PR2

Preface to this STU ballot

The goal of this Implementation Guide is to specify how to represent in HL7 CDA R2 the International Patient Summary (IPS) (see also the ART-DECOR repository). An alternative representation as HL7 FHIR is also provided (see the HL7 build site).

The initial focus of the International Patient Summary (IPS) was the unplanned care across national borders. This specification can be used and be useful also in local applications and be supportive of planned care.

Compared to the previous STU specification, developments took place mainly around additional data to be conveyed (Alert, Patient Story), input that comes from the underlying ISO Standard 27269:2021 Health informatics — International patient summary and its updates. In addition, terminology aspects have been discussed and further developed. The terminology changes are listed in details below. With a few exceptions, FHIR and CDA terminologies used are the same. One exception is the update Allergy and Intolerances Value Set, in FHIR made for binding at one place in the associated profile but in CDA these are still two Value Sets as substances and conditions are bound to different elements in CDA.

Here is the list of change categories:

• Medications updated due to new Value Sets
• Problem Entry updated
• Procedure updated due to new Value Sets, especially Certainty
• Immunization updated due to new Value Sets
• Specimen Collection updated due to new Value Sets
• Allergy and Intolerances have been updated re/ Value Sets, defined for substances and conditions
• Laboratory/Pathology updated due to new Value Sets
• Radiology updated due to new Value Sets,
• Radiology added the result component accordingly as modelled in FHIR
• Social History (Smoking) updated due to new Value Sets
• Pregnancy updated, especially the Estimated Delivery Date Observation
• New section: Alert
• New section: Patient Story
• A new Document Level Template has been created (OID 2.16.840.1.113883.10.22.1.2) to address all changes,

The Template Definition of the document level template in ART-DECOR can be found here https://art-decor.org/ad/#/hl7ips-/rules/templates/2.16.840.1.113883.10.22.1.2/2024-08-02T13:02:39. From that all other header, section and entry level templates are listed.

Expressing HL7 CDA® R2 template definitions as FHIR Structure Definitions

As a pilot efforts have been made to convert the definitions of the HL7 CDA® R2 Implementation Guide of the International Patient Summary, that were done in ART-DECOR using the former HL7 Templates Standard: Specification and Use of Reusable Information Constraint Templates, in short Templates ITS into FHIR Structure Definitions and to use the FHIR IG publisher for the CDA IG. This is still experimental and offered as an informational IG, reachable under HL7 build site.