IPS NoInfos section

Introduction

It has been discussed in the group the best way to express the absence of information about a specific section (e.g. no data about allergies, I don't know anything about medications), since templates evaluated seem to propose different approaches for this.

Note: This is different from the case "at the best of my knowledge I'm not aware about allergies for this patient".

This problem mainly applies for mandatory sections.

The solution should be the same for all the sections.

Cases to be covered

1. No info about allergies/intollerances
2. No info about medications
3. No info about problems
4. No info about procedures
5. No info about medical devices, implants

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
• Facilitate 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) indipendently by the fact they are looking for a positive assertions, 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	???	716186003 | No known allergy (situation) OR other more specific concepts (e.g. NKDA) see note2
Medications	182904002 | Drug treatment unknown (finding) (see note1) No, we need a situation here.	182849000 | No drug therapy prescribed (situation) OR 408350003 | Patient not on self-medication (finding)
Problems	396782006 | Medical history unknown (situation)	160245001 | No current problems or disability (situation) (tentative FM)
Procedures	399714002 | Procedure status unknown (situation) (tentative FM)	416128008 | No history of procedure (situation) (tentative FM)
Medical devices, implants	concept "Presence of implanted device not known (situation)" to be created in HL7 Int extension (tentative FM)	concept "No implant in situ (situation)" to be created in HL7 Int extension (tentative FM)

Note1: is this correct ? does it mean that there is a treatment that is unknown ? or are the "drug treatments" unknown ? (GC)
The concepts in the left column o this matrix should come from the Situation with explicit context hierarchy, not Clinical finding, and should be defined with the value "Unknown (qualifier value)" for the "finding context" or "procedure context" attribute. (FM)

Note2: what about "no known allergies or intolerances" ?

To Do

• Search for possible candidates in existing code systems
• Define the missing codes to be added
• Evaluate the request to have an HL7 extension in SNOMED CT
• 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

Contras:

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

Contras:

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

Contras:

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.