and result interpretation are unchanged by the addition, edit, or correction of non-result data. The specification to represent the change has been left for future work.

• Use Case 3 – A laboratory report was issued with incomplete or incorrect non-result data. In this case, the results and interpretation, defined as the information found in an observation, organizer, or media, are changed by the addition, edit, or correction of non-result data. The specification to represent the change and the interpretation impact has been left for future work.

• Use Case 4 – A laboratory report was issued with incomplete or incorrect result data. The specification to represent the change and the interpretation impact has been left for future work.

• Use Case 5 – A laboratory report was issued with incomplete or incorrect non-result and result data. The specification to represent the change and the interpretation impact has been left for future work.

Discussion

Bob Dolin 10/14/2008 - I think the RIM has what we need - we'd mainly want to add new actRelationship type codes into the EntryRelationship class.

Austin Kreisler 08/10/2009 - SDWG should consider consistency with the use of controlAct.

Resolution

(Resolution is to be recorded here and in the referenced minutes, which are the authoritative source of resolution).