Integrating the Healthcare Enterprise
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IHE Patient Care Coordination (PCC) Technical Framework 10 Volume 2
Revision 6.0
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Final Text
August 30, 2010
IHE Patient Care Coordination Technical Framework, Volume 2 (PCC TF-2): Transactions and
Content Profiles
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Rev. 6.0 Final Text 2010-08-30 Copyright © 2010: IHE International, Inc.
Contents
1 Preface to Volume 2 ................................................................................................................ 6 20
1.1 Intended Audience ............................................................................................................ 6
1.2 Related Information for the Reader .................................................................................. 6
1.2.1 How this Document is Organized ........................................................................... 7
1.2.2 Conventions Used in this Volume .......................................................................... 7
1.2.2.1 The Generic IHE Transaction Model ................................................................ 7 25
1.3 Copyright Permissions ...................................................................................................... 8
1.4 How to Contact Us ........................................................................................................... 8
2 Introduction .............................................................................................................................. 9
2.1 Relationship to Standards ................................................................................................. 9
2.2 Relationship to Product Implementations ...................................................................... 10 30
2.3 Relation of this Volume to the Technical Framework ................................................... 11
2.3.1 Content Modules ................................................................................................... 11
2.3.1.1 Document Content Module Constraints.......................................................... 13
2.3.1.2 Section Content Module Constraints .............................................................. 15
2.3.1.3 Entry and Header Content Modules Constraints ............................................ 17 35
2.3.1.4 ...................................... 18
2.3.1.5 ................................................................................. 18
3 IHE Transactions ................................................................................................................... 19
3.1 Cross Enterprise Document Content Transactions ......................................................... 19
3.1.1 View Option .......................................................................................................... 19 40
3.1.2 Document Import Option ...................................................................................... 19
3.1.3 Section Import Option........................................................................................... 20
3.1.4 Discrete Data Import Option ................................................................................. 20
4 IHE Patient Care Coordination Bindings .............................................................................. 21
4.1 Medical Document Binding to XDS, XDM and XDR ................................................... 22 45
4.1.1 XDSDocumentEntry Metadata ............................................................................. 22
4.1.1.1 XDSSubmissionSet Metadata ......................................................................... 28
4.1.1.2 Use of XDS Submission Set ........................................................................... 28
4.1.1.3 Use of XDS Folders ........................................................................................ 28
4.1.1.4 Configuration .................................................................................................. 28 50
4.1.2 Extensions from other Domains............................................................................ 28
4.1.2.1 Scanned Documents (XDS-SD) ...................................................................... 28
4.1.2.2 Basic Patient Privacy Consents (BPPC) ......................................................... 29
4.1.2.3 Laboratory Reports (XD-LAB) ....................................................................... 29
5 Namespaces and Vocabularies .............................................................................................. 31 55
5.1.1 IHE Format Codes ................................................................................................ 32
5.1.2 IHEActCode Vocabulary ...................................................................................... 33
5.1.3 IHERoleCode Vocabulary .................................................................................... 34
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6 PCC Content Modules ........................................................................................................... 35
6.1 Conventions .................................................................................................................... 35 60
6.2 Folder Content Modules ................................................................................................. 35
6.2.1 EDES Folder Specification ................................................................................... 36
6.2.2 APR Folder Specification ..................................................................................... 36
6.2.3 LDR Folder Specification ..................................................................................... 36
6.3 HL7 Version 3.0 Content Modules ................................................................................ 36 65
6.3.1 CDA Document Content Modules ........................................................................ 36
6.3.1.1 Medical Documents Specification 1.3.6.1.4.1.19376.1.5.3.1.1.1 ................... 36
6.3.1.2 Medical Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.2 ...................... 39
6.3.1.3 Referral Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.3 ...................... 40
6.3.1.4 Discharge Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.4 ................... 47 70
6.3.1.5 PHR Extract Specification 1.3.6.1.4.1.19376.1.5.3.1.1.5 ............................... 52
6.3.1.6 PHR Update Specification 1.3.6.1.4.1.19376.1.5.3.1.1.6 ............................... 61
6.3.1.7 Emergency Department Referral Specification 1.3.6.1.4.1.19376.1.5.3.1.1.10........................................................................................................................ 63
6.3.1.8 History and Physical Specification ................................................................. 69 75
6.3.1.9 Antepartum Summary Specification ............................................................... 69
6.3.2 CDA Header Content Modules ............................................................................. 69
6.3.2.1 Language Communication 1.3.6.1.4.1.19376.1.5.3.1.2.1 ............................... 69
6.3.2.2 Employer and School Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.2 ........................ 70
6.3.2.3 Healthcare Providers and Pharmacies 1.3.6.1.4.1.19376.1.5.3.1.2.3 .............. 72 80
6.3.2.4 Patient Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.4 ............................................... 74
6.3.3 CDA Section Content Modules ............................................................................ 76
6.3.3.1 Reasons for Care ............................................................................................. 76
6.3.3.1.1 Reason for Referral Section 1.3.6.1.4.1.19376.1.5.3.1.3.1 ........................ 77
6.3.3.1.2 Coded Reason for Referral Section 1.3.6.1.4.1.19376.1.5.3.1.3.2 ............. 77 85
6.3.3.1.3 Chief Complaint Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 ..................... 78
6.3.3.1.4 Hospital Admission Diagnosis Section 1.3.6.1.4.1.19376.1.5.3.1.3.3 ....... 78
6.3.3.2 Other Condition Histories ............................................................................... 79
6.3.3.2.1 History of Present Illness Section 1.3.6.1.4.1.19376.1.5.3.1.3.4 ............... 79
6.3.3.2.2 Hospital Course Section 1.3.6.1.4.1.19376.1.5.3.1.3.5 .............................. 80 90
6.3.3.2.3 Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6 ............................. 80
6.3.3.2.4 Discharge Diagnosis Section 1.3.6.1.4.1.19376.1.5.3.1.3.7 ....................... 81
6.3.3.2.5 History of Past Illness Section 1.3.6.1.4.1.19376.1.5.3.1.3.8 ..................... 82
6.3.3.2.6 Encounter Histories Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3 .................. 83
6.3.3.2.7 History of Outpatient Visits Section 1.3.6.1.4.1.19376.1.5.3.1.3.9 ........... 83 95
6.3.3.2.8 History of Inpatient Visits Section 1.3.6.1.4.1.19376.1.5.3.1.3.10 ............ 84
6.3.3.2.9 List of Surgeries Section 1.3.6.1.4.1.19376.1.5.3.1.3.11 ........................... 84
6.3.3.2.10 Coded List of Surgeries Section 1.3.6.1.4.1.19376.1.5.3.1.3.12 ................ 85
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6.3.3.2.11 Allergies and Other Adverse Reactions Section 1.3.6.1.4.1.19376.1.5.3.1.3.13 .................................................................... 86 100
6.3.3.2.12 Family Medical History Section 1.3.6.1.4.1.19376.1.5.3.1.3.14 ................ 87
6.3.3.2.13 Coded Family Medical History Section 1.3.6.1.4.1.19376.1.5.3.1.3.15 .... 88
6.3.3.2.14 Social History Section 1.3.6.1.4.1.19376.1.5.3.1.3.16 ............................... 88
6.3.3.2.15 Functional Status Section 1.3.6.1.4.1.19376.1.5.3.1.3.17 .......................... 89
6.3.3.2.16 Review of Systems Section 1.3.6.1.4.1.19376.1.5.3.1.3.18 ....................... 89 105
6.3.3.2.17 Hazardous Working Conditions Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1 90
6.3.3.2.18 Pregnancy History Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 .................... 90
6.3.3.2.19 Medical Devices Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5 ....................... 91
6.3.3.2.20 Foreign Travel Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6 .......................... 92
6.3.3.3 Medications ..................................................................................................... 92 110
6.3.3.3.1 Medications Section 1.3.6.1.4.1.19376.1.5.3.1.3.19 .................................. 92
6.3.3.3.2 Admission Medication History Section 1.3.6.1.4.1.19376.1.5.3.1.3.20 .... 93
6.3.3.3.3 Medications Administered Section 1.3.6.1.4.1.19376.1.5.3.1.3.21 ........... 94
6.3.3.3.4 Hospital Discharge Medications Section 1.3.6.1.4.1.19376.1.5.3.1.3.22 .. 95
6.3.3.3.5 Immunizations Section 1.3.6.1.4.1.19376.1.5.3.1.3.23 .............................. 95 115
6.3.3.4 Physical Exams ............................................................................................... 96
6.3.3.4.1 Physical Exam Section 1.3.6.1.4.1.19376.1.5.3.1.3.24 .............................. 96
6.3.3.4.2 Physical Exam Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 ........................... 97
6.3.3.5 Relevant Studies............................................................................................ 120
6.3.3.5.1 Results Section 1.3.6.1.4.1.19376.1.5.3.1.3.27 ........................................ 120 120
6.3.3.5.2 Coded Results Section 1.3.6.1.4.1.19376.1.5.3.1.3.28 ............................. 120
6.3.3.5.3 Hospital Studies Summary Section 1.3.6.1.4.1.19376.1.5.3.1.3.29 ......... 121
6.3.3.6 Plans of Care ................................................................................................. 122
6.3.3.6.1 Care Plan Section 1.3.6.1.4.1.19376.1.5.3.1.3.31 .................................... 123
6.3.3.6.2 Assessment and Plan Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 ............ 123 125
6.3.3.6.3 Discharge Disposition Section 1.3.6.1.4.1.19376.1.5.3.1.3.32 ................ 124
6.3.3.6.4 Discharge Diet Section 1.3.6.1.4.1.19376.1.5.3.1.3.33 ............................ 124
6.3.3.6.5 Advance Directives Section 1.3.6.1.4.1.19376.1.5.3.1.3.34 .................... 125
6.3.3.6.6 Coded Advance Directives Section 1.3.6.1.4.1.19376.1.5.3.1.3.35 ......... 125
6.3.3.6.7 Transport Mode Section 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 .................... 126 130
6.3.3.7 Administrative and Other Information.......................................................... 127
6.3.3.7.1 Payers Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7 ..................................... 127
6.3.3.7.2 Referral Source Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3 ..................... 128
6.3.3.7.3 Transport Mode Section 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 .................... 128
6.3.3.7.4 ED Disposition Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10 ................... 129 135
6.3.4 CDA Entry Content Modules.............................................................................. 130
6.3.4.1 Authors and Informants ................................................................................ 130
6.3.4.2 Linking Narrative and Coded Entries ........................................................... 131
6.3.4.3 Severity 1.3.6.1.4.1.19376.1.5.3.1.4.1 .......................................................... 133
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6.3.4.4 Problem Status Observation 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 ........................ 135 140
6.3.4.5 Health Status 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 ............................................... 137
6.3.4.6 Comments 1.3.6.1.4.1.19376.1.5.3.1.4.2 ...................................................... 139
6.3.4.7 Patient Medication Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3 ..................... 142
6.3.4.8 Medication Fulfillment Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3.1 ........... 144
6.3.4.9 External References 1.3.6.1.4.1.19376.1.5.3.1.4.4 ....................................... 145 145
6.3.4.10 Internal References 1.3.6.1.4.1.19376.1.5.3.1.4.4.1 ..................................... 147
6.3.4.11 Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.1 ............................................. 148
6.3.4.12 Problem Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.2............................... 151
6.3.4.13 Allergy and Intolerance Concern 1.3.6.1.4.1.19376.1.5.3.1.4.5.3 ................ 152
6.3.4.14 Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5 ................................................ 154 150
6.3.4.15 Allergies and Intolerances 1.3.6.1.4.1.19376.1.5.3.1.4.6.............................. 159
6.3.4.16 Medications 1.3.6.1.4.1.19376.1.5.3.1.4.7 .................................................... 162
6.3.4.17 Immunizations 1.3.6.1.4.1.19376.1.5.3.1.4.12.............................................. 174
6.3.4.18 Supply Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.3 ............................................... 177
6.3.4.19 Product Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.2 .............................................. 180 155
6.3.4.20 Simple Observations 1.3.6.1.4.1.19376.1.5.3.1.4.13 .................................... 182
6.3.4.21 Vital Signs Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.1 ................................ 185
6.3.4.22 Vital Signs Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.2 ............................ 186
6.3.4.23 Family History Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.15 ............................ 188
6.3.4.24 Social History Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.4 ....................... 191 160
6.3.4.25 Pregnancy Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 ............................. 193
6.3.4.26 Pregnancy History Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.5.1 ................. 195
6.3.4.27 Birth Event Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.5.2 ............................ 197
6.4 HL7 Version 2.0 Content Modules For care management .......................................... 200
6.5 PCC Value Sets ............................................................................................................ 200 165
6.5.1 APR H&P History of Past Illness Value Set ..................................................... 200
6.5.2 APR H&P Social History Value Set ................................................................... 200
Examples Using PCC Content Profiles....................................................................................... 200
Validating CDA Documents using the Framework ................................................................... 200
A.1 Validating Documents .................................................................................................. 201 170
A.2 Validating Sections ....................................................................................................... 203
A.3 Phases of Validation and Types of Errors .................................................................... 204
Extensions to CDA Release 2.0 .................................................................................................. 205
A.4 IHE PCC Extensions .................................................................................................... 205
A.4.1 replacementOf ..................................................................................................... 206 175
A.5 Extensions Defined Elsewhere used by IHE PCC ....................................................... 206
A.5.1 Entity Identifiers ................................................................................................. 207
A.5.2 Patient Identifier.................................................................................................. 207
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Rev. 6.0 Final Text 2010-08-30 Copyright © 2010: IHE International, Inc.
1 Preface to Volume 2
1.1 Intended Audience
The intended audience of this document is:
Technical staff of vendors planning to participate in the IHE initiative
IT departments of healthcare institutions 185
Experts involved in standards development
Anyone interested in the technical aspects of integrating healthcare information systems
1.2 Related Information for the Reader
The reader of volume 2 should read or be familiar with the following documents:
Volume 1 of the Cross-Enterprise Document Sharing (XDS) Integration Profile 190 documented in the ITI Infrastructure Technical Framework (See http://www.ihe.net/Technical_Framework/index.cfm).
Volume 1 of the Notification of Document Availability (NAV) Integration Profile documented in the ITI Infrastructure Technical Framework (See http://www.ihe.net/Technical_Framework/index.cfm). 195
Volume 1 of the Audit Trail and Node Authentication (ATNA) Integration Profile documented in the ITI Infrastructure Technical Framework (See http://www.ihe.net/Technical_Framework/index.cfm).
HL7 Clinical Document Architecture Release 2: Section 1, CDA Overview.
Care Record Summary – Implementation Guide for CDA Release 2 (US Realm): Section 200 1
Presentations from IHE Workshop: Effective Integration of the Enterprise and the Health System - June 28–29, 2005: http://www.ihe.net/Participation/workshop_2005.cfm, June 2005:
For a RHIO-3.ppt Leveraging IHE to Build RHIO Interoperability 205
Cross-Enterprise Document Sharing (XDS)
Notification of Document Availability (NAV)
Use Cases for Medical Summaries
Ovrw.ppt Patient Care Coordination - Overview of Profiles
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IHE Patient Care Coordination Technical Framework, Volume 2 (PCC TF-2): Transactions and
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Rev. 6.0 Final Text 2010-08-30 Copyright © 2010: IHE International, Inc.
1.2.1 How this Document is Organized
Section 1 is the preface, describing the intended audience, related resources, and organizations and conventions used within this document.
Section 2 provides an overview of the concepts of IHE actors and transactions used in IHE to define the functional components of a distributed healthcare environment. 215
Section 3 defines transactions in detail, specifying the roles for each actor, the standards employed, the information exchanged, and in some cases, implementation options for the transaction.
Section 4 defines a set of payload bindings with transactions.
Section 5 defines the content modules that may be used in transactions. 220
1.2.2 Conventions Used in this Volume
This document has adopted the following conventions for representing the framework concepts and specifying how the standards upon which the IHE Technical Framework is based should be applied.
1.2.2.1 The Generic IHE Transaction Model 225
Transaction descriptions are provided in section 4. In each transaction description, the actors, the roles they play, and the transactions between them are presented as use cases.
The generic IHE transaction description includes the following components:
Scope: a brief description of the transaction.
Use case roles: textual definitions of the actors and their roles, with a simple |
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