IHE Educational Workshop Keith W. Boone, Dictaphone Corporation Patient Care Coordination TC Co-chair Cross Enterprise Sharing of Medical Summaries (XDS-MS)

IHE Educational WorkshopKeith W. Boone, Dictaphone Corporation

Patient Care Coordination TC Co-chair

Cross Enterprise Sharing ofCross Enterprise Sharing ofMedical Summaries (XDS-MS)Medical Summaries (XDS-MS)

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PresenterPresenter

• Keith W. Boone– Sr. Consulting Engineer, Dictaphone Corporation– Co Chair, IHE Patient Care Coordination TC– Member, IHE IT Infrastructure Technical Committee– Editor, HL7 Care Record Summaries Implementation Guide– Member, HL7 Structured Documents TC– [email protected]

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OutlineOutline

• XDS-MS Profile Transactions• XDS• NAV• ATNA

• Quick Overviews• HL7 CDA Release 2.0 • HL7 Care Record Summary

• IHE Medical Summaries Content Profile

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Cross-Enterprise Sharing of Medical Cross-Enterprise Sharing of Medical Summaries (XDS-MS)Summaries (XDS-MS)

Discharge or Referral Document

Created

Report Repository

Referred Physician

Review ofMedical Summary

EMR

EMR

Patient Examination or Discharge

Notification

The Cross-Enterprise Sharing of Medical Summaries Integration Profile solves the problem of transferring summary patient information between providers in different clinical settings.

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TransactionsTransactions

DocumentSource

Document Consumer

Document Registry

Document Repository

Provide & RegisterDocument Set [ITI-15]

Register Document Set [ITI-14]

Retrieve Document [ITI-17]

Query Registry [ITI-16]

Patient Identity Source

Patient Identity Feed [ITI-8]

Send Notification [ITI-25] Receive Notification [ITI-26]

SMTPReceive Acknowledgement[ITI-28] Send Acknowledgement [ITI-27]

Notification Sender

Notification Receiver

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XDS TransactionsXDS Transactions

• Sender– Provide and Register Document Set– Register Document Set

• Receiver– Query Registry– Retrieve Document

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XDS Provide and Register XDS Provide and Register Document SetDocument Set

• Must include a Medical Summary

• May include other clinical documents

• Log the export (see ATNA and ITI-20)

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XDS Register Document SetXDS Register Document Set

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NAV Send NotificationNAV Send Notification

Create MIME multipart/mixed message

1. Text instructions

2. Notification attachment

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multipart/mixed Messagemultipart/mixed MessageFrom: [email protected]: [email protected]: <[email protected]>Subject: Notification of Document AvailabilityMIME-Version: 1.0Content-Type: multipart/mixed; boundary='boundary'--boundaryContent-Type: text/plain; charset=us-asciiInstructions to the user as to the use of this e-mail message.To acknowledge receipt of this message, please click on the following link:mailto:[email protected]?subject=XDS%20Acknowlegement%3A%20signatureID&body=OK --boundaryContent-Type: application/xml; charset=UTF-8Content-Disposition: attachment; filename='IHEXDSNAV-UUID.xml'<Signature Id="signatureID" xmlns="http://www.w3.org/2000/09/xmldsig#">

…</Signature>--boundary--

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Notification AttachmentNotification Attachment<Signature Id="signatureID" xmlns="http://www.w3.org/2000/09/xmldsig#">

<SignedInfo><CanonicalizationMethod Algorithm="http://www.w3.org/TR/2001/REC-xml-c14n-20010315#WithComments" /> <SignatureMethod Algorithm="urn:ihe:iti:dsg:nosig" /> <Reference URI="#IHEManifest" Type="http://www.w3.org/2000/09/xmldsig#Manifest">

<DigestMethod Algorithm="http://www.w3.org/2000/09/xmldsig#sha1" /> <DigestValue>base64DigestValue</DigestValue>

</Reference></SignedInfo><SignatureValue>base64SignatureValue</SignatureValue> <Object>

<SignatureProperties><SignatureProperty Id="recommendedRegistry" target="signatureID"

>http://registryServer/registryBaseURL</SignatureProperty> <SignatureProperty Id="sendAcknowledgementTo" target="signatureID"

>[email protected]</SignatureProperty> </SignatureProperties><Manifest Id="IHEManifest">

 <Reference URI=“urn:ihe:iti:xds:registry:xxxx-xxxx">

<DigestMethod Algorithm="http://www.w3.org/2000/09/xmldsig#sha1" /> <DigestValue>base64DigestValue</DigestValue>

</Reference></Manifest></Object>

</Signature>

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NAV Receive NotificationNAV Receive Notification

• Receive e-mail message

• Verify Attachment

• Extract Document UUIDs

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XDS Query RegistryXDS Query Registry

• Use GetDocument query to obtain document metadata

SELECT doc.id

FROM ExtrinsicObject doc

WHERE doc.id IN (list of ids)

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XDS Retrieve DocumentXDS Retrieve Document

• Retrieve the Medical Summary– Most recent document whose document type is

one of the following LOINC codes:

• HTTP GET on the URI

• Log the import (see ATNA and ITI-20)

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ATNA Record Audit Event ATNA Record Audit Event

• Type of Log– BSD Syslog– Reliable Syslog

• Format of Log Message– IHE Provisional Format– RFC-3881

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BSD Syslog (RFC-3164)BSD Syslog (RFC-3164)

<(0-191)> Aug 30 09:00:00 aegeus Hello World!

Priority – A value from 0 to 191

Timestamp – MMM DD hh:mm:ss

Hostname – First part of DNS name, or IP address.

The rest is the message, and should conform to one of the two logging options.

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ATNA Log FormatATNA Log Format(RFC-3881)(RFC-3881)

• See the RFC– http://www.faqs.org/rfcs/rfc3881.html

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CDA BasicsCDA Basics

• Dates and Times• Identifiers• Codes• Names• Addresses• Phone Numbers• People• Organizations

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<effectiveTime value='20050329224411+0500'/><effectiveTime>

<low value='20050329224411+0500'/><high value='20050329224411+0500'/>

</effectiveTime>

HL7 Date Time Values:CCYYMMDDHHMMSS(Z|([+|-]HHMM))Century

YearMonth

DayHour

MinuteSecond

Time Zone

Dates and TimesDates and Times

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IdentifiersIdentifiers

<id extension='12345678' root='1.3.6.4.1.4.1.2835'/>

root – Identifies the namespace. extension – Provides the identifier.• Roots are typically ISO Object Identifiers, otherwise

known as OIDs, but may also be a GUID.• An OID is an assigned value. Someone has to give you

a root OID. Then you can make your own, or give OIDs to others.

• If your root OID is X, then you can assign X.1 through X.somereallybignumber to yourself or others.

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CodesCodes

<code code='59058001'displayName='General Physician'codeSystem='1.3.6.4.1.4.1.2835'codeSystemName='SNOMED CT'

/>

code – Provides the code value. displayName – A human readable name.codeSystem – Identify the coding system used.codeSystemName – As above, but for humans.• Not all coded values require the specification of

codeSystem, especially when it is already known.• Values used for human readability are optional.

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NamesNames

• Organizational Names<name>Good Health Clinic</name>

• Personal Names<name>

<prefix>Mr.</prefix><given>Keith</given><given>W.</given><family>Boone</family><suffix>Sr.</suffix>

</name>

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AddressesAddresses

<addr><streetAddressLine>21 North Ave</streetAddressLine><streetAddressLine>Suite #142</streetAddressLine><city>Burlington</city><state>MA</state><postalCode>01803</postalCode><country>USA</country>

</addr>

• Repeat streetAddressLine if needed.

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Phone NumbersPhone Numbers

<telecom value="tel:+1(999)555-1212" use="WP"/>

value - The telephone number, as a URL

use - One of a restricted set of values:HP - Home Phone

HV - Vacation Home

WP - Work Phone

AS - Answering Service

EC - Emergency Contact

PG - Pager

MC - Mobile

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PeoplePeople

<person><name>

<prefix>Mr.</prefix><given>Keith</given><given>W.</given><family>Boone</family><suffix>Sr.</suffix>

</name></person>

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OrganizationsOrganizations

<organization>

<id extension="1" root="1.3.6.4.1.4.1.2835.3"/><name>Good Health Clinic</name><telecom value="tel:(999)555 1212" use="WP"/><addr>

<streetAddressLine>21 North Ave</streetAddressLine> <city>Burlington</city> <state>MA</state><postalCode>01803</postalCode><country>USA</country>

</addr></organization>

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Reading SchematronReading Schematron

• Schema is a collection of patterns.

• Patterns contain one or more rules with a context.

• Rules assert that a test has passed.

• Failures issue diagnostics

• Now you can read the Schema

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Sample Schema RuleSample Schema Rule

<schema xmlns="http://www.ascc.net/xml/schematron"><title>Sample Schematron schema</title><ns prefix="cda" uri="urn:hl7 org:v3" />

<pattern name='ClinicalDocument' see=‘Sample.htm#ClinicalDocument'><p>This schema applies to CDA Release 2.0 documents.</p><rule id='cda root' context='/*'>

<assert diagnostics="CNF 1" test='self::cda:ClinicalDocument'>The root of a Care Record Summary must be a ClinicalDocument element from the <emph>urn:hl7 org v3</emph> namespace.

</assert></rule>

</pattern><diagnostics>

<diagnostic id=‘CNF 1’>Ensure the appropriate namespace declaration exists.The root element must be ClinicalDocument.

</diagnostic></diagnostics>

</schema>

Schema is a collection of patterns.

Patterns contain one or more rules with a context.

Rules assert that a test has passed.

Failures issue diagnostics.

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An ExampleAn Example

In this example, we will create a CDA Instance that provides the following information in a Care Record Summary

• Ellen Ross is a 45 year old female who sprained her ankle by slipping on ice. She was treated in the ER and the next day goes to see Dr. Bernard Wiseman Sr., her PCP, who creates a referral for her to see Dr. Phil Green, an orthopedist.

• In 1994, she and her husband filed a number of legal documents regarding their advanced directives for healthcare. Her father had a history of alcohol abuse and died of liver cancer. She quit smoking in 1996, and has 1-2 drinks per week. Her prior medical history is significant for cholecystitis which occurred during a difficult pregnancy. Her gall bladder was removed after delivery. She is presently on Indomethacin, and was given Tylenol #3 for the ankle sprain. She is allergic to Penicillin but similar drugs are OK. She had the usual run of pediatric immunizations. An X-Ray of her ankle was done in the ER.

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Steps in Creating the CDA Steps in Creating the CDA InstanceInstance

• Describe the Document• Describe the Participants

Patient Author(s) Data Entry Personnel Informant(s) Custodian Intended Recipient(s) Authenticator(s) Legal Authenticator(s) Other Participant(s)

• Describe the event the document is about• Describe the encounter• Provide the Human Readable Content• Describe Problems, Medications and Allergies

Level 1

Level 2

Level 3

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Describe the DocumentDescribe the Document

<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:crs="urn:hl7-org:crs" ><realmCode code="US" /><typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3" /><templateId extension="IMPL_CDAR2_LEVEL1 2REF_US_I2_2005SEP"

root="2.16.840.1.113883.10" /><id extension="999021" root="1.3.6.4.1.4.1.2835.2" /><code code="34133-9"

codeSystem="2.16.840.1.113883.6.1“codeSystemName="LOINC"displayName="SUMMARIZATION OF EPISODE NOTE" />

<title>Good Health Clinic Care Record Summary</title><effectiveTime value="20050329224411+0500" /><confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" /><languageCode code="en US" /><setId extension="999021" root="1.3.6.4.1.4.1.2835.1" /><versionNumber value="1" />

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Patient Patient <recordTarget>

<patientRole> <id extension="12345" root="2.16.840.1.113883.3.933"/>

<addr><streetAddressLine>17 Daws Rd.</streetAddressLine><city>Blue Bell</city><state>MA</state><postalCode>02368</postalCode><country>USA</country>

</addr><telecom value="tel:(781)555-1212" use="HP"/><patient>

<name><prefix>Mrs.</prefix><given>Ellen</given><family>Ross</family>

</name><administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/><birthTime value="19600127"/>

</patient>⋮

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Patient (cont.)Patient (cont.)

⋮<providerOrganization>

<id extension="M345" root="2.16.840.1.113883.3.933"/><name>Good Health Clinic</name><telecom value="tel:(999)555-1212" use="WP"/><addr>

<streetAddressLine>21 North Ave</streetAddressLine><city>Burlington</city><state>MA</state><postalCode>01803</postalCode><country>USA</country>

</addr></providerOrganization>

</patientRole></recordTarget>

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AuthorsAuthors<author>

<time value="20050329224411+0500"/><assignedAuthor>

<id extension="1" root="1.3.6.4.1.4.1.2835.1"/><addr>


</addr><telecom value="tel:(999)555-1212" use="WP"/><assignedPerson> OR <assignedAuthoringDevice>

<name> <softwareName><prefix>Dr.</prefix> Good Health Clinic System v1.0<given>Bernard</given> </softwareName><family>Wiseman</family> </assignedAuthoringDevice><suffix>Sr.</suffix>

</name></assignedPerson>

</assignedAuthor></author>

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Data Entry PersonnelData Entry Personnel

<dataEnterer><time value="20050329222451+0500"/><assignedEntity>

<id extension="2" root="1.3.6.4.1.4.1.2835.2"/><assignedPerson>

<name><prefix>Mrs.</prefix><given>Bernice</given><family>Wiseman</family>


</assignedEntity></dataEnterer>

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InformantsInformants

<informant><relatedEntity classCode="PRS">

<code code="MTH" codeSystem="2.16.840.1.113883.5.111"/><relatedPerson>

<name><prefix>Mrs.</prefix><given>Abigail</given><family>Ruth</family>

</name></relatedPerson>

</relatedEntity></informant>

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CustodianCustodian

<custodian><assignedCustodian>

<representedCustodianOrganization><id extension="1" root="1.3.6.4.1.4.1.2835.3"/><name>Good Health Clinic</name><telecom value="tel:(999)555-1212" use="WP"/><addr>

<streetAddressLine>21 North Ave</streetAddressLine> <city>Burlington</city><state>MA</state><postalCode>01803</postalCode><country>USA</country>

</addr></representedCustodianOrganization>

</assignedCustodian></custodian>

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Information Recipient(s)Information Recipient(s)<informationRecipient>

<intendedRecipient><id extension="4" root="1.3.6.4.1.4.1.2835.2"/><addr>


</addr><telecom value="tel:(999)555-1212" use="WP"/><informationRecipient>

<name><prefix>Dr.</prefix><given>Phil</given><family>Green</family>

</name></informationRecipient><receivedOrganization>

<name>Good Health Clinic</name></receivedOrganization>

</intendedRecipient></informationRecipient>

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AuthenticatorsAuthenticators<legalAuthenticator> OR <authenticator>

<time value="20050329224512+0500"/><signatureCode code="S"/><assignedEntity>

<id extension="1" root="1.3.6.4.1.4.1.2835.1"/><addr>


</addr><telecom value="tel:(999)555-1212" use="WP"/><assignedPerson>

<name><prefix>Dr.</prefix><given>Bernard</given><family>Wiseman</family><suffix>Sr.</suffix>


</assignedEntity></legalAuthenticator> OR </authenticator>

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ParticipantsParticipants<participant typeCode="HLD">

<time><low value="20050101"/><high value="20051231"/>

</time><associatedEntity classCode="POLHOLD">

<id extension="123456789" root="00000000-0000-0000-0000 000000000000"/>

<code code="PHFAMDEP" codeSystem="2.16.840.1.113883.5.1095"/><addr>I assume you’ve figured this out by now</addr><telecom value="tel:(999)555-1212" use="WP"/><associatedPerson>

<name>This too</name><crs:asPatientRelationship classCode='PRS'>

<code code='MTH' codeSystem='2.16.840.1.113883.5.111'/></crs:asPatientRelationship>

</associatedPerson><scopingOrganization>

<name>Good Health Insurance Company</name><telecom value="tel:(203)555-1212" use="WP"/><addr>And this</addr>

</scopingOrganization></associatedEntity>

</participant>

CDA Extension

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The Service EventThe Service Event<documentationOf>

<serviceEvent classCode="PCPR"><effectiveTime>

<low value="19600127"/><high value="20050329"/>

</effectiveTime><performer typeCode="PRF">

<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/><time>


</time><assignedEntity>

<id extension="1" root="1.3.6.4.1.4.1.2835.1"/><code code="59058001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="General Physician"/><addr></addr><telecom value="tel:(999)555-1212" use="WP"/><assignedPerson>

<name></name></assignedPerson>

</assignedEntity></performer>

</serviceEvent></documentationOf>

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The EncounterThe Encounter<componentOf>

<encompassingEncounter><id extension="9937012" root="1.3.6.4.1.4.1.2835.12"/><code code="99213"

codeSystem="2.16.840.1.113883.6.12"displayName="Evaluation and Managment"codeSystemName="CPT-4"

/><effectiveTime>


</effectiveTime><dischargeDispositionCode code="01"

codeSystem="2.16.840.1.113883.6.21"displayName="Routine Discharge"codeSystemName="UB92"

/></encompassingEncounter>

</componentOf>

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Level 2 – Basic ContentLevel 2 – Basic Content• Paragraphs

<paragraph>Ankle Sprain.</paragraph>

• Lists<list><item>Cholecystectomy</item>

<item>Cesarian Section</item></list>

• Tables<table border="1">

<thead><tr> <th>Date</th><th>Height</th><th>Weight</

th><th>Temperature</th><th>BP</th><th>Pulse</th><th>Respiration</th><th>O2</th>

</tr></thead><tbody>

<tr><th>3/28/2005</th><th>5'9"</th><th>215 lbs.</th><th>98.7 °F</th><th>120/80</th><th>68</th><th>16</th><th>99%</th>

</tr></tbody>

</table>

XHTML Tables

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Level Level 22 – Section Structure – Section Structure

<component><section>

<code code="X-RFVCC"codeSystem="2.16.840.1.113883.6.1"

/><title>Reason for Visit/Chief Complaint</title><text> OR <component>

⋮</text> </component>

</section></component>

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Level 2Level 2 – Body Structure – Body Structure

<structuredBody><templateId

extension="IMPL_CDAR2_LEVEL1-2REF_US_I2_2005SEP"root="2.16.840.1.113883.10"

/><component>

⋮</component>

⋮<structuredBody>

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Level 2Level 2 – Narrative Text – Narrative Text

<component><section>

<code code="X-RFR"codeSystem="2.16.840.1.113883.6.1"/>

<title>Reason for Referral</title><text>

<paragraph>Follow-up care for Ankle Sprain</paragraph>

</text></section>

</component>

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Level 2 – ListLevel 2 – List

<section><code code="10160-0"

codeSystem="2.16.840.1.113883.6.1"/><title>Medications</title><text>

<list><item> Indomethacin, 50mg bid with food,

12/10/2003 - present</item><item> Acetaminophen with codeine, #3 1-2

tablets for pain as needed, 03/28/2005</item>

</list></text>

</section>

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Level 2 – TablesLevel 2 – Tables<component>

<section><code code="29274-8" codeSystem="2.16.840.1.113883.6.1"/><title>Vital Signs</title><text>

<table border="1"><thead>

<tr><th>Date</th><th>Height</th><th>Weight</th><th>Temperature</th><th>BP</th><th>Pulse</th><th>Respiration</th><th>O2</th>

</tr></thead><tbody>

<tr><th>3/28/2005</th><th>5'9"</th><th>215 lbs.</th><th>98.7 °F</th><th>120/80</th><th>68</th><th>16</th><th>99%</th>

</tr></tbody>

</table></text>


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Level 3 – ConditionsLevel 3 – Conditions<component xmlns="urn:hl7-org:v3">

<section><code code="11450-4" codeSystem="2.16.840.1.113883.6.1" /> <title>Conditions</title> <text><table border="1"><thead><tr><th>Severity</th><th>Problem</th><th>Date</th><th>Status</th><th>Comments</th> </tr></thead><tbody><tr><td ID="severity-2">Severe</td><td ID="problem-1">Ankle Sprain</td> <td>3/28/2005</td><td>Current</td> <td ID="comment-2">Slipped on ice and fell</td> </tr></tbody></table></text>  </section>

</component>

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Level 3 Level 3 – – Condition EntryCondition Entry<entry>

<observation classCode="COND" moodCode="EVN"><id root="6a2fa88d-4174-4909-aece-db44b60a3aba" />  <code code="" codeSystem="Any" codeSystemName="Any" /> <statusCode code="active" />  <effectiveTime><low value="20050328" /></effectiveTime> <value xsi:type="CV" code="44465007"

codeSystem="2.16.840.1.113883.6.96“ codeSystemName="SNOMED CT"><originalText mediaType="text/xml">

 <reference value="#problem-1" />

</originalText></value> 

</observation></entry>

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Level 3 – Condition SeverityLevel 3 – Condition Severity

 <entryRelationship typeCode="SUBJ" inversionInd="true">

<observation classCode="OBS" moodCode="EVN"><code code="SEV" /> <statusCode code="completed" /> <value xsi:type="CV" code="TBD" codeSystem="TBD"

codeSystemName="SeverityObservation"><originalText mediaType="text/xml">

 <reference value="#severity-2" />

</originalText></value>

</observation></entryRelationship>

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Level 3 – Condition CommentsLevel 3 – Condition Comments

 <entryRelationship typeCode="SUBJ" inversionInd="true">

<observation classCode="OBS" moodCode="EVN"><code code="COMMENT"

codeSystem="2.16.840.1.113883.5.112" codeSystemName="ActCode" /> <text mediaType="text/xml">

 <reference value="#comment-2" />

</text><statusCode code="completed" />


53

Level 3 – AllergiesLevel 3 – Allergies<component>

<section><code code="10155-0" codeSystem="2.16.840.1.113883.6.1" /> <title>Allergies and Adverse Reactions</title> <text>

<table border="1"><thead><tr><th>Allergen</th><th>Reaction</th><th>Severity</th><th>Onset</th><th>Comments</th></tr></thead><tbody><tr><td ID="allergen-1">Penicillin</td> <td ID="reaction-1">Hives</td> <td ID="severity-1">Severe</td><td>11/2004</td> <td ID="comment-1">Amoxicillin is OK</td> </tr></tbody>

</table></text>


54

Level 3 – Allergy EntryLevel 3 – Allergy Entry<entry>

<observation classCode="COND" moodCode="EVN"><id root="dc6d49d1-9371-40bb-9507-90ca93e181a6" /> <code code="Allergy" codeSystem="TBD“

codeSystemName="ObservationAllergyCode" /> <statusCode code="active" /> <effectiveTime value="200411" /> <value xsi:type="CV" code="TBD"

codeSystem="TBD"codeSystemName="IntoleranceAgentValue">

<originalText mediaType="text/xml"><reference value="#allergen-1" />

</originalText></value>

</observation></entry>

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Level 3 – ReactionsLevel 3 – Reactions<entryRelationship typeCode="SPRT">

<observation classCode="OBS" moodCode="EVN"><code code="RXNASSESS" />  <entryRelationship typeCode="REFR">

<observation classCode="OBS" moodCode="EVN"><id root="369bb3eb-c7f6-4e5e-9c44-96c6bcbb8a3d" /> <code code="DX" /> <statusCode code="completed" /> <value xsi:type="CV" code="247472004"

displayName ="Hives"codeSystem="2.16.840.1.113883.6.96"codeSystemName="SNOMED CT">

<originalText mediaType="text/xml"><reference value="#reaction-1" />

</originalText></value>



56

Level 3 – MedicationsLevel 3 – Medications<component>

<section><code code="10160-0" codeSystem="2.16.840.1.113883.6.1" /> <title>Medications</title> <text>


<tr><th>Medication</th><th>Dose</th><th>Date</th></tr></thead><tbody>

<tr ID="med-1"><td ID="medication-1">Acetaminophen with codeine</td> <td><content ID="strength-1">#3</content>

<content ID="dose-1">1-2 tablets</content> <content ID="route-1">PO</content> <content ID="frequency-1">every four hours</content> <content ID="instruct-1">for pain as needed</content>

</td><td>03/28/2005 - 4/6/2005</td> </tr>

</tbody></table>

</text><!– Entries[1..N] -->


57

Level 3 – Medication EntryLevel 3 – Medication Entry<entry>

<substanceAdministration classCode="SBADM" moodCode="EVN"><id root="af30c55f-afa7-44f1-9fbb-caab0e994a72" /> <code code="377261001"

codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"><originalText mediaType="text/xml">

<reference value="#medication-1" /> </originalText>

</code><text mediaType="text/xml">

<reference value="#med-1" /> </text><statusCode code="active" />

58

Level 3 – Start, Stop and FrequencyLevel 3 – Start, Stop and Frequency

<effective_time xsi:type="SXPR_TS" operator="I" ><comp xsi:type="IVL_TS">

<low value="20050328" /> <high value="20050405" />

</comp><comp xsi:type="PIVL_TS">

<period value="4" unit="h" institutionSpecified=“false" /> </comp>

</effective_time>

59

Level 3 – RouteLevel 3 – Route

<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112"codeSystemName="RouteOfAdministration">

<originalText mediaType="text/xml"><reference value="#route" />

</originalText></routeCode>

60

Level 3 – DoseLevel 3 – Dose<doseQuantity>

<low value="1" unit="tablet"><translation>

<originalText mediaType="text/xml"><reference value="#dose-1" />

</originalText></translation>

</low><high value="2" unit="tablet">

<translation><originalText mediaType="text/xml">

<reference value="#dose-1" /> </originalText>

</translation></high>

</doseQuantity>

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Level 3 – StuffLevel 3 – Stuff

<consumable typeCode="CSM"/> <entryRelationship typeCode="SUBJ" inversionInd="true">

<observation classCode="OBS" moodCode="EVN"><code code="INSTRUCT"

codeSystem="2.16.840.1.113883.5.112" codeSystemName="ActCode" />

<text><reference value="#instruct-1" /></text><statusCode>completed</statusCode>


</substanceAdministration></entry>

62

Level 3 – ReferencesLevel 3 – References<component>

<section><code code="X-SS" codeSystem="2.16.840.1.113883.6.1" /> <title>Related Reports</title> <text>


<tr><th>Study</th><th>Summary</th><th>Date</th> </tr>

</thead><tbody>

<tr><td ID="study-1">X-Ray Study - Left Ankle</td> <td>No Fracture</td> <td>3/28/2005</td>

</tr></tbody>

</table></text>


63

Level 3 – Reference EntryLevel 3 – Reference Entry<entry>

<act classCode="ACT" moodCode="EVN"><id root="6b55d2e7-78f1-49a4-bb18-ace4c9b6e1f1" />  <code code="24541-5" codeSystem="2.16.840.1.113883.6.1“

codeSystemName="LOINC“displayName="X-RAY ANKLE, STUDY" />

<reference typeCode="REFR"><externalDocument classCode="DOC" moodCode="EVN">

<id extension="999020" root="1.3.6.4.1.4.1.2835.2" /> <code>

<originalText mediaType="text/xml"><reference value="#study-1" />

</originalText></code><setId root="999019" extension="1.3.6.4.1.4.1.2835.2" /> <versionNumber value="1" />

</externalDocument></reference>

</act></entry>

64

Final ResultFinal Result

65

QuestionsQuestions

?

66

ReferencesReferences• Care Record Summary

http://www.hl7.org/Library/Committees/structure/crs.zip

• CDA Release 2.0http://www.hl7.org/Edition2005/html/infrastructure/cda/cda.htm

• XMLhttp://www.w3.org/TR/xml

• XSLThttp://www.w3.org/TR/xslt

• XHTMLhttp://www.w3.org/TR/xhtml-modularization/

• Schematronhttp://www.schematron.com/http://xml.ascc.net/resource/schematron/schematron.html

http://www.hl7.org/Library/Committees/structure/crs.zip

http://www.hl7.org/Edition2005/html/infrastructure/cda/cda.htm

http://www.w3.org/TR/xml

http://www.w3.org/TR/xslt

http://www.w3.org/TR/xhtml-modularization/

http://www.schematron.com/

http://xml.ascc.net/resource/schematron/schematron.html