TermInfo - CCDA sample for No Immunization administered (email thread)

4 April 2013

Vinayak Kulkarni

• I am looking for an example of "No Immunization Administered". Since we have CVX code fore "No Vaccine Administered" with Code = 998, shall we use it without using negationInd="true"?

Is following sample is a valid example?

<section>
 <templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
 <code code="11369-6" codeSystem="2.16.840.1.113883.6.1" displayName="History of immunizations" codeSystemName="LOINC"/>
 <title>Immunizations</title>
 <!--**** Immunzations Section Narrative Block ****-->
 <text>
  <paragraph>
   <content ID="ZImmunizations.Immunizations.ORD-PHL02-NO-DATA">No immunizations administered or ordered.</content>
  </paragraph>
 </text>
 <entry typeCode="DRIV">
  <!--**** Immunzations Section Narrative Block ****-->
   <substanceAdministration classCode="SBADM" moodCode="INT" negationInd="false">   
   <templateId root="2.16.840.1.113883.10.20.22.4.52"/>
   <id nullFlavor="NI"/>
   <statusCode code="completed"/>
   <effectiveTime nullFlavor="NI"/>
   <consumable>
    <manufacturedProduct classCode="MANU">
     <templateId root="2.16.840.1.113883.10.20.22.4.54"/>
     <manufacturedMaterial>
       <code code="998" displayName="No Immunization administered" codeSystem="2.16.840.1.113883.12.292" codeSystemName="CVX"/>    
     </manufacturedProduct>
   </consumable>
  </substanceAdministration>
 </entry>
</section>

Lisa Nelson

• Vinayak,

Two things I notice about the sample you provided:

1. The moodCode=”INT” says, the entry is intended or planned. I don’t think that represents the right verb tense for the act. I think you need moodCode=”EVN”. (see table below for options)
2. I prefer to see examples include information in the effectiveTime element. I think you should explicitly think through the effectiveTime element and show if there should be a low or high or both, etc., just to make sure the longitudinal aspect of things doesn’t complicate the analysis.

Finally, I know these issues of semantics always open a large can of worms, but….

I think we have a vocabulary issue here. When the term is not just a clean “noun concept”, the semantics of what we are saying gets really messy and confusing. See how the concept includes the notion of the act (the verb) “baked in”, so to speak. The action concepts of “administered” and “ordered” are acts that I think our CDA architecture intends for us to represent in our act statements. Using the substance administration act already gives us the action concept of “administering a substance”. We have the moodCode attribute to control the verb tense of that action. Now, when we plug in the noun, we really need a term that is free from the other “conceptual clutter” of verbs or timeframes. So, I’m sorry to say, I think the code you are using makes for a problematic clinical statement that is necessarily ambiguous. Am I preaching to the choir, barking up the wrong tree, or being too idealistic in my expectations of what we should be aiming to accomplish with our machine readable data?

Lisa

This table is from the CDA R2 standard. It shows the moodCode attribute valueSet for CDA R2. Further constraints may be included in specific templates, but this is the initial starter set of possible moodCodes for SubstanceAdministration:

Table 109: Value set for SubstanceAdministration.moodCode (CNE)
Code	Definition
EVN (event)	The entry defines an actual occurrence of an event.
INT (intent)	The entry is intended or planned.
PRMS (promise)	A commitment to perform the stated entry.
PRP (proposal)	A proposal that the stated entry be performed.
RQO (request)	A request or order to perform the stated entry.

Tom de Jong

• Dear Vinayak,

I am not an expert in the modelling of immunizations, but Pharmacy WG and PHER WG have always shared the opinion that we should treat vaccines just like ‘regular’ medicines. Having said that, and please don’t take this personally, the example below is a semantic monstrosity. One thing is clear ‘No Immunization administered‘ is not a manufactured material. You can’t administer ‘No Immunization administered‘ as a vaccine, you can’t even NOT administer it. The proper way to represent this using SBADM is by either using a SBADM.code that represents ‘immunization’ (as a general concept) or having a manufactured material code that represents all vaccines (i.e. ‘vaccine’ as a general concept). The resulting substance administration can then be negated to express that there was no occurrence of an administration of a vaccine (i.e. no immunization).

By the way, this is the same method that was used to represent ‘no known medication’ in the context of C-CDA (at least while I was involved).

I copied PHER WG, since I strongly believe domain-specific concepts should be represented consistently, regardless of the exchange mechanism.

Best wishes,

Tom

Jean Duteau

• I agree with Tom.

Since you're not asserting that any specific vaccine/immunization did not occur, I would leave out the manufacturedMaterial altogether and just set negationInd to true and possibly use a code in the SBADM to indicate that it was an immunization. The other thing is that the mood needs to be EVN or you are just saying "we do not intend to give any immunizations".

  <!--**** Immunzations Section Narrative Block ****-->
   <substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="TRUE">   
   <templateId root="2.16.840.1.113883.10.20.22.4.52"/>
   <id nullFlavor="NI"/>
   <statusCode code="completed"/>
   <effectiveTime nullFlavor="NI"/>
  </substanceAdministration>

Thanks,

Jean Duteau