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Semantic Bootcamp Countries situation on coding the data elements 2017-05-16 Agenda and goals • Discussion on challenges • Wave 1 PS findings • Actors and transactions in Patient Summary creation and exchange • Member States Compliance to IG / MVC • After lunch: • Groupwork on prepraring patient cases that take into account identified national variations and illustrate challenges. (This will be used for the scrutiny session in the afternoon) Actors and transactions in Patient Summary creation and exchange Patient Summary Man/Semi/Auto PS Author Section/entry Author when combining sources Signed by Single/Multiple Differens sources have different degree of encoding Avoiding duplication of information One consent or many On demand/ Stored/Published Relevant/ Rule based Medication/Prescription summary eHDSI Friendly / eHDSI Pivot Complementary info • • • Medication summary Perscription summary Patient reported medication statements Coded information Differens sources have different degree of encoding Derived information Compliance to Value Sets Patient Summary MVC Challenge Allergies AdverseEventType SNOMED-CT kind of adverse reactions against substance, food or drugs. AllergenNoDrugs SNOMED-CT allergenic agents (apart from drugs) against which the patient has developed an adverse reaction. ReactionAllergy SNOMED-CT clinical manifestations of allergy developed by patient UnknownInformation SNOMED-CT information about a problem or allergy is unknown or where there are no problems or allergies. Mostly available as free text or as coded information using national codes. Kind of adverse reaction may be part of the allergy concept. Scope may vary: some food allergies, only drug allergies etc. If only free text is recorded or if scope varies it’s hard to say if there are no known alleriges. Compliance to Value Sets, continued Patient Summary MVC Illness&Disorders ICD-10 Italy illnesess, allergies, syndromes or symptoms the patient suffered in the past or is currently suffering. CodeProb SNOMED-CT information on the circumstances under which the problem was defined/discovered. ResolutionOutcome SNOMED-CT describe the clinical status of a problem outcome. Mapping ICD9CM against ICD-10 National “extensions” ICD-10 diagnoses for reaction allergy, is this a condition or an allergy Same thing for pregnancy National code systems Physical Findings / Vital Signs BloodPressure LOINC Observation Interpretation HL7 BloodGroup SNOMED-CT Blood Pressure recorded in the section for Vital Signs Observations classify the result of an observation or a measurement patient's blood group + Rh May be recoded elsewhere, as lab result Compliance to Value Sets , continued Patient Summary MVC Italy MedicalDevices SNOMED-CT the patients Medical Devices and implants Can be recorded as procedures/DRG codes for reimbursement. Procedures SNOMED-CT encode procedures in the section "Surgical Procedures prior past six months" National code system or ICD-9-CM PCS? Vaccine SNOMED-CT patient's vaccinations Can it be derived from administered or prescribed medication? AdministrativeGender HL7 PregnancyInformation LOINC adminstrative purposes (as opposed to clinical gender) Pregnancy status and patient's delivery date estimation SocialHistory SNOMED-CT different elements of the patient's social history StatusCode SNOMED-CT encode the clinical status of both problems and concerns Different source than other information? Patient consent? Member States Compliance to IG / MVC: describe PS in your MS Patient Summary Confidentiality HealthcareProfessionalR oles PersonalRelationship RoleClass CountryCode Language MVC HL7 ISCO HL7 RoleCode HL7 ISO 3166-1 ISO 639-1 confidentiality level of the entire CDA HCP's profession the type of contact relationship between a person and the patient. distinction between an emergency contact and the next of kin for a patient. Code of the Country Language of the document Is confidentiality used nationally? How to handle multiple sources. Header information For existing national PS, how does the header information match against the mandatory header elements of the Pivot format? • Author on section and entry level when combining multiple sources. Groups PS eP Manual A Automatic B Prepraring patient cases • Summary of challenges regarding coded information • Representable test data • Preparing patient cases Thank you!
