Download Boston Public Health Commission Data Collection Regulation: Boston Health Equity Measure Set

Boston Public Health Commission Data Collection Regulation: Boston Health Equity Measure Set APPROVED: Barbara Ferrer, PhD, MPH, MEd Executive Director Date: September 2, 2013 This page intentionally left blank. Page 2 of 256 BPHC Boston Health Equity Measure Set Table of Contents I. Introduction 5 II. References 9 III. Data Submission Guide 37 IV. Appendices 225 Page 3 of 256 BPHC Boston Health Equity Measure Set This page intentionally left blank. Page 4 of 256 BPHC Boston Health Equity Measure Set I. Introduction Background Eliminating prevailing health care disparities related to race, ethnicity, and socioeconomic factors are key goals of the U.S. Department of Health and Human Services’ Action Plan to Reduce Racial and Ethnic Health Disparities (Disparities Action Plan).1 According to the Agency for Healthcare Research and Quality’s (AHRQ) 2012 National Healthcare Disparities Report, however, few measures of disparities in health care quality related to race or ethnicity have shown improvement over time, and almost no disparities in access to care have improved. 2 Incomplete data on vulnerable populations limit the ability to identify problems, target resources, and design interventions. Increasing the availability and quality of data collected and reported on racial and ethnic minority populations is a national priority supported by the Affordable Care Act and numerous federal agency standards and recommendations. To address this issue, the Boston Public Health Commission (BPHC) promulgated the Data Collection Regulation on July 1, 2006 (Appendix C). This regulation requires all hospitals and community health centers in Boston to collect four fields of self-reported demographic information on all inpatient, outpatient observation, ambulatory, and emergency department visits. The regulation also required the convening of a committee of healthcare providers and other stakeholders to develop a measure set to identify healthcare disparities that may guide quality improvement efforts (see Appendix D for committee membership). Boston Health Equity Measure Set The Health Equity Committee met for a year and recommended nineteen measures related to health care quality and utilization in two priority areas, primary care and emergency care. In their process of measure selection, the Committee considered the validity (i.e., soundness) and practicality (i.e., ease of data collection) of candidate measures. Whenever possible, measures were drawn from existing nationally accepted standard measures. Through input from the public review process and with expert technical assistance from the Disparities Solution Center of Massachusetts General Hospital the measure set recommended by the Health Equity Committee were revised and finalized constituting the first Boston Health Equity Measure Set (BHEMS) (Table 1). 3 1 U.S. Department of Health and Human Services, HHS Action Plan to Reduce Racial and Ethnic Disparities: A Nation Free of Disparities in Health and Health Care. Washington, D.C.: U.S. Department of Health and Human Services, April 2011:12-14. 2 U.S. Department of Health and Human Services, Agency for Health Care Quality and Research, National Healthcare Quality Report 2012. Washington, D.C.: Agency for Healthcare Research and Quality, May 2013:H7-H8. 3 See Appendix E for a summary of the Health Equity Measure Set development. Page 5 of 256 BPHC Boston Health Equity Measure Set BHEMS aligns with both federal and state health care quality measurement and improvement initiatives. Six of the nineteen measures in BHEMS are Healthcare Data Effectiveness and Information Set (HEDIS) measures developed by the National Committee for Quality Assurance (NCQA), a private not-for-profit health care quality improvement organization. HEDIS is used by more than ninety percent of American health plans to measure health care provider performance. Nine of the nineteen measures in BHEMS are endorsed by the National Quality Forum (NQF), a non-profit, public-private partnership responsible for developing a portfolio of quality and efficiency measures for the US Department of Health and Human Services. Eight of the nineteen measures in BHEMS are recommended by the Massachusetts Statewide Quality Advisory Committee (SQAC) for the Commonwealth’s first Standard Quality Measure Set (SQMS). While there is significant overlap in the BHEMS with other quality reporting and improvement initiatives there may be differing priorities and data collection methods used to generate reports. BHEMS will be calculated from individual level demographic and clinical data for all inpatient, outpatient observation, ambulatory and emergency department encounters submitted by all hospitals and community health centers in Boston as required by the BPHC Data Collection Regulation. Measures will be stratified by demographic in order to identify and address inequities in care utilization and quality. Future BHEMS may include measures related to health care outcomes and patient experiences with care. Providers will be given an opportunity to review and to comment on the BHEMS that is calculated from their submitted data. Annually, BPHC will issue an analysis of the BHEMS to reporting hospitals and community health centers to guide quality improvement initiatives developed to reduce health care inequities. Table 1. Boston Health Equity Measure Set Data Source Measure # Priority Area 1 Primary care utilization Primary care utilization Primary care utilization Primary care utilization Primary care quality Primary care quality 2 3 4 5 6 7 Primary care NQF# Measure Total number of primary care visits 24 (ages 3-17) 36 Total number of patients (include patients with one or more visits in the reporting period) Total number of primary care visits by asthma patients (564), as defined by HEDIS Total number of primary care visits by diabetic patients, as defined by HEDIS Total number of primary care visits by hypertension patients, as defined by HEDIS (HEDIS) Weight assessment and counseling for nutrition and physical activity for children and adolescents (Age 217) (HEDIS) Use of an asthma controller medication for Hospital X CHC X X X X X X X X X X X X X Page 6 of 256 BPHC Boston Health Equity Measure Set 8 quality Primary care quality 731 9 Primary care quality 18 10 1392, 1516 12 13 Primary care quality Primary care quality ED utilization ED utilization 14 ED utilization 15 ED utilization 16 ED utilization 17 18 ED utilization ED quality 11 90 289 163 132 19 ED quality 93 persons with asthma (Age 5-64) Comprehensive diabetes care (Age 18-75): (HEDIS) Yearly screening: HbA1c; LDL-C, retinal eye exam, nephropathy screen, blood pressure Controlling high blood pressure (Age 18-85): (HEDIS) Patient with a diagnosis of hypertension whose most recent blood pressure reading was controlled (HEDIS) Well-child visits (Ages 0-15 months and 3-6 years) X X X X X X (HEDIS) Adolescent well-child visits (Age 12-21 years) X X Total number of ED visits Number of patients with high ED utilization (4 or more visits in one year) Number of ED visits by day of week and time of day for the top ten “non-emergent conditions” as defined by the MA Division of Healthcare Finance and Policy in Massachusetts Health Care Cost Trends: Efficiency of Emergency Department Utilization in Massachusetts; August, 2012 Number of ED visits by day of week and time of day for the top ten “emergency but primary care treatable conditions” as defined by the MA Division of Healthcare Finance and Policy in Massachusetts Health Care Cost Trends: Efficiency of Emergency Department Utilization in Massachusetts; August, 2012 Discharge status (home, observation and inpatient admissions) Number of visits to the ED for asthma-related conditions MI Guidelines (ECG): a) CMS PQRS: Measure #54: 12-Lead Electrocardiogram (ECG) Performed for Non-traumatic Chest Pain (in patients 40 years and older) MI Guidelines (ECG): b) CMS OPPS: OP-5: ED Median Time to ECG X X MI Guidelines (PCI): c) AMI-8: Median Time to PCI (Door to Balloon time) X MI Guidelines (PCI): d) AMI – 8a: Primary PCI within 90 minutes of hospital arrival MI Guidelines (Aspirin): e) AMI-1: Aspirin at Arrival X Syncope Guideline: CMS PQRS: Measure #55: 12-Lead Electrocardiogram (ECG) Performed for Syncope (in patients 60 years and older) X X X X X X X X Page 7 of 256 BPHC Boston Health Equity Measure Set This page intentionally left blank. Page 8 of 256 BPHC Boston Health Equity Measure Set II. References This section identifies the following for each measure of the Boston Health Equity Measure Set:  Brief description of the measure  Definitions and relevant references used by BPHC to calculate the measure  Additional Notes which may be used to help to identify data fields BPHC will use to calculate the measure Individual level data (i.e., not aggregate level data) is required to be submitted for all inpatient, outpatient observation, ambulatory, and emergency department encounters from all Boston hospitals and community health centers. See Section III, Data Submission Guide, for technical guidance regarding required data submission content, format, and procedures. Page 9 of 256 BPHC Boston Health Equity Measure Set Measure #1: Total Number of Primary Care Visits Measure #1: Total Number of Primary Care Visits This measure is used to assess the total number of primary care visits within the measurement year. It excludes visits where the Visit Type is Emergency Department or Inpatient. In support of the measure, payment method will also be captured including commercial health plans, public health plans such as Medicaid and Medicare, and/or out of pocket. Reference: Definition of Primary Care Visit for Children HEDIS measure “Children and Adolescents’ Access to Primary Care Practitioners (CAP)” contains definitions that were used to determine the fields to capture for this measure. The text below contains excerpts from HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 244. Reference: Definition of Well Visits for Adults HEDIS measure “Adults’ Access to Preventive/Ambulatory Health Services (AAP)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 242. Page 10 of 256 BPHC Boston Health Equity Measure Set Measure #2: Total Number of Patients Measure #2: Total Number of Patients (One or More Visits during Report Period) This measure is used to assess the total number of patients that had one or more primary care visits during the measurement year. For this measure, each patient is counted once, even if the patient has more than one visit to one or more providers at the reporting institution. Reference: Definition of Well Visits for Adults HEDIS measure “Adults’ Access to Preventive/Ambulatory Health Services (AAP)” contains definitions that were used to determine the fields to capture for this measure. The text below contains excerpts from HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 242. Reference: Definition of Primary Care Visit for Children HEDIS measure “Children and Adolescents’ Access to Primary Care Practitioners (CAP)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 244. Page 11 of 256 BPHC Boston Health Equity Measure Set Measure #3: Total Number of Primary Care Visits by Asthma Patients (5-64) Measure #3: Total Number of Primary Care Visits by Asthma Patients (564), as Defined by HEDIS This measure is used to assess the number of primary care visits by patients 5-64 years of age during the reporting year who were identified as having persistent asthma. Reference: Definition of Primary Care Visit for Children HEDIS measure “Children and Adolescents’ Access to Primary Care Practitioners (CAP)” contains definitions that were used to determine the fields to capture for this measure. The text below contains excerpts from HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 244. Reference: Definition of Well Visits for Adults HEDIS measure “Adults’ Access to Preventive/Ambulatory Health Services (AAP)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 242. Reference: Definition of Persistent Asthma HEDIS measure “Use of Appropriate Medications for People With Asthma (ASM)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care Respiratory Cardiovascular page 123. Page 12 of 256 BPHC Boston Health Equity Measure Set Measure #4: Total Number of Primary Care Visits by Diabetic Patients Measure #4: Total Number of Primary Care Visits by Diabetic Patients, as Defined by HEDIS This measure is used to assess the number of primary care visits by patients who are identified as diabetic. The definition of “diabetic” is based on the HEDIS measure entitled Comprehensive Diabetes Care cited below. Reference: Definition of Primary Care Visit for Children HEDIS measure “Children and Adolescents’ Access to Primary Care Practitioners (CAP)” contains definitions that were used to determine the fields to capture for this measure. The text below contains excerpts from HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 244. Reference: Definition of Well Visits for Adults HEDIS measure “Adults’ Access to Preventive/Ambulatory Health Services (AAP)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 242. Reference: Definition of Diabetic HEDIS measure “Comprehensive Diabetes Care (CDC)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care Musculo Skeletal Behavioral page 152. Page 13 of 256 BPHC Boston Health Equity Measure Set Measure #5: Total Number of Primary Care Visits by Hypertension Patients Measure #5: Total Number of Primary Care Visits by Hypertension Patients, as Defined by HEDIS This measure is used to assess the total number of primary care visits by patients identified as having hypertension during the measurement year. The definition of “hypertension” is based on the HEDIS measure entitled Controlling High Blood Pressure cited below. Reference: Definition of Primary Care Visit for Children HEDIS measure “Children and Adolescents’ Access to Primary Care Practitioners (CAP)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 244. Reference: Definition of Well Visits for Adults HEDIS measure “Adults’ Access to Preventive/Ambulatory Health Services (AAP)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Access and Availability of Care and Experience with Care page 242. Reference: Definition of Hypertension HEDIS measure “Controlling High Blood Pressure (CBP)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care Respiratory Cardiovascular page 142. Page 14 of 256 BPHC Boston Health Equity Measure Set Measure 6: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (Age 2-17) Measure #6: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (Age 2-17) This measure is used to assess the percentage of patients 2–17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following during the measurement year.  BMI percentile documentation (including height and weight).  Counseling for nutrition.  Counseling for physical activity. Note that the age range of this BHEMS measure is age 2-17 years and varies from the HEDIS measure of age 3-17. Reference: Applicable HEDIS Measure HEDIS measure “Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care Prevention and Screening page 61. Page 15 of 256 BPHC Boston Health Equity Measure Set Measure 7: Use of an Asthma Controller Medication for Persons with Asthma (Age 5-56) Measure #7: Use of an Asthma Controller Medication for Persons with Asthma (Age 5-64) This measure is used to assess the percentage of patients 5–64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. References HEDIS measure “Use of Appropriate Medications for People With Asthma (ASM)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care Respiratory Cardiovascular page 123. Page 16 of 256 BPHC Boston Health Equity Measure Set Measure 8: Comprehensive Diabetes Care (Age 18-75) Measure #8: Comprehensive Diabetes Care (Age 18-75) This measure is used to assess the percentage of patients 18–75 years of age with diabetes (type 1 and type 2) who had each of the following.  Hemoglobin A1c (HbA1c) testing.  HbA1c poor control (>9.0%).  HbA1c control (<8.0%).  HbA1c control (<7.0%) for a selected population*.  LDL-C screening.  LDL-C control (<100 mg/dL).  Medical attention for nephropathy.  BP control (<140/80 mm Hg).  BP control (<140/90 mm Hg).  Eye exam (retinal) performed. Reference: Applicable HEDIS Measure HEDIS measure “Comprehensive Diabetes Care (CDC)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care Musculo Skeletal Behavioral page 152. Page 17 of 256 BPHC Boston Health Equity Measure Set Measure 9: Controlling High Blood Pressure (Age 18-85) Measure #9: Controlling High Blood Pressure (Age 18-85) This measure is used to assess the percentage of patients 18–85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the measurement year. References HEDIS measure “Controlling High Blood Pressure (CBP)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care Respiratory Cardiovascular page 142. Page 18 of 256 BPHC Boston Health Equity Measure Set Measure 9: Controlling High Blood Pressure (Age 18-85) Measure #10: Well Child Visits (Age 0-15 Months and 3-6 Years) This measure is used to assess:  the percentage of patients who turned 15 months old during the measurement year and who had 0, 1, 2, 3, 4, 5, 6 or more well-child visits with a PCP during their first 15 months of life  the percentage of patients 3–6 years of age who had one or more well-child visits with a PCP during the measurement year. The two different HEDIS references for this measure are described below. Reference: Well-Child Visits First 15 Months HEDIS measure “Well-Child Visits in the First 15 Months of Life (W15)” contains definitions that were used to determine the fields to capture for this measure. The text below contains excerpts from HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page 285. Reference: Well-Child Visits 3-6 years HEDIS measure “Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page 288. Page 19 of 256 BPHC Boston Health Equity Measure Set Measure 11: Adolescent Well-Child Visits (age 12-21 years) Measure #11: Adolescent Well-Child Visits (Age 12-21 years) This measure is used to assess the percentage of patients age 12-21 years old during the measurement year who had at least one comprehensive well-child visit with a PCP or an OB/GYN practitioner during the measurement year. Reference: Adolescent Well-Child Visits (AWC) HEDIS measure “Adolescent Well-Care Visits (AWC)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page 291. Page 20 of 256 BPHC Boston Health Equity Measure Set Measure 12: Total Number of ED Visits Measure #12: Total Number of ED Visits This measure is used to assess the total number of Emergency Department visits for the measurement year. Reference: Definition of ED Visit See ED Visit excerpt from HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page 304. The HEDIS reference indicates “Count each visit to an ED that does not result in an inpatient stay once…”. However, the BPHC Boston Health Equity Measure Set does include these ED visits, so varies from HEDIS for that particular part of the definition. Page 21 of 256 BPHC Boston Health Equity Measure Set Measure 13: Number of Patients with High ED Utilization (four or more in one year) Measure #13: Number of Patients with High ED Utilization (four or more in one year) This measure is used to assess the number of patients who have had four or more ED visits in the measurement year. References See ED Visit excerpt from HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page 304. Page 22 of 256 BPHC Boston Health Equity Measure Set Measure 14: Number of ED Visits by Day of Week and Time of Day for the Top Ten “Non-Emergent Conditions” as defined by the Massachusetts Division of Healthcare Finance and Policy Measure #14: Number of ED Visits by Day of Week and Time of Day for the Top Ten “Non-Emergent Conditions” as defined by the Massachusetts Division of Healthcare Finance and Policy in Massachusetts Health Care Cost Trends: Efficiency of Emergency Department Utilization in Massachusetts This measure is used to assess the number of Emergency Department (ED) visits by day of the week and time of day for one or more of the top ten clinical conditions categorized as “nonemergent conditions” by the Massachusetts Division of Healthcare Finance and Policy. Count the number of Encounters where the Visit Type is ED (CPT 99281-99285) and the only Diagnosis(es) is one or more of the conditions in the table below. References The following contains definitions that were used to identify “Preventable/Avoidable ED Visits”. The text below contains excerpts from “Massachusetts Health Care Cost Trends, Efficiency of Emergency Department Utilization in Massachusetts”, authored by the Massachusetts Division of Health Care Finance and Policy 4. The following is from page 21 of this document. 4 http://www.mass.gov/chia/docs/cost-trend-docs/cost-trends-docs-2012/emergency-department-utilization.pdf Page 23 of 256 BPHC Boston Health Equity Measure Set Measure 14: Number of ED Visits by Day of Week and Time of Day for the Top Ten “Non-Emergent Conditions” as defined by the Massachusetts Division of Healthcare Finance and Policy Page 24 of 256 BPHC Boston Health Equity Measure Set Measure 15: Number of ED Visits by Day of Week and Time of Day for the Top Ten “Emergency But Primary Care Treatable Conditions” as defined by the Massachusetts Division of Healthcare Finance and Policy Measure #15: Number of ED Visits by Day of Week and Time of Day for the Top Ten “Emergency But Primary Care Treatable Conditions” as defined by the Massachusetts Division of Healthcare Finance and Policy in Massachusetts Health Care Cost Trends: Efficiency of Emergency Department Utilization in Massachusetts This measure is used to assess the number of Emergency Department (ED) visits by day of the week and time of day for one or more of the top ten clinical conditions categorized as “emergency but primary care treatable” by the Massachusetts Division of Healthcare Finance and Policy. Count the number of Encounters where the Visit Type is ED (CPT 99281-99285) and the only Diagnosis(es) is one or more of the conditions in the table below. References The following contains definitions that were used to identify “Preventable/Avoidable ED Visits”. The text below contains excerpts from “Massachusetts Health Care Cost Trends, Efficiency of Emergency Department Utilization in Massachusetts”, authored by the Massachusetts Division of Health Care Finance and Policy 5. The following is from page 21 of this document. 5 http://www.mass.gov/chia/docs/cost-trend-docs/cost-trends-docs-2012/emergency-department-utilization.pdf Page 25 of 256 BPHC Boston Health Equity Measure Set Measure 15: Number of ED Visits by Day of Week and Time of Day for the Top Ten “Emergency But Primary Care Treatable Conditions” as defined by the Massachusetts Division of Healthcare Finance and Policy Page 26 of 256 BPHC Boston Health Equity Measure Set Measure 16: Discharge Status (Home, Observation and Inpatient Admissions Measure #16: Discharge Status (Home, Observation and Inpatient Admissions) This measure is used to assess the Discharge Status for patients with Home, Observation and Inpatient Admissions. Reference: Definition of Discharge Status The BHEMS did not reference a HEDIS or other nationally recognized standard for this measure. In lieu of another standard, information published by the Centers for Medicare and Medicaid Services in “Clarification of Patient Discharge Status Codes and Hospital Transfer Policies” MLN Matters Number: SE0801 Revised provides the following definition on Page 2.6 The Discharge Status identifies where the patient is at the conclusion of a health care facility encounter (can be a visit or an actual inpatient stay) or at the end time of a billing cycle. The Discharge Status is captured in the discharge disposition code (field sdtc:dischargeDispositionCode) with the exception of hospital discharges, in which case it is captured in the Hospital Discharge Diagnosis (field statusCode within Hospital Discharge Diagnosis of an Encounter). The following describes the discharge disposition codes and their meaning. HL7 Discharge Disposition Codes Code System: HL7 Discharge Disposition 2.16.840.1.113883.12.112 Code Print Name 01 Discharged to home or self-care (routine discharge) 02 Discharged/transferred to another short-term general hospital for inpatient care 03 Discharged/transferred to skilled nursing facility (SNF) 04 Discharged/transferred to an intermediate-care facility (ICF) 05 Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution 06 Discharged/transferred to home under care of organized home health service Organization 07 Left against medical advice or discontinued care 08 Discharged/transferred to home under care of Home IV provider 09 Admitted as an inpatient to this hospital 10…19 Discharge to be defined at state level, if necessary 20 Expired (i.e., dead) 21…29 Expired to be defined at state level, if necessary 30 Still patient or expected to return for outpatient services (i.e., still a patient) 6 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf Page 27 of 256 BPHC Boston Health Equity Measure Set 31…39 40 41 42 Measure 16: Discharge Status (Home, Observation and Inpatient Admissions Still patient to be defined at state level, if necessary (i.e., still a patient) Expired (i.e., died) at home Expired (i.e., died) in a medical facility; e.g., hospital, SNF, ICF, or freestanding Hospice Expired (i.e., died) - place unknown Page 28 of 256 BPHC Boston Health Equity Measure Set Measure 17: Number of Visits to the ED for Asthma Related Conditions Measure #17: Number of Visits to the ED for Asthma Related Conditions This measure is used to assess the total number of visits to the ED that displayed asthma related conditions within the measurement year. The following highlight some of the key information within the reference above:  Total count of Encounters where the Visit Type is ED (CPT 99281-99285) and the Date is within the measurement year in which one of the diagnosis entries is asthma.  The Emergency Department visits are defined by CPT codes: 99281-99285. And ICD-9 codes under 493 indicate an asthma diagnosis. So, the count of the combination of CPT code 99281-99285 and ICD-9 codes under 493 will indicate number of visits to the ED for asthma-related conditions and symptoms. Reference: Definition of ED Visit See the ED Visit excerpt from HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page 304. The HEDIS reference indicates “Count each visit to an ED that does not result in an inpatient stay once…”. However, the BPHC Boston Health Equity Measure Set does include these ED visits, so varies from HEDIS for that particular part of the definition. Reference: Definition of Asthma Related Condition HEDIS measure “Use of Appropriate Medications for People With Asthma (ASM)” contains definitions that were used to determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care Respiratory Cardiovascular page 123. Page 29 of 256 BPHC Boston Health Equity Measure Set Measure 18a: 12-Lead Electrocardiogram (ECG) Performed for Non-traumatic Chest Pain (patients 40 years and older with ED Discharge) Measure #18a: 12-Lead Electrocardiogram (ECG) Performed for Nontraumatic Chest Pain (patients 40 years and older with ED Discharge) This measure is used to assess the percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG performed. Reference: Definition from AMA NCQA of Non-traumatic Chest Pain and 12-Lead Electrocardiogram See definitions in the American Medical Association National Committee for Quality Assurance 54 -Electrocardiogram Performed for Non-Traumatic Chest Pain. Reference: Definition from CMS PQRS Measure #54 12-Lead Electrocardiogram CMS PQRS: Measure #54 contains definitions that were used to determine the fields to capture for this measure. See excerpts from worksheet “Current” row number 688 in the Excel file “CMS.Measures.Inventory.web posting.Dec2013.alsb”. Page 30 of 256 BPHC Boston Health Equity Measure Set Measure 18b: ED Median Time to ECG Measure #18b: ED Median Time to ECG This measure is used to assess the median time from emergency department arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain patients (with Probable Cardiac Chest Pain). Reference: CMS Hospital OQR Specifications Manual Chest Measures See excerpts from CMS Hospital OQR Specifications Manual Chest Measures pages 15 through 17. Reference: CMS OPPS: OP-5 “‘Median time to ECG’ as defined by Continuous Variable Statement” contains definitions that were used to determine the fields to capture for this measure. See excerpts from worksheet “Current” row number 246 in the Excel file “CMS.Measures.Inventory.webposting.Dec2013.alsb”. Page 31 of 256 BPHC Boston Health Equity Measure Set Measure 18c: AMI-8: Median Time to PCI (Door to Balloon time) Measure #18c: AMI-8: Median Time to PCI (Door to Balloon time) This measure is used to assess the Median time from arrival to primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time. References Specifications Manual for Joint Commission National Quality Core Measures (Measure AMI-8: Median Time to PCI) was used to determine the fields to capture for this measure. See the full AMI-8 text at the following link: https://manual.jointcommission.org/releases/archive/TJC2010B1/MIF0023.html Page 32 of 256 BPHC Boston Health Equity Measure Set Measure 18d: AMI-8a: Primary PCI within 90 Minutes of Hospital Arrival Measure #18d: AMI – 8a: Primary PCI within 90 Minutes of Hospital Arrival This measure is used to assess the number of acute myocardial infarction (AMI) patients receiving primary percutaneous coronary intervention (PCI) during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. References Specifications Manual for Joint Commission National Quality Core Measures (Measure: AMI – 8a: Primary PCI within 90 minutes of hospital arrival) was used to determine the fields to capture for this measure. See the full AMI-8a text at the following link: https://manual.jointcommission.org/releases/archive/TJC2010B1/MIF0024.html Page 33 of 256 BPHC Boston Health Equity Measure Set Measure 18e: AMI-1: Aspirin at Arrival Measure #18e: AMI-1: Aspirin at Arrival This measure is used to assess acute myocardial infarction (AMI) patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. References Specifications Manual for Joint Commission National Quality Core Measures (Measure: AMI-1 Aspirin at Arrival) was used to determine the fields to capture for this measure. See the full AMI-1 text at the following link: https://manual.jointcommission.org/releases/archive/TJC2010B1/MIF0015.html Page 34 of 256 BPHC Boston Health Equity Measure Set Measure 19: 12-Lead Electrocardiogram (ECG) Performed for Syncope (in patients 60 years and older) Measure #19: 12-Lead Electro cardiogram (ECG) Performed for Syncope (in patients 60 years and older) This measure is used to assess the percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed. References CMS PQRS: Measure #55: “12-Lead Electro cardiogram (ECG) Performed for Syncope (in patients 60 years and older)” contains definitions that were used to determine the fields to capture for this measure. See excerpts from worksheet “Current” row number 688 in the Excel file “CMS.Measures.Inventory.web posting.Dec2013.alsb”. Page 35 of 256 BPHC Boston Health Equity Measure Set Measure 19: 12-Lead Electrocardiogram (ECG) Performed for Syncope (in patients 60 years and older) This page intentionally left blank. Page 36 of 256 III. Data Submission Guide Introduction 1.1 Purpose of This Document This document presents the Data Submission Guide for the Boston Public Health Commission (BPHC) Data Collection Regulation Boston Equity Measure Set (BHEMS) via the BPHC Health Information Exchange (HIE) Gateway. This document provides guidance to health care provider sites designing and implementing information system interfaces to securely exchange clinical data using messages of a standard format. This document is a collection of Health Level Seven’s (HL7) Clinical Document Architecture (CDA) templates that describe the Continuity of Care Document (CCD) supported by BPHC. The document follows the guidelines within the CDA Release 2 Consolidation Guide so that messages conform to the nationally recognized HL7 standard. This document is intended for business and technical staff of health care providers who are required to report demographic and clinical data to the BPHC. Reporting facilities are responsible for understanding the operation of the BPHC HIE Gateway. 1.2 Scope This document describes information regarding the BPHC reporting requirements for BHEMSrelated data. The document includes information about the following:  High level overview of the HIE infrastructure  Detailed message definition for CDA compliant BHEMS data This document does not describe the detailed steps necessary to establish the transport layer data connection from provider sites to BPHC. To support the transmission of messages, BPHC has partnered with the Commonwealth of Massachusetts and utilizes the Mass HIway (www.mass.gov/hhs/masshiway) as a secure method of sending messages to BPHC. As such, this partnership should reduce the work required for provider sites to send messages to the Health Equity Data Exchange system at BPHC. The details about the implementation of this transport layer are not included in this Guide, but instead are within Mass HIway documents. 1.3 How this Guide is Organized The following table describes the sections within this guide: Section Description High Level Description of This section briefly describes the entire HIE Gateway HIE system to give readers and implementers an overall idea of how the system works and is used. Possible Events That Trigger This section lists some typical events Sending Health Equity Data that may be considered as triggers for Pages 42-44 45-49 Page 37 of 256 Message Construction and Document Conventions BPHC Health Equity Reporting Appendix A: OIDS Appendix B: Vocabulary sending Health Equity Data messages to the Boston Public Health Commission This section signifies the transition of the document from describing the background and high level architecture of the HIE Gateway to the specific detailed information necessary to construct a Health Equity Data Message to be sent to BPHC. This section describes conventions used throughout the document. This section describes the constrained CCD document type and its associated CDA templates. This section describes every component of a BPHC Health Equity Data Report and should be used by organizations to create messages for submission to BPHC. This section describes any custom object identifiers (OIDs) defined within the document. This section describes all code value sets used within the BPHC Health Equity Data Report and is referenced within the templates defined in Section 7. 46-49 50-224 225 226-247 Page 38 of 256 1.4 References This Data Submission Guide is derived from and references the following documents. Document/Reference Description HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, DSTU Release 1.1 Draft Standard for Trial User The guide can be found at http://www.hl7.org The guide describes the implementation of 8 different document types within the CDA R2 framework. The guide was produced and developed through the joint efforts of Health Level Seven (HL7), Integrating the Healthcare Environment (IHE), the Health Story Project, and the Office of the National Coordinator (ONC) within the US Department of Health and Human Services (HSS). The BPHC Health Equity Data Report is a constrained version of the CCD document template described in the guide. Section 7 re-uses the templates defined in the IHE Health Story Consolidation Guide, customizing them to fit the particular requirements for BPHC’s Health Equity Measure Set. HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD) The guide can be found at http://www.hl7.org This CCD implementations guide was published by Health Level Seven (HL7) and was developed to support CCD implementers. The scope is “just enough” to get started and is based on the CCR standard – it is not a standalone or complete guide or reference. Page 39 of 256 1.5 Glossary of Terms and Acronyms Term and Acronym Definition HL7 Acknowledgment (HL7) (ACK) In the HL7 Standard, acknowledgements (ACK’s) are sent from applications receiving HL7 messages as a means to confirm that inbound messages have been received. When the receiving application accepts and consumes the data within an HL7 message, the receiving application is expected to send an ACK back to the sending application. If the sending application does not receive the ACK, it may continue to send the same message until an ACK is received. Boston Public Health Commission The oldest health department in the United States, BPHC (BPHC) is an independent public agency providing a wide range of health services and programs. It is governed by a seven-member board of health appointed by Boston's mayor. Its mission is to "protect, preserve, and promote the health and well-being of all Boston residents, particularly those who are most vulnerable." Center for Disease Control and The national public health institute of the United States. Prevention (CDC) The CDC is a federal agency under the Department of Health and Human Services. Clinical Document Architecture An XML-based markup standard intended to specify the (CDA) encoding, structure and semantics of clinical documents for exchange. CDA is an ANSI-certified standard from Health Level Seven (HL7.org) Electronic Health Record (EHR) A digital version of a patient’s paper chart. Health Equity Data Healthcare equity refers to equal access to or availability of healthcare facilities and services. Health status equity refers to the absence of variation in rates of disease occurrence and disabilities between socioeconomically-, racially-, and/or geographically-defined population groups. Health Information Exchange (HIE) A system that enables the electronic sharing of healthrelated information Health Level Seven (HL7) Global authority on standards for interoperability of health information technology Mass HIway The HIway is a secure statewide network that facilitates the transmission of healthcare data and health information among providers, hospitals and other healthcare entities. www.mass.gov/hhs/masshiway Meaningful Use (MU) Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Page 40 of 256 Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria Page 41 of 256 High Level Description of HIE Gateway For informational purposes, this section describes the high level functionality and conceptual architecture of the BPHC HIE Gateway. 1.6 High Level Functional Description of BPHC HIE Gateway The BPHC HIE Gateway provides clinical data exchange services to be used by Health Care Provider Sites to send Health Equity and other clinical data to BPHC. The primary functions of the BPHC HIE Gateway include the following:     Security: Handles authentication and authorization of Health Care Provider Sites, and ensures proper message security including encryption. Logging: Logs transactions to support troubleshooting and data quality and to meet auditing and disclosure reporting requirements. Data Services: Provides persistent storage and management of data, including security of data at rest and appropriate archiving. Message Transport: Enables secure, reliable, standards-based communication between Health Care Provider Sites and BPHC. Page 42 of 256 1.7 High Level Conceptual Architecture This section describes the high level architecture of the BPHC HIE Gateway. The HIE Gateway serves two primary functions:   Message transport services Message storage Regarding message transport, the BPHC Gateway utilizes the existing Massachusetts HIway infrastructure to enable Health care Provider Sites to easily send messages to BPHC. Health Care Provider Sites can utilize the Mass HIway LAND device to send messages to the BPHC. The Mass HIway LAND device should be installed locally on the network of the Health Care Provider Site and serves to send messages to a corresponding Mass HIway LAND device installed within the BPHC infrastructure. The interaction between the Health Care Provider Site applications, the Mass HIway and the Boston Public Health Commission HIE Infrastructure is illustrated in Figure III-1. Figure III-1: HIE Gateway Infrastructure BPHC Network Sending Health Care Provider Site Network Health Care Provider Site Application BPHC LAND Device Provider Site LAND Device BPHC HIE Warehouse BPHC HIE Database Data Exchange Broker Mass HiWAY The HIE Gateway is invoked through the Mass HIway by message interactions between the Health Care Provider Site LAND Device and the BPHC LAND Device. To achieve interoperability between Health Care Provider Sites and the BPHC, the LAND devices serve as intermediaries that mediate communications between the backend systems involved. Page 43 of 256 1.8 Typical Transaction Sequence Diagram A typical flow of a message through the infrastructure is that messages are constructed by the Health Care Provider Site Electronic Health Record systems. Then, the message is transmitted from the MassHIway LAND device at the Health Care Provider Site to the MassHIway LAND device at BPHC. From there, the message is forwarded to the BPHC HIE Gateway which includes a message processing engine and secure data warehouse. After processing, a message Acknowledgement is sent back through the MassHIway LAND devices from BPHC to the sending Health Care Provider Site to confirm receipt of the message. The following diagram illustrates this system interaction: Figure III-2: Send / Receive Health Equity Message Choreography Boston Public Health HIE System Sending Organization Capture Data Related to the Patient Encounter Perform Coding for the Encounter and Related Activities Create BPHC Health Disparities Report Send to BPHC via the Mass HiWAY ACK returned to sending system Page 44 of 256 Page 45 of 256 Possible Events That Trigger Sending Health Equity Data As part of establishing this data exchange interface with BPHC, Health Care Provider Sites must determine when they will send information. That is, they must determine the specific trigger points for when their Electronic Health Record Systems will construct and send messages to BPHC. This section lists some typical events that may be considered as triggers for sending Health Equity messages to the Boston Public Health Commission. BPHC recognizes that the workflow at provider sites may differ, so these are just meant as options and will be discussed further as part of the work effort in establishing the interface. # 1. 2. 3. 4. 5. Events to Use as Triggers for Sending Messages Signing of notes from Inpatient Encounter. Signing of notes from Outpatient Encounter. Signing of notes from Emergency Department Encounter. Update to information within Clinical Record. Receive Error Acknowledgement. Page 46 of 256 Message Construction While the sections above provide some background information and describe the high level architecture of the BPHC HIE Gateway, the following sections include the detailed information necessary to construct messages to send to the BPHC. Document Conventions This section describes some of the document conventions used in describing the message structure for sending Health Equity data to BPHC. 1.9 Keywords The optionality constraints in this Data Submission Guide use the HL7 Consolidated CDA conformance verbs (copyright 2011 Health Level Seven International): “The keywords SHALL, SHOULD, MAY, NEED NOT, SHOULD NOT, and SHALL NOT in this document are to be interpreted as described in the HL7 Version 3 Publishing Facilitator's Guide (http://www.hl7.org).  SHALL: an absolute requirement.  SHALL NOT: an absolute prohibition against inclusion.  SHOULD/SHOULD NOT: best practice or recommendation. There may be valid reasons to ignore an item, but the full implications must be understood and carefully weighed before choosing a different course.  MAY/NEED NOT: truly optional. Can be included or omitted as the author decides with no implications. The keyword "SHALL" allows the use of Null Flavor unless the requirement is on an attribute or the use of Null Flavor is explicitly precluded. The subject of a conformance verb (keyword) in a top-level constraint is the template itself; in nested constraints, the subject is the element in the containing constraint. 1.10 Use of XPath Compliance statements that refer to elements of a CDA document are identified using the notation defined in XML Path Language (XPath), which is available at http://www.w3.org/TR/xpath. 1.11 Cardinality Cardinality expresses the number of times an attribute or association may appear in a CDA document instance that conforms to the specifications described within section 8. Cardinality is expressed as a minimum and a maximum value separated by ‘..’, and enclosed in ‘* +’, e.g., ‘*0..1+’. Minimum cardinality is expressed as an integer that is equal to or greater than zero. If the minimum cardinality is zero, the element need only appear in message instances when the sending application has data with which to value the element. Mandatory elements must have Page 47 of 256 a minimum cardinality greater than zero. The maximum cardinality is expressed either as a positive integer (greater than zero and greater than or equal to the minimum cardinality) or as unlimited using an asterisk (“*”). The cardinality indicators may be interpreted as follows:     0..1 as zero to one present 1..1 as one and only one present 1..* as one or more present 0..* as zero to many present 1.12 Null Flavor The Null Flavor definitions in this Data Submission Guide use the HL7 Consolidated CDA Null Flavor (copyright 2011 Health Level Seven International): “Information technology solutions store and manage data, but sometimes data are not available: an item may be unknown, not relevant, or not computable or measureable. In HL7, a flavor of null, or Null Flavor, describes the reason for missing data.” For example, if a patient arrives at an Emergency Department unconscious and with no identification, we would use a null flavor to represent the lack of information. The patient’s birth date would be represented with a null flavor of “NAV”, which is the code for “temporarily unavailable”. When the patient regains consciousness or a relative arrives, we expect to know the patient’s birth date. Use null flavors for unknown, required, or optional attributes:  NI No information. This is the most general and default null flavor.  NA Not applicable. Known to have no proper value (e.g., last menstrual period for a male).  UNK Unknown. A proper value is applicable, but is not known.  ASKU Asked, but not known. Information was sought, but not found (e.g., the patient was asked but did not know).  NAV Temporarily unavailable. The information is not available, but is expected to be available later.  NASK Not asked. The patient was not asked.  MSK There is information on this item available but it has not been provided by the sender due to security, privacy, or other reasons. There may be an alternate mechanism for gaining access to this information. Page 48 of 256 This above list contains those null flavors that are commonly used in clinical documents. For the full list and descriptions, see the Null Flavor vocabulary domain in the CDA normative edition. (HL7 Clinical Document Architecture (CDA Release 2) http://www.hl7.org/implement/standards/cda.cfm) 1.13 Required Field Notation The ‘Opt.’ column used in this guide follows HL7 rules for required element codes that are described in the table below: Table III-1: Required Column Codes Reqd. Meaning Comment R Required R2 Required if known CR Conditionally Required A conforming sending application shall populate all “R” elements with a non-empty value. Conforming receiving application shall process or ignore the information conveyed by required elements. A conforming receiving application must not raise an error due to the presence of a required element, but may raise an error due to the absence of a required element. Fields identified as “R2” may be missing from the message, but must be sent by the sending application if the data is available. If the sending application does not know the values, then that element will be omitted. Receiving applications will be expected to process or ignore data contained in the element, but must be able to successfully process the message if the element is omitted (no error message should be generated because the element is missing). This usage has an associated condition predicate. This predicate is an attribute within the message. If the predicate is satisfied: A conformant sending application must always send the element. A conformant receiving application must process or ignore data in the element. It may raise an error if the element is not present. If the predicate is NOT satisfied: A conformant sending application must NOT send the element. O Optional A conformant receiving application must NOT raise an error if the condition predicate is false and the element is not present, though it may raise an error if the element IS present. This usage indicates that the element may or may not be present in a message. Conformant receiving applications may not raise an error if it Page 49 of 256 Reqd. Meaning Comment receives an unexpected optional element. N Not used The usage indicates that the element is not supported. Sending applications should not send this element. Receiving applications should ignore this element if present. A receiving application should not raise an error if it receives an unsupported element. 1.14 Message Examples Each template described in section 8 provides an XML example for that template. Dynamic message components are bolded to draw attention to the parts of the message that will change. Static parts of the message are lightened as these will be the same in all messages. Figure III-3 Message Example Convention Figure <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.7"/> <id root="2.16.840.1.113883.3.96.1.3" extension=“9d9ee34a-23f4-47eb-8298-f520fc2cc9d1”/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/> <effectiveTime> <low value="20060501"/> <high value="20120601"/> </effectiveTime> <value xsi:type="CD" code="419511003" displayName="Propensity to adverse reactions to drug" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> <originalText> The free text from which the value code was derived from </originalText> </value> <participant typeCode="CSM"> <participantRole classCode="MANU"> <playingEntity classCode="MMAT"> <code code="763049" displayName="Codeine 30mg/ml" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"> <originalText> The free text from which the product code was derived from </originalText> </code> </playingEntity> </participantRole> </participant> </observation> Page 50 of 256 BPHC Health Equity Reporting 1.15 CDA CCD Document Module The CCD is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. The primary use case for the CCD is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient Template Id Document Code Opt R [1..1] R [1..1] R [1..1] R [1..1] R2 [1..1] R [1..1] R [1..1] R2 [0..1] R [1..1] R2 [0..1] R2 [0..1] Data Element or Section Name US Realm Clinical Document = 2.16.840.1.113883.10.20.22.1.1 LOINC = 34133-9 Summarization of Episode Note Data Submission Guide Location Section Template Id CCD Header Section 2.16.840.1.113883.10.20.22.1.2 CDA Header Content Allergies Section 2.16.840.1.113883.10.20.22.2.6 Allergies Section Medications Section 2.16.840.1.113883.10.20.22.2.1.1 Medications Section Problem List Section 2.16.840.1.113883.10.20.22.2.5.1 Problem List Section Procedures Section 2.16.840.1.113883.10.20.22.2.7.1 Procedures Section Results Section 2.16.840.1.113883.10.20.22.2.3.1 Results Section Encounters Section 2.16.840.1.113883.10.20.22.2.22 Encounters Section Immunizations Section 2.16.840.1.113883.10.20.22.2.2 Immunizations Section Payers Section 2.16.840.1.113883.10.20.22.2.18 Payers Section Social History Section 2.16.840.1.113883.10.20.22.2.17 Social History Section Vital Signs Section 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section 1.15.1 CDA Header Content Table III-2 CCD Document Constraints Overview Name XPath Card Opt ClinicalDocument 1..1 R Data Type Fixed Value Page 51 of 256 Name XPath Card Opt Data Type @xmlns:xsi R http://www.w3.org/2001/XMLSche ma-instance @xmlns R urn:hl7-org:v3 @xmlns:cda R urn:hl7-org:v3 @xmlns:sdtc R urn:hl7-org:sdtc R US realCode 1..1 @code typeId R 1..1 R @root R 2.16.840.1.113883.1.3 @extension R POCD_HD000040 templateId 2..2 R 2.16.840.1.113883.10.20.22.1.1 and 2.16.840.1.113883.10.20.22.1.2 for the second @root id Message Id Fixed Value 1..1 R 1..1 R @root code CD @code R 34133-9 @displayName R Summarization of Episode Note @codeSystem R 2.16.840.1.113883.6.1 @codeSystemName R LOINC title 1..1 R 1..1 R effectiveTime Start Date low @value End Date high R 0..1 @value confidentialityCode R2 TS R 1..1 R CD @code R N @displayName R Normal @codeSystem R 2.16.840.1.113883.5.25 @codeSystemName R Confidentiality Code languageCode 1..1 @code Service Event TS documentationOf R R 1..1 CD en-US R Page 52 of 256 Name XPath serviceEvent Card Opt 1..1 R Document Author author 1..1 R Patient recordTarget 1..1 R patientRole 1..1 R Document Owner custodian 1..1 R Relatives participant 1..* R @typeCode Encounter componentOf encompassingEncounter Data Type Fixed Value R 1..1 R 1..1 R Specification 1. SHALL contain exactly one [1..1] realmCode="US" 2. SHALL contain exactly one [1..1] typeId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3" b. SHALL contain exactly one [1..1] @extension="POCD_HD000040" 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1" 4. SHALL contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root set to the organization id in which the message was generated by b. SHALL contain exactly one [1..1] @extension set to a unique identifier for the message within the organization. If the same message is sent at a later date, the id SHOULD contain the same message id. c. BPHC Captured: The message id is requested for capture to allow BPHC to easily identify a message. The unique identifier will help to distinguish repeat message, determine which message resulted in changes and for easy reference to the same message among systems. 5. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="34133-9" b. SHALL contain exactly one @displayName = “Summarization of Episode Note” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 6. SHALL contain exactly one [1..1] title a. Can either be a locally defined name or the display name corresponding to clinicalDocument/code 7. SHALL contain exactly one [1..1] effectiveTime a. BPHC Captured: The effective time signifies that time that encounter took place. Minimally the start time of the encounter should be specified and the end time is strongly suggested. The encounter start and end date is used by BPHC to Page 53 of 256 determine the timeframe in which the encounter belongs as well as to determine the order and distance between chronological events related to the encounter. The encounter time is used in utilization measures and for measures that measure time from the encounter start to a specific event occurring such as the time to PCI. 8. SHALL contain exactly one [1..1] confidentialityCode such that it a. SHALL contain exactly one @code="N" b. SHALL contain exactly one @displayName = “Normal” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.25”. d. SHOULD contain exactly one @codeSystemName = “Confidentiality Code” 9. SHALL contain exactly one [1..1] languageCode such that it a. SHALL contain exactly one @code="en-US" Figure III-4 CCD Document Example  <ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">  <realmCode code="US"/> <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <templateId root="2.16.840.1.113883.10.20.22.1.1"/> <!—CCD Template --> <templateId root="2.16.840.1.113883.10.20.22.1.2"/> <id extension="TT988" root="2.16.840.1.113883.19.5.99999.1"/> <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/> <title>Community Health and Hospitals: Health Summary</title> <effectiveTime > <low value="201209150000-0400"/> </effectiveTime> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="en-US"/> <recordTarget> <patientRole> … </patientRole </recordTarget> <author> … </author> <custodian> <assignedCustodian> … </assignedCustodian> </custodian> <documentationOf> <serviceEvent classCode="PCPR"> … </serviceEvent> </documentationOf> <component> <structuredBody>  <component> <section> … </section> </component> … </structuredBody> Page 54 of 256 </component> </ClinicalDocument> 1.15.2 CCD Author Content The author element represents the creator of the clinical document. The author may be a device, or a person. Table III-3 CCD Author Constraints Overview Name XPath Card Opt author 1..1 R time Data Type R @value assignedAuthor id PCPR R 1..1 R 1..1 R @root R @extension R code Fixed Value 1..1 R CD @code R @displayName R @codeSystem R 2.16.840.1.113883.6.101 @codeSystemName R NUCC Health Care Provider Taxonomy addr 1..1 R Addr telecom 1..1 R2 Tel assignedPerson 0..1 R2 Person 0..1 R2 manufacturuerModelName 1..1 R softwareName 1..1 R assignedDevice Specification 1. SHALL contain at least one [1..*] author such that it a. SHALL contain exactly one [1..1] time i. SHALL contain exactly one [1..1] @value b. SHALL contain exactly one [1..1] assignedAuthor such that it i. SHALL contain exactly one [1..1] id such that it 1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" National Provider Identifier ii. SHOULD contain zero or one [0..1] code such that it Page 55 of 256 iii. iv. v. vi. vii. 1. SHOULD contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (NUCC HIPAA) 2.16.840.1.114222.4.11.1066 DYNAMIC SHALL contain at least one [1..*] addr SHALL contain at least one [1..*] telecom SHOULD contain zero or one [0..1] assignedPerson SHOULD contain zero or one [0..1] assignedAuthoringDevice such that it 1. SHALL contain exactly one [1..1] manufacturerModelName 2. SHALL contain exactly one [1..1] softwareName There SHALL be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice Figure III-5 CCD Author Example <author> <time value="20050329224411+0500"/> <assignedAuthor> <id extension="99999999" root="2.16.840.1.113883.4.6"/> <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic & Osteopathic Physicians"/> <addr> <streetAddressLine>1002 Healthcare Drive </streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:555-555-1002"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedAuthor> </author> Page 56 of 256 1.15.3 CCD Custodian Content The custodian element represents the organization that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Since CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Table III-4 CCD Custodian Constraints Overview Name XPath Card Opt custodian 1..1 R 1..1 R 1..1 R assignedCustodian representedCustodianOrganiza tion Data Type Fixed Value Organiz ation Specification 1. SHALL contain exactly one [1..1] custodian such that it a. SHALL contain exactly one [1..1] assignedCustodian such that it i. SHALL contain exactly one [1..1] representedCustodianOrganization such that it 1. SHALL contain at least one [1..*] id such that it a. SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier 2. SHALL contain exactly one [1..1] name 3. SHALL contain exactly one [1..1] telecom 4. SHALL contain at least one [1..*] addr Figure III-6 CCD Custodian Example <custodian> <assignedCustodian> <representedCustodianOrganization> <id extension="99999999" root="2.16.840.1.113883.4.6"/> <name>Community Health and Hospitals</name> <telecom value="tel: 555-555-1002" use="WP"/> <addr use="WP"> <streetAddressLine>1002 Healthcare Drive </streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </representedCustodianOrganization> </assignedCustodian> </custodian> Page 57 of 256 1.15.4 CCD Record Target Content The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. Table III-5 CCD Record Target Constraints Overview Name XPath Card Opt recordTarget/patientRole 1..1 R 1..1 R id @root R @extension R addr 1..* R telecom 1..* R 1..1 R2 Data Type Fixed Value Addr patient id Gender Marital Status Race Ethnicity @root R @extension R name 1..1 R administrativeGenderCode 1..1 R Person @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.1 @codeSystemName R2 AdministrativeGender maritalStatusCode 0..1 R2 @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.2 @codeSystemName R2 MaritalStautsCode raceCode 0..1 R2 @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.238 @codeSystemName R2 Race & Ethnicity - CDC ethnicGroupCode @code 0..1 R2 R Page 58 of 256 Name Guardian Relative Type XPath Card Opt Data Type Fixed Value @displayName R2 @codeSystem R 2.16.840.1.113883.3.539.1.1 @codeSystemName R2 BPHC Ethnicity ValueSet guardian 0..* R2 code @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.111 @codeSystemName R2 RoleCode addr 0..* R2 Addr telecom 0..* R2 Tel guardianPerson 0..1 R2 Person birthplace 0..1 R2 place 1..1 R 1..1 R 0..* R2 1..1 R addr languageCommunication code Addr @code R @displayName R2 @codeSystem R 2.16.840.1.113883.1.11.11526 @codeSystemName R2 Internet Society Language preferenceInd 0..1 @value providerOrganization id R2 R 0..1 R2 1..1 R @root R @extension R name 1..1 R ED telecom 1..* R Tel addr 1..* R Addr Specification 1. SHALL contain exactly one [1..1] recordTarget such that it a. Such recordTargets SHALL contain exactly one [1..1] patientRole i. This patientRole SHALL contain at least one [1..*] id such that it 1. SHALL contain exactly one @root Page 59 of 256 a. The root should contain the OID of the sending application/EMR in which the MRN for the patient is assigned and maintained for this encounter. If an organization has a specific OID representing the MRN number then that OID should be used. 2. SHALL contain exactly one @extension a. BPHC requires that the extension be populated with the patient’s MRN number. 3. BPHC Captured: BPHC requires the MRN field for capture to uniquely identify a patient without complex patient matching algorithm when multiple messages are received from the same organization for the same patient. ii. This patientRole SHALL contain at least one [1..*] addr 1. BPHC Captured: BPHC requires the patient’s address for research purposes that may include, but are not limited to, research on health equity and how it pertains to and is potentially impacted by geographic address of their residence. iii. This patientRole SHALL contain at least one [1..*] telecom 1. iv. This patientRole SHALL contain exactly one [1..1] patient such that it 1. SHOULD contain exactly one [1..1] id for the SSN such that it a. SHALL contain exactly one [1..1] @root = “2.16.840.1.113883.4.1” b. SHALL contain exactly one [1..1] @extension i. The extension should be set to the Patient’s Social Security Number in the formatted without spaces or dashes. (999999999) c. BPHC Captured: BPHC requires the SSN field for capture to uniquely identify a patient that has been assigned one. The SSN can be used to match patients across multiple organizations that with separate medical record numbers. 2. This patient SHALL contain exactly one [1..1] name 3. This patient SHALL contain exactly one [1..1] administrativeGenderCode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 DYNAMIC a. BPHC Captured: BPHC requires the patient’s gender for research purposes that may include, but are not limited to, research on risk factors and how they pertain to each gender, gender inequality, and gender specific diagnoses. 4. This patient SHALL contain exactly one [1..1] birthTime a. SHALL be precise to year b. SHOULD be precise to day c. BPHC Captured: BPHC requires the patient’s birth time to determine that patient’s age at the time of an encounter. Page 60 of 256 Many of the national HEDIS measures require reporting on specific age ranges and therefore require the patient’s age to be known. 5. This patient SHOULD contain zero or one [0..1] maritalStatusCode, which SHALL be selected from ValueSet HL7 MaritalStatus 2.16.840.1.113883.1.11.12212 DYNAMIC a. BPHC Captured: BPHC requires the patient’s marital status for research purposes that may include, but are not limited to, research on health equity and how it pertains to and is potentially impacted by marital status. 6. This patient MAY contain zero or one [0..1] raceCode, which SHALL be selected from ValueSet Race 2.16.840.1.113883.1.11.14914 DYNAMIC a. BPHC Captured: BPHC requires the patient’s race for research purposes that may include, but are not limited to, research on health equity and how it pertains to and is potentially impacted by race. 7. This patient MAY contain zero or one [0..1] ethnicGroupCode, which SHALL be selected from ValueSet Ethnicity Value 2.16.840.1.114222.4.11.837 DYNAMIC a. BPHC Captured: BPHC requires the patient’s ethnicity for research purposes that may include, but are not limited to, research on health equity and how it pertains to and is potentially impacted by ethnicity. 8. This patient MAY contain zero or more [0..*] guardian a. The guardian, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Personal Relationship Role Type 2.16.840.1.113883.1.11.19563 DYNAMIC b. The guardian, if present, SHOULD contain zero or more [0..*] addr c. The guardian, if present, MAY contain zero or more [0..*] telecom d. The guardian, if present, SHALL contain exactly one [1..1] guardianPerson 9. This patient MAY contain zero or one [0..1] birthplace a. The birthplace, if present, SHALL contain exactly one [1..1] place i. This place SHALL contain exactly one [1..1] addr 10. This patient SHOULD contain zero or more [0..*] languageCommunication a. The languageCommunication, if present, SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language 2.16.840.1.113883.1.11.11526 DYNAMIC Page 61 of 256 b. The languageCommunication, if present, MAY contain zero or one [0..1] preferenceInd v. This patientRole MAY contain zero or one [0..1] providerOrganization 1. BPHC Captured: BPHC requests the provider organization to facilitate any follow-up and support research. Figure III-7 CCD Record Target Example <recordTarget> <patientRole> <id extension="998991" root="2.16.840.1.113883.19.5.99999.2"/>  <id extension="111-00-2330" root="2.16.840.1.113883.4.1"/>  <addr use="HP">  <streetAddressLine>1357 Amber Drive</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97867</postalCode> <country>US</country>  </addr> <telecom value="tel:(816)276-6909" use="HP"/>  <patient> <name use="L">  <given>Isabella</given> <given>Isa</given>  <family>Jones</family> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/> <birthTime value="19750501"/> <maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/> <raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/> <ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/> <guardian> <code code="PRN" displayName="Parent" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 Role code"/> <addr use="HP">  <streetAddressLine>1357 Amber Drive</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97867</postalCode> <country>US</country>  </addr> <telecom value="tel:(816)276-6909" use="HP"/> <guardianPerson> <name> <given>Ralph</given> <family>Jones</family> </name> </guardianPerson> </guardian> <birthplace> <place> <addr> <city>Beaverton</city> <state>OR</state> Page 62 of 256 <postalCode>97867</postalCode> <country>US</country> </addr> </place> </birthplace> <languageCommunication> <languageCode code="en"/> <preferenceInd value="true"/> </languageCommunication> </patient> <providerOrganization> <id root="2.16.840.1.113883.4.6"/> <name>Community Health and Hospitals</name> <telecom use="WP" value="tel: 555-555-5000"/> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </providerOrganization> </patientRole> </recordTarget> Page 63 of 256 1.15.5 CCD Service Event Content A serviceEvent represents the main act, such as a colonoscopy or a cardiac stress study, being documented. In a continuity of care document, CCD, the serviceEvent is a provision of healthcare over a period of time. In a provision of healthcare serviceEvent, the care providers, PCP or other longitudinal providers, are recorded within the serviceEvent. The BPHC Health Equity Report constrains the message to refer only to a single encounter recorded in the Encounters Section. Table III-6 CCD Service Event Constraints Overview Name XPath Car d Op t serviceEvent 1..1 R @classCode Data Type R Fixed Value PCPR effectiveTime Start Date low 1..1 @value End Date high 0..1 Provider Role performer functionCode R2 TS R 0..* R2 0..1 R2 @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.88 @codeSystemName R2 ParticipationFunction assignedEntity id Provider Type TS R @value Provider(s) R 1..1 R 1..1 R @root R @extension R code 0..1 O @code R @displayName R2 @codeSystem R @codeSystemName R2 addr 1..1 R Addr telecom 1..1 R Tel assignedPerson 0..1 R2 Person Page 64 of 256 Name XPath representedOrganization Car d Op t Data Type 0..1 R2 Organiza tion Fixed Value Specification 1. MAY contain zero or more [0..*] documentationOf such that it a. SHALL contain exactly one [1..1] serviceEvent such that it i. SHALL contain exactly one [1..1] effectiveTime such that it 1. SHALL contain exactly one [1..1] low ii. SHOULD contain zero or more [0..*] performer such that it 1. SHALL contain exactly one [1..1] @typeCode="PRF" Participation physical performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) a. The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors 2. SHOULD contain zero or one [0..1] functionCode a. SHALL contain exactly one [1..1] @code, which SHALL be selected from CodeSystem ParticipationFunction 2.16.840.1.113883.5.88 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.88” d. SHOULD contain exactly one @codeSystemName = “ParticipationFunction” e. BPHC Captured: BPHC requires this field to capture the provider’s role in the healthcare of a patient. Many of the HEDIS Measures require a determination if the role of a provider is a Primary Care Physician or not. 3. SHALL contain exactly one [1..1] assignedEntity such that it a. SHALL contain exactly one [1..1] id such that it i. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.4.6" National Provider Identifier ii. SHALL contain exactly one [1..1] @extension 1. The extension shall be populated with the provider’s NPI. Page 65 of 256 b. c. d. e. f. iii. BPHC Captured: BPHC requires the id field to uniquely identify a provider using a national identifier. The identifier can be used to reference the provider internally as well as to perform follow up with outside systems. SHOULD contain zero or one [0..1] code for the provider type such that it i. SHALL contain exactly one [1..1] @code, which SHOULD be selected from CodeSystem NUCCProviderTaxonomy (2.16.840.1.113883.6.101) ii. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen iii. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.101” iv. SHOULD contain exactly one @codeSystemName = “NUCCProviderTaxonomy” v. BPHC Captured: The provider type is required for capture since it is used in various HEDIS measures to help determine the visit type. The provider type should always be specified when known. SHALL contain exactly one [1..1] addr SHALL contain exactly one [1..1] telecom SHOULD contain zero or one [0..1] assignedPerson i. BPHC Captured: BPHC requests the assigned person to facilitate any follow-up and support research. SHOULD contain zero or one [0..1] representedOrganization i. BPHC Captured: BPHC requests the provider organization to facilitate any follow-up and support research. Figure III-8 CCD Service Event Example <documentationOf> <serviceEvent classCode="PCPR"> <code code="73761001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonoscopy"/> <effectiveTime> <low value="201209080000-0400"/> <high value="201209150000-0400"/> </effectiveTime> <performer typeCode="PRF"> <functionCode code="PP" displayName="Primary Performer" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role"> <originalText>Primary Care Provider</originalText> </functionCode> <assignedEntity>  <id extension="PseudoMD-1" root="2.16.840.1.113883.4.6"/> Page 66 of 256 <code code="207RG0100X" displayName="Gastroenterologist" codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101"/> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom value="tel:+1-555-555-5000" use="HP"/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5.9999.1393"/> <name>Community Health and Hospitals</name> <telecom value="tel:+1-555-555-5000" use="HP"/> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </representedOrganization> </assignedEntity> </performer> </serviceEvent> </documentationOf> Page 67 of 256 1.16 CDA Section Level Templates The BPHC Health Equity Report uses the HL7 CCD Templates described in this section with additional constraints where indicated. 1.16.1 Allergies Section This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives) used to assure the safety of health care delivery. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. Table III-1 – Allergies Section 2.16.840.1.113883.10.20.22.2.6 Opt R2 [0..1] Template Id 2.16.840.1.113883.10.20.22.2.6 Section Code LOINC 48765-2 Allergies, adverse reactions, alerts Entry Name Allergy Problem Entry Template Id 2.16.840.1.113883.10.20.22.4.30 Data Submission Guide Location Allergy Problem Act Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.28". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="48765-2" b. SHALL contain exactly one @displayName = “Allergies, adverse reactions, alerts” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Allergies” 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes all current and historical allergies and adverse reactions. b. BPHC Captured: The section text is a human readable summary of all Allergies and related information. The text should be a detailed representation of the coded content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. 5. SHALL contain at least one [1..*] entry such that it a. SHALL contain exactly one [1..1] @typeCode = “DRIV” (Is Derived From) b. SHALL contain exactly one [1..1] Allergy Problem Act (2.16.840.1.113883.10.20.22.4.30) Page 68 of 256 Figure III-9 Allergies Section Example <section> <templateId root="2.16.840.1.113883.10.20.22.2.6"/> <code code="48765-2" displayName="Allergies, adverse reactions, alerts" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Allergies</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.30"/> !-- Allergy Problem Act template --> ... </act> </entry> </section> Page 69 of 256 1.16.2 Encounters Section This section lists and describes healthcare encounters. An Encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, as well as non-face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment. This section is further constrained for the BPHC Health Equity Report to include exactly one encounter which is the encounter for which the CCD document is about. Table III-2 – Encounters Section 2.16.840.1.113883.10.20.22.2.22.1 Opt R [1..1] Template Id 2.16.840.1.113883.10.20.22.2.22.1 Section Code LOINC 46240-8 History of encounters Entry Name Encounter Activities Entry Template Id 2.16.840.1.113883.10.20.22.4.49 Data Submission Guide Location Encounter Activities_Allergy_problem_Ent ry Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.22.1". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="46240-8" b. SHALL contain exactly one @displayName = “History of encounters” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Encounters” 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes the encounter in which the CCD document is describing b. BPHC Captured: The section text is a human readable summary of the single encounter and related information. The text should be a detailed representation of the coded content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. 5. SHALL contain at least one [1..*] entry such that it a. SHALL contain exactly one [1..1] @typeCode = “DRIV” (Is Derived From) Page 70 of 256 b. SHALL contain exactly one [1..1] Encounter Activities (2.16.840.1.113883.10.20.22.4.49) Figure III-10 Encounters Section Example <section> <templateId root="2.16.840.1.113883.10.20.22.2.22"/>  <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/> <title>Encounters</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <encounter classCode="ENC" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.49"/>  ... </encounter> </entry> </section> Page 71 of 256 1.16.3 Immunizations Section The Immunizations section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized. Table III-3 – Immunizations Section 2.16.840.1.113883.10.20.22.2.2 Template Id 2.16.840.1.113883.10.20.22.2.2 Section Code LOINC 11369-6 Immunizations Opt Entry Name R [0..*] Immunization Activity Entry Template Id 2.16.840.1.113883.10.20.22.4.52 Data Submission Guide Location Immunization Activity_Coverage_Activity Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.2". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="11369-6" b. SHALL contain exactly one @displayName = “Immunizations” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Immunizations” 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes all current and relevant historical immunizations for the patient. b. BPHC Captured: The section text is a human readable summary of all Immunizations and related information. The text should be a detailed representation of the coded content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. 5. SHALL contain at least one [1..*] entry such that it a. SHALL contain exactly one [1..1] @typeCode = “DRIV” (Is Derived From) b. SHALL contain exactly one [1..1] Immunization Activity (2.16.840.1.113883.10.20.22.4.52) Page 72 of 256 Figure III-11 Immunizations Section Example <section> <templateId root="2.16.840.1.113883.10.20.22.2.2"/> <code code="11369-6" displayName="Immunizations" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Immunizations</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false"> <templateId root="2.16.840.1.113883.10.20.22.4.52"/>  ... </substanceAdministration> </entry> ... </section> Page 73 of 256 1.16.4 Medications Section The Medications section defines a patient's current medications and pertinent medication history. At a minimum, the currently active medications are to be listed, with an entire medication history as an option. The section may also include a patient's prescription and dispense history. This section requires that there be either an entry indicating the subject is not known to be on any medications, or that there be entries summarizing the subject's medications. Table III-4 – Medications Section 2.16.840.1.113883.10.20.22.2.1 Opt R [0..1] Template Id 2.16.840.1.113883.10.20.22.2.1 Section Code LOINC 10160-0 History of medication use Entry Name Medication Activity Entry Template Id 2.16.840.1.113883.10.20.22.4.16 Data Submission Guide Location Medication Activity_Allergy_problem_Entry Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.1". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="10160-0 " b. SHALL contain exactly one @displayName = “History of medication use” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Medications” 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes all current and historical medications for the patient. b. BPHC Captured: The section text is a human readable summary of all Medications and related information. The text should be a detailed representation of the coded content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. 5. SHALL contain at least one [1..*] entry such that it a. SHALL contain exactly one [1..1] @typeCode = “DRIV” (Is Derived From) b. SHALL contain exactly one [1..1] Medication Activity (2.16.840.1.113883.10.20.22.4.16) Page 74 of 256 Figure III-12 Medications Section Example <section> <templateId root="2.16.840.1.113883.10.20.22.2.6"/> <code code="10160-0 " displayName=" History of medication use " codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Medications</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.16"/>  ... </substanceAdministration> </entry> … </section> Page 75 of 256 1.16.5 Payers Section The Payers section contains data on the patient’s payers, whether a ‘third party’ insurance, selfpay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient’s care. Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient’s pertinent current payment sources should be listed. The sources of payment are represented as a Coverage Activity, which identifies all of the insurance policies or government or other programs that cover some or all of the patient's healthcare expenses. The policies or programs are sequenced by preference. The Coverage Activity has a sequence number that represents the preference order. Each policy or program identifies the covered party with respect to the payer, so that the identifiers can be recorded. Table III-5 – Payers Section 2.16.840.1.113883.10.20.22.2.18 Template Id 2.16.840.1.113883.10.20.22.2.18 Section Code LOINC 48768-6 Payers Opt Entry Name R [0..*] Coverage Activity Entry Template Id 2.16.840.1.113883.10.20.22.4.60 Data Submission Guide Location Coverage Activity Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.2.18". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code=" 48768-6" b. SHALL contain exactly one @displayName = “Payers” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Payers” 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes all current and relevant historical medications for the patient. b. BPHC Captured: The section text is a human readable summary of all Payers and related information. The text should be a detailed representation of the coded Page 76 of 256 content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. 5. SHALL contain at least one [1..*] entry such that it a. SHALL contain exactly one [1..1] @typeCode = “DRIV” (Is Derived From) b. SHALL contain exactly one [1..1] Coverage Activity (2.16.840.1.113883.10.20.22.4.60) Figure III-13 Payers Section Example <section> <templateId root=" 2.16.840.1.113883.10.20.22.2.18"/> <code code=" 48768-6" displayName="Payers" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Insurance Providers</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="DEF"> <templateId root="2.16.840.1.113883.10.20.22.4.60"/>  ... </act> </entry> … </section> Page 77 of 256 1.16.6 Problem List Section This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed. Table III-6 – Problem List Section 2.16.840.1.113883.10.20.22.2.5 Opt R [0..*] Template Id 2.16.840.1.113883.10.20.22.2.5 Section Code LOINC 11450-4 Problem List Entry Name Product Concern Act Entry Template Id 2.16.840.1.113883.10.20.22.4.3 Data Submission Guide Location Problem Concern Act_Allergy_problem_Entry Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.5". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="11450-4" b. SHALL contain exactly one @displayName = “Problem List” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Problems” 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes all current and relevant historical medications for the patient. b. BPHC Captured: The section text is a human readable summary of all Problems and related information. The text should be a detailed representation of the coded content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. 5. SHALL contain at least one [1..*] entry such that it a. SHALL contain exactly one [1..1] @typeCode = “DRIV” (Is Derived From) b. SHALL contain exactly one [1..1] Problem Concern Act (Condition) (2.16.840.1.113883.10.20.22.4.3) Figure III-14 Problem List Section Example <section> <templateId root="2.16.840.1.113883.10.20.22.2.5"/> <code code="11450-4" displayName="Problem List" codeSystem="2.16.840.1.113883.6.1" Page 78 of 256 codeSystemName="LOINC"/> <title>Problems</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN">  ... </act> </entry> … </section> Page 79 of 256 1.16.7 Procedures Section This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section is intended to include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore this section contains procedure templates represented with three RIM classes: Act, Observation, and Procedure. Procedure act is for procedures that alter that physical condition of a patient (Splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (EEG). Act is for all other types of procedures (dressing change). Table III-7 – Procedures Section 2.16.840.1.113883.10.20.22.2.5 Opt R2 [0..*] R2 [0..*] R2 [0..*] Template Id 2.16.840.1.113883.10.20.22.2.7 Section Code LOINC 47519-4 History of Procedures Entry Name Procedure Activity Procedure Procedure Activity Observation Procedure Activity Act Entry Template Id 2.16.840.1.113883.10.20.22.4.14 Data Submission Guide Location Procedure Activity Procedure_Problem_Concern_A ct_Allergy_problem_Entry 2.16.840.1.113883.10.20.22.4.13 Procedure Activity Observation 2.16.840.1.113883.10.20.22.4.12 Procedure Activity Act Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.7". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="47519-4 " b. SHALL contain exactly one @displayName = “History of Procedures” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Procedures” 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes all current and relevant historical procedures for the patient. b. BPHC Captured: The section text is a human readable summary of all Procedures and related information. The text should be a detailed representation of the coded content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. Page 80 of 256 5. MAY contain zero or more [0..*] entry such that it a. SHALL contain exactly one [1..1] Procedure Activity Procedure (2.16.840.1.113883.10.20.22.4.14) 6. MAY contain zero or more [0..*] entry such that it a. SHALL contain exactly one [1..1] Procedure Activity Observation (2.16.840.1.113883.10.20.22.4.13) 7. MAY contain zero or more [0..*] entry such that it a. SHALL contain exactly one [1..1] Procedure Activity Act (2.16.840.1.113883.10.20.22.4.12) 8. There SHALL be at least one procedure, observation or act entry conformant to Procedure Activity Procedure template, Procedure Activity Observation template or Procedure Activity Act template in the Procedure Section Figure III-15 Procedures Section Example <section> <templateId root="2.16.840.1.113883.10.20.22.2.7"/>  <code code="47519-4" displayName="PROCEDURES" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" /> <title>Procedures</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <procedure classCode="PROC" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.14"/> ... </procedure> </entry> <entry> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.13"/>  ... </observation> </entry> <entry> <act classCode="ACT" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.12"/>  ... </act> </entry> </section> Page 81 of 256 1.16.8 Results Section The Results section contains the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy. Table III-8 – Results Section 2.16.840.1.113883.10.20.22.2.3.1 Opt R2 [0..*] Template Id 2.16.840.1.113883.10.20.22.2.3.1 Section Code LOINC 30954-2 Relevant diagnostic tests and/or laboratory data Entry Name Result Organizer Entry Template Id 2.16.840.1.113883.10.20.22.4.1 Data Submission Guide Location Result Organizer_Medication_Activity_ Allergy_problem_Entry Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.3.1". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="30954-2" b. SHALL contain exactly one @displayName = “Relevant diagnostic tests and/or laboratory data” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Results” Page 82 of 256 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes all current and historical results for the patient. b. BPHC Captured: The section text is a human readable summary of all Results and related information. The text should be a detailed representation of the coded content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. 5. SHALL contain at least one [1..*] entry such that it a. SHALL contain exactly one [1..1] Result Organizer (2.16.840.1.113883.10.20.22.4.1) Figure III-16 Results Section Example <section> <templateId root="2.16.840.1.113883.10.20.22.2.3.1"/> <code code="30954-2" displayName=" Relevant diagnostic tests and/or laboratory data " codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Results</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <organizer classCode="BATTERY" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.1"/> ... </organizer> </entry> … </section> Page 83 of 256 1.16.9 Social History Section This section contains data defining the patient’s occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation. Social history can have significant influence on a patient’s physical, psychological and emotional health and wellbeing so should be considered in the development of a complete record. Table III-9 – Social History Section 2.16.840.1.113883.10.20.22.2.17 Opt O [0..*] O [0..*] R2 [0..*] Template Id 2.16.840.1.113883.10.20.22.2.17 Section Code LOINC 29762-2 Social History Entry Name Social History Observation Pregnancy Observation Smoking Status Observation Entry Template Id 2.16.840.1.113883.10.20.22.4.38 Data Submission Guide Location Social History Observation_Medication_Activit y_Allergy_problem_Entry 2.16.840.1.113883.10.20.15.3.8 Pregnancy Observation 2.16.840.1.113883.10.22.4.78 Smoking Status Observation Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.2.17". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="29762-2" b. SHALL contain exactly one @displayName = “Social History” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Social History” 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes the patients social history b. BPHC Captured: The section text is a human readable summary of the patients Social History and related information. The text should be a detailed representation of the coded content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. 5. MAY contain zero or more [0..*] entry such that it a. SHALL contain at least one [1..*] Social History Observation (2.16.840.1.113883.10.20.22.4.38) 6. MAY contain zero or more [0..*] entry such that it Page 84 of 256 a. SHALL contain exactly one [1..1] Pregnancy Observation (2.16.840.1.113883.10.20.15.3.8) 7. 7. SHOULD contain zero or more [0..*] entry such that it a. SHALL contain exactly one [1..1] Smoking Status Observation (templateId:2.16.840.1.113883.10.22.4.78) Figure III-17 Social History Section Example <section> <templateId root="2.16.840.1.113883.10.20.22.2.17"/> <code code="29762-2" displayName=" Social History" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Social History</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.38"/>  ... </observation> </entry> <entry typeCode="DRIV"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.38"/>  ... </observation> </entry> … </section> Page 85 of 256 1.16.10 Vital Signs Section The Vital Signs section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, and pulse oximetry. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions. Table III-10 – Vital Signs Section 2.16.840.1.113883.10.20.22.2.4.1 Opt R2 [0..*] Template Id 2.16.840.1.113883.10.20.22.2.4.1 Section Code LOINC 30954-2 Relevant diagnostic tests and/or laboratory data Entry Name Vital Signs Organizer Entry Template Id 2.16.840.1.113883.10.20.22.4.26 Data Submission Guide Location Vital Signs Organizer_Result_Organizer_Me dication_Activity_Allergy_probl em_Entry Specification 1. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.4.1". 2. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="8716-3" b. SHALL contain exactly one @displayName = “Vital Signs” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 3. SHALL contain exactly one [1..1] title such that it a. SHALL contain the text “Vital Signs” 4. SHALL contain exactly one [1..1] text. a. SHALL contain a text narrative that lists and describes all vital signs taken during the encounter b. BPHC Captured: The section text is a human readable summary of all Vital Signs and related information taken during an encounter. The text should be a detailed representation of the coded content within the section including all original text from which the codes were determined. BPHC requires the text field for auditing purposes. 5. SHALL contain at least one [1..*] entry such that it Page 86 of 256 a. SHALL contain exactly one [1..1] Vital Signs Organizer(2.16.840.1.113883.10.20.22.4.26) Figure III-18 Vital Signs Section Example <section> <templateId root="2.16.840.1.113883.10.20.22.2.4.1"/> <code code="8716-3" displayName="Vital Signs" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Vital Signs</title> <text> The text narrative as described above </text> <entry typeCode="DRIV"> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.26"/>  ... </organizer> </entry> … </section> Page 87 of 256 1.17 CDA Entry Level Templates The BPHC Health Equity Report uses the HL7 CCD templates described below, with additional constraints where indicated. 1.17.1 Allergy – Intolerance Observation Used By Allergy Problem Act Contains Entries Allergy Status Observation Severity Observation This clinical statement represents that an allergy or adverse reaction exists or does not exist. The agent that is the cause of the allergy or adverse reaction is represented as a manufactured material participant playing entity in the allergy - intolerance observation. While the agent is often implicit in the alert observation (e.g. "allergy to penicillin"), it should also be asserted explicitly as an entity. The manufactured material participant is used to represent natural and non-natural occurring substances. Note: The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, and should be used to represent any type of responsible agent. Table III-7 Allergy - Intolerance Observation Constraints Overview Name XPath Car d Op t observation 1..1 R Data Type Fixed Value @classCode R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN templateId 1..1 @root id R R 1..1 R2 @root R @extension R code 1..1 R 2.16.840.1.113883.10.20.22.4.7 SET<II > CD @code R ASSERTION @displayName R2 Assertion @codeSystem R 2.16.840.1.113883.5.4 @codeSystemName R2 ActCode Page 88 of 256 Name XPath statusCode Op t Data Type 1..1 R CS R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus low 1..1 R IVL<TS > 1..1 R TS @value End Date high R 0..1 @value Allergy Type Allergy Type Free Text Product value 1..1 R CD R @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT originalText participant participantRole playingEntity 0..1 R2 0..1 R2 R 1..1 1..1 code 2.16.840.1.113883.5.110 (RoleClass) = MANU 2.16.840.1.113883.5.41 (EntityClass) = MMAT R @code R @displayName R2 @codeSystem R R2 @codeSystemName originalText 2.16.840.1.113883.5.90 (HL7ParticipationType) = CSM R R 1..1 CD R R classCode Product Free Text TS @xsi:type @classCode Product Code R2 R @typeCode Product Detail Fixed Value @code effectiveTime Start Date Car d 0..1 R2 Page 89 of 256 Name Allergy Status Observation Severity Observation XPath entryRelationship Car d Op t 0..1 O Data Type Fixed Value @typeCode R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ @inversionInd R true entryRelationship 0..1 R2 @typeCode R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ @inversionInd R true Specification Note: The specification starts within the observation element 1. Conforms to Substance or Device Allergy – Intolerance Observation template (2.16.840.1.113883.10.20.24.3.90) See HL7 Consolidation Guide. 2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 4. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.7" 5. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Allergy Intolerance Observation within the sending organization. This ID should be used whenever this particular Allergy Intolerance Observation is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the observation. The unique id can be used to identify the same observation used in different messages. The HL7 Consolidation Guide requires an id for this element. 6. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="ASSERTION" b. SHOULD contain exactly one @displayName = “Assertion” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.4” d. SHOULD contain exactly one @codeSystemName = “ActCode” 7. SHALL contain exactly one [1..1] statusCode such that it Page 90 of 256 a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 8. SHALL contain exactly one [1..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly one [1..1] @value set to the time that the allergy began. If it is unknown when the allergy began, this low SHALL contain @nullFLavor="UNK" instead of @value b. SHOULD contain zero or one [0..1] high if the allergy is no longer a concern such that it i. SHALL contain exactly one [1..1] @value set to the time that the allergy was determined to no longer be a concern c. BPHC Captured: The effective time of the allergy marks the point at which the allergy was first discovered and the high time can mark that it is no longer an allergy. The allergies effective time is captured to help determine the relevance of the allergy during the encounter. 9. SHALL contain exactly one [1..1] value such that it a. SHALL contain exactly one [1..1] @xsi:type = "CD" b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Allergy/Adverse Event Type 2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC c. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen d. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” e. SHOULD contain exactly one @codeSystemName = “SNOMED CT” f. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. g. BPHC Captured: BPHC requires the type of allergy to easily categorize the allergy into a general category of allergies. Allergy type is supplemental information for various measures that can be the reason in which certain decisions are made during an encounter. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. 10. SHOULD contain zero or one [0..1] participant such that it a. SHALL contain exactly one [1..1] @typeCode="CSM" Consumable (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) b. SHALL contain exactly one [1..1] participantRole such that it i. SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) ii. SHALL contain exactly one [1..1] playingEntity such that it 1. SHALL contain exactly one [1..1] @classCode="MMAT" Manufactured Material (CodeSystem: EntityClass 2.16.840.1.113883.5.41 STATIC) 2. SHALL contain exactly one [1..1] code such that it Page 91 of 256 a. SHALL contain exactly one [1..1] @code, which SHALL be according to type of allergy i. In an allergy to a specific medication the code SHALL be selected from the ValueSet 2.16.840.1.113883.3.88.12.80.16 Medication Brand Name DYNAMIC or the ValueSet 2.16.840.1.113883.3.88.12.80.17 Medication Clinical Drug DYNAMIC ii. In an allergy to a class of medications the code SHALL be selected from the ValueSet 2.16.840.1.113883.3.88.12.80.18 Medication Drug Class DYNAMIC iii. In an allergy to a food or other substance the code SHALL be selected from the ValueSet 2.16.840.1.113883.3.88.12.80.20 Ingredient Name DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem such that the value is set accordingly based on the code chosen d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. f. BPHC Captured: BPHC requires the product code in which the patient has an allergy to. The product code marks the specific substance whether it be food, medication or something else. The allergy substance is supplemental information for various measures that can be the reason in which certain decisions are made during an encounter. For example, if a patient is allergic to aspirin then it will not be given upon arrival for chest pain. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. 11. MAY contain zero or one [0..1] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] @inversionInd="true" True c. SHALL contain exactly one [1..1] Allergy Status Observation (templateId:2.16.840.1.113883.10.20.22.4.28) Page 92 of 256 12. SHOULD (Not Used) contain zero or more [0..*] entryRelationship (Reaction Observation) 13. SHOULD contain zero or one [0..1] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] @inversionInd="true" True c. SHALL contain exactly one [1..1] Severity Observation (templateId:2.16.840.1.113883.10.20.22.4.8) Figure III-19 Allergy - Intolerance Observation Example <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.7"/> <id root="2.16.840.1.113883.3.96.1.3" extension=“9d9ee34a-23f4-47eb-8298-f520fc2cc9d1”/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/> <effectiveTime> <low value="20060501"/> <high value="20120601"/> </effectiveTime> <value xsi:type="CD" code="419511003" displayName="Propensity to adverse reactions to drug" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> <originalText> The free text from which the value code was derived from </originalText> </value> <participant typeCode="CSM"> <participantRole classCode="MANU"> <playingEntity classCode="MMAT"> <code code="763049" displayName="Codeine 30mg/ml" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"> <originalText> The free text from which the product code was derived from </originalText> </code> </playingEntity> </participantRole> </participant> </observation> Page 93 of 256 1.17.2 Allergy Problem Act Used By Allergies Section_Allergy_problem_Entry Contains Entries Allergy – Intolerance Observation This clinical statement act represents a concern relating to a patient's allergies or adverse events. A concern is a term used when referring to patient's problems that are related to one another. Observations of problems or other clinical statements captured at a point in time are wrapped in an Allergy Problem Act, or "Concern" act, which represents the ongoing process tracked over time. This outer Allergy Problem Act (representing the "Concern") can contain nested problem observations or other nested clinical statements relevant to the allergy concern. Table III-8 Allergy Problem Act Constraints Overview Name XPath Car d Op t act 1..1 R Data Type Fixed Value @classCode R 2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN templateId 1..1 @root id R R 1..1 R2 @root R @extension R code 1..1 R 2.16.840.1.113883.10.20.22.4.30 SET_II CD @code R 48765-2 @displayName R2 Allergies, adverse reactions, alerts @codeSystem R 2.16.840.1.113883.6.1 @codeSystemName R2 LOINC statusCode 1..1 R CS @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low @value 1..1 R IVL_TS 1..1 R TS R Page 94 of 256 high 0..1 @value Allergy Observation entryRelationship @typeCode R2 TS R 1..* R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ Specification Note: The specification starts within the act element 1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.30" 4. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Allergy Problem Act (Concern) within the sending organization. This ID should be used whenever this particular Allergy Problem Act is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Allergy Problem Act. The unique id can be used to identify the same Allergy Problem Act used in different messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code="48765-2" Allergies, adverse reactions, alerts (CodeSystem: LOINC 2.16.840.1.113883.6.1) a. SHALL contain exactly one @code="48765-2" b. SHOULD contain exactly one @displayName = “Allergies, adverse reactions, alerts” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”. d. SHOULD contain exactly one @codeSystemName = “LOINC” 6. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code which SHALL be selected from Value Set: ProblemAct statusCode 2.16.840.1.113883.11.20.9.19 STATIC 2011-09-09 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” e. BPHC Captured: BPHC requires the status of an allergy concern. The status helps to determine the relevance of the allergy concern at the time of an encounter. 7. SHALL contain exactly one [1..1] effectiveTime Page 95 of 256 a. If statusCode=“active” Active, then effectiveTime SHALL contain [1..1] low b. If statusCode=“completed” Completed, statusCode=“suspended” Suspended, statusCode=“aborted” Aborted, then effectiveTime SHALL contain [1..1] high and SHALL contain [1..1] low marking the effective start time c. BPHC Captured: BPHC requires the effective time of an allergy concern to determine if the time at which an allergy concern is valid makes the allergy relevant to the encounter in question. 8. SHALL contain one or more [1..*] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] Allergy – Intolerance Observation (templateId: 2.16.840.1.113883.10.20.22.4.7) Figure III-20 Allergy Problem Act Example <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.30"/> <id root=“2.16.840.1.113883.3.96.1.3” extension="36e3e930-7b14-11db-9fe1-0800200c9a66"/> <code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts" /> <statusCode code="completed" displayName=“completed” codeSystem=“2.16.840.1.113883.5.14” codeSystemName=“ActStatus”/> <effectiveTime"> <low value="20060501"/> <high value="20100501"/> </effectiveTime> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.7"/> ... </act> </entry> Page 96 of 256 1.17.3 Allergy Status Observation Used By Allergy – Intolerance Observation_Allergy_problem_Entry Contains Entries This template represents the status of the allergy indicating whether it is active, no longer active, or is an historic allergy. There can be only one allergy status observation per alert observation. Table III-9 Allergy Status Observation Constraints Overview Name XPath Car d Op t observation 1..1 R Fixed Value @classCode R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN templateId 1..1 @root code R R 1..1 R 2.16.840.1.113883.10.20.22.4.28 CD @code R 33999-4 @displayName R2 Status @codeSystem R 2.16.840.1.113883.6.1 @codeSystemName R2 LOINC statusCode Allergy Status Data Type 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus value 1..1 R CE @xsi:type R CE @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT Specification Note: The specification starts within the observation element Page 97 of 256 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.28" 4. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="33999-4" b. SHOULD contain exactly one @displayName = “Status” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1” d. SHOULD contain exactly one @codeSystemName = “LOINC” 5. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 6. SHALL contain exactly one [1..1] value such that it a. SHALL contain exactly one [1..1] @xsi:type = "CE" b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet HITSPProblemStatus 2.16.840.1.113883.3.88.12.80.68 DYNAMIC a. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen b. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” c. SHOULD contain exactly one @codeSystemName = “SNOMED CT” d. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. e. BPHC Captured: BPHC requires the problem status for an allergy to determine the relevance of the allergy to the encounter in question. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. Figure III-21 Allergy Status Observation Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.28" />  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖ /> <value xsi:type="CE" code="55561003" displayName="Active" codeSystem="2.16.840.1.113883.6.96" codeSystemName=“SNOMED CT”/> </observation> Page 98 of 256 1.17.4 Coverage Activity Used By Payers Section_Allergy_problem_Entry Contains Entries Policy Activity A Coverage Activity groups the policy and authorization acts within a Payers Section to order the payment sources. A Coverage Activity contains one or more policy activities, each of which contains zero or more authorization activities. The Coverage Activity id is the Id from the patient's insurance card. The sequenceNumber/@value shows the policy order of preference. Table III-10 Coverage Activity Constraints Overview Name XPath Car d Op t act 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root id R @extension R 1..1 Policy R 2.16.840.1.113883.10.20.22.4.60 SET_II CD @code R 48768-6 @displayName R2 Payment Sources @codeSystem R 2.16.840.1.113883.6.1 @codeSystemName R2 LOINC 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 0..1 R2 IVL_TS 1..1 R TS @value Expiration R2 @root statusCode Effective R R 1..1 code Encounter Time Fixed Value @classCode templateId Coverage Id Data Type high @value entryRelationship R 0..1 R2 1..* R R TS Page 99 of 256 @typeCode sequenceNumber 0..1 R R2 ="COMP" CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 Specification Note: The specification starts within the act element 1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode=“EVN” Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.60" 4. SHOULD contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Coverage Activity within the sending organization. This ID should be used whenever this Coverage Activity is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Coverage Activity. The unique id can be used to identify the same Coverage Activity used in different messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code for the procedure type such that it a. SHALL contain exactly one [1..1] @code = “48768-6” b. SHOULD contain exactly one @ = “Payment Sources” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1” d. SHOULD contain exactly one @codeSystemName = “LOINC” 6. SHALL contain exactly one [1..1] statusCode for the procedure type such that it a. SHALL contain exactly one [1..1] @code = “completed” b. SHOULD contain exactly one @ = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 7. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value set to the effective time of coverage b. SHOULD contain zero or one [1..1] high such that it i. SHALL contain exactly [1..1] @value set to the expiration of coverage c. BPHC Captured: The coverage effective time describes the period in which the coverage is valid. The HEDIS measures requires determining gaps in coverage and therefor BPHC requires the effectiveTime. 8. SHALL contain one or more [1..*] entryRelationship for a specific policy such that it Page 100 of 256 a. SHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHOULD contain zero or one [0..1] sequenceNumber to signify the preference order of the policy c. SHALL contain exactly one [1..1] Policy Activity (templateId:2.16.840.1.113883.10.20.22.4.61) Figure III-22 Coverage Activity Example <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.60"/>  <id root="1fe2cdd0-7aad-11db-9fe1-0800200c9a66"/> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment sources"/> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/> <effectiveTime"> <low value="20120227"/> <high value="20140227"/> </effectiveTime> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.61"/>  ... </act> </entryRelationship> </act> Page 101 of 256 1.17.5 Encounter Activities Used By Encounters Section_Allergy_problem_Entry Contains Entries Encounter Diagnosis Indication Service Delivery Location Addr Organization Person Telecom This clinical statement describes the interactions between the patient and clinicians. Interactions include in-person encounters, telephone conversations, and email exchanges. Table III-11 Encounter Activities Constraints Overview Name XPath Car d Op t procedure 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root id Encounter Type Free Text Encounter Time Start 1..1 R @root R @extension R code 1..1 R 2.16.840.1.113883.10.20.22.4.49 SET_II CD @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.12 @codeSystemName R2 CPT-4 originalText effectiveTime low 0..1 R2 0..1 R2 IVL_TS 1..1 R TS high R 0..1 @value Disposition R R @value End Fixed Value @classCode templateId Visit Type Data Type sdtc:dischargeDispositionCode R2 TS R 0..1 R2 Page 102 of 256 Code Encounter Provider Provider Role @code R @displayName R2 @codeSystem R 2.16.840.1.113883.12.112 HL7 @codeSystemName R2 Discharge Disposition performer functionCode @code @displayName @codeSystem @codeSystemName assignedEntity id @root @extension Provider Type code @code @displayName @codeSystem 0..* R2 0..1 R2 R R2 R 2.16.840.1.113883.5.88 R2 ParticipationFunction 1..1 1..* R R R R 0..1 O R R2 R addr telecom assignedPerson 1..1 1..1 0..1 R2 R R R2 Addr Tel Person representedOrganization 0..1 R2 Organiza tion 0..* O @codeSystemName Service Delivery Location participant Visit Reason @typeCode entryRelationship Diagnosis @typeCode entryRelationship 0..1 R R2 0..* R R2 Code System 2.16.840.1.113883.5.90 (HL7ParticipationType) = LOC 2.16.840.1.113883.5.1002 (HL7ActRelationshipType)= RSON Specification Note: The specification starts within the encounter element 1. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode=“EVN” Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.49" Page 103 of 256 4. SHALL contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Encounter within the sending organization. This ID should be used whenever this particular Encounter is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Encounter. The unique id can be used to identify the same Encounter in the case of messages being resent as an update to a previous encounter. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code for the procedure type such that it a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet EncounterTypeCode 2.16.840.1.113883.3.88.12.80.32 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.12” d. SHOULD contain exactly one @codeSystemName = “CPT” e. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. f. BPHC Captured: BPHC requires the encounter type to categorize the type of visit. Many of the HEDIS and other national measures are restricted to certain visit types. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. 6. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value set to the start time for the encounter b. SHOULD contain zero or one [1..1] high such that it i. SHALL contain exactly [1..1] @value set to the end time for the encounter c. BPHC Captured: The effective time of an encounter marks the start and end of an encounter. The effective time of the encounter is considered the visit time. The visit time is used by the majority of the national measures to determine if an encounter is within the time frame covered by the measure. The start time can be used to determine time between related events. 7. MAY contain zero or one [0..1] sdtc:dischargeDispositionCode, which SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status DYNAMIC or, if access to NUBC is unavailable, from CodeSystem 2.16.840.1.113883.12.112 HL7 Discharge Disposition. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element 8. SHOULD contain zero or more [0..*] performer for the Provider such that it Page 104 of 256 a. SHOULD contain zero or one [0..1] functionCode i. SHALL contain exactly one [1..1] @code, which SHALL be selected from CodeSystem ParticipationFunction 2.16.840.1.113883.5.88 ii. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen iii. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.88” iv. SHOULD contain exactly one @codeSystemName = “ParticipationFunction” v. BPHC Captured: BPHC requires this field to capture the provider’s role in the healthcare of a patient. Many of the HEDIS Measures require a determination if the role of a provider is a Primary Care Physician or not. b. SHALL contain exactly one [1..1] assignedEntity such that it i. SHALL contain at least one [1..*] id such that it 1. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.4.6" National Provider Identifier 2. SHALL contain exactly one [1..1] @extension a. The extension shall be populated with the provider’s NPI. ii. SHALL contain exactly one [1..1] addr iii. SHALL contain exactly one [1..1] telecom iv. SHALL contain exactly one [1..1] assignedPerson_Telecom v. SHOULD contain zero or one [0..1] representedOrganization 1. BPHC Captured: BPHC requests the represented organization to facilitate any follow-up and support research. 9. MAY contain zero or more [0..*] participant for the Service Delivery Location such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) b. SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) 10. MAY contain zero or more [0..*] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] Indication (templateId:2.16.840.1.113883.10.20.22.4.19) 11. MAY contain zero or more [0..*] entryRelationship for the encounter diagnosis such that it a. SHALL contain exactly one [1..1] Encounter Diagnosis (templateId:2.16.840.1.113883.10.20.22.4.80 Figure III-23 Encounter Activities Example <entry typeCode="DRIV"> <encounter classCode="ENC" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.49"/>   Page 105 of 256 <id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/> <code code="99241" displayName="Office consultation - 15 minutes" codeSystemName="CPT" codeSystem="2.16.840.1.113883.6.12" codeSystemVersion="4"> <originalText> The encounter type free text as described above </originalText> </code> <effectiveTime"> <low value="20090227130000+0500"/> </effectiveTime> <performer> <assignedEntity> <id root=“2.16.840.1.113883.3.96.1.3” extension ="2a620155-9d11-439e-92a3-5d9815ff4de8"/> <code code="59058001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="General Physician"/> </assignedEntity> </performer> <participant typeCode="LOC"> <participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32"/>  ... </participantRole> </participant> <entryRelationship typeCode="RSON"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.19"/> ... </observation> </entryRelationship> </encounter> </entry> Page 106 of 256 1.17.6 Encounter Diagnosis Used By Encounter Activities_Encounters_Section_Allergy_problem_Entry Contains Entries Problem Observation This template wraps relevant problems or diagnoses at the close of a visit or that need to be followed after the visit. If the encounter is associated with a Hospital Discharge, the Hospital Discharge Diagnosis template id and codes should be used below must be used. This entry requires at least one Problem Observation entry Table III-12 Encounter Diagnosis Constraints Overview Name XPath Car d Op t act 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN @negationInd O 1..1 @root Problem Observation Fixed Value @classCode templateId Diagnosis Type Data Type code R 2.16.840.1.113883.10.20.22.4.80 or (2.16.840.1.113883.10.20.22.4.33 for Hospital Discharge) R 1..1 R CD 29308-4 or (1535-2 for Hospital Discharge Diagnosis) @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.1 @codeSystemName R2 LOINC entryRelationship @typeCode 1..* R R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ Specification Note: The specification starts within the act element 1. SHALL contain exactly one [1..1] @classCode="Act" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it Page 107 of 256 a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.4.80" or “2.16.840.1.113883.10.20.22.4.33” for a hospital discharge diagnosis 4. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code =“29308-4” or “1535-2” for hospital discharge diagnosis b. SHOULD contain exactly one @displayName = “Diagnosis” or “Hospital Discharge Diagnosis” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1” d. SHOULD contain exactly one @codeSystemName = “LOINC” e. BPHC Captured: The encounter diagnosis or diagnoses are captured by BPHC to determine the relevance of the encounter to specific measures. E.g. an encounter with a diagnosis related to asthma would cause the encounter to be included in the Asthma related HEDIS measures run by BPHC. 5. SHALL contain one or more [1..1] entryRelationship for the problem observation such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] Problem Observation (templateId:2.16.840.1.113883.10.20.22.4.4) Figure III-24 Encounter Diagnosis Example <act classCode="ACT" moodCode="EVN"> <!—Encounter diagnosis act --> <templateId root="2.16.840.1.113883.10.20.22.4.80"/> <code code="29038-4” codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName=" DIAGNOSIS"/> <entryRelationship typeCode="SUBJ" > <observation classCode="OBS" moodCode="EVN" > <templateId root="2.16.840.1.113883.10.20.22.4.4"/>  ... </observation> </entryRelationship> </act> Page 108 of 256 1.17.7 Health Status Observation Used By Problem Observation_Encounters_Section_Allergy_problem_Entry Contains Entries The Health Status Observation records information about the current health status of the patient. Table III-13 Health Status Observation Constraints Overview Name XPath Car d Op t observation 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root code Problem Status Fixed Value @classCode templateId Problem Status Free Text Data Type R R 1..1 R 2.16.840.1.113883.10.20.22.4.5 CE @code R 11323-3 @displayName R2 Health Status @codeSystem R 2.16.840.1.113883.6.1 @codeSystemName R2 LOINC text 0..1 R2 statusCode 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus value 1..1 R CD @xsi:type R CD @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT Page 109 of 256 Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.5" 4. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="11323-3" b. SHOULD contain exactly one @displayName = “Health Status” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1” d. SHOULD contain exactly one @codeSystemName = “LOINC” 5. SHOULD contain zero or one [0..1] text such that it contains free text describing the health status and SHOULD include all relevant text used to derived the health status value code. a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the health status value code was determined for auditing purposes. 6. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 7. SHALL contain exactly one [1..1] value such that it a. SHALL contain exactly one [1..1] @xsi:type = "CD" b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet HealthStatus 2.16.840.1.113883.1.11.20.12 DYNAMIC f. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen g. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” h. SHOULD contain exactly one @codeSystemName = “SNOMED CT” i. BPHC Captured: The value specifies the general health status of the patient. The health status provides supporting information about the severity of the encounter and the diagnosis. It also can provide supporting information to the resolution of health issues related to the encounter. Figure III-25 Health Status Observation Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.5" />  <code code="11323-3" displayName="Health status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> Page 110 of 256 <text> The problem status free text as described above </text> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖ /> <value xsi:type="CD" code="81323004" displayName="Alive and well" codeSystem="2.16.840.1.113883.6.96" codeSystemName=“SNOMED CT”/> </observation> Page 111 of 256 1.17.8 Immunization Activity Used By Immunizations Section_Encounters_Section_Allergy_problem_Entry Contains Entries Immunization Medication Information Immunization Refusal Reason Instructions Medication Dispense Medication Supply Order An Immunization Activity describes immunization substance administrations that have actually occurred or are intended to occur. Immunization Activities in "INT" mood are reflections of immunizations a clinician intends a patient to receive. Immunization Activities in "EVN" mood reflect immunizations actually received. An Immunization Activity is very similar to a Medication Activity with some key differentiators. The drug code system is constrained to CVX codes. Administration timing is less complex. Patient refusal reasons should be captured. All vaccines administered should be fully documented in the patient's permanent medical record. Healthcare providers who administer vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the permanent medical record of the recipient indicates: 1. 2. 3. 4. Date of administration Vaccine manufacturer Vaccine lot number Name and title of the person who administered the vaccine and the address of the clinic or facility where the permanent record will reside 5. Vaccine information statement (VIS) a. date printed on the VIS b. date VIS given to patient or parent/guardian. This information should be included in an Immunization Activity when available. Table III-14 Immunization Activity Constraints Overview Name XPath Car d Op t substanceAdministration 1..1 R @classCode R @moodCode R @negationInd R2 templateId 1..1 @root id Data Type 2.16.840.1.113883.5.6 (HL7ActClass) = SBADM R R 1..1 Fixed Value R2 2.16.840.1.113883.10.20.22.4.52 SET_II Page 112 of 256 Name Car d XPath @root R @extension R Delivery Method Medication Free Text Administere d Date Medication Start 1..1 R text 0..1 R2 statusCode 1..1 R CS R2 @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low high 1..1 R IVL_TS 1..1 R TS R 1..1 R TS R O effectiveTime PIVL_T S @institutionSpecified O @operator @xsi:type R A R PIVL_TS O @value O @unit O O repeatNumber Repeat Number low Repeat Number High high Medication Route CD @displayName period Series Number Fixed Value R @value Admin Timing Data Type @code @value Medication Stop Op t R R2 routeCode 0..1 O @code R @displayName R2 CE Page 113 of 256 Name Body Site Dose Quantity Car d XPath 2.16.840.1.113883.3.26.1.1 @codeSystemName R2 NCI Thesaurus approachSiteCode CD @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT doseQuantity 0..1 O 1..1 R @value R @unit R2 0..1 R @unit R2 rateQuantity 0..1 O 1..1 R @value R @unit R2 0..1 R @unit R2 0..1 O @value R @unit R2 administrationUnitCode 0..1 IVL_P Q R2 @value maxDoseQuantity IVL_P Q R2 @value O PQ CE @code R @displayName R2 @codeSystem R NCI Thesaurus R2 R 2.16.840.1.113883.3.26.1.1 1..1 1..1 R 0..1 O @codeSystemName consumable manufacturedProduct Patient Instructions O R high Medication Information 0..1 @code low Product Form Fixed Value R high Dose Restriction Data Type @codeSystem low Rate Quantity Op t entryRelationship Page 114 of 256 Name XPath Car d @typeCode @inversionInd Medication Supply Order entryRelationship R 0..1 @typeCode Medication Dispense entryRelationship 0..* entryRelationship @typeCode Fixed Value 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ true 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR R2 R 0..* Data Type O R @typeCode Refusal Reason Op t R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR R2 R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSON Specification Note: The specification starts within the substanceAdmin element 1. SHALL contain exactly one [1..1] @classCode=" SBADM" Substance Administration (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 a. BPHC Captured: The mood determines whether the observation is an actual event in which an immunization is to occur or if this marks the intent to perform an immunization in the future. BPHC requires the field to support the idea of a scheduled immunization versus one that has been given. 3. SHOULD contain exactly one [1..1] @negationInd, which SHALL be selected as either “true” or “false”. A value of “true” should be used to indicate that the medication was not given. “false” is the default value and the attribute is not required if unless the value should be “true”. a. BPHC Captured: The negation indicator is required by BPHC if the immunization was not given for any reason. The field is used as supporting information to demonstrate that a particular immunization was not given. 4. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.52" 5. SHOULD contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Immunization Activity within the sending organization. This ID should be used whenever this particular Immunization Activity is referenced. Page 115 of 256 6. 7. 8. 9. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Immunization Activity. The unique id can be used to identify the same Immunization Activity across separate messages. The HL7 Consolidation Guide requires an id for this element. SHOULD contain zero or one [0..1] text such that it contains free text describing the immunization activity and SHOULD include all relevant text used to derived the immunization activity codes. a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the immunization activity codes were determined for auditing purposes. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code, which SHALL be “completed” or “aborted” b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” e. BPHC Captured: BPHC captures the immunization status in order to mark that a particular immunization is either complete or aborted and is supporting information to the immunization activity for the person in question. SHALL contain exactly one [1..1] effectiveTime for medication timing such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value set to the start time for the medication b. SHALL contain exactly one [1..1] high such that it ii. SHALL contain exactly [1..1] @value set to the stop time for the medication c. BPHC Captured: BPHC captures the medication timing for the immunization to determine when a specific immunization was given. The timing knowledge allows BPHC to perform research and audit surrounding the validity of immunizations and their effectiveness over time. SHOULD contain zero or one [0..1] effectiveTime for Administration Timing such that it a. MAY contain zero or one [0..1] @institutionSpecified, which should be set to either “true” or “false” b. SHALL contain exactly one [1..1] @operator="A" c. SHALL contain exactly one [1..1] @xsi:type=“PIVL_TS” d. MAY contain zero or one [0..1] period such that it i. SHALL contain exactly one [1..1] @value ii. SHALL contain exactly one [1..1] @unit e. BPHC Captured: BPHC captures the administration timing when available to further investigate how an immunization was given to the patient. Page 116 of 256 10. MAY contain zero or one [0..1] repeatNumber such that it a. SHALL contain exactly one [1..1] low b. SHOULD contain zero or one [0..1] high c. In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series d. BPHC Captured: BPHC captures the repeat number to determine where the immunization stands in a series of shots that may be given overtime. 11. MAY contain zero or one [0..1] routeCode such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.3.26.1.1” d. SHOULD contain exactly one @codeSystemName = “NCI Thesaurus” e. BPHC Captured: The route code is captured by BPHC to indicate the method for the immunization received by the individual. Knowledge of the route can provide insight into the effectiveness of the available methods for a particular immunization. 12. MAY contain zero or one [0..1] approachSiteCode such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” e. SHOULD contain exactly one @codeSystemName = “SNOMED CT” f. BPHC Captured: The approach site code is captured by BPHC to indicate the anatomical site in which the immunization was given. 13. SHOULD contain zero or one [0..1] doseQuantity such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly one [1..1] @value ii. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC b. SHOULD contain zero or one [0..1] high such that it i. SHALL contain exactly one [1..1] @value Page 117 of 256 ii. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC c. Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g. "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g. "2", meaning 2 x "metoprolol 25mg tablet") d. Not pre-coordinated consumable: If the consumable code is not pre coordinated (e.g. is simply "metoprolol"), then doseQuantity must represent a physical quantity with @unit, e.g. "25" and "mg", specifying the amount of product given per administration e. BPHC Captured: BPHC captures the dose quantity of the immunization to assign a measurable value to the immunization given. 14. MAY contain zero or one [0..1] rateQuantity such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly one [1..1] @value ii. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC b. SHOULD contain zero or one [0..1] high such that it i. SHALL contain exactly one [1..1] @value ii. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC c. BPHC Captured: BPHC captures (if applicable) the rate quantity of the immunization to assign a measurable value to the rate at which the immunization is given. 15. MAY contain zero or one [0..1] maxDoseQuantity such that it a. SHALL contain exactly one [1..1] @value b. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC c. BPHC Captured: BPHC captures the max dosage (if applicable) for the particular person and immunization. 16. MAY contain zero or one [0..1] administrationUnitCode such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Medication Product Form 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen Page 118 of 256 c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.3.26.1.1” d. SHOULD contain exactly one @codeSystemName = “NCI Thesaurus” e. BPHC Captured: BPHC captures the administration unit code when available to indicate the physical form of the immunization as presented to the individual. 17. SHALL contain exactly one [1..1] consumable for Medication Information a. This consumable SHALL contain exactly one [1..1] Immunization Medication Information (templateId:2.16.840.1.113883.10.20.22.4.54) 18. MAY contain zero or one [0..1] entryRelationship for Patient Instructions such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] @inversionInd="true" True c. SHALL contain exactly one [1..1] Instructions (templateId:2.16.840.1.113883.10.20.22.4.20) 19. MAY contain zero or one [0..1] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] Medication Supply Order (templateId:2.16.840.1.113883.10.20.22.4.17) 20. MAY contain zero or more [0..*] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] Medication Dispense (templateId:2.16.840.1.113883.10.20.22.4.18) 21. MAY contain zero or one [0..1] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] Immunization Refusal Reason templateId:2.16.840.1.113883.10.20.22.4.53) Figure III-26 Immunization Activity Example <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false"> <templateId root="2.16.840.1.113883.10.20.22.4.52"/>  <id root=“2.16.840.1.113883.3.96.1.3” extension ="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/> <text> The immunization activity free text as described above </text> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/> <effectiveTime xsi:type="IVL_TS"> <low value="20070103"/> </effectiveTime> <routeCode code="C28161" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="National Cancer Institute (NCI) Thesaurus" displayName="Intramuscular injection"/> <doseQuantity value="50" unit="mcg"/> <consumable> Page 119 of 256 <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.54" />  <manufacturedMaterial> ... </manufacturedMaterial> <manufacturerOrganization> <name>Health LS - Immuno Inc.</name> </manufacturerOrganization> </manufacturedProduct> </consumable> <entryRelationship> <act classCode="ACT" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.20" />  ... </act> </entryRelationship> </substanceAdministration> </entry> 1.17.9 Immunization Medication Information Used By Immunization Activity Medication Dispense Medication Supply Order_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries The Immunization Medication Information represents product information about the immunization substance. The vaccine manufacturer and vaccine lot number are typically recorded in the medical record and should be included if known. Table III-15 Immunization Medication Information Constraints Overview Name XPath Car d Op t manufacturedProduct 1..1 R @classCode R templateId R @root R manufacturedMaterial Product Name Product Name Free code 1..1 R 1..1 R @code R @displayName R2 @codeSystem R @codeSystemName R2 originalText 0..1 Data Type Fixed Value 2.16.840.1.113883.5.110 (RoleClass) = MANU 2.16.840.1.113883.10.20.22.4.54 R2 Page 120 of 256 Name XPath Car d Op t 0..1 O Data Type Fixed Value Text Brand Name translation @code O @displayName O @codeSystem O @codeSystemName O Lot Number lotNumberText 0..1 O Drug Manu. manufacturerOrganization 0..1 O 0..1 O name Specification Note: The specification starts within the manufacturedProduct element 1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.10.20.22.4.54" 3. SHALL contain exactly one [1..1] manufacturedMaterial such that it a. SHALL contain exactly one [1..1] code such that it i. SHALL contain exactly one [1..1] @code for the product, which SHALL be selected from ValueSet Vaccine Administered 2.16.840.1.113883.3.88.12.80.22 DYNAMIC ii. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen iii. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.88” iv. SHOULD contain exactly one @codeSystemName = “RxNorm” v. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. such that it which vi. MAY contain zero or more [0..*] translation such that it 1. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.80.16 Medication Brand Name DYNAMIC 2. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen 3. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.88” 4. SHOULD contain exactly one @codeSystemName = “RxNorm” 5. Translations can be used to represent generic product name, packaged product code, etc. Page 121 of 256 vii. BPHC Captured: BPHC requires the vaccine and brand name for an immunization to identify the specific immunization given during an encounter. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. b. SHOULD contain zero or one [0..1] lotNumberText i. BPHC Captured: BPHC requires the lot number of the immunization to identify the particular lot in which the vaccination is from. 4. MAY contain zero or one [0..1] manufacturerOrganization such that it a. MAY contain zero or one [0..1] name b. BPHC Captured: BPHC requires the immunization manufacturer’s name to identify where the immunization given was produced. Figure III-27 Immunization Medication Information Example <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.54"/>  <manufacturedMaterial> <code code="88" codeSystem="2.16.840.1.113883.12.292 " displayName="Influenza virus vaccine" codeSystemName="CVX"> <originalText> The immunization information free text as described above </originalText> <translation code="111" displayName="influenza, live, intranasal" codeSystemName="CVX" codeSystem=" 2.16.840.1.113883.12.292 " /> </code> <lotNumberText>1</lotNumberText> </manufacturedMaterial> <manufacturerOrganization> <name>Health LS - Immuno Inc.</name> </manufacturerOrganization> </manufacturedProduct> Page 122 of 256 1.17.10 Immunization Refusal Reason Used By Immunization Activity_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries The Immunization Refusal Reason Observation documents the rationale for the patient declining an immunization. Table III-16 Immunization Refusal Reason Constraints Overview Name XPath Car d Op t observation 1..1 R Data Type Fixed Value @classCode R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN templateId 1..1 @root code R R 1..1 R 2.16.840.1.113883.10.20.22.4.53 CE @code R 11323-3 @displayName R2 Health Status @codeSystem R 2.16.840.1.113883.6.1 @codeSystemName R2 LOINC statusCode 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.53" 4. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code, which SHALL be selected ValueSet No Immunization Reason Value Set 2.16.840.1.113883.1.11.19717 DYNAMIC Page 123 of 256 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.8” d. SHOULD contain exactly one @codeSystemName = “ActReason” e. BPHC Captured: BPHC captures the immunization refusal reason such as allergies or religious beliefs in order to document any justification of refusing an immunization that is normally given. 5. SHOULD contain zero or one [0..1] text such that it contains free text describing the health status and SHOULD include all relevant text used to derived the health status code. a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the instruction codes were determined for auditing purposes. 6. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” Figure III-28 Immunization Refusal Reason Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.53" /> <!—Immunization Refusal template --> <code displayName="Patient Objection" code="PATOBJ" codeSystemName="HL7 ActNoImmunizationReason" codeSystem="2.16.840.1.113883.5.8"/> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖ /> </observation> Page 124 of 256 1.17.11 Indication Used By Encounter Activities_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries The Indication Observation documents the rationale for an activity. It can do this with the id element to reference a problem recorded elsewhere in the document or with a code and value to record the problem type and problem within the Indication. For example, the indication for a prescription of a painkiller might be a headache that is documented in the Problems Section. Table III-17 Indication Constraints Overview Name XPath Car d Op t observation 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood)= EVN 1..1 @root code CD R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 0..1 R2 IVL_TS 1..1 R TS high R 0..1 @value Value Code R 2.16.840.1.113883.10.20.22.4.19 @code @value End R R 1..1 statusCode Start Fixed Value @classCode templateId Time Data Type value R2 TS R 1..1 R @xsi:type CD CD @code R @displayName R2 Page 125 of 256 Name XPath Car d Op t Data Type Fixed Value @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT originalText 0..1 R2 ED Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.4.19" 4. SHALL contain exactly one [1..1] id a. Set the observation/id equal to an ID on the problem list to signify that problem as an indication. b. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Indication. The unique id can be used to identify the same indication across separate messages and also allow reference to problems on the problem list. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” e. BPHC Captured: BPHC requires the problem type to categorize the type of problem in which it refers. Many of the HEDIS and other national measures are restricted to certain conditions that can be identified based on the problem type and value. The general category of a problem type can also provide justification as to why a certain medication was given or prescribed. 6. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 7. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value set to the start time for the indication Page 126 of 256 b. SHOULD contain zero or one [0..1] high such that it i. SHALL contain exactly [1..1] @value set to the end time for the indication c. BPHC Captured: BPHC captures the start and end time for the indication to determine the relevance of the indication for the time period being evaluated for a particular measure. 8. SHALL contain exactly one [1..1] value for the indication value such that it a. SHALL contain exactly one[1..1] @xsi:type =“CD” b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet: Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC c. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen d. SHALL contain exactly one @codeSystem=“2.16.840.1.113883.6.96” e. SHOULD contain exactly one @codeSystemName=“SNOMED CT” f. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. g. BPHC Captured: BPHC requires the indication value to provide insight as to why a medication may have been given or subscribed. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. Figure III-29 Indication Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.19"/> <id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/> <code code="404684003" displayName="Finding" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/> <effectiveTime> <low value="20070103"/> </effectiveTime> <value xsi:type="CD" code="233604007" displayName="Pneumonia" codeSystem="2.16.840.1.113883.6.96"/> </observation> Page 127 of 256 1.17.12 Instructions Used By Immunization Activity Medication Activity Medication Dispense Medication Supply Order_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries The Instructions template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. The act/code defines the type of instruction. Though not defined in this template, a Vaccine Information Statement (VIS) document could be referenced through act/reference/externalDocument, and patient awareness of the instructions can be represented with the generic participant and the participant/awarenessCode. Table III-18 Instructions Constraints Overview Name XPath Car d Op t act 1..1 R Data Type Fixed Value @classCode R 2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = INT templateId 1..1 @root code R R 1..1 R 2.16.840.1.113883.10.20.22.4.20 CD @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT text 0..1 R2 statusCode 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus Specification Note: The specification starts within the act element 1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) Page 128 of 256 2. SHALL contain exactly one [1..1] @moodCode="INT" Intent (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.4.20" 4. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Patient Education 2.16.840.1.113883.11.20.9.34 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” e. BPHC Captured: BPHC captures the type of instruction to provide context for the particular instruction. The actual instructions are recorded in the text field. 5. SHOULD contain zero or one [0..1] text such that it contains free text instructions and SHOULD include all relevant text used to derive the instruction code as well as the actual instructions themselves. a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the instruction codes were determined for auditing purposes. 6. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” Figure III-30 Instructions Example <act classCode="ACT" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.20"/>  <code code="171044003" displayName="immunization education" codeSystem="2.16.840.1.113883.6.96" codeSystemName=“SNOMED CT”/> <text> The instruction free text as described above </text> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/> </act> Page 129 of 256 1.17.13 Medication Activity Used By Medications Section Procedure Activity Act Procedure Activity Observation Procedure Activity Procedure_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Instructions Medication Dispense Medication Information Medication Supply Order A medication activity describes substance administrations that have actually occurred (e.g. pills ingested or injections given) or are intended to occur (e.g. "take 2 tablets twice a day for the next 10 days"). Medication activities in "INT" mood are reflections of what a clinician intends a patient to be taking. Medication activities in "EVN" mood reflect actual use. Medication timing is complex. This template requires that there be a substanceAdministration/effectiveTime valued with a time interval, representing the start and stop dates. Additional effectiveTime elements are optional, and can be used to represent frequency and other aspects of more detailed dosing regimens. Table III-19 Medication Activity Constraints Overview Name XPath Car d Op t substanceAdministration 1..1 R @classCode R @moodCode R @negationInd R2 templateId 1..1 @root id Medication Free Text Fixed Value 2.16.840.1.113883.5.6 (HL7ActClass) = SBADM R R 1..1 R2 @root R @extension R Delivery Method Data Type 1..1 R text 0..1 R2 statusCode 1..1 R 2.16.840.1.113883.10.20.22.4.16 SET_II CD CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus Page 130 of 256 Name Medication Timing Medication Start XPath effectiveTime low Car d Op t Data Type 1..1 R IVL_TS 1..1 R TS @value Medication Stop high R 1..1 @value Admin Timing O effectiveTime PIVL_T S O @operator @xsi:type R A R PIVL_TS O @value O @unit O Repeat Number low Repeat Number High high Dose Quantity TS @institutionSpecified repeatNumber Body Site R R period Medication Route Fixed Value O R R2 routeCode 0..1 O CE @code R @displayName R2 @codeSystem R 2.16.840.1.113883.3.26.1.1 @codeSystemName R2 NCI Thesaurus approachSiteCode 0..1 O CD @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT doseQuantity low 0..1 O 1..1 R @value R @unit R2 IVL_P Q Page 131 of 256 Name XPath high Rate Quantity Medication Information Medication Supply Order R2 @unit R2 rateQuantity 0..1 O 1..1 R @value R @unit R2 0..1 R @unit R2 maxDoseQuantity 0..1 R @unit R2 0..1 Fixed Value IVL_P Q O PQ CE @code R @displayName R2 @codeSystem R NCI Thesaurus R2 R 2.16.840.1.113883.3.26.1.1 1..1 1..1 R 0..1 O @codeSystemName consumable entryRelationship @typeCode R @inversionInd R entryRelationship 0..1 @typeCode Medication Dispense O @value administrationUnitCode Data Type R2 @value manufacturedProduct Patient Instructions 0..1 R high Product Form Op t @value low Dose Restriction Car d entryRelationship @typeCode O R 0..* 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ true 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR R2 R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR Specification Note: The specification starts within the substanceAdmin element Page 132 of 256 1. SHALL contain exactly one [1..1] @classCode=" SBADM" Substance Administration (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 a. BPHC Captured: The mood determines whether the observation is an actual event in which medication is received or if medication activity marks the intent to prescribe medication for the future. BPHC requires the field to pinpoint when a particular medication is given or to be used based on the encounter. 3. SHOULD contain exactly one [1..1] @negationInd, which SHALL be selected as either “true” or “false”. A value of “true” should be used to indicate that the medication was not given. “false” is the default value and the attribute is not required if unless the value should be “true”. a. BPHC Captured: The negation indicator is required by BPHC if the medication was not given for any reason. The field is used as supporting information to demonstrate that a particular medication was not given in the event that it typically would. 4. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.16" 5. SHOULD contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Medication Activity within the sending organization. This ID should be used whenever this particular Medication Activity is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Medication Activity. The unique id can be used to identify the same Medication Activity across separate messages. The HL7 Consolidation Guide requires an id for this element. 6. SHOULD contain zero or one [0..1] text such that it contains free text describing the medication activity and SHOULD include all relevant text used to derived the medication activity codes. a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the medication activity codes were determined for auditing purposes. 7. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 8. SHALL contain exactly one [1..1] effectiveTime for medication timing such that it a. SHALL contain exactly one [1..1] low such that it Page 133 of 256 iii. SHALL contain exactly [1..1] @value set to the start time for the medication b. SHALL contain exactly one [1..1] high such that it iv. SHALL contain exactly [1..1] @value set to the stop time for the medication c. BPHC Captured: The medication timing is captured by BPHC to provide a measure of when the medication is in effect. Measures relating to controlling certain conditions such as high blood pressure require knowledge of the medication and the time period in which it is effective. 9. SHOULD contain zero or one [0..1] effectiveTime for Administration Timing such that it a. MAY contain zero or one [0..1] @institutionSpecified, which should be set to either “true” or “false” b. SHALL contain exactly one [1..1] @operator="A" c. SHALL contain exactly one [1..1] @xsi:type=“PIVL_TS” d. MAY contain zero or one [0..1] period such that it iii. SHALL contain exactly one [1..1] @value iv. SHALL contain exactly one [1..1] @unit e. BPHC Captured: The administration timing is captured by BPHC to provide a measure of when the medication is to be applied during the given medication time period. Measures relating to controlling certain conditions such as high blood pressure require knowledge of the medication and how the medication is administered. 10. MAY contain zero or one [0..1] repeatNumber such that it a. SHALL contain exactly one [1..1] low b. SHOULD contain zero or one [0..1] high c. In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series d. BPHC Captured: BPHC captures the repetition number for the medication to determine number of allowed administrations or the current count of the particular medication administration. 11. MAY contain zero or one [0..1] routeCode such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.3.26.1.1” Page 134 of 256 d. SHOULD contain exactly one @codeSystemName = “NCI Thesaurus” e. BPHC Captured: The route code is captured by BPHC to indicate the method for the medication received by the individual and is supporting information for controlling conditions through use of medications. 12. MAY contain zero or one [0..1] approachSiteCode such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” e. SHOULD contain exactly one @codeSystemName = “SNOMED CT” f. BPHC Captured: The approach site code is captured by BPHC to indicate the anatomical site in which the medication was given. 13. SHOULD contain zero or one [0..1] doseQuantity such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly one [1..1] @value ii. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC b. SHOULD contain zero or one [0..1] high such that it i. SHALL contain exactly one [1..1] @value ii. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC c. Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g. "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g. "2", meaning 2 x "metoprolol 25mg tablet") d. Not pre-coordinated consumable: If the consumable code is not pre coordinated (e.g. is simply "metoprolol"), then doseQuantity must represent a physical quantity with @unit, e.g. "25" and "mg", specifying the amount of product given per administration e. BPHC Captured: BPHC captures the dose quantity to identify the dose given or prescribed to the patient. As supporting information to controlling a condition through medication. 14. MAY contain zero or one [0..1] rateQuantity such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly one [1..1] @value Page 135 of 256 ii. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC b. SHOULD contain zero or one [0..1] high such that it i. SHALL contain exactly one [1..1] @value ii. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC c. BPHC Captured: BPHC captures the rate that the medication is given or should be taken as supporting information to controlling a condition through medication. 15. MAY contain zero or one [0..1] maxDoseQuantity such that it a. SHALL contain exactly one [1..1] @value b. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC c. BPHC Captured: BPHC captures the max dose quantity when available to identify the maximum dosage allowed by the patient when taking the medication and is used as supporting information to controlling a condition through medication. 16. MAY contain zero or one [0..1] administrationUnitCode such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Medication Product Form 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.3.26.1.1” d. SHOULD contain exactly one @codeSystemName = “NCI Thesaurus” e. BPHC Captured: BPHC captures the administration unit code when available to indicate the physical form of the medication as presented to the individual. 17. SHALL contain exactly one [1..1] consumable for Medication Information a. This consumable SHALL contain exactly one [1..1] Medication Information (templateId:2.16.840.1.113883.10.20.22.4.23) 18. MAY contain zero or one [0..1] entryRelationship for Patient Instructions such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] @inversionInd="true" True c. SHALL contain exactly one [1..1] Instructions (templateId:2.16.840.1.113883.10.20.22.4.20) 19. MAY contain zero or one [0..1] entryRelationship such that it Page 136 of 256 a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] Medication Supply Order (templateId:2.16.840.1.113883.10.20.22.4.17) 20. MAY contain zero or more [0..*] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] Medication Dispense (templateId:2.16.840.1.113883.10.20.22.4.18) Figure III-31 Medication Activity Example <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.16"/> <id root=“2.16.840.1.113883.3.96.1.3” extension="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/> <text> The medication activity free text as described above </text> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/> <effectiveTime xsi:type="IVL_TS"> <low value="20070103"/> <high value="20120515"/> </effectiveTime> <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A"> <period value="6" unit="h"/> </effectiveTime> <routeCode code="C38216" displayName="RESPIRATORY (INHALATI ON)" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" /> <doseQuantity> <low value="1" unit="mg/actuat" /> </doseQuantity> <rateQuantity> <low value="90" unit="ml/min"/> </rateQuantity> <maxDoseQuantity value="1" unit="mg/actuat" /> <administrationUnitCode code="C42944" displayName="INHALANT" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" /> <consumable> <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23" /> ... </manufacturedProduct> </consumable> <entryRelationship typeCode="SUBJ"> <act classCode="ACT" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.20" />  ... </act> </entryRelationship> <entryRelationship typeCode="REFR"> <supply classCode="SPLY" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.17" />  ... </supply> </entryRelationship> <entryRelationship typeCode="REFR"> <supply classCode="SPLY" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.18" />  ... </supply> </entryRelationship> Page 137 of 256 </substanceAdministration> </entry> 1.17.14 Medication Dispense Used By Medication Activity Immunization Activity_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Immunization Medication Information Medication Information Medication Supply Order This template records the intent to supply a patient with medications. Table III-20 Medication Dispense Constraints Overview Name XPath Car d Op t supply 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = SPLY @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root Fill Status Dispense Date id R R @root R @extension R statusCode 2.16.840.1.113883.10.20.22.4.18 R 1..1 1..1 R SET_II CS @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 0..1 R2 IVL_TS 0..1 R2 TS @value high R 0..1 @value Current Dispension Number Fixed Value @classCode templateId Prescription Number Data Type repeatNumber O TS R 0..1 R2 Page 138 of 256 Name XPath Car d @value Quantity Dispensed Medication Information quantity R2 product entryRelationship @typeCode Fixed Value R2 @unit manufacturedProduct Medication Supply Order 0..1 R2 product Data Type R2 @value manufacturedProduct Immunization Information Op t 0..1 CR 1..1 R 0..1 CR 1..1 R 0..1 O R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR Specification Note: The specification starts within the supply element 1. SHALL contain exactly one [1..1] @classCode=" SPLY " Supply (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode=" EVN " Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.18" 4. SHOULD contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value that represents the prescription number. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Dispense Activity. The unique id can be used to identify the same Medication Dispense across separate messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Medication Fill Status 2.16.840.1.113883.3.88.12.80.64 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” Page 139 of 256 e. BPHC Captured: BPHC captures the fill status of the medication dispense to determine if a medication has been filled at the time of the encounter or when it should be expected to become relevant for the particular patient. The fill status provides supporting information for measures for controlling conditions through the use of appropriate medication. 6. SHALL contain exactly one [1..1] effectiveTime for the dispense date such that it a. SHOULD contain zero or one [0..1] low such that it i. SHALL contain exactly [1..1] @value set to the date that the medication was dispensed b. MAY contain zero or one [0..1] high such that it i. SHALL contain exactly [1..1] @value c. BPHC Captured: BPHC requires the date in which the medication was dispensed to determine the relevance of the medication to the time period in which a measure covers. 7. SHOULD contain zero or one [0..1] repeatNumber such that it a. SHALL contain exactly one [1..1] @value set to the dispense number out of a number of refills i. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a dispense act means that the current dispensation is the 3rd b. BPHC Captured: The repeat number is captured by BPHC to specify the current refill number for the particular dispense event. Some measures allow the use medication dispenses to determine presence of certain condition within a patient such as the presence to asthma and is therefore requested for capture by BPHC. 8. SHOULD contain zero or one [0..1] quantity such that it a. SHALL contain exactly one [1..1] @value b. SHOULD contain zero or one [0..1] @unit, which SHOULD be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC c. BPHC Captured: The quantity of medication dispensed is captured by BPHC as supporting information in determining the total amount of medication given to a patient. In conjunction with the time period and the type of product, the medication dispense can be used as evidence of a certain conditions within a patient. 9. SHOULD contain zero or one [0..1] product (Medication Information) such that it a. SHALL contain exactly one [1..1] Medication Information (templateId:2.16.840.1.113883.10.20.22.4.23) 10. SHOULD contain zero or one [0..1] product (Immunization Information) such that it a. SHALL contain exactly one [1..1] Immunization Medication Information (templateId:2.16.840.1.113883.10.20.22.4.54) i. A supply act SHALL contain one product/Medication Information or one product/Immunization Medication Information template Page 140 of 256 11. MAY contain zero or one [0..1] entryRelationship for Patient Instructions such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] Medication Supply Order (templateId:2.16.840.1.113883.10.20.22.4.17) Figure III-32 Medication Dispense Example <supply classCode="SPLY" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.18"/> <id root=“2.16.840.1.113883.3.96.1.3” extension="cb734647-fc99-424c-a864-7e3cda82e704"/> <statusCode code="completed" codeSystem=“2.16.840.1.113883.5.14”/> <effectiveTime> <low value="20070103" /> <high value="20070104" /> </effectiveTime> <repeatNumber value="1" /> <quantity value="50" /> <product> <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23" /> ... </manufacturedProduct> </product> <entryRelationship typeCode="REFR"> <supply classCode="SPLY" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.17" />  ... </supply> </entryRelationship> </supply> 1.17.15 Medication Information Used By Medication Supply Order Medication Dispense Medication Activity_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries The medication can be recorded as a pre-coordinated product strength, product form, or product concentration (e.g., "metoprolol 25mg tablet", "amoxicillin 400mg/5mL suspension"); or not pre-coordinated (e.g., "metoprolol product"). Table III-21 Medication Information Constraints Overview Name XPath Car d Op t manufacturedProduct 1..1 R @classCode R Data Type Fixed Value 2.16.840.1.113883.5.110 (RoleClass) = MANU Page 141 of 256 Name Car d XPath templateId R @root R manufacturedMaterial Product Name Op t code 1..1 R 1..1 R @code R @displayName R2 @codeSystem R @codeSystemName R2 Product Name Free Text originalText 0..1 R2 Brand Name translation 0..1 O Drug Manu. @code O @displayName O @codeSystem O @codeSystemName O manufacturerOrganization name 0..1 O 0..1 O Data Type Fixed Value 2.16.840.1.113883.10.20.22.4.23 Specification Note: The specification starts within the manufacturedProduct element 1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.10.20.22.4.23" 3. SHALL contain exactly one [1..1] manufacturedMaterial such that it a. SHALL contain exactly one [1..1] code such that it i. SHALL contain exactly one [1..1] @code for the product, which SHALL be selected from ValueSet Medication Clinical Drug 2.16.840.1.113883.3.88.12.80.17 DYNAMIC ii. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen iii. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.88” iv. SHOULD contain exactly one @codeSystemName = “RxNorm” v. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. such that it which vi. MAY contain zero or more [0..*] translation such that it Page 142 of 256 1. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.80.16 Medication Brand Name DYNAMIC 2. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen 3. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.88” 4. SHOULD contain exactly one @codeSystemName = “RxNorm” 5. Translations can be used to represent generic product name, packaged product code, etc. vii. BPHC Captured: BPHC requires the medication and the medication brand name for a medication event to identify the specific medication given during an encounter. The medication code and brand can be used in conjunction with other medication usage information as evidence of conditions within a patient. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. 4. MAY contain zero or one [0..1] manufacturerOrganization such that it a. MAY contain zero or one [0..1] name b. BPHC Captured: The name of the manufacturing organization for the particular medication is captured by BPHC if available as supporting information about a particular medication and for auditing purposes. Figure III-33 Medication Information Example <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <manufacturedMaterial> <code code="219483" displayName="ProventilHFA" codeSystem="2.16.840.1.113883.6.88" codeSystemName=“RxNorm”> <originalText> The medication information free text as described above </originalText> <translation code="219483" displayName="Proventil HFA" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" /> </code> </manufacturedMaterial> <manufacturerOrganization> <name>Medication Factory Inc.</name> </manufacturerOrganization> </manufacturedProduct> 1.17.16 Medication Supply Order Used By Medication Dispense Medication Activity Immunization Activity_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Immunization Medication Information Instructions Medication Information This template records the intent to supply a patient with medications. Page 143 of 256 Table III-22 Medication Supply Order Constraints Overview Name XPath Car d Op t supply 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = SPLY @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = INT 1..1 @root Fill Status Fill Date id R @extension R statusCode 1..1 CS @displayName R2 @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime 0..1 R2 IVL<TS > 0..1 R2 TS R 1..1 repeatNumber quantity R 0..1 R2 R2 0..1 R2 @value R2 @unit R2 product manufacturedProduct product manufacturedProduct entryRelationship TS R @value Patient Instructions R SET<II > R @value Immunization Information 2.16.840.1.113883.10.20.22.4.17 @code high Medication Information R @root @value Quantity Dispensed R R 1..1 low Allowed Fills Fixed Value @classCode templateId Order Number Data Type 0..1 CR 1..1 R 0..1 CR 1..1 R 0..1 O Page 144 of 256 Name XPath Car d Op t Data Type Fixed Value @typeCode R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ @inversionInd R true act R Specification Note: The specification starts within the supply element 1. SHALL contain exactly one [1..1] @classCode=" SPLY " Supply (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode=" INT " Intent (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.17" 4. SHOULD contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to for the medication supply order number within the organization requesting the supply. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Medication Supply Order. The unique id can be used to identify the same Medication Supply Order across separate messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Medication Fill Status 2.16.840.1.113883.3.88.12.80.64 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” e. BPHC Captured: The medication supply order fill status is captured by BPHC to provide supporting information to the medication in use or to be used by the patient. Medication usage can be used as evidence of certain conditions in measures as well as in controlling a condition through the appropriate medications. 6. SHALL contain exactly one [1..1] effectiveTime for the fill date such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value set to the date that the medication start time b. SHALL contain exactly one [1..1] high such that it ii. SHALL contain exactly [1..1] @value set to the expiration date Page 145 of 256 c. BPHC Captured: BPHC captures the fill date to determine the relevance of the medication supply to the time period considered by the particular measure. 7. SHALL contain exactly one [1..1] repeatNumber such that it a. SHALL contain exactly one [1..1] @value set to the number of times the substance can be supplied. i. In "INT" (intent) mood, the repeatNumber defines the number of allowed fills. For example, a repeatNumber of "3" means that the substance can be supplied up to 3 times (or, can be dispensed, with 2 refills) b. BPHC Captured: The repeat number specifies the number of refills allowed for the prescribed medication. The refill number is captured by BPHC to provide supporting information about the amount of medication prescribed to the patient for a condition. 8. SHOULD contain zero or one [0..1] quantity such that it a. SHALL contain exactly one [1..1] @value b. SHOULD contain zero or one [0..1] @unit, which SHOULD be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC c. BPHC Captured: The quantity is captured by medication as supporting information for the amount of medication prescribed. In measures that allow the use of medication as a valid identifier of a condition within a patient, there is a minimum amount of medication needed to meet the requirements. 9. SHOULD contain zero or one [0..1] product (Medication Information) such that it a. SHALL contain exactly one [1..1] Medication Information (templateId:2.16.840.1.113883.10.20.22.4.23) 10. SHOULD contain zero or one [0..1] product (Immunization Information) such that it a. SHALL contain exactly one [1..1] Immunization Medication Information (templateId:2.16.840.1.113883.10.20.22.4.54) i. A supply act SHALL contain one product/Medication Information or one product/Immunization Medication Information template 11. MAY contain zero or one [0..1] entryRelationship for Patient Instructions such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] @inversionInd="true" True c. SHALL contain exactly one [1..1] Instructions (templateId:2.16.840.1.113883.10.20.22.4.20) Figure III-34 Medication Supply Order Example <supply classCode="SPLY" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.17" /> <id root=“2.16.840.1.113883.3.96.1.3” extension="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/> <statusCode code="completed" codeSystem=“2.16.840.1.113883.5.14”/> <effectiveTime> <low value="20070103" /> <high value="20070104" /> </effectiveTime> <repeatNumber value="1" /> Page 146 of 256 <quantity value="75" /> <product> <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23" /> ... </manufacturedProduct> </product> <entryRelationship typeCode="SUBJ" inversionInd="true"> <act classCode="ACT" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.20" />  ... </act> </entryRelationship> </supply> Page 147 of 256 1.17.17 Policy Activity Used By Coverage Activity_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Organization Person A policy activity represents the policy or program providing the coverage. The person for whom payment is being provided (e .g. the patient) is the covered party. The subscriber of the policy or program is represented as a participant that is the holder the coverage. The payer is represented as the performer of the policy activity. Table III-23 Policy Activity Constraints Overview Name XPath Car d Op t act 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root Health Insurance Type Policy Status Payer Fixed Value @classCode templateId Policy Id Data Type id R R 1..1 R2 @root R @extension R code 0..1 R2 2.16.840.1.113883.10.20.22.4.12 SET<II > CE @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.255.1336 @codeSystemName R2 ASC X12 statusCode 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 R2 R ActStatus @codeSystemName performer @typeCode templateId @root 1..1 1..1 R R R 2.16.840.1.113883.5.90 (HL7ParticipationType) = PRF 2.16.840.1.113883.10.20.22.4.87 Page 148 of 256 assignedEntity PBM routing numbers, or payer ids Provider Type 1..1 R id 1..* R code @code @displayName @codeSystem 0..1 O R R2 R End Financial Responsible Id Provider Type Organizati on 0..1 1..1 R2 R @typeCode templateId @root 1..1 R R R effectiveTime 0..1 R2 1..1 1..1 R R R2 R R id 0..1 R2 code @code @displayName @codeSystem 1..1 R R R2 R GUAR Guarantor 2.16.840.1.113883.5.111 R2 RoleCode representedOrganization Financial Responsibilit y Time Start RoleCode R2 @codeSystemName Guarantor 2.16.840.1.113883.5.110 performer low @value high @value assignedEntity 0..1 @codeSystemName 2.16.840.1.113883.5.90 (HL7ParticipationType) = PRF 2.16.840.1.113883.10.20.22.4.88 IVL<TS > TS TS representedOrganization 0..1 1..1 R2 R @typeCode templateId @root 1..1 R R R time low high participantRole 0..1 0..1 0..1 1..1 R2 R2 R2 R id 1..* @root code 1..1 R R R or assigned person Patient Health Plan Coverage Dates Cover Party Member Id participant Patient 2.16.840.1.113883.5.90 (HL7ParticipationType) = COV 2.16.840.1.113883.10.20.22.4.89 IVL_TS TS TS Page 149 of 256 @code @displayName @codeSystem R R2 R 0..1 R2 R2 1..1 1..1 R R2 @codeSystemName playingEntity Patient Name Subscriber name participant Health Plan @typeCode templateId @root time low high participantRole id @root entryRelationship 1..1 0..1 0..1 0..1 1..1 1..* 1..* @typeCode Coverage Description act R 1..1 @classCode @moodCode templateId @root id Health Plan Id Health Plan Name R R R O O O R R R R 1..1 RoleCode PN 2.16.840.1.113883.5.90 (HL7ParticipationType) = HLD IVL_TS TS TS 2.16.840.1.113883.10.20.22.4.90 Health Plan Coverage Dates Subscriber Information Subscriber Member Id @typeCode="REFR" CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 R R 1..1 2.16.840.1.113883.5.111 R R R R 2.16.840.1.113883.5.6 (HL7ActClass) = ACT 2.16.840.1.113883.5.6 (HL7ActClass) = DEF 2.16.840.1.113883.10.20.1.19 @root text Specification Note: The specification starts within the act element 1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode= “EVN” Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.4.61 " 4. SHOULD contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the health insurance NAIC identification number or another unique identification number for the health insurance Page 150 of 256 company providing the policy. If the policy is a self then set to the sending organization OID. b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value that represents the policy number. In the case of self pay, set to a unique identifier within the sending organization that represents the self-pay policy. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Policy Activity. The unique id can be used to identify the same Policy Activity across separate messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code for the health insurance type such that it a. SHALL contain exactly one [1..1] @code ValueSet: Health Insurance Type Value Set 2.16.840.1.113883.3.88.12.3221.5.2 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.255.1336” d. SHOULD contain exactly one @codeSystemName = “ASC X12” e. BPHC Captured: The Health Insurance type is captured by BPHC as supporting information to measures restricted to certain health insurance types. 6. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code = “completed” b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 7. SHALL contain exactly one [1..1] performer that represents the payer such that it a. SHALL contain exactly one [1..1] @typeCode="PRF" Performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) b. SHALL contain exactly one [1..1] templateId such that it i. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.87" Payer Performer c. SHALL contain exactly one [1..1] assignedEntity such that it i. SHALL contain at least one [1..*] id ii. SHOULD contain zero or one [0..1] code 1. The code, if present, SHALL contain zero or one [0..1] @code (ValueSet: HL7FinanciallyResponsiblePartyType 2.16.840.1.113883.1.11.10416 DYNAMIC) 2. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen 3. SHALL contain exactly one @codeSystem =“2.16.840.1.113883.5.110” 4. SHOULD contain exactly one @codeSystemName =“RoleCode” 5. BPHC Captured: The role code is captured by BPHC in order to identify the responsible party even if it is the patient themselves. Page 151 of 256 The role code is supporting information for the health insurance policy. iii. SHOULD contain zero or one [0..1] representedOrganization 1. BPHC Captured: The organization responsible financially if applicable is capture by BPHC as supporting information for health insurance as it pertains to the measures. 8. SHOULD contain zero or one [0..1] performer="PRF" Performer that represents the guarantor (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) such that it a. SHALL contain exactly one [1..1] templateId such that it i. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.88" Guarantor Performer b. SHOULD contain zero or one [0..1] time such that it i. SHALL contain exactly one [1..1] low such that it 1. SHALL contain exactly [1..1] @value set to the date that financial responsibility begins ii. SHOULD contain zero or one [1..1] high such that it 1. SHALL contain exactly [1..1] @value set to the date that financial responsibility ends iii. BPHC Captured: BPHC captures the date from and to which financial responsibility is valid. Measures have requirements that health insurance cannot have major gaps and therefore the guarantor time is important. c. SHALL contain exactly one [1..1] assignedEntity such that it i. This assignedEntity SHALL contain exactly one [1..1] code 1. This code SHALL contain exactly one [1..1] @code="GUAR" 2. SHOULD contain exactly one @displayName =“ Guarantor” 3. SHALL contain exactly one @codeSystem =“2.16.840.1.113883.5.111” 4. SHOULD contain exactly one @codeSystemName =“RoleCode” ii. SHOULD include assignedEntity/assignedPerson AND/OR assignedEntity/representedOrganization 1. BPHC Captured: BPHC requires either the person or organization that is the guarantor for the policy to identify the particular entity responsible. 9. SHALL contain exactly one [1..1] participant that represents the patient such that it a. SHALL contain exactly one [1..1] @typeCode="COV" Coverage target (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) b. SHALL contain exactly one [1..1] templateId such that it i. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.89" Covered Party Participant c. SHOULD contain zero or one [0..1] time such that it i. SHOULD contain zero or one [0..1] low such that it 1. SHALL contain exactly one [1..1] @value set to health plan coverage start ii. SHOULD contain zero or one [0..1] high such that it Page 152 of 256 1. SHALL contain exactly one [1..1] @value set to the health plan coverage expiration iii. BPHC Captured: BPHC requires the health plan coverage start and expiration dates to help identify any gaps in coverage that may remove the patient’s encounters from a particular measure. d. SHALL contain exactly one [1..1] participantRole i. This participantRole SHALL contain at least one [1..*] id 1. This id is a unique identifier for the covered party member. Implementers SHOULD use the same GUID for each instance of a member identifier from the same health plan ii. This participantRole SHALL contain exactly one [1..1] code such that it 1. This code SHOULD contain zero or one [0..1] @code (ValueSet: Coverage Role Type Value Set 2.16.840.1.113883.1.11.18877 DYNAMIC) 2. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen 3. SHALL contain exactly one @codeSystem =“2.16.840.1.113883.5.111” 4. SHOULD contain exactly one @codeSystemName =“RoleCode” 5. BPHC Captured: BPHC requires the coverage role of the covered party member to further identify the patient’s responsibility. Selfcoverage would be specified by a code of SELF which is used as one of the health care type restrictions within the set of measures that BPHC will consider. iii. This participantRole SHOULD contain zero or one [0..1] playingEntity such that it 1. SHALL contain exactly one [1..1] name a. If the member name as recorded by the health plan differs from the patient name as recorded in the registration/medication summary (e.g., due to marriage or for other reasons), then the member name SHALL be recorded in the name element 10. SHOULD contain zero or one [0..1] participant for the policy subscriber such that it a. SHALL contain exactly one [1..1] @typeCode="HLD" Holder (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) b. SHALL contain exactly one [1..1] templateId such that it i. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.90" Policy Holder Participant c. MAY contain zero or one [0..1] time such that it i. SHOULD contain zero or one [0..1] low such that it 1. SHALL contain exactly one [1..1] @value set to health plan coverage start ii. SHOULD contain zero or one [0..1] high such that it Page 153 of 256 1. SHALL contain exactly one [1..1] @value set to the health plan coverage expiration iii. BPHC Captured: BPHC requires the health plan coverage start and expiration dates to help identify any gaps in coverage that may remove the patient’s encounters from a particular measure. d. SHALL contain exactly one [1..1] participantRole such that it i. SHALL contain at least one [1..*] id 1. This id is a unique identifier for the subscriber of the coverage 11. SHALL contain at least one [1..*] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] @typeCode="DEF", representing a description of the coverage plan c. SHALL contain exactly one [1..1] id, to represent the plan identifier such that it d. SHALL contain exactly one [1..1] text with the name of the plan e. BPHC Captured: BPHC requires the health plan name as supporting information about the type coverage that a patient has at the time of the encounter. Figure III-35 Policy Activity Example <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.61" />  <id root="3e676a50-7aac-11db-9fe1-0800200c9a66" /> <code code="SELF" codeSystemName="HL7 RoleClassRelationship" codeSystem="2.16.840.1.113883.5.110" /> <statusCode code="completed" />  <performer typeCode="PRF"> <templateId root="2.16.840.1.113883.10.20.22.4.87"/>  <assignedEntity> <id root="2.16.840.1.113883.19"/> <code code="PAYOR" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7 RoleCode" /> <representedOrganization> <name>Good Health Insurance</name> </representedOrganization> </assignedEntity> </performer>  <performer typeCode="PRF"> <templateId root="2.16.840.1.113883.10.20.22.4.88" /> <time> <low nullFlavor="UNK" /> <high nullFlavor="UNK" /> </time> <assignedEntity> <id root="329fcdf0-7ab3-11db-9fe1-0800200c9a66" /> <code code="GUAR" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" /> <assignedPerson> <name> <prefix>Mr.</prefix> <given>Adam</given> <given>Frankie</given> <family>Everyman</family> Page 154 of 256 </name> </assignedPerson> </assignedEntity> </performer> <participant typeCode="COV">  <templateId root="2.16.840.1.113883.10.20.22.4.89" /> <time> <low nullFlavor="UNK" /> <high nullFlavor="UNK" /> </time> <participantRole classCode="PAT"> <id root="14d4a520-7aae-11db-9fe1-0800200c9a66" extension="1138345"/>  <code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="Self" /> <playingEntity> <name>  <prefix>Mr.</prefix> <given>Frank</given> <given>A.</given> <family>Everyman</family> </name> </playingEntity> </participantRole> </participant>  <participant typeCode="HLD"> <templateId root="2.16.840.1.113883.10.20.22.4.90" /> <time> <low nullFlavor="UNK" /> <high nullFlavor="UNK" /> </time> <participantRole> <id extension="1138345" root="2.16.840.1.113883.19" /> </participantRole> </participant> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="DEF"> <id root="329fcdf0-7ab3-11db-9fe1-0800200c9a66" /> <text>Health Plan Name</text> </act> </entryRelationship> </act> Page 155 of 256 1.17.18 Pregnancy Observation Used By Social History Section_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries This clinical statement represents current and/or prior pregnancy dates enabling investigators to determine if the subject of the case report was pregnant during the course of a condition. Table III-24 Pregnancy Observation Constraints Overview Name XPath Car d Op t observation 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root Observation Status Observation Time Start code Value Code R R 0..1 R2 2.16.840.1.113883.10.20.15.3.8 CD @code R ASSERTION @displayName R2 Assertion @codeSystem R 2.16.840.1.113883.5.4 @codeSystemName R2 ActCode statusCode 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 0..1 R2 IVL_TS 1..1 R TS @value End Fixed Value @classCode templateId Social History Type Data Type high @value value @xsi:type @code @displayName R 0..1 R2 TS 1..1 R R CD R R2 CD 77386006 Pregnant with Page 156 of 256 @codeSystem @codeSystemName Value Free Text Est. Date of Delivery originalText 0..1 R2 entryRelationship 0..1 O @typeCode observation 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR 1..1 R @moodCode templateId @root code @code @displayName @codeSystem R R R R R 1..1 1..1 @codeSystemName 1..1 @codeSystemName Estimated Date of Delivery R @classCode statusCode @code @displayName @codeSystem value @value 2.16.840.1.113883.6.96 SNOMED CT R R2 1..1 2.16.840.1.113883.5.6 (HL7ActClass) = OBS 2.16.840.1.113883.5.1001 (ActMood) = EVN 2.16.840.1.113883.10.20.15.3.1 CE R 11778-8 Estimated date of delivery 2.16.840.1.113883.6.1 R2 R R R2 R LOINC completed completed completed 2.16.840.1.113883.5.14 R2 ActStatus R R TS Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.13" 4. SHALL contain exactly one [1..1] code for the procedure type such that it a. SHALL contain exactly one [1..1] @code =“ASSERTION” b. SHOULD contain exactly one @displayName = “Assertion” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.4” d. SHOULD contain exactly one @codeSystemName = “ActCode” 5. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code = “completed” b. SHOULD contain exactly one @displayName = completed Page 157 of 256 c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 6. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value b. SHOULD contain zero or one [1..1] high such that it i. SHALL contain exactly [1..1] @value c. BPHC Captured: The pregnancy observation effective time is captured by BPHC to determine if pregnancy is a factor to be considered for a particular patient within the time frame covered by the measure. 7. SHALL contain exactly one [1..1] value such that it a. SHALL contain exactly one @code = “ 77386006” b. SHOULD contain exactly one @displayName = “Pregnant with” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” 8. MAY contain zero or one [0..1] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] observation such that it i. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) ii. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) iii. SHALL contain exactly one [1..1] templateId such that it 1. a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.15.3.1" iv. SHALL contain exactly one [1..1] code such that it 1. SHALL contain exactly one @code = “11778-8” 2. SHOULD contain exactly one @displayName = “Estimated date of delivery” 3. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1” 4. SHOULD contain exactly one @codeSystemName = “LOINC” v. SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) 1. SHALL contain exactly one @code = “completed” 2. SHOULD contain exactly one @displayName = completed 3. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” 4. SHOULD contain exactly one @codeSystemName = “ActStatus” vi. SHALL contain exactly one [1..1] value with @xsi:type="TS" such that it 1. SHALL contain exactly one @value Page 158 of 256 2. BPHC Captured: BPHC requires the estimated date of delivery if known to determine relevance of the pregnancy to other encounters by the patient as well as during the measured timeframe. Figure III-36 Pregnancy Observation Example <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.15.3.8"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖ /> <effectiveTime> <low value="20110410"/> </effectiveTime> <value xsi:type="CD" code="77386006" displayName="pregnant" codeSystem="2.16.840.1.113883.6.96"/> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.15.3.1"/> <code code="11778-8" codeSystem="2.16.840.1.113883.6.1" displayName="Estimated date of delivery"/> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖ /> <value xsi:type="TS">20110919</value> </observation> </entryRelationship> </observation> Page 159 of 256 1.17.19 Problem Concern Act Used By Problem Section_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Problem Observation Observations of problems or other clinical statements captured at a point in time are wrapped in a "Concern" act, which represents the ongoing process tracked over time. This allows for binding related observations of problems. For example, the observation of "Acute MI" in 2004 can be related to the observation of "History of MI" in 2006 because they are the same concern. The conformance statements in this section define an outer "problem act" (representing the "Concern") that can contain a nested "problem observation" or other nested clinical statements. Table III-25 Problem Concern Act Constraints Overview Name XPath Car d Op t act 1..1 R Fixed Value @classCode R 2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN templateId 1..1 @root id R R 1..1 R2 @root R @extension R code 1..1 R 2.16.840.1.113883.10.20.22.4.3 SET_II CD @code R CONC @displayName R2 Concern @codeSystem R 2.16.840.1.113883.5.6 @codeSystemName R2 ActClass statusCode Concern Active Date Data Type 1..1 R CS @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 1..1 R IVL_TS 1..1 R TS Page 160 of 256 @value high R 0..1 @value Problem Observation entryRelationship @typeCode R2 TS R 1..* R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ Specification Note: The specification starts within the act element 1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.30" 4. SHOULD contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Problem Concern Act within the sending organization. This ID should be used whenever this Problem Concern Act is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the Problem Concern Act. The unique id can be used to identify the same Problem Concern Act used in different messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="CONC" b. SHOULD contain exactly one @displayName = “Concern” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.6” d. SHOULD contain exactly one @codeSystemName = “ActClass” 6. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code which SHALL be selected from Value Set: ProblemAct statusCode 2.16.840.1.113883.11.20.9.19 STATIC 2011-09-09 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” e. BPHC Captured: BPHC captures the status of the problem concern to determine the problem’s relevance for the measure in question. 7. SHALL contain exactly one [1..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it Page 161 of 256 i. SHALL contain exactly [1..1] @value set to the date that the concern became active b. SHOULD contain zero or one [1..1] high such that it i. SHALL contain exactly [1..1] @value set to the date that the concern is no longer active c. BPHC Captured: BPHC captures the status of the problem concern to determine the problem’s relevance based on the time period covered by the particular measure taken. 8. SHALL contain one or more [1..*] entryRelationship such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) b. SHALL contain exactly one [1..1] Problem Observation (2.16.840.1.113883.10.20.22.4.4) Figure III-37 Problem Concern Act Example <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.30"/> <id root=“2.16.840.1.113883.3.96.1.3” extension="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="ActClass" displayName="Concern" /> <statusCode code="completed" displayName=“completed” codeSystem=“2.16.840.1.113883.5.14” codeSystemName=“ActStatus”/> <effectiveTime"> <low value="20060501"/> <high value="20100501"/> </effectiveTime> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.4"/> .. </observation> </entryRelationship> </act> </entry> Page 162 of 256 1.17.20 Problem Observation Used By Encounter Diagnosis Problem Concern Act_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Health Status Observation Problem Status A problem is a clinical statement that a clinician has noted. In health care it is a condition that requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any unmet or partially met basic human need. A Problem Observation is required to be wrapped in an act wrapper in locations such as the Problem Section, Allergies Section, and Hospital Discharge Diagnosis Section, where the type of problem needs to be identified or the condition tracked. A Problem Observation can be a valid "standalone" template instance in cases where a simple problem observation is to be sent. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). NegationInd='true' is an acceptable way to make a clinical assertion that something did not occur, for example, "no diabetes". Table III-26 Problem Observation Constraints Overview Name XPath Car d Op t observation 1..1 R Fixed Value @classCode R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN @negationInd O templateId 1..1 @root id Problem Type Data Type R R 1..1 R2 @root R @extension R code 1..1 R @code R @displayName R2 2.16.840.1.113883.10.20.22.4.4 SET_II CD Page 163 of 256 Name Problem Observation Free Text Car d XPath 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT text 0..1 R2 statusCode 1..1 R Problem Code Free Text Problem Status R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus low 1..1 R IVL_TS 1..1 R TS high R 0..1 value R2 TS R 1..1 R CD @xsi:type R @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT originalText 0..1 R2 entryRelationship 0..1 O @typeCode Health Observation Status CS @code @value Problem Code Fixed Value R @value Resolution Date Data Type @codeSystem effectiveTime Onset Date Op t entryRelationship @typeCode 0..1 CD R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR O 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR R Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) Page 164 of 256 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. MAY contain zero or one [0..1] @negationInd a. Use negationInd="true" to indicate that the problem was not observed 4. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4" 5. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Problem Observation within the sending organization. This ID should be used whenever this particular Problem Observation is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the observation. The unique id can be used to identify the same observation used in different messages. The HL7 Consolidation Guide requires an id for this element. 6. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code which SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” e. BPHC Captured: BPHC captures the problem type to categorize the problem. The problem type aids in the identification of conditions explored by national measures. 7. SHOULD contain zero or one [0..1] text such that it contains free text describing the problem observation and SHOULD include all relevant text used to derived the problem observation codes. a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the problem observation codes were determined for auditing purposes. 8. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 9. SHALL contain exactly one [1..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly one [1..1] @value set to the problem onset date Page 165 of 256 b. SHOULD contain zero or one [0..1] high if the problem is no longer a concern such that it ii. SHALL contain exactly one [1..1] @value set to the time that the problem was determined to no longer be a concern c. If the problem is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within a problem does indicate that the problem has been resolved d. BPHC Captured: The problem’s effective time is required for capture by BPHC to determine the relevance of the problem during the time period of the measure being explored. 10. SHALL contain exactly one [1..1] value such that it a. SHALL contain exactly one [1..1] @xsi:type = "CD" b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC i. If the diagnosis is unknown, @nullFlavor may be used and SHOULD be set to “UNK” c. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen d. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” e. SHOULD contain exactly one @codeSystemName = “SNOMED CT” f. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. g. BPHC Captured: Many of the national measures are specific to a certain condition such as Diabetes or Asthma. The problem code can be used to identify the presence of one of these conditions and therefore is required for capture by BPHC. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. 11. MAY contain zero or one [0..1] entryRelationship for the Problem Status such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] Problem Status (templateId:2.16.840.1.113883.10.20.22.4.6) 12. MAY contain zero or one [0..1] entryRelationship for the Health Observation Status such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] Health Status Observation (templateId:2.16.840.1.113883.10.20.22.4.5) Figure III-38 Problem Observation Example <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.4" /> <id root="2.16.840.1.113883.3.96.1.3" extension="ab1791b0-5c71-11db-b0de-0800200c9a66" /> <code code="409586006" displayName="Complaint" Page 166 of 256 codeSystem="2.16.840.1.113883.6.96 codeSystemName="SNOMED CT"/> <text> The problem observation free text as described above </text> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/> <effectiveTime> <low value="20070103" /> </effectiveTime> <value xsi:type="CD" code="195967001" displayName="Asthma" codeSystem="2.16.840.1.113883.6.96" <originalText> The free text from which the value code was derived from </originalText </value> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.6" /> <!—Problem Status template --> ... </observation> </entryRelationship> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.5" />  ... </observation> </entryRelationship> </observation> Figure III-39 Problem Observation for No Known Problems <observation classCode="OBS" moodCode="EVN" negationInd="true">  <templateId root="2.16.840.1.113883.10.20.22.4.4" /> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7ActCode" /> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/> <value xsi:type="CD" code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /> </observation> Page 167 of 256 1.17.21 Problem Status Used By Problem Observation_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries The Problem Status records whether the indicated problem is active, inactive, or resolved. Table III-27 Problem Status Constraints Overview Name XPath Car d Op t observation 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root code Problem Status Fixed Value @classCode templateId Problem Status Free Text Data Type R R 1..1 R 2.16.840.1.113883.10.20.22.4.6 CD @code R 33999-4 @displayName R2 Status @codeSystem R 2.16.840.1.113883.6.1 @codeSystemName R2 LOINC text 0..1 R2 statusCode 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus value 1..1 R CD @xsi:type R CD @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT Specification Page 168 of 256 Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.6" 4. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="33999-4" b. SHOULD contain exactly one @displayName = “Status” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1” d. SHOULD contain exactly one @codeSystemName = “LOINC” 5. SHOULD contain zero or one [0..1] text such that it contains free text describing the problem status and SHOULD include all relevant text used to derived the problem status code. a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the problem status codes were determined for auditing purposes. 6. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 7. SHALL contain exactly one [1..1] value such that it a. SHALL contain exactly one [1..1] @xsi:type = "CD" b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet HITSPProblemStatus 2.16.840.1.113883.3.88.12.80.68 DYNAMIC c. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen d. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” e. SHOULD contain exactly one @codeSystemName = “SNOMED CT” f. BPHC Captured: BPHC captures the problem status to determine the relevance of a problem to the measure being explored. Figure III-40 Problem Status Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.6" />  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> The problem status free text as described above </text> Page 169 of 256 <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖ /> <value xsi:type="CD" code="55561003" displayName="Active" codeSystem="2.16.840.1.113883.6.96" codeSystemName=“SNOMED CT”/> </observation> Page 170 of 256 1.17.22 Procedure Activity Act Used By Procedures Section_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Medication Activity Service Delivery Location Addr Organization Telecom The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g. splenectomy). This clinical statement represents any procedure that cannot be classified as an observation or a procedure according to the HL7 RIM. Examples of these procedures are a dressing change, teaching or feeding a patient or providing comfort measures. Table III-28 Procedure Activity Act Constraints Overview Name XPath Car d Op t act 1..1 R @classCode R @moodCode R templateId 1..1 @root id Procedure Type Procedure Type Free Text Procedure Status R R2 @root R @extension R 1..1 Fixed Value 2.16.840.1.113883.5.6 (HL7ActClass) = ACT R 1..1 code Data Type R 2.16.840.1.113883.10.20.22.4.12 SET_II CE @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.1 or 2.16.840.1.113883.6.96 @codeSystemName R2 LOINC or SNOMED originalText statusCode 0..1 R2 1..1 R @code R @displayName R2 CS Page 171 of 256 Procedure Time Start @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 0..1 R2 IVL_TS 1..1 R TS @value End high R 0..1 @value Priority Code priorityCode Provider Type performer assignedEntity id code @code @displayName @codeSystem TS R 0..1 @code @displayName @codeSystem @codeSystemName Procedure Provider R2 R2 CE R R2 R R2 0..* 1..1 1..* R2 R R 0..1 O R R2 R addr telecom 1..1 1..1 R2 R R representedOrganization 0..1 R2 0..* O @codeSystemName 2.16.840.1.113883.5.7 ActPriority Procedure Provider Addr Tel Organizati Service Delivery Location Encounter participant @typeCode entryRelationship 0..1 @typeCode Medication Activity entryRelationship @typeCode R O R 0..1 on Code System 2.16.840.1.113883.5.90 (HL7ParticipationType) = LOC 2.16.840.1.113883.5.1002 (HL7ActRelationshipType)= COMP (Has Component) O R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP Specification Note: The specification starts within the act element 1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) Page 172 of 256 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.12" 4. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Procedure Activity Act within the sending organization. This ID should be used whenever this particular Procedure Activity Act is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the act. The unique id can be used to identify the same act used in different messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code for the procedure type such that it a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12), ICD9 Procedures (CodeSystem: 2.16.840.1.113883.6.104), ICD10 Procedure Coding System (CodeSystem: 2.16.840.1.113883.6.4) If the diagnosis is unknown, @nullFlavor may be used and SHOULD be set to “UNK” b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. f. BPHC Captured: BPHC requires the procedure type to perform research on particular measures that require knowledge of certain procedures. e.g. Measuring Median Time to PCI where the PCI would be represented as a procedure in the CDC message. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. 6. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” e. BPHC Captured: The status of a procedure is captured by BPHC to determine the relevance of the procedure to the measure being taken. 7. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value set to the start time for the procedure Page 173 of 256 b. SHOULD contain zero or one [1..1] high such that it i. SHALL contain exactly [1..1] @value set to the end time for the procedure c. BPHC Captured: The procedures start and end time are captured to determine the procedures relevance to the measure being taken. The start and end time of the procedure is important in determining the timeline in which the procedure occurred. E.g. Median Time to PCI looks at the time of the PCI (procedure) compared to the start time of the encounter itself. 8. MAY contain zero or one [0..1] priorityCode such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.7” d. SHOULD contain exactly one @codeSystemName = “ActPriority” e. BPHC Captured: The priority code is captured by BPHC as supporting information to the procedure activity. 9. SHOULD contain zero or more [0..*] performer for the Procedure Provider such that it a. SHALL contain exactly one [1..1] assignedEntity such that it i. SHALL contain at least one [1..*] id such that it 1. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.4.6" National Provider Identifier 2. SHALL contain exactly one [1..1] @extension a. The extension shall be populated with the provider’s NPI. ii. SHALL contain exactly one [1..1] addr iii. SHALL contain exactly one [1..1] telecom iv. SHOULD contain zero or one [0..1] representedOrganization 10. MAY contain zero or more [0..*] participant for the Service Delivery Location such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) b. SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) 11. MAY contain zero or more [0..*] entryRelationship for a reference encounter such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] @inversionInd="true" true c. SHALL contain exactly one [1..1] encounter such that it i. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) ii. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) iii. SHALL contain exactly one [1..1] id 1. Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter 12. MAY contain zero or one [0..1] entryRelationship for Medication Activity such that it Page 174 of 256 a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] Medication Activity (templateId:2.16.840.1.113883.10.20.22.4.16) Figure III-41 Procedure Activity Act Example <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.12" />  <id root=“2.16.840.1.113883.3.96.1.3” extension="d68b7e32-7810-4f5b-9cc2-acd54b0fd8zz" /> <code code="274025005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonic polypectomy"> <originalText> The procedure type free text as described above </originalText> </code> <statusCode code="completed" displayName=“completed” codeSystem=“2.16.840.1.113883.5.14” codeSystemName=“ActStatus”/> <effectiveTime"> <low value="20060501"/> <high value="20100501"/> </effectiveTime> <priorityCode code="CR" codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority" displayName="Callback results" /> <performer> <assignedEntity> <id root=“2.16.840.1.113883.3.96.1.3” extension="2.16.840.1.113883.19.5.9999.456" extension="2981823" /> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom use="WP" value="555-555-5000" /> <representedOrganization> <id root=“2.16.840.1.113883.3.96.1.3” extension="2.16.840.1.113883.19.5.9999.1393" /> <name>Community Health and Hospitals</name> <telecom use="WP" value="555-555-5000" /> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </representedOrganization> </assignedEntity> </performer> <participant typeCode="LOC"> <participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32" />  ... </participantRole> </participant> </act> Page 175 of 256 1.17.23 Procedure Activity Observation Used By Procedures Section_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Medication Activity Service Delivery Location Addr Organization Telecom The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g. splenectomy). This clinical statement represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs and EKGs. Table III-29 Procedure Activity Observation Constraints Overview Name XPath Car d Op t observation 1..1 R @classCode R @moodCode R templateId 1..1 @root id Procedure Type Procedure Type Free Text Procedure Status R R2 @root R @extension R 1..1 Fixed Value 2.16.840.1.113883.5.6 (HL7ActClass) = OBS R 1..1 code Data Type R 2.16.840.1.113883.10.20.22.4.13 SET_II CE @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.1 or 2.16.840.1.113883.6.96 @codeSystemName R2 LOINC or SNOMED originalText statusCode 0..1 R2 1..1 R @code R @displayName R2 CS Page 176 of 256 Procedure Time Start @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 0..1 R2 IVL_TS 1..1 R TS @value End high R 0..1 @value Priority Code Value Code Value Free Text Method Code priorityCode @code @displayName @codeSystem @codeSystemName value @xsi:type @code @displayName 0..1 R2 1..1 R R2 R R2 R @codeSystemName R2 targetSiteCode 0..1 R2 0..1 R2 Provider Type performer assignedEntity id code @code @displayName @codeSystem 0..1 representedOrganization 2.16.840.1.113883.6.1 or 2.16.840.1.113883.6.96 LOINC or SNOMED CT CE R2 CE R R2 R R2 0..* 1..1 1..* R2 R R 0..1 O R R2 R @codeSystemName addr telecom CD R R2 R R2 @code @displayName @codeSystem @codeSystemName Procedure Provider 2.16.840.1.113883.5.7 ActPriority CD R methodCode CE R R2 @codeSystem originalText TS R @code @displayName @codeSystem @codeSystemName Target Site Code R2 1..1 1..1 0..1 R2 R R R2 2.16.840.1.113883.6.96 SNOMED CT Procedure Provider Addr Tel Organizati Page 177 of 256 on Service Delivery Location Encounter participant @typeCode entryRelationship 0..* 0..1 @typeCode Medication Activity entryRelationship @typeCode O R O R 0..1 Code System 2.16.840.1.113883.5.90 (HL7ParticipationType) = LOC 2.16.840.1.113883.5.1002 (HL7ActRelationshipType)= COMP (Has Component) O R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.13" 4. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Procedure Activity Observation within the sending organization. This ID should be used whenever this particular Procedure Activity Observation is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the observation. The unique id can be used to identify the same observation used in different messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code for the procedure type such that it a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12), ICD9 Procedures (CodeSystem: 2.16.840.1.113883.6.104), ICD10 Procedure Coding System (CodeSystem: 2.16.840.1.113883.6.4) If the diagnosis is unknown, @nullFlavor may be used and SHOULD be set to “UNK” b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen Page 178 of 256 6. 7. 8. 9. c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. f. BPHC Captured: BPHC requires the procedure type to perform research on particular measures that require knowledge of certain procedures. e.g. Measuring Median Time to PCI where the PCI would be represented as a procedure in the CDC message. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” e. BPHC Captured: The status of a procedure is captured by BPHC to determine the relevance of the procedure to the measure being taken. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value set to the start time for the procedure b. SHOULD contain zero or one [1..1] high such that it i. SHALL contain exactly [1..1] @value set to the end time for the procedure c. BPHC Captured: The procedures start and end time are captured to determine the procedures relevance to the measure being taken. The start and end time of the procedure is important in determining the timeline in which the procedure occurred. E.g. Median Time to PCI looks at the time of the PCI (procedure) compared to the start time of the encounter itself. MAY contain zero or one [0..1] priorityCode such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.7” d. SHOULD contain exactly one @codeSystemName = “ActPriority” e. BPHC Captured: The priority code is captured by BPHC as supporting information to the procedure activity. SHALL contain exactly one [1..1] value for the procedure type such that it Page 179 of 256 a. SHALL contain exactly one[1..1] @xsi:type =“CD” b. SHALL contain exactly one [1..1] @code c. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen d. SHALL contain exactly one @codeSystem e. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen f. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. g. BPHC Captured: BPHC requires the procedure type to perform research on particular measures that require knowledge of certain procedures. e.g. Measuring Median Time to PCI where the PCI would be represented as a procedure in the CDC message. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. 10. MAY contain zero or one [0..1] methodCode such that it a. SHALL contain exactly one @code b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. MethodCode SHALL NOT conflict with the method inherent in observation / value and should be omitted if the value adequately describes the method. f. BPHC Captured: The method code is captured by BPHC as supporting information to the procedure activity. 11. SHOULD contain zero or more [0..*] targetSiteCode such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” e. BPHC Captured: The target site code is captured by BPHC as supporting information to the procedure activity. 12. SHOULD contain zero or more [0..*] performer for the Procedure Provider such that it a. SHALL contain exactly one [1..1] assignedEntity such that it i. SHALL contain at least one [1..*] id such that it 1. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.4.6" National Provider Identifier 2. SHALL contain exactly one [1..1] @extension a. The extension shall be populated with the provider’s NPI. Page 180 of 256 ii. SHALL contain exactly one [1..1] addr iii. SHALL contain exactly one [1..1] telecom iv. SHOULD contain zero or one [0..1] representedOrganization 1. BPHC Captured: BPHC requests the represented organization to facilitate any follow-up and support research. 13. MAY contain zero or more [0..*] participant for the Service Delivery Location such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) b. SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) 14. MAY contain zero or more [0..*] entryRelationship for a reference encounter such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] @inversionInd="true" true c. SHALL contain exactly one [1..1] encounter such that it i. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) ii. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) iii. SHALL contain exactly one [1..1] id 1. Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter 15. MAY contain zero or one [0..1] entryRelationship for Medication Activity such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] Medication Activity (templateId:2.16.840.1.113883.10.20.22.4.16) Figure III-42 Procedure Activity Observation Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.13" />  <id extension="123456789" root="2.16.840.1.113883.19" /> <code code="274025005" codeSystem="2.16.840.1.113883.6.96" displayName="Colonic polypectomy" codeSystemName="SNOMED-CT"> <originalText> The procedure type free text as described above </originalText> </code> <statusCode code="aborted" 2.16.840.1.113883.5.14 /> <effectiveTime"> <low value="20060501"/> </effectiveTime> <priorityCode code="CR" codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority" displayName="Callback results" /> <value xsi:type="CD" /> <methodCode nullFlavor="UNK" /> <targetSiteCode code="416949008" codeSystem="2.16.840.1.113883.6.96 " Page 181 of 256 codeSystemName="SNOMED CT" displayName="Abdomen and pelvis" /> <performer> <assignedEntity> <id root=“2.16.840.1.113883.3.96.1.3” extension="2.16.840.1.113883.19.5.9999.456" extension="2981823" /> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom use="WP" value="555-555-5000" /> <representedOrganization> <id root=“2.16.840.1.113883.3.96.1.3” extension="2.16.840.1.113883.19.5.9999.1393" /> <name>Community Health and Hospitals</name> <telecom use="WP" value="555-555-5000" /> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </representedOrganization> </assignedEntity> </performer> <participant typeCode="LOC"> <participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32" />  ... </participantRole> </participant> </observation> Page 182 of 256 1.17.24 Procedure Activity Procedure Used By Procedures Section_Encounters_Section_Allergy_problem_Entry Contains Entries Medication Activity Service Delivery Location Addr Organization Telecom The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g. splenectomy). This clinical statement represents procedures whose immediate and primary outcome (postcondition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement and a creation of a gastrostomy. Table III-30 Procedure Activity Procedure Constraints Overview Name XPath Car d Op t procedure 1..1 R @classCode R @moodCode R templateId 1..1 @root id Procedure Type Procedure Type Free Text Procedure Status R R2 @root R @extension R 1..1 Fixed Value 2.16.840.1.113883.5.6 (HL7ActClass) = PROC R 1..1 code Data Type R 2.16.840.1.113883.10.20.22.4.14 SET_II CE @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.1 or 2.16.840.1.113883.6.96 @codeSystemName R2 LOINC or SNOMED originalText statusCode 0..1 R2 1..1 R CS Page 183 of 256 Procedure Time Start @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 0..1 R2 IVL_TS 1..1 R TS @value End high R 0..1 @value Priority Code priorityCode methodCode 0..1 Specimen targetSiteCode @code @displayName @codeSystem @codeSystemName specimen specimenRole id specimenPlayingEntity code @code @displayName @codeSystem 0..1 Provider R2 0..1 R2 0..* 1..1 0..* R R2 R R2 O R R2 0..1 0..1 quantity @value name desc performer assignedEntity id code CE 2.16.840.1.113883.5.7 ActPriority CE R R2 R R2 @codeSystemName Procedure Provider R2 R R2 R R2 @code @displayName @codeSystem @codeSystemName Target Site Code TS R @code @displayName @codeSystem @codeSystemName Method Code R2 0..* 1..1 1..* 0..1 CE 2.16.840.1.113883.6.96 SNOMED CT O O R R2 R R2 O PQ O O PN ED R2 R R O Procedure Provider Page 184 of 256 Type @code @displayName @codeSystem R R2 R addr telecom 1..1 1..1 R2 R R representedOrganization 0..1 R2 0..* O @codeSystemName Addr Tel Organizati Service Delivery Location Encounter participant @typeCode entryRelationship 0..1 @typeCode Medication Activity entryRelationship @typeCode R O R 0..1 on Code System 2.16.840.1.113883.5.90 (HL7ParticipationType) = LOC 2.16.840.1.113883.5.1002 (HL7ActRelationshipType)= COMP (Has Component) O R 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP Specification Note: The specification starts within the procedure element 1. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.14" 4. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Procedure Activity Procedure within the sending organization. This ID should be used whenever this particular Procedure Activity Procedure is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the procedure. The unique id can be used to identify the same procedure used in different messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code for the procedure type such that it a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: Page 185 of 256 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12), ICD9 Procedures (CodeSystem: 2.16.840.1.113883.6.104), ICD10 Procedure Coding System (CodeSystem: 2.16.840.1.113883.6.4) If the diagnosis is unknown, @nullFlavor may be used and SHOULD be set to “UNK” b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. f. BPHC Captured: BPHC requires the procedure type to perform research on particular measures that require knowledge of certain procedures. e.g. Measuring Median Time to PCI where the PCI would be represented as a procedure in the CDC message. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. 6. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” e. BPHC Captured: The status of a procedure is captured by BPHC to determine the relevance of the procedure to the measure being taken. 7. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value set to the start time for the procedure b. SHOULD contain zero or one [1..1] high such that it i. SHALL contain exactly [1..1] @value set to the end time for the procedure c. BPHC Captured: The procedures start and end time are captured to determine the procedures relevance to the measure being taken. The start and end time of the procedure is important in determining the timeline in which the procedure occurred. E.g. Median Time to PCI looks at the time of the PCI (procedure) compared to the start time of the encounter itself. 8. MAY contain zero or one [0..1] priorityCode such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC Page 186 of 256 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.7” d. SHOULD contain exactly one @codeSystemName = “ActPriority” e. BPHC Captured: The priority code is captured by BPHC as supporting information to the procedure activity. 9. MAY contain zero or one [0..1] methodCode such that it a. SHALL contain exactly one @code b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName e. MethodCode SHALL NOT conflict with the method inherent in observation / value and should be omitted if the value adequately describes the method. f. BPHC Captured: The method code is captured by BPHC as supporting information to the procedure activity. 10. SHOULD contain zero or more [0..*] targetSiteCode such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” e. BPHC Captured: The target site code is captured by BPHC as supporting information to the procedure activity. 11. MAY contain zero or more [0..*] specimen such that it a. SHALL contain exactly one [1..1] specimenRole such that it i. SHOULD contain zero or more [0..*] id such that it 1. SHALL contain exactly one [1..1] @root, which is set to the organization’s OID 2. SHALL contain exactly one [1..1] @extension, which should be set to a unique value to represent the specimen within the organization. This ID should be used whenever this particular specimen is referenced. 3. If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id SHOULD be set to equal an Organizer/specimen/ specimenRole/id 4. BPHC Captured: BPHC captures this field to provide a unique id for the specimen. The unique id can be used to identify the same specimen used in different messages. ii. MAY contain zero or one [0..1] specimenPlayingEntity such that it Page 187 of 256 1. MAY contain zero or one [0..1] code such that it a. SHALL contain exactly one @code which SHOULD be selected from ValueSet b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” 2. MAY contain zero or one [0..1] quantity such that it a. SHOULD contain zero or one [0..1] @value 3. MAY contain zero or one [0..1] name 4. MAY contain zero or one [0..1] description b. This specimen is for representing specimens obtained from a procedure 12. SHOULD contain zero or more [0..*] performer for the Procedure Provider such that it a. SHALL contain exactly one [1..1] assignedEntity such that it i. SHALL contain at least one [1..*] id such that it 1. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.4.6" National Provider Identifier 2. SHALL contain exactly one [1..1] @extension a. The extension shall be populated with the provider’s NPI. ii. SHALL contain exactly one [1..1] addr iii. SHALL contain exactly one [1..1] telecom iv. SHOULD contain zero or one [0..1] representedOrganization 1. BPHC Captured: BPHC requests the represented organization to facilitate any follow-up and support research.MAY contain zero or more [0..*] participant for the Service Delivery Location such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) b. SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) 13. MAY contain zero or more [0..*] entryRelationship for a reference encounter such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] @inversionInd="true" true c. SHALL contain exactly one [1..1] encounter such that it i. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) ii. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) iii. SHALL contain exactly one [1..1] id Page 188 of 256 1. Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter 14. MAY contain zero or one [0..1] entryRelationship for Medication Activity such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) b. SHALL contain exactly one [1..1] Medication Activity (templateId:2.16.840.1.113883.10.20.22.4.16) Figure III-43 Procedure Activity Procedure Example <procedure classCode="PROC" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.14" />  <id root=“2.16.840.1.113883.3.96.1.3” extension="d68b7e32-7810-4f5b-9cc2-acd54b0fd85d" /> <code code="73761001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonoscopy"> <originalText> The procedure type free text as described above </originalText> </code> <statusCode code="completed" displayName=“completed” codeSystem=“2.16.840.1.113883.5.14” codeSystemName=“ActStatus”/> <effectiveTime"> <low value="20060501"/> <high value="20100501"/> </effectiveTime> <methodCode nullFlavor="UNK" /> <targetSiteCode code="appropriate_code" displayName="colon" codeSystem="2.16.840.1.113883.3.88.12.3221.8.9" codeSystemName="Body Site Value Set"/> <specimen typeCode="SPC"> <specimenRole classCode="SPEC"> <id root=“2.16.840.1.113883.3.96.1.3” extension="c2ee9ee9-ae31-4628-a919-fec1cbb58683" /> <specimenPlayingEntity> <code code="309226005" codeSystem="2.16.840.1.113883.6.96" displayName="colonic polyp sample" codeSystemName=“SNOMED CT” /> </specimenPlayingEntity> </specimenRole> </specimen> <performer> <assignedEntity> <id root=“2.16.840.1.113883.3.96.1.3” extension="2.16.840.1.113883.19.5.9999.456" extension="2981823" /> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom use="WP" value="555-555-5000" /> <representedOrganization> <id root=“2.16.840.1.113883.3.96.1.3” extension="2.16.840.1.113883.19.5.9999.1393" /> <name>Community Health and Hospitals</name> <telecom use="WP" value="555-555-5000" /> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </representedOrganization> </assignedEntity> </performer> <participant typeCode="LOC"> Page 189 of 256 <participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32" />  ... </participantRole> </participant> </procedure> Page 190 of 256 1.17.25 Result Observation Used By Result Organizer_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries This clinical statement represents details of a lab, radiology, or other study performed on a patient. The result observation includes a statusCode to allow recording the status of an observation. If a Results Observation is not completed, the Result Organizer must include corresponding statusCode. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus. Table III-31 Result Observation Constraints Overview Name XPath Car d Op t observation 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root id R R 1..1 R2 @root R @extension R code 1..1 R 2.16.840.1.113883.10.20.22.4.2 SET_II CD @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.1 or 2.16.840.1.113883.6.96 @codeSystemName R2 LOINC or SNOMED Result Free Text text 0..1 R2 ED Result Status statusCode 1..1 R CS Result Time Fixed Value @classCode templateId Result Type Data Type @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime 0..1 R2 IVL_TS Page 191 of 256 Start low 1..1 @value End Value Code Interpretation Code high @value value @xsi:type @value @unit interpretationCode methodCode 0..1 1..1 0..1 Range Text targetSiteCode @code @displayName @codeSystem @codeSystemName referenceRange observationRange text R2 R R R R R2 R2 TS PQ PQ CE R R2 R R2 0..1 @code @displayName @codeSystem @codeSystemName Target Site Code TS R @code @displayName @codeSystem @codeSystemName Method Code R R2 2.16.840.1.113883.5.83 ObservationInterpretation CE R R2 R R2 0..1 R2 0..1 1..1 0..1 R R2 R R2 R2 R2 R2 CE 2.16.840.1.113883.6.96 SNOMED CT Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode=“EVN” Event 2.16.840.1.113883.5.1001 (ActMood) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.2" 4. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Result Observation within the sending organization. This ID should be used whenever this particular Result Observation is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the observation. The unique id can be used to identify the same observation Page 192 of 256 5. 6. 7. 8. used in different messages. The HL7 Consolidation Guide requires an id for this element. SHALL contain exactly one [1..1] code for the result type such that it a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) i. Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other constrained terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency. Local and/or regional codes for laboratory results are allowed. The Local and/or regional codes SHOULD be sent in the translation element. See the Local code example figure b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. BPHC Captured: BPHC captures the result type to categorize the result. Some measures are dependent on results of certain procedures to identify if the patient and/or encounter is included in the measure. E.g. The result of certain lab requests can identify conditions such as diabetes. SHOULD contain zero or one [0..1] text such that it contains free text describing the result and SHOULD include all relevant text used to derive any result codes. a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the result codes were determined for auditing purposes. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet Result Status 2.16.840.1.113883.11.20.9.39 STATIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” e. BPHC Captured: The result status code is captured by BPHC to determine the relevance of the result to any measure considering result observations. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value b. SHOULD contain zero or one [0..1] high such that it i. SHALL contain exactly [1..1] @value Page 193 of 256 c. Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) d. BPHC Captured: The result effective time is captured by BPHC to determine the relevance of the result given the time frame in which the measure is being taken. 9. SHALL contain exactly one [1..1] value for the result such that it a. SHALL contain exactly one[1..1] @xsi:type =“PQ” b. SHALL contain exactly one [1..1] @value c. SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC d. BPHC Captured: The value is captured to provide a measurable value for the result. The value is then used within a measure to identify conditions such as diabetes. 10. SHOULD contain zero or one [0..1] interpretationCode such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet Observation Interpretation (HL7)2.16.840.1.113883.1.11.78 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = 2.16.840.1.113883.5.83 d. SHOULD contain exactly one @codeSystemName = ObservationInterpretation e. MethodCode SHALL NOT conflict with the method inherent in Procedure / code f. BPHC Captured: The interpretation code describes how the value should be interpreted (e.g. Abnormal, Normal, etc…). The interpretation code is to supporting information to examining the result and should be sent if available. 11. MAY contain zero or one [0..1] methodCode such that it a. SHALL contain exactly one @code b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. MethodCode SHALL NOT conflict with the method inherent in observation / value and should be omitted if the value adequately describes the method. f. BPHC Captured: BPHC captures the method code as supporting information for the result observation. 12. SHOULD contain zero or more [0..*] targetSiteCode such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” Page 194 of 256 d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” e. BPHC Captured: BPHC captures the target site code as supporting information for the result observation. 13. SHOULD contain zero or one [0..1] referenceRange for the result such that it a. SHALL contain exactly one [1..1] observationRange such that it i. SHOULD contain zero or one [0..1] text containing the free text reference range for the result observation Figure III-44 Result Observation Example <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.2" /> <id extension="123456789" root ="107c2dc0-67a5-11db-bd13-0800200c9a66" /> <code code="30313-1" displayName="Hgb BldA-mCnc" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" /> <text> The result free text as described above </text> <statusCode code="completed" displayName=“completed” codeSystem=“2.16.840.1.113883.5.14” codeSystemName=“ActStatus”/> <effectiveTime"> <low value="200003231430"/> </effectiveTime> <value xsi:type="PQ" value="13.2" unit="g/dl" /> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" /> <referenceRange> <observationRange> <text>M 13-18 g/dl; F 12-16 g/dl</text> </observationRange> </referenceRange> </observation> Page 195 of 256 1.17.26 Result Organizer Used By Results Section_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Result Observation This clinical statement identifies set of result observations. It contains information applicable to all of the contained result observations. Result type codes categorize a result into one of several commonly accepted values (e.g., “Hematology”, “Chemistry”, and “Nuclear Medicine”). These values are often implicit in the Organizer/code (e.g., an Organizer/code of “complete blood count” implies a ResultTypeCode of “Hematology”). This template requires Organizer/code to include a ResultTypeCode either directly or as a translation of a code from some other code system. An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown. If any Results Observation within the organizer has a statusCode of ‘active’, the Result Organizer must also have as statusCode of ‘active. Table III-32 Result Organizer Constraints Overview Name XPath Car d Op t organizer 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) (CLUSTER or BATTERY) @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root id Result Status Fixed Value @classCode templateId Result Type Data Type R R 1..1 R2 @root R @extension R code 1..1 R 2.16.840.1.113883.10.20.22.4.1 SET_II CE @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.1 or 2.16.840.1.113883.6.96 @codeSystemName R2 LOINC or SNOMED statusCode 1..1 R @code R @displayName R2 CS Page 196 of 256 @codeSystem Specimen @codeSystemName specimen specimenRole id specimenPlayingEntity code @code @displayName @codeSystem 0..* 1..1 0..* 0..1 0..1 @codeSystemName quantity @value name desc Result Observation Procedure Reference 2.16.840.1.113883.5.14 R2 O R R2 ActStatus O O R R2 R R2 O PQ O O PN ED component 1..* R component procedure 0..1 1..1 R2 R @classCode @moodCode templateId @root Procedure Identifier R id 1..1 1..1 @root @extension R R R R 2.16.840.1.113883.5.6 (HL7ActClass) = PROC 2.16.840.1.113883.10.20.22.4.14 R R R Specification Note: The specification starts within the organizer element 1. SHALL contain exactly one [1..1] @classCode such that it 2. SHOULD contain zero or one [0..1] @classCode="CLUSTER" Cluster (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) OR SHOULD contain zero or one [0..1] @classCode="BATTERY" Battery (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 4. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.1" 5. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Result Organizer within the sending organization. This ID should be used whenever this particular Result Organizer is referenced. Page 197 of 256 c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the organizer. The unique id can be used to identify the same organizer used in different messages. The HL7 Consolidation Guide requires an id for this element. 6. SHALL contain exactly one [1..1] code for the result type such that it a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) i. Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other constrained terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency. Local and/or regional codes for laboratory results SHOULD also be allowed b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. f. BPHC Captured: BPHC requires the result type to perform research on diabetic related measures to determine if a result is pertinent to a person having diabetes. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. 7. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code which SHALL be selected ValueSet Result Status 2.16.840.1.113883.11.20.9.39 STATIC 2012-04-27 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” e. BPHC Captured: The result organizer status code is captured to determine the relevance of the set of results described by the organizer. 8. MAY contain zero or more [0..*] specimen such that it a. SHALL contain exactly one [1..1] specimenRole such that it i. SHOULD contain zero or more [0..*] id such that it 1. SHALL contain exactly one [1..1] @root, which is set to the organization’s OID 2. SHALL contain exactly one [1..1] @extension, which should be set to a unique value to represent the specimen within the organization. This ID should be used whenever this particular specimen is referenced. Page 198 of 256 3. If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id SHOULD be set to equal an Organizer/specimen/ specimenRole/id ii. MAY contain zero or one [0..1] specimenPlayingEntity such that it 1. MAY contain zero or one [0..1] code such that it a. SHALL contain exactly one @code which SHOULD be selected from ValueSet b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” 2. MAY contain zero or one [0..1] quantity such that it a. SHOULD contain zero or one [0..1] @value 3. MAY contain zero or one [0..1] name 4. MAY contain zero or one [0..1] description b. This specimen is for representing specimens used in determining the results 9. SHALL contain one or more [1..*] component for Result Observations such that it a. SHALL contain exactly one [1..1] Result Observation (templateId:2.16.840.1.113883.10.20.22.4.2) 10. SHOULD contain zero or one [0..1] component for the associate procedure if there is one such that it a. SHALL contain exactly one [1..1] procedure such that it i. SHALL contain exactly one [1..1] @classCode = “PROC” 2.16.840.1.113883.5.6 (HL7ActClass) ii. SHALL contain exactly one [1..1] @moodCode = “EVN” b. SHALL contain exactly one [1..1] templateId such that it i. SHALL contain exactly one [1..1] @root=“2.16.840.1.113883.10.20.22.4.14” b. SHALL contain exactly one [1..1] id such that it i. SHALL contain exactly one [1..1] @root, which is set to the organization’s OID ii. SHALL contain exactly one [1..1] @extension, which should be set to a unique value to represent the procedure within the organization. This ID should be used whenever this particular procedure is referenced. iii. BPHC Captured: If the procedure in which this result or set of results belongs is known, the id field should be included and set to the id of that procedure. The id is captured by BPHC to provide a clear connection between procedures and their associated results. Page 199 of 256 Figure III-45 Results Organizer Example <organizer classCode="BATTERY" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.1" /> <id root=“2.16.840.1.113883.3.96.1.3” extension ="7d5a02b0-67a4-11db-bd13-0800200c9a66" /> <code code="43789009" displayName="CBC WO DIFFERENTIAL" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" > </code> <statusCode code="completed" displayName=“completed” codeSystem=“2.16.840.1.113883.5.14” codeSystemName=“ActStatus”/> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.2" /> ... </observation> </component> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.2" /> ... </observation> </component> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.2" /> ... </observation> </component> </organizer> Page 200 of 256 1.17.27 Service Delivery Location Used By Encounter Activities Procedure Activity Act Procedure Activity Observation Procedure Activity Procedure_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Addr Telecom This clinical statement represents the location of a service event where an act, observation or procedure took place. Table III-33 Service Delivery Location Constraints Overview Name XPath Car d Op t participantRole 1..1 R @classCode templateId 1..1 code R R 1..1 R 2.16.840.1.113883.10.20.22.4.32 CE @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.259 @codeSystemName R2 HealthcareServiceLocation Place Address addr 0..* R2 Addr Place Telecom Address telecom 0..* R2 Tel playingEntity 0..1 O 2.16.840.1.113883.5.41 (EntityClass) = PLC @classCode Place Name Fixed Value 2.16.840.1.113883.5.111 (RoleCode) = SDLOC R @root Service Location Data Type name PN Specification Note: The specification starts within the participantRole element 1. SHALL contain exactly one [1..1] @classCode="SDLOC" Service Delivery Location (CodeSystem: RoleCode 2.16.840.1.113883.5.111 STATIC) 2. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.32" Page 201 of 256 SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code, which SHALL be selected from ValueSet HealthcareServiceLocation 2.16.840.1.113883.1.11.20275 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.259” d. SHOULD contain exactly one @codeSystemName = “HealthcareServiceLocation” 4. SHOULD contain zero or more [0..*] addr 5. SHOULD contain zero or more [0..*] telecom 6. MAY contain zero or one [0..1] playingEntity for the Place such that it a. SHALL contain exactly one [1..1] @classCode="PLC" (CodeSystem: EntityClass 2.16.840.1.113883.5.41 STATIC) b. MAY contain zero or one [0..1] name 3. Figure III-46 Service Delivery Location Example <participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32" />  <code code="1160-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="HealthcareServiceLocation" displayName="Urgent Care Center" /> <addr> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom nullFlavor="UNK" /> <playingEntity classCode="PLC"> <name>Community Health and Hospitals</name> </playingEntity> </participantRole> Page 202 of 256 1.17.28 Severity Observation Used By Allergy – Intolerance Observation_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries This clinical statement represents the gravity of the problem, such as allergy or reaction, in terms of its actual or potential impact on the patient. The Severity Observation can be associated with an Allergy Observation, Reaction Observation or both. When the Severity Observation is associated directly with an Allergy it characterizes the Allergy. When the Severity Observation is associated with a Reaction Observation it characterizes a Reaction. A person may manifest many symptoms in a reaction to a single substance, and each reaction to the substance can be represented. However, each reaction observation can have only one severity observation associated with it. For example, someone may have a rash reaction observation as well as an itching reaction observation, but each can have only one level of severity. Table III-34 Severity Observation Constraints Overview Name XPath Car d Op t observation 1..1 R Fixed Value @classCode R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN templateId 1..1 @root code Severity Free Text Data Type R R 1..1 R 2.16.840.1.113883.10.20.22.4.8 CE @code R SEV @displayName R2 Severity Observation @codeSystem R 2.16.840.1.113883.5.4 @codeSystemName R2 Act Code text 0..1 R2 statusCode 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime 1..1 R IVL_TS Page 203 of 256 Name Severity Coded XPath value Car d Op t Data Type 1..1 R CD Fixed Value @xsi:type R @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED CT interpretationCode 0..1 CD R2 @code R @displayName R2 @codeSystem R 2.16.840.1.113883.5.83 @codeSystemName R2 Observation Interpretation Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.8" 4. SHALL contain exactly one [1..1] code such that it a. SHALL contain exactly one @code="SEV" b. SHOULD contain exactly one @displayName = “Severity Observation” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.4” d. SHOULD contain exactly one @codeSystemName = “ActCode” 5. SHOULD contain zero or one [0..1] text such that it contains free text describing the severity and SHOULD include all relevant text used to derived the severity code a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the severity codes were determined for auditing purposes. 6. SHALL contain exactly one [1..1] statusCode such that it a. SHALL contain exactly one @code="completed" b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 7. SHALL contain exactly one [1..1] value such that it a. SHALL contain exactly one [1..1] @xsi:type = "CD" Page 204 of 256 b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Problem Severity 2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC c. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen d. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” e. SHOULD contain exactly one @codeSystemName = “SNOMED CT” f. BPHC Captured: The severity of the problem is captured by BPHC to help determine the relevance of a problem to the measures being executed. g. SHALL contain exactly one [0..1] interpretationCode such that it i. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Observation Interpretation (HL7) 2.16.840.1.113883.1.11.78 DYNAMIC ii. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen iii. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.83” iv. SHOULD contain exactly one @codeSystemName = “Observation Interpretation” v. BPHC Captured: The interpretation is captured to provide additional information to the severity of the problem. Figure III-47 Problem severity Observation Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.8" />  <code code="SEV" displayName="Severity Observation" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" /> <text> The severity free text as described above </text> <statusCode code="completed" /> <value xsi:type="CD" code="371924009" displayName="Moderate to severe" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /> <interpretationCode code="S" displayName="Susceptible" codeSystem="2.16.840.1.113883.1.11.78" codeSystemName="Observation Interpretation"/> </observation> Page 205 of 256 1.17.29 Smoking Status Observation Used By Social History Section_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries This clinical statement represents a patient’s current smoking status. The vocabulary selected for this clinical statement is the best approximation of the statuses in Meaningful Use (MU) Stage 1. If the patient is a smoker (77176002), the effectiveTime/low element must be present. If the patient is an ex-smoker (8517006), both the effectiveTime/low and effectiveTime/high element must be present. The smoking status value set includes a special code to communicate if the smoking status is unknown which is different from how Consolidated CDA generally communicates unknown information. Table III-35 Smoking Status Observation Constraints Overview Name XPath Car d Op t observation 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root Observation Status Observation Time Fixed Value @classCode templateId Social History Type Data Type code R R 0..1 R2 2.16.840.1.113883.10.22.4.78 CD @code R ASSERTION @displayName R2 Assertion @codeSystem R 2.16.840.1.113883.5.4 @codeSystemName R2 ActCode statusCode 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime 0..1 R2 IVL_TS Page 206 of 256 Start low 1..1 @value End Value Code Value Free Text high @value value @xsi:type @code @displayName @codeSystem @codeSystemName originalText R TS R 0..1 R2 TS 1..1 R R CD R R2 R R2 0..1 Shows CD as example CD 2.16.840.1.113883.6.96 SNOMED CT R2 Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 1. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 2. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.22.4.78" 3. SHALL contain exactly one [1..1] code for the observation type such that it a. SHALL contain exactly one [1..1] @code = “ASSERTION” b. SHOULD contain exactly one @displayName = “Assertion” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.4” d. SHOULD contain exactly one @codeSystemName = “ActCode” 4. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code = “completed” b. SHOULD contain exactly one @displayName = completed c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 5. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value b. SHOULD contain zero or one [1..1] high such that it i. SHALL contain exactly [1..1] @value c. BPHC Captured: BPHC captures the smoking status effective time to determine the relevance of the smoking status to the timeframe of measure in question. 6. SHALL contain exactly one [1..1] value such that it a. SHALL contain exactly one[1..1] @xsi:type = “CD” b. SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Smoking Status 2.16.840.1.113883.10.22.4.78 DYNAMIC c. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen Page 207 of 256 d. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” e. SHOULD contain exactly one @codeSystemName = “SNOMED CT” f. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. g. BPHC Captured: BPHC requires the smoking status value code to identify if smoking is a risk factor for the particular person. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. Figure III-48 Smoking Status Observation Example <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.78" /> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" /> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖ /> <effectiveTime> <low value="20050501" /> <high value="20090227130000+0500" /> </effectiveTime> <value xsi:type="CD" code="8517006" displayName="Former smoker" codeSystem="2.16.840.1.113883.6.96" /> </observation> Page 208 of 256 1.17.30 Social History Observation Used By Social History Section_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries This Social History Observation defines the patient’s occupational, personal (e.g., lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity, and religious affiliation. Table III-36 Social History Observation Constraints Overview Name XPath Car d Op t observation 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root id Observation Type Free Text Observation Status Observation Time Start Fixed Value @classCode templateId Social History Type Data Type R R 1..1 R2 @root R @extension R code 0..1 R2 2.16.840.1.113883.10.20.22.4.38 SET_II CD @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED originalText statusCode 0..1 R2 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 0..1 R2 IVL_TS 1..1 R TS Page 209 of 256 @value End Value Code Value Free Text high @value value @xsi:type @code @displayName @codeSystem @codeSystemName originalText R 0..1 R2 TS 1..1 R R CD Shows CD as example CD or PQ or ST or ED R R2 R R2 0..1 R2 Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.13" 4. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Social History Observation within the sending organization. This ID should be used whenever this particular Social History Observation is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the observation. The unique id can be used to identify the same observation used in different messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code for the observation type such that it a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Social History Type Set Definition 2.16.840.1.113883.3.88.12.80.60 STATIC 2008-12-18 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” e. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. f. BPHC Captured: BPHC requires the social history observation type code to identify the type of observation. A person’s social history can identify lifestyle risk factors that are commonly studied such as the effects of drinking and smoking on one’s health. The original text should contain all free text originally Page 210 of 256 used to determine the coded value. BPHC requires the originalText for auditing purposes. 6. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code = “completed” b. SHOULD contain exactly one @displayName = completed c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 7. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value b. SHOULD contain zero or one [1..1] high such that it i. SHALL contain exactly [1..1] @value c. BPHC Captured: BPHC captures the social history observation effective time to determine the relevance of the observation given the timeframe of measure in question. 8. SHALL contain exactly one [1..1] value such that it a. SHALL contain exactly one[1..1] @xsi:type i. The HL7 CDA R2 Consolidation guides states that the type can be ANY. The BPHC Health Equity limits the @xsi:type to CD, PQ , ST, ED. When value is a physical quantity, the unit of measure SHALL be expressed using a valid Unified Code for Units of Measure (UCUM) expression. b. SHOULD contain zero or one [0..1] originalText. The original text is a free text value that should contain all relevant text from which the code was derived. c. BPHC Captured: BPHC requires the social history observation value code to assign a measureable value to the social history observation. The original text should contain all free text originally used to determine the coded value. BPHC requires the originalText for auditing purposes. Figure III-49 Social History Observation Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.38" />  <id root=“2.16.840.1.113883.3.96.1.3” extension ="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1" /> <code code="229819007" codeSystem="2.16.840.1.113883.6.96" displayName="Tobacco use and exposure"> <originalText> The social observation type free text as described above </originalText> </code> <statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖ /> <value xsi:type="ST">1 pack per day</value> </observation> Page 211 of 256 1.17.31 Vital Signs Observation Used By Vital Signs Organizer_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Vital signs are represented as are other results, with additional vocabulary constraints. Table III-37 Vital Signs Observation Constraints Overview Name XPath Car d Op t observation 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root id R R 1..1 R2 @root R @extension R code 1..1 R 2.16.840.1.113883.10.20.22.4.27 SET_II CD @code R @displayName R2 @codeSystem R 2.16.840.1.113883.6.1 @codeSystemName R2 LOINC Result Free Text text 0..1 R2 ED Result Status statusCode 1..1 R CS Result Time Start @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 1..1 R IVL_TS 1..1 R TS @value End Value Code Fixed Value @classCode templateId Result Type Data Type high @value value @xsi:type R 0..1 R2 TS 1..1 R R R PQ PQ Page 212 of 256 @value @unit Interpretation Code interpretationCode R R2 0..1 @code @displayName @codeSystem @codeSystemName Method Code methodCode Range Text targetSiteCode @code @displayName @codeSystem @codeSystemName referenceRange observationRange text CE R R2 R R2 0..1 @code @displayName @codeSystem @codeSystemName Target Site Code R2 R2 2.16.840.1.113883.5.83 ObservationInterpretation CE R R2 R R2 0..1 R2 0..1 1..1 0..1 R R2 R R2 R2 R2 R2 CE 2.16.840.1.113883.6.96 SNOMED CT Specification Note: The specification starts within the observation element 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 2. SHALL contain exactly one [1..1] @moodCode=“EVN” Event 2.16.840.1.113883.5.1001 (ActMood) 3. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.4.27" 4. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Vital Signs Observation within the sending organization. This ID should be used whenever this particular Vital Signs Observation is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the observation. The unique id can be used to identify the same observation used in different messages. The HL7 Consolidation Guide requires an id for this element. 5. SHALL contain exactly one [1..1] code for the result type such that it a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet HITSP Vital Sign Result Type 2.16.840.1.113883.3.88.12.80.62 DYNAMIC Page 213 of 256 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. BPHC Captured: BPHC captures the vital sign result type to categorize the vital sign reading. The result type can be used to identify those vital sign readings applicable to the measure being run. 6. SHOULD contain zero or one [0..1] text such that it contains free text describing the result and SHOULD include all relevant text used to derive any result codes. a. BPHC Captured: BPHC is not only interested in research surrounding national measures, but also in the quality of the data being submitted. BPHC requires the relevant text from which the result codes were determined for auditing purposes. 7. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code = “completed” b. SHOULD contain exactly one @displayName = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 8. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it i. SHALL contain exactly [1..1] @value b. SHOULD contain zero or one [0..1] high such that it i. SHALL contain exactly [1..1] @value c. Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) d. BPHC Captured: BPHC captures the effective time of the vital sign observation to determine its relevance given the time period covered by the measure in question. 9. SHALL contain exactly one [1..1] value for the result such that it a. SHALL contain exactly one[1..1] @xsi:type =“PQ” b. SHALL contain exactly one [1..1] @value c. SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC d. BPHC Captured: The vital sign result is captured by BPHC since the available measurements can be used to determine conditions such as high blood pressure and to see how the condition is managed overtime. 10. SHOULD contain zero or one [0..1] interpretationCode such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet Observation Interpretation (HL7)2.16.840.1.113883.1.11.78 DYNAMIC Page 214 of 256 b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = 2.16.840.1.113883.5.83 d. SHOULD contain exactly one @codeSystemName = ObservationInterpretation e. BPHC Captured: The interpretation code is captured by BPHC as supporting information to the vital sign observation. 11. MAY contain zero or one [0..1] methodCode such that it a. SHALL contain exactly one @code b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem d. SHOULD contain exactly one @codeSystemName such that the value is set accordingly based on the codeSystem chosen e. MethodCode SHALL NOT conflict with the method inherent in observation / value and should be omitted if the value adequately describes the method. f. BPHC Captured: The method code is captured by BPHC as supporting information to the vital sign observation. 12. SHOULD contain zero or more [0..1] targetSiteCode such that it a. SHALL contain exactly one @code which SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC b. SHOULD contain exactly one @displayName such that the value is set accordingly based on the code chosen c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName = “SNOMED CT” e. BPHC Captured: The target site code is captured by BPHC as supporting information to the vital sign observation. Figure III-50 Vital Signs Observation Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" />  <id root=“2.16.840.1.113883.3.96.1.3” extension ="c6f88321-67ad-11db-bd13-0800200c9a66" /> <code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Height" /> <text> The result free text as described above </text> <statusCode code="completed" displayName=―completed‖ codeSystem=―2.16.840.1.113883.5.14‖ codeSystemName=―ActStatus‖/> <effectiveTime"> <low value="19991114"/> </effectiveTime> <value xsi:type="PQ" value="177" unit="cm" /> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" /> </observation> Page 215 of 256 1.17.32 Vital Signs Organizer Used By Vital Signs Section_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Vital Sign Observation The Vital Signs Organizer groups vital signs, which is similar to the Result Organizer, but with further constraints. An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown. Table III-38 Vital Signs Organizer Constraints Overview Name XPath Car d Op t organizer 1..1 R R 2.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER @moodCode R 2.16.840.1.113883.5.1001 (ActMood) = EVN 1..1 @root id Status R R 1..1 R2 @root R @extension R code 1..1 R 2.16.840.1.113883.10.20.22.4.26 SET_II CE @code R 46680005 @displayName R2 "Vital signs" @codeSystem R 2.16.840.1.113883.6.96 @codeSystemName R2 SNOMED statusCode 1..1 R CS @code R completed @displayName R2 completed @codeSystem R 2.16.840.1.113883.5.14 @codeSystemName R2 ActStatus effectiveTime low 1..1 R IVL_TS 1..1 R TS @value high Vital Signs Fixed Value @classCode templateId Type Data Type @value component R 0..1 R2 1..* R R TS Page 216 of 256 Observation Specification Note: The specification starts within the organizer element 1. SHALL contain exactly one [1..1] @classCode such that it 2. SHOULD contain zero or one [0..1] @classCode="CLUSTER" Cluster (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) 4. SHALL contain exactly one [1..1] templateId such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.26" 5. SHOULD exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique value to represent the Vital Signs Organizer within the sending organization. This ID should be used whenever this particular Vital Signs Organizer is referenced. c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the organizer. The unique id can be used to identify the same organizer used in different messages. The HL7 Consolidation Guide requires an id for this element. 6. SHALL contain exactly one [1..1] code for the organizer type such that it a. SHALL contain exactly one [1..1] @code = “46680005” b. SHOULD contain exactly one @displayName = "Vital signs" c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96” d. SHOULD contain exactly one @codeSystemName =“SNOMED CT” 7. SHALL contain exactly one [1..1] statusCode, such that it a. SHALL contain exactly one @code = “completed” b. SHOULD = “completed” c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.14” d. SHOULD contain exactly one @codeSystemName = “ActStatus” 8. SHOULD contain zero or one [0..1] effectiveTime such that it a. SHALL contain exactly one [1..1] low such that it ii. SHALL contain exactly [1..1] @value set to the start time for the organizer b. SHOULD contain zero or one [0..1] high such that it ii. SHALL contain exactly [1..1] @value set to the end time for the organizer c. BPHC Captured: The vital sign organizer effective time is captured by BPHC to determine the relevance of the vital sign result(s) within the organizer based on the time period considered by the measure. 9. SHALL contain one or more [1..*] component for Result Observations such that it a. SHALL contain exactly one [1..1] Vital Sign Observation (2.16.840.1.113883.10.20.22.4.27) Page 217 of 256 Figure III-51 Vital Signs Organizer Example <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.26" />  <id root=“2.16.840.1.113883.3.96.1.3” extension ="c6f88320-67ad-11db-bd13-0800200c9a66" /> <code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Vital signs" /> <statusCode code="completed" displayName=“completed” codeSystem=“2.16.840.1.113883.5.14” codeSystemName=“ActStatus”/> <effectiveTime> <low value="19991114"/> </effectiveTime> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" />  ... </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" />  ... </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" />  ... </observation> </component> </organizer> Page 218 of 256 1.18 CDA Common Data Types 1.18.1 Addr [addr: 2.16.840.1.113883.10.20.22.5.2(open)] Used By Author Content Custodian Content Record Target Content Service Event Content Encounter Activities Procedure Activity Act Procedure Activity Observation Procedure Activity Procedure Service Delivery Location Organization _Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Reusable "address" template, designed for use in US Realm CDA Header. Table III-39 Addr Constraints Overview Name XPath Car d Op t addr 1..1 R @use Data Type Fixed Value R country 0..1 R2 state 0..1 CR city 1..1 R postalCode 0..1 CR streetAddressLine 1..4 R Specification Note: The specification starts within the addr element 1. SHOULD contain exactly one [1..1] @use, which SHALL be selected from ValueSet PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01 2. SHOULD contain zero or one [0..1] country, where the @code SHALL be selected from ValueSet CountryValueSet 2.16.840.1.113883.3.88.12.80.63 DYNAMIC 3. SHOULD contain zero or one [0..1] state (ValueSet: StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMIC) a. State is required if the country is US. If country is not specified, it is assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies 4. SHALL contain exactly one [1..1] city Page 219 of 256 5. SHOULD contain zero or one [0..1] postalCode (ValueSet: PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMIC) a. PostalCode is required if the country is US. If country is not specified, it is assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies 6. SHALL contain at least one and not more than 4 streetAddressLine 7. SHALL NOT have mixed content except for white space Figure III-52 Addr Example <addr use="H"> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> Page 220 of 256 1.18.2 Organization Used By Custodian Content Record Target Content Service Event Content Encounter Activities Policy Activity Procedure Activity Act Procedure Activity Observation Procedure Activity Procedure_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Addr Telecom Reusable "organization" template for the Organization data type. Table III-40 Organization Constraints Overview Name XPath Car d Op t id 1..1 R @root R @extension R Data Type name 1..1 R addr 1..* R Addr telecom 0..* R2 Tel Fixed Value Specification Note: The specification starts within the associated organization element 1. SHALL contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root i. The root should be set to the sending to the organization OID b. SHALL contain exactly one [1..1] @extension i. The extension should be set to a unique identifier of a specific office/department within the organization. c. BPHC Captured: BPHC requires the organization identifier to be supplied with every organization element. The organization identifier root uniquely identifies the organization providing the associated services. The extension is required to uniquely identify the actual office/department in which the services are provided to allow BPHC to run reports at a more granular level. 2. SHALL contain exactly one [1..1] name 3. SHALL contain one or more [1..*] addr 4. SHOULD contain zero or more [0..*] telecom Page 221 of 256 Figure III-53 Organization Example (providerOrganization case) <providerOrganization> <id root="2.16.840.1.113883.4.6"/> <name>Community Health and Hospitals</name> <telecom use="WP" value="tel: 555-555-5000"/> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </providerOrganization> Page 222 of 256 1.18.3 Person Used By Author Content Record Target Content Service Event Content Encounter Activities Policy Activity_Immunizations_Section_Encounters_Section_Allergy_problem_Entry Contains Entries Reusable "person" template for the Person data type. Table III-41 Person Constraints Overview Name XPath Car d Op t Data Type id 1..1 R SET_II @root R @extension R name 1..1 @use Fixed Value R R2 given 1..* R family 1..1 R Specification Note: The specification starts within the associated person element 1. SHALL contain exactly one [1..1] id such that it a. SHALL contain exactly one [1..1] @root which SHOULD be set to the assigning authority for the person b. SHALL contain exactly one [1..1] @extension which SHOULD be set to the unique id of the person with the assigning authority 2. SHALL contain exactly one [1..1] name such that it a. SHOULD contain zero or one @use, which SHALL be selected from Value Set: EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01 b. SHALL contain one or more [1..*] given i. The first given will be the person’s first name ii. A second given if present will be the person’s middle name c. SHALL contain exactly one [1..1] family which is the person’s last name Figure III-54 Person Example (assignedPerson case) <assignedPerson> <id root="2.16.840.1.113883.4.6" extension=“1234”/> <name user=―L‖> <given>Christine</given> <family>Cure</family> </name> </assignedPerson> Page 223 of 256 1.18.4 Telecom Used By Author Content Custodian Content Record Target Content Service Event Content Encounter Activities Procedure Activity Act Procedure Activity Observation Procedure Activity Procedure Service Delivery Location Organization _Encounters_Section_Allergy_problem_Entry Contains Entries Telecom Reusable "telecom" template Table III-42 Telecom Constraints Overview Name XPath Car d Op t telecom 1..1 R @use R @value R Data Type Fixed Value Specification Note: The specification starts within the telecom element 1. SHALL contain exactly one [1..1] @use, which SHALL be selected from ValueSet: Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC 2. SHALL contain exactly one [1..1] @value Figure III-55 Telecom Example <telecom use="WP" value="tel:555-555-1212"/> Page 224 of 256 IV. Appendices Appendix A: OIDS This section lists the OIDs used throughout this document. BPHC Defined OIDs Name BPHC Location ID BPHC Organization ID BPHC DEA OID 2.16.840.1.113883.3.96.1.1 2.16.840.1.113883.3.96.1.3 2.16.840.1.113883.3.96.1.4 Page 225 of 256 Appendix B: Vocabulary The following sub-sections contain code set values that must be used for particular fields within the Health Equity message. 1.19 Act Priority Value Set Value Set Code System Description Code A CR CS CSP CSR EL EM P PRN R RR S T UD UR ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC ActPriority 2.16.840.1.113883.5.7 A code or set of codes (e.g., for routine, emergency,) specifying the urgency under which the Act happened, can happen, is happening, is intended to happen, or is requested/demanded to happen. Print Name ASAP Callback results Callback for scheduling Callback placer for scheduling Contact recipient for scheduling Elective Emergency Preoperative As needed Routine Rush reporting Stat Timing critical Use as directed Urgent 1.20 Administrative Gender Value Set Value Set Code System Description Code F M UN Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 DYNAMIC AdministrativeGender 2.16.840.1.113883.5.1 Gender Codes Print Name Female Male Undifferentiated 1.21 Allergy/Adverse Event Type Value Set Value Set Code System Description Code Allergy/Adverse Event Type 2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC SNOMED CT 2.16.840.1.113883.6.96 This Value Set describes the type of product and intolerance suffered by the patient http://phinvads.cdc.gov/vads/ViewValueSet.action?id=7AFDBFB5-A277DE11-9B52-0015173D1785 Print Name Page 226 of 256 420134006 418038007 419511003 418471000 419199007 416098002 414285001 59037007 235719002 Propensity to adverse reactions (disorder) Propensity to adverse reactions to substance (disorder) Propensity to adverse reactions to drug (disorder) Propensity to adverse reactions to food (disorder) Allergy to substance (disorder) Drug allergy (disorder) Food allergy (disorder) Drug intolerance (disorder) Food intolerance (disorder) 1.22 Body Site Value Set Value Set Code System Description Code Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC SNOMED CT 2.16.840.1.113883.6.96 Contains values descending from the SNOMED CT® Anatomical Structure (91723000) hierarchy or Acquired body structure (body structure) (280115004) or Anatomical site notations for tumor staging (body structure) (258331007) or Body structure, altered from its original anatomical structure (morphologic abnormality) (118956008) or Physical anatomical entity (body structure) (91722005) This indicates the anatomical site. http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html Print Name Page 227 of 256 1.23 Country Value Set Value Set Code System Description Code CountryValueSet 2.16.840.1.113883.3.88.12.80.63 DYNAMIC ISO 3166-1 Country Codes: 1.0.3166.1 A value set of codes for the representation of names of countries, territories and areas of geographical interest. Note: This table provides the ISO 3166-1 code elements available in the alpha-2 code of ISO's country code standard http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm Print Name 1.24 Coverage Role Value Set Value Set Code System Description Code FAMDEP FSTUD HANDIC INJ PSTUD SELF SPON STUD Coverage Role Type Value Set 2.16.840.1.113883.1.11.18877 DYNAMIC RoleCode 2.16.840.1.113883.5.111 The type of coverage Print Name Family dependent Full-time student Handicapped dependent Injured plaintiff Part-time student Self Sponsored dependent Student 1.25 Discharge Disposition Value Set Value Set Code System Description Code 01 02 03 04 05 06 07 08 09 10 …19 20 21 ... 29 30 31 … 39 HL7 Discharge Disposition 2.16.840.1.113883.12.112 Alternative Discharge Disposition Codes Print Name Discharged to home or self-care (routine discharge) Discharged/transferred to another short-term general hospital for inpatient Care Discharged/transferred to skilled nursing facility (SNF) Discharged/transferred to an intermediate-care facility (ICF) Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution Discharged/transferred to home under care of organized home health service Organization Left against medical advice or discontinued care Discharged/transferred to home under care of Home IV provider Admitted as an inpatient to this hospital Discharge to be defined at state level, if necessary Expired (e.g., dead) Expired to be defined at state level, if necessary Still patient or expected to return for outpatient services (e.g., still a patient) Still patient to be defined at state level, if necessary (e.g., still a patient) Page 228 of 256 40 41 Expired (e.g., died) at home Expired (e.g., died) in a medical facility; e.g., hospital, SNF, ICF, or freestanding hospice 1.26 Encounter Type Value Set Value Set Code System Description Code EncounterTypeCode 2.16.840.1.113883.3.88.12.80.32 DYNAMIC CPT-4 2.16.840.1.113883.6.12 This value set includes only the codes of the Current Procedure and Terminology designated for Evaluation and Management (99200 – 99607) (subscription to AMA Required http://www.amacodingonline.com/) Print Name 1.27 Entity Name Use Value Set Value Set Code System Description Code A ABC ASGN C I IDE L P PHON R SNDX SRCH SYL EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01 EntityNameUse 2.16.840.1.113883.5.45 The name usage Print Name Artist/Stage Alphabetic Assigned License Indigenous/Tribal Ideographic Legal Pseudonym Phonetic Religious Soundex Search Syllabic 1.28 Ethnicity (BPHC Vocabulary) Value Set OID Description Code 2135-2 2186-5 2058-6 US 2148-5 2151-9 BPHC Ethnicity Codes 2.16.840.1.113883.3.539.1.1 BPHC specified ethnicity codes. This code set is a combination of the HITSP recommended CDC Ethnicity Codes, ISO country codes, and custom BPHC codes. Print Name Hispanic or Latino Not Hispanic or Latino African American American Mexican, Mexican American, Chicano Page 229 of 256 2155-0 2157-6 2158-4 2161-8 2135-2 2186-5 2058-6 2156-8 2159-2 2160-0 2162-6 BZ 2165-9 2166-7 2167-5 BR 2168-3 2169-1 2170-9 2171-7 2172-5 2173-3 2I74-1 2175-8 2176-6 GY 2060-2 2062-8 2061-0 RW KE MA DZ 2120-4 SN CD CD CM NA 2065-1 ZW ZM TZ 2052-9 ER MU LY TD CV BIRUANDI AO MZ Central American Guatemalan Honduran Salvadoran Hispanic or Latino Not Hispanic or Latino African American Costa Rican Nicaraguan Panamanian Central American Indian Belizean South American Argentinean Bolivian Brazilian Chilean Columbian Ecuadorian Paraguayan Peruvian Uruguayan Venezuelan South American Indian Criollo Guyanan African Ethiopian Botswanan Rwanda Kenyan Moroccan Algerian Egyptian Senegalese Democratic Republic of the Congo Central African Republic Cameroon Nambia Niger Zimbabwian Zambia Tanzinia Madagascar Eriteria Mauritia Libia Chad Cape Verdean Biruandi Angola Mozambique Page 230 of 256 GH 2063-6 2065-1 SL SO 2028-9 2029-7 2030-5 2031-3 2032-1 2033-9 2034-7 2035-4 2036-2 2037-0 2038-8 2039-6 2040-4 2041-2 2042-0 2043-8 2044-6 2045-3 2046-1 2047-9 2048-7 2049-5 2050-3 2051-1 MN TIBET KARON CARIBI 2182-4 2184-0 2071-9 2068-5 2180-8 2070-1 2072-7 2074-3 2073-5 2075-0 2108-9 2110-5 2111-3 2112-1 GR 2113-9 2114-7 2116-2 2137-8 Ghanian Liberian Nigerian Sierra Leonian Somalian Asian Asian Indian Bangladeshi Bhutanese Burmese Cambodian Chinese Taiwanese Filipino Hmong Indonesian Japanese Korean Laotian Malaysian Okinawan Pakistani Sri Lankan Thai Vietnamese Iwo Jiman Maldivian Nepalese Singaporean Mongolian Tibetan Karon Caribbean Island Cuban Dominican Haitian Barbadian Puerto Rican Dominica Islander Jamaican Trinidadian Tobagoan West Indian European English French German Greek Irish Italian Scottish Spanish Page 231 of 256 PT AT CH LT EE LV FI SE DK NO WELSH 2118-8 2119-6 2121-2 2122-0 2123-8 KW KURDISH TR YE SA 2124-6 2129-5 2125-3 2126-1 2127-9 EASTEU AL RU 2109-7 BA 1207-0 2115-4 UA MD CZ HU RO BG SK SI OTH UNKNOW Portuguese Austrian Swiss Lithuania Estonia Latvia Finish Swedish Danes Norwegian Welsh Middle Eastern Assyrian Iranian Iraqi Lebanese Kuwati Kurdish Turkish Yemen Saudi Arabian Palestinian Arab Syrian Afghanistani Israeli Eastern European Albanian Russian Armenian Bosnian Croatian Polish Ukranian Moldovian Czech Hungarian Romanian Bulgarian Slovakian Slovenian Other Ethnicity (please specify) Unknown/not specified 1.29 Financially Responsible Party Value Set Value Set Code System Description Code FinanciallyResponsiblePartyType 2.16.840.1.113883.1.11.10416 DYNAMIC RoleCode 2.16.840.1.113883.5.110 The entity responsible financially http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008 Print Name Page 232 of 256 1.30 Health Insurance Type Value Set Value Set Code System Description Code Health Insurance Type Value Set 2.16.840.1.113883.3.88.12.3221.5.2 DYNAMIC ASC X12 2.16.840.1.113883.6.255.1336 The health insurance type. The full value set is available in HITSP C80 Print Name 1.31 Health Status Value Set Value Set Code System Description Code 81323004 313386006 162467007 161901003 271593001 21134002 161045001 HealthStatus 2.16.840.1.113883.1.11.20.12 DYNAMIC SNOMED CT 2.16.840.1.113883.6.96 Represents the general health status of the patient. Print Name Alive and well In remission Symptom free Chronically ill Severely ill Disabled Severely disabled 1.32 Healthcare Provider Taxonomy Value Set Value Set Code System Description Code Healthcare Provider Taxonomy (NUCC - HIPAA) 2.16.840.1.114222.4.11.1066 DYNAMIC NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101 Print Name 1.33 Healthcare Service Location Value Set Value Set Code System Descripti on Code HealthcareServiceLocation 2.16.840.1.113883.1.11.20275 DYNAMIC HealthcareServiceLocation 2.16.840.1.113883.6.259 A comprehensive classification of locations and settings where healthcare services are provided. This value set is based on the National Healthcare Safety Network (NHSN) location code system that has been developed over a number of years through CDC's interaction with a variety of healthcare facilities and is intended to serve a variety of reporting needs where coding of healthcare service locations is required. Full value set may be found at: http://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=Healthcare+Se rvice+Location+%28NHSN%29 Print Name Page 233 of 256 1.34 HITSP Problem Status Value Set Value Set HITSPProblemStatus 2.16.840.1.113883.3.88.12.80.68 DYNAMIC Code System SNOMED CT 2.16.840.1.113883.6.96 Description The status of the problem. Code Print Name 55561003 Active 73425007 Inactive* 413322009 Resolved** * An inactive problem refers to one that is quiescent, and may appear again in the future ** A resolved problem refers to one that use to affect a patient, but does not anymore 1.35 HITSP Vital Sign Result Type Value Set Value Set Code System Description Code 9279-1 8867-4 2710-2 8480-6 8462-4 8310-5 8302-2 8306-3 8287-5 3141-9 39156-5 3140-1 HITSP Vital Sign Result Type 2.16.840.1.113883.3.88.12.80.62 DYNAMIC LOINC 2.16.840.1.113883.6.1 This identifies the vital sign result type Print Name Respiratory Rate Heart Rate O2 % BldC Oximetry BP Systolic BP Diastolic Body Temperature Height Height (Lying) Head Circumference Weight Measured BMI (Body Mass Index) BSA (Body Surface Area) 1.36 Ingredient Name Value Set Value Set Code System Description Code Ingredient Name 2.16.840.1.113883.3.88.12.80.20 DYNAMIC Unique Ingredient Identifier (UNII) 2.16.840.1.113883.4.9 Unique ingredient identifiers (UNIIs) for substances in drugs, biologics, foods, and devices. http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabeling/ucm162523.htm Print Name 1.37 Insurance Type Code Value Set Name: CoverageType Value Set OID: 2.16.840.1.113883.3.88.12.3221.5.2 Code Set OID: 2.16.840.1.113883.6.255.1336 Value Set Author: HITSP Value Set Version: 20071213 Page 234 of 256 Base Code Set(s): X12N Data Element 1336 Code 12 Description Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer’s group health plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker’s Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran’s Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary AP Auto Insurance Policy C1 Commercial CO Consolidated Omnibus Budget Reconciliation Act (COBRA) CP Medicare Conditionally Primary D Disability DB Disability Benefits EP Exclusive Provider Organization FF Family or Friends GP Group Policy HM Health Maintenance Organization (HMO) HN Health Maintenance Organization (HMO) - Medicare Risk HS Special Low Income Medicare Beneficiary IN Indemnity IP Individual Policy LC Long Term Care LD Long Term Policy LI Life Insurance LT Litigation MA Medicare Part A MB Medicare Part B MC Medicaid MH Medigap Part A MI Medigap Part B MP Medicare Primary OT Other PE Property Insurance - Personal Page 235 of 256 PL Personal PP Personal Payment (Cash - No Insurance) PR Preferred Provider Organization (PPO) PS Point of Service (POS) QM Qualified Medicare Beneficiary RP Property Insurance - Real SP Supplemental Policy TF Tax Equity Fiscal Responsibility Act (TEFRA) WC Workers Compensation WU Wrap Up Policy Page 236 of 256 1.38 Language Value Set Value Set Code System Description Code Language 2.16.840.1.113883.1.11.11526 DYNAMIC Internet Society Language 2.16.840.1.113883.1.11.11526 A value set of codes defined by Internet RFC 4646 (replacing RFC 3066). Please see ISO 639 language code set maintained by Library of Congress for enumeration of language codes http://www.ietf.org/rfc/rfc4646.txt Print Name 1.39 Marital Status Value Set Code System Description Code A D I L M P S T W HL7 Marital Status 2.16.840.1.113883.1.11.12212 DYNAMIC MaritalStatus 2.16.840.1.113883.5.2 Martial Statuses Print Name Annulled Divorced Interlocutory Legally Separated Married Polygamous Never Married Domestic partner Widowed 1.40 Medication Brand Name Value Set Value Set Code System Description Code Medication Brand Name 2.16.840.1.113883.3.88.12.80.16 DYNAMIC RxNorm 2.16.840.1.113883.6.88 Medication Brand Names http://phinvads.cdc.gov/vads/ViewValueSet.action?id=229BEF3E-971C-DF11-B3340015173D1785 Print Name 1.41 Medication Clinical Drug Value Set Value Set Code System Description Code Medication Clinical Drug 2.16.840.1.113883.3.88.12.80.17 DYNAMIC RxNorm 2.16.840.1.113883.6.88 Clinical Drug Names http://phinvads.cdc.gov/vads/ViewValueSet.action?id=239BEF3E-971C-DF11-B3340015173D1785 Print Name Page 237 of 256 1.42 Medication Drug Class Value Set Value Set Code System Description Code Medication Drug Class 2.16.840.1.113883.3.88.12.80.18 DYNAMIC NDF-RT 2.16.840.1.113883.3.26.1.5 This identifies the pharmacological drug class, such as Cephalosporins. Shall contain a value descending from the NDF-RT concept types of “Mechanism of Action N0000000223”, “Physiologic Effect - N0000009802” or “Chemical Structure N0000000002”. NUI will be used as the concept code. http://phinvads.cdc.gov/vads/ViewValueSet.action?id=77FDBFB5-A277-DE11-9B520015173D1785 Print Name 1.43 Medication Fill Status Value Set Value Set Code System Description Code aborted completed Medication Fill Status 2.16.840.1.113883.3.88.12.80.64 DYNAMIC ActStatus 2.16.840.1.113883.5.14 Subset of ActStatus to be used as a medication fill status Print Name Aborted Completed Page 238 of 256 1.44 Medication Product Form Value Set Value Set Code System Description Code Medication Product Form 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC National Cancer Institute (NCI) Thesaurus 2.16.840.1.113883.3.26.1.1 This is the physical form of the product as presented to the individual. For example: tablet, capsule, liquid or ointment. http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabeling/ucm162038 .htm Print Name 1.45 Medication Route FDA Value Set Value Set Code System Description Code C38192 C38193 C38194 C38675 C38197 C38633 C38205 C38206 C38208 C38209 C38210 C38211 C38212 C38200 C38215 C38219 C38220 C38221 C38222 C38223 C38224 C38225 C38226 C38227 C38228 C38229 C38230 C38231 C38232 C38233 C38234 Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC National Cancer Institute (NCI) Thesaurus 2.16.840.1.113883.3.26.1.1 This indicates the method for the medication received by the individual (e.g., by mouth, intravenously, topically, etc.). NCI concept code for route of administration: C38114 http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabeling/ucm162034.htm Print Name BUCCAL CONJUNCTIVAL CUTANEOUS DENTAL ELECTRO-OSMOSIS ENDOCERVICAL ENDOSINUSIAL ENDOTRACHEAL ENTERAL EPIDURAL EXTRA-AMNIOTIC EXTRACORPOREAL HEMODIALYSIS INFILTRATION INTERSTITIAL INTRA-ABDOMINAL INTRA-AMNIOTIC INTRA-ARTERIAL INTRA-ARTICULAR INTRABILIARY INTRABRONCHIAL INTRABURSAL INTRACARDIAC INTRACARTILAGINOUS INTRACAUDAL INTRACAVERNOUS INTRACAVITARY INTRACEREBRAL INTRACISTERNAL INTRACORNEAL INTRACORONAL, DENTAL Page 239 of 256 C38217 C38218 C38235 C38236 C38238 C38239 C38240 C38241 C38242 C79144 C38243 C38245 C38246 C38247 C38248 C38249 C38250 C79138 C38251 C38252 C79137 C38253 C38254 C28161 C79141 C38255 C79142 C38256 C38257 C38258 C38259 C38260 C38261 C79139 C38262 C38263 C38264 C38265 C38266 C38267 C38207 C38268 C38269 C38270 C38272 C38273 C38276 C38277 C38278 C38280 C38203 C38281 INTRACORONARY INTRACORPORUS CAVERNOSUM INTRACRANIAL INTRADERMAL INTRADISCAL INTRADUCTAL INTRADUODENAL INTRADURAL INTRAEPICARDIAL INTRAEPIDERMAL INTRAESOPHAGEAL INTRAGASTRIC INTRAGINGIVAL INTRAHEPATIC INTRAILEAL INTRALESIONAL INTRALINGUAL INTRALUMINAL INTRALYMPHATIC INTRAMAMMARY INTRAMEDULLARY INTRAMENINGEAL INTRAMUSCULAR INTRANODAL INTRAOCULAR INTRAOMENTUM INTRAOVARIAN INTRAPERICARDIAL INTRAPERITONEAL INTRAPLEURAL INTRAPROSTATIC INTRAPULMONARY INTRARUMINAL INTRASINAL INTRASPINAL INTRASYNOVIAL INTRATENDINOUS INTRATESTICULAR INTRATHECAL INTRATHORACIC INTRATUBULAR INTRATUMOR INTRATYMPANIC INTRAUTERINE INTRAVASCULAR INTRAVENOUS INTRAVENTRICULAR INTRAVESICAL INTRAVITREAL IONTOPHORESIS IRRIGATION LARYNGEAL Page 240 of 256 C38282 C38284 C38285 C48623 C38286 C38287 C38288 C38289 C38291 C38676 C38292 C38677 C38293 C38294 C38295 C38216 C38296 C38198 C38297 C38298 C38299 C65103 C38300 C38301 C79143 C38304 C38305 C79145 C38283 C38307 C38308 C38309 C38312 C38271 C38313 NASAL NASOGASTRIC NOT APPLICABLE OCCLUSIVE DRESSING TECHNIQUE OPHTHALMIC ORAL OROPHARYNGEAL PARENTERAL PERCUTANEOUS PERIARTICULAR PERIDURAL PERINEURAL PERIODONTAL RECTAL RESPIRATORY (INHALATION) RETROBULBAR SOFT TISSUE SUBARACHNOID SUBCONJUNCTIVAL SUBCUTANEOUS SUBGINGIVAL SUBLINGUAL SUBMUCOSAL SUBRETINAL TOPICAL TRANSDERMAL TRANSENDOCARDIAL TRANSMUCOSAL TRANSPLACENTAL TRANSTRACHEAL TRANSTYMPANIC URETERAL URETHRAL VAGINAL Page 241 of 256 1.46 Mood Code Evn/Int Value Set Value Set Code System Description Code EVN INT MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 ActMood 2.16.840.1.113883.5.1001 Subset of HL7 ActMood codes, constrained to represent event (EVN) and intent (INT) moods Print Name Event Intent 1.47 No Immunization Reason Value Set Value Set Code System Description Code IMMUNE MEDPREC OSTOCK PATOBJ PHILISOP RELIG VACEFF VACSAF No Immunization Reason Value Set 2.16.840.1.113883.1.11.19717 DYNAMIC ActReason 2.16.840.1.113883.5.8 Reason for not getting an immunization Print Name Immunity Medical precaution Out of stock Patient objection Philosophical objection Religious objection Vaccine efficacy concerns Vaccine safety concerns 1.48 Observation Interpretation Value Set Value Set Code System Description Code A HX LX B Carrier D U IND I MS NEG N POS R S VS Observation Interpretation (HL7) 2.16.840.1.113883.1.11.78 DYNAMIC ObservationInterpretation 2.16.840.1.113883.5.83 Describes how to interpret the associated observation Print Name Abnormal above high threshold below low threshold better Carrier decreased increased Indeterminate intermediate moderately susceptible Negative Normal Positive resistent susceptible Very susceptible Page 242 of 256 W worse 1.49 Participation Function Value Set Value Set Code System Description Code ParticipationFunction 2.16.840.1.113883.5.88 ParticipationFunction 2.16.840.1.113883.5.88 http://wiki.hl7.de/index.php/2.16.840.1.113883.5.88 Print Name 1.50 Patient Education Value Set Value Set Code System Description Code Patient Education 2.16.840.1.113883.11.20.9.34 DYNAMIC SNOMED CT 2.16.840.1.113883.6.96 Limited to terms descending from the Education (409073007) hierarchy. Code system browser: https://uts.nlm.nih.gov/snomedctBrowser.html Print Name 1.51 Personal Relationship Role Type Value Set Value Set Code System Description Code Personal Relationship Role Type 2.16.840.1.113883.1.11.19563 DYNAMIC RoleCode 2.16.840.1.113883.5.111 A Personal Relationship records the role of a person in relation to another person. This value set is to be used when recording the relationships between different people who are not necessarily related by family ties, but also includes family relationships. http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008 Print Name 1.52 Postal Address Use Value Set Value Set Code System Description Code BAD DIR H HP HV PHYS PST PUB TMP WP PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01 AddressUse 2.16.840.1.113883.5.1119 How the address is used Print Name bad address direct home address primary home vacation home physical visit address postal address public temporary work place Page 243 of 256 1.53 Postal Code Value Set Value Set Code System Description PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMIC Code Print Name US Postal Codes 2.16.840.1.113883.6.231 A value set of codes postal (ZIP) Code of an address in the United States. http://zip4.usps.com/zip4/welcome.jsp 1.54 Problem Value Set Value Set Code System Description Code Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC SNOMED CT 2.16.840.1.113883.6.96 Problems and diagnoses. Limited to terms descending from the Clinical Findings (404684003) or Situation with Explicit Context (243796009) hierarchies. http://phinvads.cdc.gov/vads/ViewValueSet.action?id=70FDBFB5-A277-DE11-9B520015173D1785 Print Name 1.55 Problem Act statusCode Value Set Value Set Code System Description Code active suspended aborted completed ProblemAct statusCode 2.16.840.1.113883.11.20.9.19 STATIC 2011-09-09 ActStatus 2.16.840.1.113883.5.14 This Value Set indicates the status of the problem concern act. Print Name active suspended aborted completed 1.56 Problem Severity Value Set Value Set Code System Description Code 255604002 371923003 6736007 371924009 24484000 399166001 Problem Severity 2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC SNOMED CT 2.16.840.1.113883.6.96 This is a description of the level of the severity of the problem. Print Name Mild (qualifier value) Mild to moderate (qualifier value) Moderate (severity modifier) (qualifier value) Moderate to severe (qualifier value) Severe (severity modifier) (qualifier value) Fatal (qualifier value) 1.57 Problem Type Value Set Value Set Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 Page 244 of 256 Code System Description Code 404684003 409586006 282291009 64572001 248536006 418799008 55607006 373930000 SNOMED CT 2.16.840.1.113883.6.96 This value set indicates the level of medical judgment used to determine the existence of a problem. Print Name Finding Complaint Diagnosis Condition Finding of functional performance and activity Symptom Problem Cognitive function finding 1.58 Procedure Act Status Value Set Value Set Code System Description Code completed active aborted cancelled ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC ActStatus 2.16.840.1.113883.5.14 A ValueSet of HL7 actStatus codes for use with a procedure activity Print Name Completed Active Aborted Cancelled 1.59 Provider Code Value Set Value Set Code System Description Code Provider Code (All) NUCC Provider Codes The provider codes to determine the type of the provider http://phinvads.cdc.gov/vads/http:/phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.84 0.1.113883.6.101 Print Name 1.60 Race Value Set Value Set Code System Descriptio n Code Race 2.16.840.1.113883.1.11.14914 DYNAMIC Race and Ethnicity - CDC 2.16.840.1.113883.6.238 A Value Set of codes for Classifying data based upon race. Race is always reported at the discretion of the person for whom this attribute is reported, and reporting must be completed according to Federal guidelines for race reporting. Any code descending from the Race concept (1000-9) in that terminology may be used in the exchange http://phinvads.cdc.gov/vads/ViewCodeSystemConcept.action?oid=2.16.840.1.113883.6.238&code= 1000-9 Print Name Page 245 of 256 1.61 Result Status Value Set Value Set Code System Description Code aborted active cancelled completed held suspended Result Status 2.16.840.1.113883.11.20.9.39 STATIC 2012-07-01 ActStatus 2.16.840.1.113883.5.14 This value set indicates the status of the results observation or organizer Print Name aborted active cancelled completed held suspended 1.62 Smoking Status Value Set Value Set Code System Description Code 449868002 428041000124106 8517006 266919005 77176002 266927001 Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2012-07-01 SNOMED CT 2.16.840.1.113883.6.96 This value set indicates the current smoking status of a patient Print Name Current every day smoker Current some day smoker Former smoker Never smoker (Never Smoked) Smoker, current status unknown Unknown if ever smoked 1.63 Social History Type Value Set Value Set Code System Description Code 229819007 256235009 160573003 364393001 364703007 425400000 363908000 228272008 105421008 Social History Type Set Definition 2.16.840.1.113883.3.88.12.80.60 STATIC 2008-12-18 SNOMED CT 2.16.840.1.113883.6.96 The social history type value set Print Name Tobacco use and exposure Exercise Alcohol intake Nutritional observable Employment detail Toxic exposure status Details of drug misuse behavior Health-related behavior Educational Achievement 1.64 State Value Set Value Set Code System Description StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMIC FIPS 5-2 (State) 2.16.840.1.113883.6.92 Codes for the Identification of the States, the District of Columbia and the Outlying Areas Page 246 of 256 Code of the United States, and Associated Areas Publication # 5-2, May, 1987 http://www.itl.nist.gov/fipspubs/fip5-2.htm Print Name 1.65 Telecom Use Value Set Value Set Code System Description Code HP WP MC HV Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC AddressUse 2.16.840.1.113883.5.1119 Codes for the Identification of the States, the District of Columbia and the Outlying Areas of the United States, and Associated Areas Publication # 5-2, May, 1987 http://www.itl.nist.gov/fipspubs/fip5-2.htm Print Name primary home work place mobile contact vacation home 1.66 Unit of Measure Value Set Value Set Code System Description Code UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC Unified Code for Units of Measure (UCUM) 2.16.840.1.113883.6.8 UCUM codes include all units of measures being contemporarily used in international science, engineering, and business. The purpose is to facilitate unambiguous electronic communication of quantities together with their units. The focus is on electronic communication, as opposed to communication between humans. http://www.regenstrief.org/medinformatics/ucum Print Name 1.67 Vaccine Administered Value Set Value Set Code System Description Code Vaccine Administered Value Set 2.16.840.1. 113883.3.88.12.80.22 DYNAMIC Vaccines administered (CVX) 2.16.840.1.113883.12.292 A value set of available vaccines. http://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.12.292 Print Name Page 247 of 256 Appendix C: Boston Public Health Commission Data Collection Regulation, promulgated July 1, 2006 Whereas; The Boston Public Health Commission is charged with protecting, preserving and promoting the health and well-being of all Boston residents, particularly those who are most vulnerable. Whereas; Health disparities, the differences between populations in presence of disease, access to health care, use of health care services, and health outcomes, have been recognized within the city of Boston, and nationally, over the last several years. Racial and ethnic minorities, which account for more than half of Boston’s population, are more likely to have high blood pressure, diabetes, HIV, prostate cancer, asthma, lead poisoning, and other serious health conditions. Whereas; The Boston Public Health Commission’s Disparities Project is charged with developing methods of reducing health disparities. Whereas; Patient demographic information (race, ethnicity, primary language, and education level) can be used to identify differences in health care use and health outcomes, and to develop interventions to address identified disparities. Such information should be collected by all Boston hospitals through a standardized method provided by the Commission, to ensure that data is recorded and analyzed accurately. Whereas; Collection of this information is a necessary pre-condition to strengthening internal quality improvement measures to address the needs of populations who face disparities. As such use increases and optimal internal action steps become clearer, future regulatory measures may be beneficial. Whereas; The standardized collection of demographic data will enable hospitals and the City to learn more about health disparities, and to develop practical, effective activities that Boston’s health care institutions can undertake to reduce disparities. Therefore, The Boston Public Health Commission enacts the following regulation, to be adopted for the purpose of monitoring the health status of Boston’s residents and developing initiatives that will eliminate the health disparities that exist in the city of Boston. Section 1.00 Definitions For the purposes of this regulation and its guidelines, the following terms shall be defined as follows: Acute Care Hospitals - any hospital licensed under M.G.L. c.111 §51 which contains a majority of medical-surgical, pediatric, obstetric, and maternity beds, as defined by 105 CMR 130.026 and 130.601. Page 248 of 256 Commission – The Boston Public Health Commission. Community Health Centers - defined as free-standing or hospital licensed community health centers licensed by the Massachusetts Department of Public Health pursuant to M.G.L. c.111 §51. Disparities Project – A Boston Public Health Commission initiative comprised of short and longterm strategies aimed at reducing health disparities in Boston. Education Level – Refers to the highest grade completed by the patient to-date. For children, this refers to the highest grade completed by the parent or guardian to-date. Health Disparities - Differences between populations in presence of disease, access to health care, use and delivery of health care services, and health outcomes. Hospital - Any institution within the City of Boston, however named, whether conducted for charity or for profit, which is licensed pursuant to M.G.L. c.111 §51 and advertised, announced, established or maintained for the purpose of caring for persons admitted thereto for diagnosis and/or medical, surgical or restorative treatment which is rendered within said institution. Patient Registrar– The staff person(s) responsible for registering patients prior to a hospital or office visit. Preferred Language – The language the patient prefers to speak. Registration – The process through which patient information such as name, address, health insurance information, is documented prior to a hospital or provider appointment. It is also during this time that demographic data is collected. Registration may be conducted over the telephone or in person, depending on the health care institution. Section 2.00 Institutional Commitment to Eliminating Health Disparities All hospitals, community health centers, and healthcare providers shall be committed to identifying and eliminating inequalities in health care. Section 3.00 Acute Care Hospital Data Collection Requirements 1. Using a template provided by the Commission, all acute care hospitals in the City of Boston shall collect information on each patient that includes at a minimum the following fields: a. Race b. Ethnicity c. Preferred Language d. Level of Education Page 249 of 256 2. Information shall be collected in a manner that ensures patient privacy, whether over the telephone or in person. 3. Using a template approved by the Commission, all acute care hospitals in the City of Boston shall submit to the Commission on a quarterly basis a report that aggregates data and eliminates individual patient identifiers showing the distribution of data on patients using at a minimum the following fields: a. Race b. Ethnicity c. Preferred Language d. Level of Education 4. Quarterly reports shall be made in an electronic format. 5. The Commission will endeavor to coordinate the data collection process with other Commission and State data collection requirements in order to minimize the administrative efforts of covered hospitals. Section 4.00 Quality Improvement 1. All acute care hospitals shall develop and implement quality improvement efforts, designed to identify and address disparities in treatment. These improvement efforts shall include, but are not limited to, efforts to assess and compare by patient population: a. Utilization; b. Quality of care; c. Outcomes; and, d. Satisfaction/Patient Experiences with Care. 2. All acute care hospitals shall provide to the Commission, evidence that processes and policies have been implemented to address issues of disparities. 3. The Commission will schedule a periodic, public symposium which will serve as a forum for hospitals to share information and ideas related to quality improvement efforts aimed at eliminating health disparities. 4. The Commission shall convene a committee made up of interested parties to encourage ongoing coordination among healthcare providers, the Commission and State Agencies regarding healthcare disparities. 5. The provisions of this section do not amend, modify or otherwise relieve any hospital or community health center of any other regulatory, administrative or statutory reporting requirements. Section 5.00 Non-Acute Care Hospital and Community Health Center Data Collection Page 250 of 256 Requirements 1. Upon certification by the Executive Director of substantial compliance of all acute care hospitals with the requirements of Sections 3.00 and 4.00 of this regulation, the Executive Director shall issue guidelines for the implementation of the provisions of Sections 3.00 and 4.00 of this regulation to all non-acute care hospitals and community health centers. 2. Such guidelines shall provide for an implementation period of at least six months. 3. The guidelines shall be publicly posted and subject to a 60 day comment period, during which time comments shall be received regarding the implementation of Sections 3.00 and 4.00 for non-acute care hospitals and community health centers. Section 6.00 Guidelines 1. The Executive Director of the Commission shall issue guidelines, setting forth the format for collecting and reporting procedures. Section 7.00 Enforcement 1. Authority to enforce this regulation shall be held by the Commission. 2. Any violation of this regulation may be enforced in the manner provided in M.G.L. c.111 §§ 31 and 187 by the Boston Public Health Commission, its subsidiary programs or designees. Section 8.00 Severability If any provision, clause, sentence, paragraph or word of this regulation or the application thereof to any person, entity or circumstances shall be held invalid, such invalidity shall not affect the other provisions of this article which can be given effect without the invalid provisions or application and this end the provisions of this regulation are declared severable. Section 9.00 Effective Date This regulation, except as provided for below, shall take effect July 1, 2006. Within 120 days of the effective date, all acute care hospitals shall file with the Commission a plan for compliance with Sections 3.00 and 4.00. Within 360 days of the effective date, all acute care hospitals shall comply with sections 3.00 and 4.00. If an acute care hospital can demonstrate a good faith effort to comply with the requirements of the regulation, the Executive Director may extend the period for compliance by up to 200 days. All hospitals, acute care hospitals and community health centers licensed by the Page 251 of 256 Commonwealth of Massachusetts after July 1, 2006, shall comply with all provisions within 360 days of licensing. Section 10.00 Authority This regulation is promulgated pursuant to: M.G.L. c. 111, §§ 31 and 2-7(a)(15). Page 252 of 256 Appendix D: Boston Health Equity Committee Co-Chairs Barbara Ferrer, PhD, MPH, ME.D, Executive Director, Boston Public Health Commission Joseph Betancourt, MD, MPH, Senior Scientist, Institute for Health Policy; Director, Disparities Solution Center, Massachusetts General Hospital Membership 7 Jean Bernhardt, MHSA, MSN, NHA, CNAA, APRN-BC, Director of Nursing and Chief Compliance Officer, North End Community Health Center Douglas Brooks, Vice President, Sidney Borum Health Center – JRI Health Nancy Bucken, RN, MSN, Executive Director, Neponset Community Health Center Alice Coombs, MD, Vice President, Massachusetts Medical Society Corporation Anita Crawford, Chief Executive Officer, Roxbury Comprehensive Community Health Center Sherry Dong, Director, Community Health Improvement Programs Tom Dooley, Quality Improvement Specialist, Boston Medical Center John Erwin, Executive Director, Conference of Boston Teaching Hospitals Matt Fishman, Director, Community Benefit Programs, Partners Health Care Ediss Gandelman, Director, Community Benefits, Beth Israel Deaconess Medical Center John Halamka, MD, MS, Chief Information Officer of the CareGroup Health System; Chief Information Officer and Dean for Technology at Harvard Medical School Anne Levine, Vice President of External Affairs, Dana-Farber Cancer Institute Mary Leach, Director of Public Affairs, Massachusetts Eye and Ear Infirmary Karen Kennedy, Vice President, Communications, Marketing & Community Benefits, Caritas Christi Health Care System Thomas Kieffer, MPH, Executive Director, Southern Jamaica Plain Health Center Wanda McClain, Director, Community Health and Health Equity, Brigham and Women’s Hospital Judy Parlato, Clinical Advisor, Health Data Policy, Division of Health Care Finance and Policy, Executive Office of Health and Human Services, Commonwealth of Massachusetts Joan Pernice, RN, Director of Clinical Affairs, Massachusetts League of Community Health Centers Jody Reifenberger, PA-C, Program Coordinator, East Boston Community Health Center Joyce Sackey, MD, Dean for Multicultural Affairs and Global Health, Tufts University Nisha Thakar, MD, Medical Director, South Boston Community Health Center Karen Van Unen, EdM, MBA, Chief Operating Officer, DotWell Joel Weissman, Massachusetts Department of Public Health Ronald Wilkinson, Manager of Decision Support Systems, Information Services Department, Children’s Hospital Boston 7 Listed titles and organizational affiliations for Committee members refers to the period of time during the convening of the Boston Health Equity Committee, 2011. Page 253 of 256 Appendix E: Boston Health Equity Measure Set Revision History # Draft Measure Final Measure 1 2 4 Total number of diabetes visits 5 Total number of hypertension visits 6 Weight assessment and counseling for nutrition and physical activity for children and adolescents (Age 2-17) 7 Use of appropriate medication for persons with asthma (Age 5-64) 8 Comprehensive diabetes care (Age 18-75): (HEDIS) Yearly screening: HbA1c; LDLC, retinal eye exam, nephropathy screen, blood pressure Controlling high blood pressure (Age 18-85): (HEDIS) Patient with a diagnosis of hypertension whose most recent blood pressure reading was controlled Well-child visits (Ages 0-15 months and 6 years or more) Well-child visits (Ages 3-6 years, 12-21 years annual) Total number of ED visits Number of patients with high ED utilization (4 or more visits in one year) Number of emergent ED visits by day of week and time of day Total number of primary care visits Total number of patients (include patients with one or more visits in the reporting period) Total number of primary care visits by asthma patients (5-64), as defined by HEDIS Total number of primary care visits by diabetic patients, as defined by HEDIS Total number of primary care visits by hypertension patients, as defined by HEDIS (HEDIS) Weight assessment and counseling for nutrition and physical activity for children and adolescents (Age 2-17) (HEDIS) Use of an asthma controller medication for persons with asthma (Age 5-64) Comprehensive diabetes care (Age 1875): (HEDIS) Yearly screening: HbA1c; LDL-C, retinal eye exam, nephropathy screen, blood pressure Controlling high blood pressure (Age 1885): (HEDIS) Patient with a diagnosis of hypertension whose most recent blood pressure reading was controlled N/A N/A 3 Total number of primary care visits Total number of patients (include patients with one or more visits in the reporting period) Total number of asthma visits (HEDIS) Well-child visits (Ages 0-15 months and 3-6 years) (HEDIS) Adolescent well-child visits (Age 12-21 years) Total number of ED visits Number of patients with high ED utilization (4 or more visits in one year) Alignment with HEDIS measure Alignment with HEDIS measure N/A N/A Number of ED visits by day of week and time of day for the top ten “nonemergent conditions” as defined by the MA Division of Healthcare Finance and Policy in Massachusetts Health Care Cost Trends: Efficiency of Emergency Department Utilization in Massachusetts; August, 2012 Number of ED visits by day of week and time of day for the top ten “emergency Clarification 9 10 11 12 13 14 15 Number of non-emergent ED visits by day of week and time of day Reason for Change Clarification Clarification Clarification N/A Clarification N/A N/A Clarification Page 254 of 256 16 17 18 Discharge status (home, observation and inpatient admissions) Number of visits to the ED for asthma-related conditions and symptoms MI Guidelines (ECG): a) EKG within 5 minutes for all patients over 30 years old with non-traumatic chest pain. MI Guidelines (ECG): b) Lytics within 20 minutes after EKG performed (only if lytics given) 19 8 MI Guidelines (Aspirin): c) Aspirin administered within 24 hours (documented) Syncope Guideline: EKG for all patients over 60 with syncope but primary care treatable conditions” as defined by the MA Division of Healthcare Finance and Policy in Massachusetts Health Care Cost Trends: Efficiency of Emergency Department Utilization in Massachusetts; August, 2012 Discharge status (home, observation and inpatient admissions) Number of visits to the ED for asthmarelated conditions N/A Clarification MI Guidelines (ECG): a) CMS PQRS: Measure #54: 12-Lead Electrocardiogram (ECG) Performed for Non-traumatic Chest Pain (in patients 40 years and older) MI Guidelines (ECG): b) CMS OPPS: OP-5: ED Median Time to ECG MI Guidelines (PCI): c) AMI-8: Median Time to PCI (Door to Balloon time) MI Guidelines (PCI): d) AMI – 8a: Primary PCI within 90 minutes of hospital arrival MI Guidelines (Aspirin): e) AMI-1: Aspirin at Arrival Alignment with NQFendorsed measures Syncope Guideline: CMS PQRS: Measure #55: 12-Lead Electrocardiogram (ECG) Performed for Syncope (in patients 60 years and older) Alignment with NQFendorsed measure Alignment with CMS8 implemented measure Alignment with NQFendorsed measures Alignment with NQFendorsed measure Centers for Medicaid and Medicare Services, US Department of Health and Human Services Page 255 of 256 Acknowledgements Primary BPHC staff for this project include Jeanne Cannata; Huy Nguyen, MD; Dan Obendorfer; Meghan Patterson, MPH; Elizabeth Russo, MD, MPH; Snehal Shah, MD, MPH; and Horace Wong. Special thanks to the Boston Health Equity Committee; Joseph Betancourt, MD, MPH, Aswita Tan-McGrory, MBA, MSPH, and Alden Landry, MD, MPH, of the Disparities Solutions Center at Massachusetts General Hospital; and Katherine Flaherty, ScD. Technical support provided by Strategic Solutions Group, LLC. Page 256 of 256

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