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===PAYER=== | ===PAYER=== | ||
* Policy Activity referencing the holder's employer providing the policy(via GitHub) | * Policy Activity referencing the holder's employer providing the policy(via GitHub) | ||
− | ** Approved by: | + | ** Approved by: Sample not yet reviewed |
** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required)] | ** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required)] | ||
** CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] | ** CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] |
Revision as of 23:55, 1 April 2014
SDWG formed the CDA template example task force to collect and share member submitted samples. The committee is currently hosting bi-weekly meetings on Thursdays from 12-1 PM Eastern. Subscribe to the SDWG listserv for more information.
Contents
Formatting of CDA Template Samples
PROTOTYPIC TEMPLATE
- Meaningful template example name (hyperlinked)
- Approved by: (list all approving bodies, including approval date)
- TemplateId(s) illustrated: (include hyperlinks where possible)
- CDA Implementation Guide where template(s) is(are) defined: (include hyperlinks where possible)
- Reference to full CDA sample: Full example in validated document (hyperlinked)
- Custodian: (who is the steward of the referenced sample? include email address)
- Validation location: (list of all validators tested against)
- Comments: (free text comments about the example)
Examples - Organized by Section
ALLERGIES AND ADVERSE REACTIONS
- No Known Allergies with Author Timestamp (GitHub)
- Approved by: Task force on 1/9/2014. Approved by SDWG 1/16/2014.
- TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: No Known Allergies in compliant MU2 Sample (via GitHub)
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of how an author can record a patient has no known allergies.
- Allergy to specific substance (cat hair)
- Approved by: Not yet approved.
- TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example with warning since severity only reported at allergy level, not reaction specific
- Reference to full CDA sample: Allergies in empty CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: TTT Validator
- Comments: This is an example of an allergy to a specific substance (cat hair) using UNII as terminology with information on both allergic reaction and allergy severity.
- Allergy to specific drug (penicillin)
- Approved by: Not yet approved.
- TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example with warning since severity only reported at allergy level, not reaction specific
- Reference to full CDA sample: Allergies in empty CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: TTT Validator
- Comments: This is an example of an allergy to a specific drug (penicillin) using RxNorm as terminology with information on both allergic reaction and allergy severity. For drug allergies, this example illustrates a good practice of encoding the allergen at the ingredient level (penicillin) not administration level (10 mg tablet).
- Allergy to drug class (penicillins)
- Approved by: Not yet approved.
- TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example with warning since severity only reported at allergy level, not reaction specific
- Reference to full CDA sample: Allergies in empty CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: TTT Validator
- Comments: This is an example of an allergy to a drug class (penicillins) using NDF-RT as terminology with information on both allergic reaction and allergy severity.
GENERAL PATTERN - NO INFORMATION
- No Information Problems Section (via GitHub)
- Status: Approved on task force 1/30/2014; Approved by SDWG on 2/6/2014.
- TemplateId(s) illustrated: Problem Section with Coded Entries(2.16.840.1.113883.10.20.22.2.5.1)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example (although not by MU2 validator today)
- Reference to full CDA sample: No Information Problem section
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of how an author can record a section contains No Information. This is an exceptional case and does not cover 'No Known' scenarios. See No Known Allergies with Author Timestamp (GitHub) for an example of 'No Known'.
IMMUNIZATIONS
- Unknown Patient Immunization Status (via GitHub)
- Approved by: Task force on 11/21/2013. Approved by SDWG 12/5/2013.
- TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Immunization section in compliant MU2 C-CDA sample
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of how an author can record they do now know whether the patient has received any vaccinations.
MEDICATIONS
- Patient prescribed oral medication QID PRN without precondition specified
- Approved by: Task force on 1/9/2014.
- TemplateId(s) illustrated: Medication Activity Medication Information Precondition for Substance Administration (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example when PRN but no precondition specified
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- Keywords: Precondition, Pre-coordinated medication code, dose frequency
- Comments: This is an example of a medication which is QID and PRN (as needed) but with no precondition specified. It was generated based on SDWG list-serv discussion in December 2013. It also demonstrated a pre-coordinated generic medication coded at the SDC level (generic 600mg Oral Tablet) in RxNorm hierarchy.
- Patient prescribed medication every 4 to 6 hours
- Approved by: Task force 1/30/2014. Approved by SDWG on 2/6/2014.
- TemplateId(s) illustrated: Medication Activity Medication Information (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 12, 2014
- Keywords: Dose frequency, pre-coordinated medication
- Comments: This is an example of a medication (Sudafed) which to be administered every 4-6 hours, a common dosing pattern. Representing the range of potential of hours is done through a low and high child element of the period within effectiveTime of PIVL_TS.
- Patient prescribed oral antibiotic with a dosing regimen that varies over course of prescription (loading or tapered dosing)
- Approved by: Task force on 3/6
- TemplateId(s) illustrated: Medication Activity Medication Information
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 12, 2014
- Keywords: Pre-coordinated medication code, dose frequency, tapered dose, loading dose
- Comments: This is an example of a common pattern for antibiotic administration which is complex (double dose on day 1, commonly known as Z-PAK). There was SDWG discussion of an appropriate means to structure this information in February 2014. This dosing regimen may be characterized as a loading dose, but a similar approach could be used for a tapered dose as well.
- Patient prescribed basal insulin administered at bedtime
- Approved by: Not yet approved
- TemplateId(s) illustrated: Medication Activity Medication Information
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 27, 2014
- Keywords: Pre-coordinated medication code, dose frequency
- Comments: This is an example of a subcutaneous dose of a common basal insulin. Please note that this insulin dosage does not vary. This dose is administered at bedtime so the dosing frequency utilizes EIVL_TS type to denote this.
- Single administration of medication (at single point in time)
- Approved by: Task force on 3/13
- TemplateId(s) illustrated: Medication Activity Medication Information
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: This timing information will not currently validate since it does not use IVL_TS type.
- Keywords: Pre-coordinated medication code, single administration, point in time
- Comments: This is an example of two baby aspirin being administered at a single point in time. At the January 2014 San Antonio meeting of HL7, this approach was decided as appropriate for medication timing of a point in time. This will not currently validate, but C-CDA 1.1 DSTU 423 states that changes will be made to accommodate value within time effectiveTime element (not just low/high children).
- No Medications (full sample)
- Approved by: Task force on 3/13.
- TemplateId(s) illustrated: Medication Activity 2.16.840.1.113883.10.20.22.4.16
- CDA Implementation Guide where template(s) is(are) defined: C-CDA R1.1
- Reference to full CDA sample: Sample is full file
- Custodian: Brett Marquard
- Validation location: TTT TOC Ambulatory
- Comments:
- Alternate Opinion: 1 Task Force member voted against approving this samples. In her opinion, the narrative text did not convey the same semantic meaning as the information represented in the structured data. For additional information on this point of view, see the sample titled, "XXXXX" in the "Unapproved Samples" area below.
PROBLEMS
- Patient with No Known Problems - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)
- Approved by: Task force on 2/27, SDWG on 3/6.
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- CDA Implementation Guide where template(s) is(are) defined: C-CDA R1.1
- Reference to full CDA sample: Full Sample No Known Problems
- Custodian: Brett Marquard
- Validation location: TTT VDT Ambulatory
- Comments:
- Complaint of No foot pain - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)
- Status: Not Yet Reviewed
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- CDA Implementation Guide where template(s) is(are) defined: C-CDA R1.1
- Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Doc-No%20Known%20Problems%2020140203.xml
- Custodian: Lisa R. Nelson LisaRNelson@cox.net
- Validation location: TTT
- Comments: This one shows use of Observation.ValueNegationInd
- No Complaint of foot pain - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)
- Status: Not Yet Reviewed
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- CDA Implementation Guide where template(s) is(are) defined: C-CDA R1.1
- Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Doc-No%20Known%20Problems%2020140203.xml
- Custodian: Lisa R. Nelson LisaRNelson@cox.net
- Validation location: TTT
- Comments: This one shows use of Act.NegationInd
RESULTS
- Result with less than a specified value (via GitHub)
- Approved by: Reviewed with SDWG on 12/5/2013. Patrick will review with OO and report back.
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- Comments: This is an example of how to encode "less than" a specific range when returned from lab equipment. The example is for BNP, an immunoassay where the lower threshold for detection is often 5 pg/mL. The lower bound of the interval is zero in this example, even though this is none may be specified, since zero is the lower bound for measures of physical quantity. This example also includes a structured reference range.
- Result with greater than a specified value (via GitHub)
- Approved by: Not yet reviewed. Based on SDWG request from Kumara February 2014.
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Not yet completed
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: Not yet validated
- Comments: This is an example of how to encode "greater than" a specific range when returned from lab equipment. The example is for a point-of-care glucometer, which measures blood sugar for diabetics. Often these devices may have an upper bound, 500 mg/dL is shown in this example. The upper bound of the interval is positive infinity in this example. This example also includes two structured reference ranges for normal and high.
- Result panel with the display of two ordinal values of negative/positive
- Approved by: Task force on 11/21/2013. Ready for SDWG review.
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- Comments: This is an example of how to encode positive and negative, which are common data types returned form lab equipment. While some technologies may represent this as a type of ST (string), it is logical and easily possible to encode this information using SNOMED-CT. This would allow structured examination of this information downstream as well as comparison to a structured reference range, as shown in the example.
- Result with an unstructured string as the value (e.g. urine color)
- Approved by: Not yet approved
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- Comments: This is an example of a value from a lab result that may not be structured.
- Result which requires translation for its unit represented in UCUM
- Approved by: Task force on 2/27, SDWG on 3/6.
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 12, 2014
- Comments: This is an example of a value from a lab which requires a translation for its unit. All units for physical quantities should be represent in UCUM.
- Result with a pending component
- Approved by: Not yet approved
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Result in C-CDA Section
- Custodian: Ed Donaldson, ed.donaldson@greenwayhealth.com (GitHub: donaldson-ed)
- Validation location: NIST TTT validator for Clinical Office Visit Summary - Clinical Summary validated March 5, 2014
- Comments: Result with a pending component.
PAYER
- Policy Activity referencing the holder's employer providing the policy(via GitHub)
- Approved by: Sample not yet reviewed
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Sample not yet reviewed
- Reference to full CDA sample:
- Custodian: Lisa R. Nelson, lisarnelson@cox.net (GitHub: lisarnelson)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- Comments: This is an example of how to encode the policy holder's employer through which the insurance is provided
KNOWN BAD EXAMPLES
- Future bad examples will go here.
FEEDBACK AND AWAITING RESPONSE
- Result with less than a specified value (via GitHub)- Awaiting review from Patrick Lloyd with OO
COMMUNITY REQUESTS FOR EXAMPLES (include name, email)
- I would like an example of a preliminary lab result (John Doe, JohnDoe@email.com)
- The SMART C-CDA Collaborative generated a list of approximately 50 requested samples here. See the section noted as "Annotated Examples." For more information on the SMART C-CDA Collaborative please visit here. (Ashley Swain, ashley.swain@lantanagroup.com, John D'Amore, jdamore@diameterhealth.com, Josh Mandel, jmandel@gmail.com)
DRAFT MATERIAL - PLEASE DON'T DELETE
How to Setup an XML example from GitHub
- Sign up for GitHub account. It's free and quick
- Once you've got an account, you will be able to fork repositories and comment on examples through the website
- To post and manage examples, you will likely want to install a graphical user interface for GitHub. Here's where you can download: For Windows or For Mac
- Once you've got the application installed, there are a few steps:
- Click the "create" button to make a repository where you would like to upload/update to GitHub
- Once you've created, the repository will exist online and on your local machine
- On your local machine, place in new or revised files in the local folder (this will generally be under Documents/GitHub). It's good practice to include a text file named README.md, which appears online when people browse your repository. This is a good place to explain what you're working on.
- Once you've made the edits (or new files) you want to post to GitHub, "commit" the sample entering a description and then hit the "sync" button to upload
- At this point the changes and new files are posted online publicly
- For an example GitHub repository with C-CDA samples, check out this one from Children's Hospital Boston
- Add instructions for how to upload examples (to github, to other sites)
- Add examples (to site of your choosing)
- Add link and metadata too
- enumerated lists
- validators
- approving bodies
- SDWG
- Infoway
- NHS
- validators
HOW TO PREPARE A SAMPLE FOR APPROVAL BY SDWG
Observing these guidelines will streamline the process for all involved.
- Include XML comments that will:
- Make assumptions explicit
- Annotate each lines
- Highlight choices and key decisions that were made
- Confirm statusCode/moodCode/effectiveTime are in agreement
- Snippet should be in the context of a section
- Confirm narrative to match entries - and content is linked
- Does final sample name accurately reflect the final sample
- Add disclaimer at the top of every sample: SAMPLE DEVELOPED BY HL7 SDWG SAMPLES TASK FORCE - PLEASE SEE http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force FOR ADDITIONAL DETAILS
- Patient with allergies to different substances (via GitHub)
- Approved by: Not yet approved
- Patient taking pre-coordinated medication (via GitHub)
- Approved by: Not yet approved
- Copy and paste the template below, and complete for your sample
- Allergy to Substance X
- Approved by: SDWG (Oct 31, 2013); NHS (Oct 31, 2013)
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.30; 2.16.840.1.113883.10.20.22.4.7
- CDA Implementation Guide where template(s) is(are) defined: C-CDA R2
- Reference to full CDA sample: N/A
- Custodian: John Doe (John.Doe@email.com)
- Validation location: validator.com
- Comments: This is the best example EVER!