International Patient Summary
This document contains: Implementation Guide International Patient Summary (0.10). The text materials belong to category cdaips.
based on Clinical Document Architecture Release 2
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Contents
- 1 Introduction
- 2 Principles and background
- 2.1 IPS Principles
- 2.2 What is a CDA
- 2.3 Templated CDA
- 2.4 Open and Closed Templates
- 2.5 Template versioning
- 2.6 Identifiers for Templates and Value Sets
- 2.7 Terminologies
- 2.8 Datatypes used in this guide
- 2.9 Design conventions and principles
- 2.10 Provenance
- 2.11 General Implementation Guidance
- 2.12 Reading Guide
- 3 Conformance clause
- 4 Functional requirements and high-level use cases
- 5 Appendix
- 6 List of all artifacts used in this guide
- 7 Examples (in progress)
Introduction
The international patient summary is a minimal and non-exhaustive patient summary, specialty-agnostic, condition-independent, but readily usable by clinicians for the cross-border unscheduled care of a patient.
Purpose
The goal of this Implementation Guide is to identify the required clinical data, vocabulary and value sets for an international patient summary. The primary use case is to provide support for cross-border emergency and unplanned care.
The international patient summary is specified as a templated document using HL7 CDA R2. The specification has taken account of how FHIR STU3 represents equivalent concepts and in some cases has followed a FHIR style of representation rather than a conventional CDA style. The variations from CDA R2 are explained in the relevant detail sections. The mechanism for negation, unknown data and known absent data does not follow the CDA conventions and is explained here.
This specification aims to support:
- Cross-jurisdictional patient summaries (through adaptation/extension for multi-language and realm scenarios, including translation).
- Emergency and unplanned care in any country, regardless of language.
- Where possible, value sets based on international vocabularies that are usable and understandable in any country.
- Data and metadata for document-level provenance.
The international patient summary defines SNOMED CT as the primary terminology (the meaning of "primary terminology" is explained in a later section) for the majority of value sets, but uses LOINC for laboratory tests, UCUM for units of measure and EDQM for dose forms and routes.
Background
This Implementation Guide has drawn upon the results of multiple previous projects on patient summaries (including but not limited to epSOS, ONC, Trillium Bridge, eHealth Exchange), rules and recommendations for vocabularies and value sets (in multilingual settings) and templates for the implementation of international patient summary documents. In particular, the white paper on Comparative Analysis Between HL7 C-CDA R1.1 CCD and epSoS PS v1.4 informed the development of this specification.
In 2010 a MoU was signed between the European Union (EU) and the United States (US) to strengthen global cooperation in eHealth/Health. As a result, the ONC S&I Interoperability of EHR work group was launched in the US in 2013 (http://wiki.siframework.org/EU-US+eHealth+Cooperation+Initiative) and the Trillium Bridge Project (www.trilliumbridge.eu) was initiated in the EU. The aim was to compare the CDA templates then specified in the EU (epSOS PS V1.4) and in the US (MU – C-CDA CCD v1.1) for patient summaries and to build a transatlantic exchange proof of concept. These initiatives identified the need for common templates and vocabularies for the patient summary. The following recommendation was endorsed by the Joint Initiative Council and by the HL7 International Council: “to advance an International Patient Summary (IPS) standard and enable people to access and share their health information for emergency or unplanned care anywhere and as needed. At minimum the IPS should include immunizations, allergies, medications, clinical problems, past operations and implants.” The Joint Initiative Council (JIC) on SDO Global Health Informatics Standardization has initiated the standard sets project with patient summary as its pilot.
The EU eHealth Digital Service Infrastructure (eHDSI) project for the operational deployment of the EU cross-borders services was launched in 2016. ART-DECOR® and the HL7 STU template exchange format are increasingly used by European countries, including for the European patient summary (epSOS) templates, so has been adopted as the specification platform for this Implementation Guide.
Scope
to be written
...a minimal and non-exhaustive patient summary, which is specialty-agnostic and condition-independent, but still clinically relevant. ...global use
Ballot Status of the Document
This Implementation Guide is STU with the intention to go normative.
Audience
The audience for this Implementation Guide includes:
Public
- Citizens who want to carry or access their healthcare data for emergency care purposes.
Regulatory
- Policy makers such as healthcare payers or government agencies.
- Healthcare information governance authorities and regulatory bodies.
Clinical
- Healthcare providers that offer unscheduled and emergency care.
- Healthcare providers that populate regional and national patient summaries.
Technical
- Vendors of EHRs unplanned care system, personal health records and mobile health data applications.
- System integrators.
- Organizations that manage regional and national patient summaries.
Relationships with other projects and guidelines
- CEN/TC 251 Project International Patient Summary
- epSOS/EXPAND/eHDSI
- Consolidated CDA (C-CDA)
- IHE-PCC
- Input from the EHR work group about how to define the source(s) of the IPS content, described in the provenance section .
How to read this document
- Kai to write a paragraph
- Balloter instructions
Principles and background
IPS Principles
HL7 International and CEN/TC 251 have agreed the following vision and scope for the international patient summary:
Vision: a single, common International Patient Summary (IPS) specification that is readily usable by all clinicians for the (cross-border) unscheduled care of a patient.
Scope: a minimal and non-exhaustive patient summary, which is specialty-agnostic and condition-independent, but still clinically relevant.
The HL7/CEN agreement identified the following principles for the IPS:
A. The standards specification for the IPS will be implementable
- Promote (the evolution and convergence of) existing standards
- Rely on solutions that are already implemented or ready for implementation
- Consider new or additional solutions as they become available
B. The standards specification for the IPS will be applicable for global use
- Strive for global accessibility of standards for free
- Strive for a core set of globally accessible and usable terminologies and value sets
- Include free text in addition to the structured codes as needed
- Do not include local solutions in the core specification that are not available in other jurisdictions
C. The standards specification will be extensible and open to future use cases and solutions
- The IPS provides common content that can be extended and specialized for other use cases, or localized for specific jurisdictional needs
- The IPS is open to emerging solutions for unresolved issues or improvements
D. The standards specifications and their implementation must be sustainable through:
- A robust maintenance and update process for the IPS
- A process to ensure clinical validity of the IPS, meeting:
- clinical requirements (including workflow)
- clinical documentation requirements
- information quality requirements
E. We will manage the expectations of the IPS standards specifications among stakeholders, by
- stipulating the role of the IPS as a foundation for others to extend
- justifying the inclusion of items in the IPS within the limited context of unplanned (cross-border) care.
What is a CDA
from famous sources like C-CDA
Templated CDA
from famous sources like C-CDA, Templates Standard
Open and Closed Templates
from famous sources like C-CDA, Templates Standard
Template versioning
from famous sources like Templates Standard
Identifiers for Templates and Value Sets
Some hints
- OIDs for Templates and Value Sets
- coming fro the HL7 OID Registry, mention the branches
Terminologies
Some hints
- Focus on Value Sets, as they are the main artefacts used for validation
- General Info about Terminology Binding
How to extend Value Sets
- ? Coded with Extensibility / no Extensions ? or other topics ?
- If needed: Example binding
Datatypes used in this guide
(This will be a list from ART-DECOR)
Design conventions and principles
How to use terminology (preferred binding)
Notion of "Primary Code"
Usage of translations
Principle on negations, data known absent and data unknown
This specification represents negations, known absent data and unknown data by leveraging the expressiveness of SNOMED CT to use explicit coded elements rather than negation indicators or null flavours. In some cases this requires the creation of new SNOMED CT concepts. For example, a known absent Allergy/Intolerance would be represented by "716186003 |No known allergy (situation)|" (or any combination of its descendants), whereas no information about Allergy/Intolerance would be represented by a code with the meaning "Allergic disposition not known (situation)".
- See Paris slides
- Usage of negations
- The choice for negation it is not that of using negation indicator @negationInd but rely on the terminologies to do this
- @negationInd in CDA has been superseded in V3 later by two other negation indicators: actNegationInd valueNegationInd
- Alignment with FHIR
The representation of “condition/activity unknown” and of “condition/activity known absent”is normalized for the IPS by leveraging the expressiveness of SNOMED CT as opposed to relying on specific mechanisms of the underlying syntactical standard (such as nullFlavor and negationInd for CDA). The main rationale for this choice is to provide one single method to express either the presence or absence of a particular condition (e.g., an allergy) or activity (e.g., an immunization), or the lack of knowledge regarding this kind of condition or activity, resulting in a more robust and easily implementable specification. The other rationale is to have a representation of the clinical content of the patient summary which is less dependent on a particular format or syntax, enabling a more practical path to transforming and exchanging data from one standard format (e.g., CDA R2) to another (e.g., FHIR).
Medicinal Product Identifications
Medication Statement
Provenance
In the development of this Implementation Guide, consideration was given to the HL7 CDA® Release 2 Implementation Guide: Data Provenance, Release 1 - US Realm Draft Standard for Trial Use (December 2015). That guide provides a matrix offering a thorough and systematic analysis of provenance characteristics of electronic health records. Given the agreed scope principle that the IPS be minimal and implementable, and the variable maturity and operational methods of existing national patient summaries, the proposal is that this first version should not attempt to require the full detail of that provenance specification.
The approach proposed for this version of the IPS is to:
- Require document-level, not section level, provenance.
- Define IPS document provenance as one of two types: human-curated or software-assembled.
- The classification is based on whether the IPS document is constructed by a human or an automated process, regardless of whether the IPS contains some content of both kinds.
- Require the IPS source system to identify the IPS document provenance type and "author".
- The "author" shall be a human, if the IPS provenance type is "human-curated", or a device or system if the IPS provenance type is "software-assembled".
- In the case of a "software-assembled" IPS that is then verified by a human, the document provenance type shall be "software-assembled" and the author shall be the device or system that constructed the IPS document, but an additional "verifier" identity shall name the human who performed this check. For the avoidance of doubt, this is not the same as legalAuthenticator. However, in cases where the verifying person intentionally wishes to sign the document, this shall be recorded as a legalAuthenticator.
- Allow optional section level author, provenance type, verifier and informant identification, for IPS source systems that can support this.
- Not attempt to implement the US Realm CDA data provenance templates.
The discussions with the EHR work group suggest that a possible future project should be an IPS functional profile, once there is greater clarity and operational experience of using the IPS.
General Implementation Guidance
- How to populate IDs in an CDA XML instance, e.g. ClinicalDocument.id, setId
- Where I can get IDs
- Relevant times for a patient summary
- Description of the different status definitions (condition, concern, observation) --> Giorgio
- (Authorship is probably a part to go to Provenance)
Reading Guide
Description of formalisms used, symbols, icons, how to read ART-DECOR artefacts
Conformance clause
Different conformance levels (to be explored)
Functional requirements and high-level use cases
- Add a reference to the CEN prEN. (to be analyzed)
- PSS
- Add a reference to the data set included in the html package
- Include in the functional area that no assumption on transport has been made…
- PS comes from one source, and covers different cases.
- Specify, how the provenance could be managed without going into details) to be included in next versions.
- To be further discussed, in any case add a paragraph in which explain the problem and how it might be faced.
Appendix
Acronyms and abbreviations
Glossary
Licenses
- for the artifacts used, for the code systems, etc.
Integrated examples
- links to example instances in the publication package
Validation artifacts
- links to xsd
- links to schematrons
Links to platforms, binaries, software libraries
- This should go away?!
Operational information
- helpdesk, actual server endpoints for testing/production/validation
FAQ’s
References / Literature
How to reuse this template
List of all artifacts used in this guide
System OIDs / IDs
Code systems
CDA Templates (list of)
Value Sets
Summary tables
Examples (in progress)
Plan:
- Create one or more storyboards (Stephen?)
- Turn the storyboards into real IPS example CDA instances
- Allow for multilingual CDA (Italian, German)
- Offer all XSD in the publication package
- include schematrons (generated by ART-DECOR)
