Download Discrete_entry_to_narrative_references

CDA Discrete Entry concepts
•
text/reference – points to the entire human readable content for an act
– In laymen terms: the entire text of the Problem, Allergy, Medication, Immunization, Procedure,
Encounter, …
•
originalText/reference – always in reference to some (code, codeSystem) as a reference to the
human readable text that led to the selection of the (code, codeSystem)
– The text the provider used/saw for a problem that led to use of a particular code, e.g., a
particular ICD-10 code
•
displayName – if present, the name as defined by the code system, or at least that does not
change the meaning as defined by the code system
Copyright © 2016 Allscripts Healthcare, LLC.
1
Industry Consistency is Important
•
text/reference may be easiest tie from discrete entry to human readable text
– Needs to be carefully dereferenced in order to have usable content
•
Importing systems benefit from reliable discrete content references to the narrative
– originalText/reference provides this for <code>, <value> and a few other coded elements
– @displayName is not for machine processing (somewhere there is a statement on “has no
semantic meaning”) and should to be used only for debugging
Copyright © 2016 Allscripts Healthcare, LLC.
2
HL7 Examples Task Force
•
Review the examples, showing content for the 3 concepts
•
What we see today from industry examples
– text/reference absent, or pointing to what really is the originalText content
– originalText/reference mostly absent
– @displayName often present, but also often containing originalText content
Copyright © 2016 Allscripts Healthcare, LLC.
3
What follows?
•
Review of selected Examples Task Force approved examples:
– Allergy
– Problem
– Medication
– Immunization
– Procedure
– Result
•
For each there is:
– Link to example
– Table where 1st row shows content from text/reference, originalText/Reference,
@displayName
– For some examples there is a second row saying something like: … below is …
• Then there is a third row presenting what would improve interoperability, or that might
just be more complete
Copyright © 2016 Allscripts Healthcare, LLC.
4
ALLERGIES, ADVERSE REACTIONS OR
ALERTS
Allergy to specific drug (penicillin) C-CDA 1.1
text/reference
originalText @displayNa
me
Absent
Penicillin
penicillin
Penicillin
penicillin
…. Below is an example where the text reference is present
Penicillin Anaphylaxis Severe Jan 4 2014 2006
Important to note: for the allergy observation, the originalText is on the code of the participant.
Note 2: review the text/reference of the reaction – shouldn’t that include the Severity?
Copyright © 2016 Allscripts Healthcare, LLC.
5
PROBLEMS
Transition of Care Active Problem
text/reference
originalText @displayNa
me
Community Acquired Pneumonia Onset: February 27 2014
Active
Absent
Community
Acquired
Pneumonia
Community
Acquired
Pneumonia
Community
acquired
pneumonia
……below is the ideal state
Community Acquired Pneumonia Onset: February 27 2014
Active
Copyright © 2016 Allscripts Healthcare, LLC.
6
MEDICATIONS
Patient prescribed medication every 4 to 6 hours
text/reference
originalText @displayNa
me
Sudafed 30mg Oral Tablet take 2 tablets every 4-6 hours
30 MG Jan-18-2014 - Active
Sudafed
30mg Oral
Tablet
Sudafed 30
MG Oral
Tablet
Note: originaltext is on code of the ManufacturedMaterial, i.e, inside the consumable; notice also the subtle difference between
originalText and @displayName
Copyright © 2016 Allscripts Healthcare, LLC.
7
IMMUNIZATIONS
Influenza Vaccination Completed
text/reference
originalText @displayNa
me
Influenza Virus Vaccine 1 8/15/2010 Completed
Absent
Influenza
virus vaccine
Influenza
Virus
Vaccine
influenza,
unspecified
formulation
…..better represented as
Influenza Virus Vaccine Lot #1 8/15/2010 Completed
Copyright © 2016 Allscripts Healthcare, LLC.
8
PROCEDURES
Procedure Activity Procedure Example in Procedures Section
text/reference
originalText @displayNa
me
Laparoscopic appendectomy >(03 Feb 2014 09:22am- 03
Feb 2014 11:15am) Completed
Laparoscopi Laparoscopic
c
appendecto
appendecto my
my
Copyright © 2016 Allscripts Healthcare, LLC.
9
RESULTS
Basic Metabolic Panel with Troponin Example
text/reference
originalText @displayNa
me
Na 140 mmol/L Normal 135-145 mmol/L
Na
Copyright © 2016 Allscripts Healthcare, LLC.
Sodium
[Moles/volu
me] in Blood
10
HL7 Examples reviewed above
•
Allergies
– https://github.com/jddamore/HL7-Task-ForceExamples/blob/master/ALLERGY_Drug_with_RxNorm.xml
•
Medications
– https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Every_46_hrs.xml
•
Immunizations
– https://github.com/brettmarquard/HL7-C-CDA-Task-ForceExamples/blob/master/Influenza_Immunization_Complete.xml
•
Procedures
– https://github.com/jddamore/HL7-Task-ForceExamples/blob/master/PROCEDURE_Procedure_Example.xml
•
Results
– https://github.com/jddamore/HL7-Task-ForceExamples/blob/master/RESULT_BMP_with_Tropinin.xml
Copyright © 2016 Allscripts
Healthcare, LLC.
11