HIMSS and RSNA
Integrating the Healthcare Enterprise
IHE Patient Care Coordination
Immunization Content (IC)
Technical Framework Supplement
- (PCC TF-1/Preface)Preface to Volume I of the PCC Technical Framework
- (PCC TF-1/Introduction)Introduction to the PCC Technical Framework
- (PCC TF-1/About)About the Patient Care Coordination Integration Profiles
- (PCC TF-1/Dependencies)Dependencies of the PCC Integration Profiles
- (PCC TF-1/Overview)PCC Integration Profiles Overview
- (PCC TF-1/History)History of Annual Changes
- (PCC TF-1/Product Implementations)Product Implementations
This is a draft of the Immunization Registry Content Profile (IRC) supplement to the PCC Technical Framework. This draft is a work in progress, not the official supplement or profile.
- 1 Volume 1
- 2 Introduction
- 3 Volume I
- 3.1 Dependencies
- 3.2 The Immunization Content Profile (IC)
- 3.2.1 Use Cases
- 3.2.2 Actors/Transaction
- 3.2.3 Options
- 3.2.4 Grouping
- 3.3 Appendix A - Actor Descriptions
- 3.4 Appendix B - Transaction Descriptions
- 3.5 Appendix C - How to Prepare an IHE Integration Statement
- 3.6 Appendix D - Braden Scale for Predicting Pressure Sore Risk
- 3.7 Glossary
- 4 Volume 2
- 4.1 Namespaces and Vocabularies
- 4.2 PCC Content Modules
- 4.3 Conventions
- 4.4 Folder Content Modules
- 4.5 HL7 Version 3.0 Content Modules
- 4.6 HL7 Version 2 Content Modules
- 4.7 PCC Value Sets
- 5 Appendix A - Examples Using PCC Content Profiles
- 6 Appendix B - Validating CDA Documents using the Framework
- 7 Appendix C - Extensions to CDA Release 2.0
The Immunization Content Profile (IC)
The Immunization Content Profile defines standard immunization data content for Immunization Information Systems (IISs), other public health systems, electronic medical records (EMR) systems, Health Information Exchanges, and others wishing to exchange immunization data electronically in a standard format.
- Immunization Information System (IIS)
- Preferred term of the American Immunization Registry Association for "Immunization Registry"
Public comment is solicited on all of the following issues:
- In preparation for the development of this profile, the compatibility of HL7 Version 3 POIZ and CareRecord were analyzed. The standards were found to be highly compatible. A few differences were identified and referred back to the HL7 Public Health and Emergency Response (PHER) Work Group for resolution through comments on both Draft Standards for Trial Use (DSTU). The approach taken in the Immunization Content (IC) Profile is to update the current PCC-2 Immunization Summary template to contain all the fields in POIZ that are also supported in CareRecord. Template for Immunizations needs to be fixed to include Lot #, Manufacturer, and Expiration Date, and a few other items. The updated template is the equivalent of a POIZ template on CareRecord. This update needs to be completed by the appropriate means.
- Template for Advanced Directives needs to be fixed to include Immunization Refusal Reasons.
- It is expected that ballot comments on the CareRecord DSTU within HL7 will include requests to add elements available in POIZ but not accommodated in CareRecord. Assuming those elements are eventually added, this IC profile will have to be updated to also include them.
- Not enough is said about precisely how the HL7 Version 2 messages are to be used. HL7 Version 2 couples content more tightly with message syntax than Verion 3. Care Management (CM) provides the notification-based integration profile, and Query for Existing Data (QED) provides a query-based integration profile for the HL7 V3 portions of this profile. However, it is unclear how CM and QED will handle V2. V2.3.1 messages blend identity resolution, which is outside the scope of this profile, with transmission of clinical data; how will this be handled? Also, if a Version 2 Implementation Guide is referenced, how will updates to that document be handled?
- This IC profile contains three options for each actor. This has been thought to be problematic because two systems implementing different options may not be able to communicate. Another approach would be to break this profile into two or even three profiles, i.e. , one for HL7 Version 2, and one or two for HL7 Version 3 (depending upon whether the Immunization Summary and Care Record options are combined).
- Implementation of this profile within PCC Volumes I and II will involve a two-part exercises: (1) update of the existing PCC-2 Immunization Summary template to reflect missing POIZ fields; and (2) creation of a new profile for the Care Record Option that includes Allergies, Problems, etc. - something that looks more like a discharge summary or a transfer of care summary, etc.
- We assume we can use the Simple Observation template of Care Record to record Vaccine Information Statement Given (VIS Given) and VIS Version fields. Is this the best approach?
- Where CareRecord and POIZ have different tags for the same elements, we have chosen to use the CareRecord tags in the templates and sample messages. The other possibility is to use the POIZ tags, which may be more meaningful to immunization domain experts. However, we felt that the POIZ tag names and definitions within the HL7 POIZ HMD were not significantly more descriptive to warrant "breaking" software that currently parses Care Record messages and may expect Care Record tags.
Add the following bullet to the list of profiles
- Immunization Content - The Immunization Content Profile defines standard immunization data content for Immunization Information Systems, other public health systems, EMR systems, Health Information Exchanges, and others wishing to exchange immunization data electronically in a standard format.
Add the following row(s) to the list of dependencies
|Integration Profile||Dependency||Dependency Type||Purpose|
|Immunization Content (IC)||Care Management (CM)||The Content Creator actor of the IC profile must be grouped with the Clinical Data Source Actor of the CM profile||The IC profile defines the content sent in the PCC-11 transaction specified in the CM profile|
|Immunization Content (IC)||Care Management (CM)||The Content Consumer actor of the IC profile must be grouped with the Care Manager Actor of the CM profile||The IC profile defines the content recieved in the PCC-11 transaction specified in the CM profile|
|Immunization Content (IC)||ATNA||Actors the IC profile shall implement the Secure Node Actor of the ATNA profile||Ensures that transmissions and changes to patient health information are logged in an audit repository, and that communication is secured between nodes.|
|Immunization Content (IC)||ATNA||Actors the IC profile shall implement the Time Client Actor of the CT profile||Ensures that concistent time is used in all messages.|
The Immunization Content Profile (IC)
The Immunization Content Profile (IC) provides a standard message, document and web service formats for exchanging immunization data. It is intended to facilitate the exchange of immunization data among multiple systems belonging to a single or to multiple organizations. Data exchange with and among the installed base of U.S. Immunization Information System (IIS) base was a critical consideration in formulating this profile. However, its intention is to go beyond data exchange among IISs, and facilitate immunization data exchange on a healthcare information network that includes electronic medical record (EMR) systems, Health Information Exchanges, other public health systems, Personal Health Record (PHR) systems, and other stakeholder systems. Thus, the profile specifies common data formats for exchanging immunization data only, or for exchanging immunization data along with medical summary data needed for the overall care of a patient related to immunizations.
To accomplish this, IC draws from two HL7 Version 3 message standards: Immunizations and Care Provision. Immunizations contains a message information model which handles detailed immunization information only. It includes history of administered vaccines with such details as lot number, who administered the shot, and so forth. Care Provision contains a message information model which handles immunization as well as other information related to the patient's care. For example, it includes medical history, medications, allergies, vital signs, and so forth. To provide for compatibility with the U.S. installed base of Immunization Information Systems (IISs), an HL7 Version 2.3.1 content option is also included.
The format of data is treated here as a separate topic from whether the data communicated in message, service, or document format, or whether an enclosing message is query-based or notification-based. By isolating content description from transaction description, the same content can be exchanged both in query and notification (unsolicited update) transaction styles, or in a service. IC is intended to be used in conjunction with integration profiles such as Query for Existing Data (QED) and Care Management (CM) to create architectures for immunization information exchange. It is also hoped that in the future, IC can be used in document-oriented profiles such as XDS. Finally, the IC Profile is also intended to pave the way for content to be passed to immunization-related decision support services. Decision support, however, is out of scope for the 2007-2009 IHE cycle and is on the IHE roadmap for the future.
The following progression of use cases is illustrated in the drawing below.
Use Case 1: Immunization Information System Participation
Various provider organizations - airport flu shot clinics, storefront vaccine clinics, and hospital vaccine clinics - wish to submit immunization histories for patients to a regional Immunization Information System (IIS) with appropriate patient consent. The provider IT departments configure HL7 Verion 2.3.1 connections with the IIS. Each time immunizations are recorded, records of the administered vaccines are automatically sent to the IIS using an HL7 version 2.3.1 standard format.
This is representative of the present-state use case in the U.S.
Use Case 2: Immunization Yellow Card
A pediatrician's office produces official immunization records (sometimes called "Yellow Card") for patients. The provider electronic medical record (EMR) system retrieves demographic information and records of immunization its immunization repository. To supplement its records with immunizations that the patient may have received from other providers, it queries the regional Immunization Information System (IIS). It passes the immunization content to a software module or service that prints the information in the official Yellow Card format.
Use Case 3: Personal Health Record
The provider wishes to make the assembled immunization information available in the patient's Personal Health Record (PHR). The pediatrician's office EMR system includes the retrieved immunization information in its complete care provision information about the patient. The standard Care Provision information contains current conditions, allergies and past adverse events, medications, vital signs, past medical history such as disease history, and so forth, in addition to immunizations. Knowing that the patient also has visited providers in a neighboring state, the EMR system queries the neighboring state's Health Information Exchange (HIE) to retrieve additional care provision information in a standard format. Since the neighboring state IIS is also part of the HIE, the retrieved information also includes immunizations. The pediatrician's office EMR system combines the retrieved and local information and sends it to the provider's PHR system in a standard format.
Use Case 4: Vaccine Forecast
The pediatrician's office wishes to run an automated Vaccine Forecast Decision Support Service to calculate which vaccines due on the next visit, and to assist with reminder/recall. The service may be integrated within the EMR or may be accessed externally using a web service interface. The service accepts a standard XML-based payload in Immunization Content format. The pediatrician's EMR system submits the patients Care Provision data that it has previously assembled to the Vaccine Forecast Decision Support Service and receives a vaccine forecast care plan in return. It records the care plan and uses it in reminder/recall.
There are two actors in this profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is to be consumed by a Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described below, and is out of scope of this profile.
|Content Consumer||No Options Defined|
|Content Creator||Immunization Summary Option (1)|
Note (1): The Actor shall support at least one of these options.
Immunization Summary Option
The Immunization Summary Option is based upon HL7 Version 3. It includes information about immunization history of a patient.
Immunization Detail Option
The Immunization Detail Option is also based upon HL7 Version 3. It includes all of the requirements of the Immunization Summary Option, plus ancillary information to support decisions about the treatment of a patient related to immunizations. For example, it includes the patient's allergies, which may be relevant in deciding whether or not to give certain vaccines.
V2 Immunization Update Option
The V2 Immunization Update Option is for backwards compatibility with existing HL7 Version 2.3.1 immunization messaging.
Care Management (CM)
Appendix A - Actor Descriptions
Actors are information systems or components of information systems that produce, manage, or act on information associated with operational activities in the enterprise.
- Content Creator
- The Content Creator Actor is responsible for the creation of content and transmission to a Content Consumer.
- Content Consumer
- A Content Consumer Actor is responsible for viewing, import, or other processing of content created by a Content Creator Actor.
- Clinical Data Consumer
- A clinical data consumer makes use of clinical patient data.
- Clinical Data Source
- A Clinical Data Sources maintains patient information about vital signs, problem and allergies, results from diagnostic tests (e.g., Lab, Imaging, or other test results), medications, immunizations or historical or planned visits and procedures.
Appendix B - Transaction Descriptions
Transactions are interactions between actors that transfer the required information through standards-based messages. The PCC Technical Framework does not define any specific transactions, as these are assumed to be carried out through the use of transactions defined in other IHE Profiles.
- Query Existing Data
- Request information about recent patient information, used to obtain vital signs measurements, problems and allergies, diagnostic results, medications, immunizations, or procedures or visits relevant for a patient. The query may request information about some or all of the above topics, or may request information on a specific topic, or one entered for a specific encounter or date range.
Appendix C - How to Prepare an IHE Integration Statement
IHE Integration Statements are documents prepared and published by vendors to describe the conformance of their products with the IHE Technical Framework. They identify the specific IHE capabilities a given product supports in terms of IHE actors and integration profiles described in the technical frameworks of each domain.
Users familiar with these concepts can use Integration Statements to determine what level of integration a vendor asserts a product supports with complementary systems and what clinical and operational benefits such integration might provide. Integration Statements are intended to be used in conjunction with statements of conformance to specific standards (e.g., HL7, IETF, DICOM, W3C, etc.).
IHE provides a process for vendors to test their implementations of IHE actors and integration profiles. The IHE testing process, culminating in a multi-party interactive testing event called the Connectathon, provides vendors with valuable feedback and provides a baseline indication of the conformance of their implementations. The process is not intended to independently evaluate, or ensure, product compliance. In publishing the results of the Connectathon and facilitating access to vendors' IHE Integration Statements, IHE and its sponsoring organizations are in no way attesting to the accuracy or validity of any vendor's IHE Integration Statements or any other claims by vendors regarding their products.
IMPORTANT -- PLEASE NOTE: Vendors have sole responsibility for the accuracy and validity of their IHE Integration Statements. Vendors' Integration Statements are made available through IHE simply for consideration by parties seeking information about the integration capabilities of particular products. IHE and its sponsoring organizations have not evaluated or approved any IHE Integration Statement or any related product, and IHE and its sponsoring organizations shall have no liability or responsibility to any party for any claims or damages, whether direct, indirect, incidental or consequential, including but not limited to business interruption and loss of revenue, arising from any use of, or reliance upon, any IHE Integration Statement.
Structure and Content of an IHE Integration Statement
An IHE Integration Statement for a product shall include:
- The Vendor Name
- The Product Name (as used in the commercial context) to which the IHE Integration Statement applies.
- The Product Version to which the IHE Integration Statement applies.
- A publication date and optionally a revision designation for the IHE Integration Statement.
- The following statement: "This product implements all transactions required in the IHE Technical Framework to support the IHE Integration Profiles, Actors and Options listed below:"
- A list of IHE Integration Profiles supported by the product and, for each Integration Profile, a list of IHE Actors supported. For each integration profile/actor combination, one or more of the options defined in the IHE Technical Framework may also be stated. Profiles, Actors and Options shall use the names defined by the IHE Technical Framework Volume I. (Note: The vendor may also elect to indicate the version number of the Technical Framework referenced for each Integration Profile.)
Note that implementation of the integration profile implies implementation of all required transactions for an actor as well as selected options.
The statement shall also include references and/or internet links to the following information:
- Specific internet address (or universal resource locator [URL]) where the vendor's Integration Statements are posted
- URL where the vendor's standards conformance statements (e.g., HL7, DICOM, etc.) relevant to the IHE transactions implemented by the product are posted.
- URL of the IHE Initiative's web page for general IHE information www.himss.org/ihe.
An IHE Integration Statement is not intended to promote or advertise aspects of a product not directly related to its implementation of IHE capabilities.
Format of an IHE Integration Statement
Each Integration Statement shall follow the format shown below. Vendors may add a cover page and any necessary additional information in accordance with their product documentation policies.
|IHE Integration Statement||Date||12 Oct 2005|
|Any Medical Systems Co.||IntegrateRecord|| V2.3|
|This product implements all transactions required in the IHE Technical Framework to support the IHE Integration Profiles, Actors and Options listed below:|
|Integration Profiles Implemented||Actors Implemented||Options Implemented|
|Cross-Enterprise Sharing of Medical Summaries||Document Consumer||View Option|
|Audit Trail and Node Authentication||Secure Node||none|
|Patient Identity Cross-referencing||Patient Identifier Cross-reference Consumer||PIX Update Notification|
|Internet address for vendor's IHE information:www.anymedicalsystemsco.com/ihe|
|Links to Standards Conformance Statements for the Implementation|
|Links to general information on IHE|
|In North America: www.ihe.het||In Europe: www.ihe-europe.org||In Japan: www.jira-net.or.jp/ihe-j|
IHE Integration Statement template
An IHE Integration Statement template (MS Word version) is available here.
The IHE Product Registry
The assumption of an integration statement is that all actors listed are functionally grouped and conform to any profile specifications for such groupings. In case of exceptions the vendor must explicitly describe the functional groupings.
IHE has developed a new Web-based database of Integration Statements. The IHE Product Registry enables developers to create, manage and publish Integration Statements for their commercial and open source healthcare IT systems. It allows users to browse for these systems based on their conformance with specific IHE Actors and Profiles. The system is open for use by developers and users now!
Appendix D - Braden Scale for Predicting Pressure Sore Risk
The following terms are used in various places within this technical framework, and are defined below. The complete IHE Glossary is available on the IHE Wiki at http://wiki.ihe.net/index.php/IHE_Glossary .
- An entity within a use case diagram that can perform an action within a use case diagram. Possible actions are creation or consumption of a message
- Acuity Assessment
Also known as triage category, this is the acuity of the patient assigned during the process of ED triage. A number of evidenced based triage scales exist, including the Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), the Australasian Triage Scale (ATS), and the Manchester Triage System. In many emergency departments, patients may simply be classified as emergent, urgent or non-urgent.
- Admit, Discharge & Transfer.
- Affinity Domain Policy
- Affinity Domain Policy that clearly defines the appropriate uses of the XDS Affinity Domain. Within this policy is a defined set of acceptable use Privacy Consent Policies that are published and understood.
- Formerly the American Society of Testing and Materials, now ASTM International. An SDO that develops a number of standards across a wide variety of industries, including healthcare.
- Audit Trail and Node Authentication. An IHE ITI profile.
- Care Context
- The participations surrounding the care provision act, and the attributes of that act. Everything in the document header. Data history, links to clinical reasoning.
- Continuity of Care Document(CCD)
- An HL7 Clinical Document Architecture (CDA) implementation alternative to ASTM ADJE2369 for institutions or organizations committed to HL7 standards. This specification was developed as a collaborative effort between ASTM and HL7. More information is available from http://www.hl7.org.
- Continuity of Care Record (CCR)
- A core data set of the most relevant administrative, demographic, and clinical information facts about a patient’s healthcare, covering one or more encounters. The CCR is Designation E2369-05 of the ASTM (American Society for Testing and Materials, International). More information is available from http://www.astm.org.
- Clinical Document Architecture (CDA)
- An HL7 standard for the exchange for clinical documents. It specifies the structure and semantics of clinical documents. More information is available from http://www.hl7.org.
- Content Binding
- A content binding describes how the payload used in an IHE transaction is related to and/or constrained by the data elements contained within the content sent or received in those transactions.
- Care Record Summary. An implementation guide that constrains CDA Release 2 for Care Record Summary documents.
- Consistent Time Integration Profile.
- Digital Imaging and Communication in Medicine
- Digital Signatures. An IHE ITI Profile.
- An Emergency Department Information System (EDIS) is an extended EHR system used to manage data in support of Emergency Department patient care and operations. The functions of an EDIS may be provided by a single application or multiple applications.
- Enterprise Master Patient Index.
- Electronic Medical Record, an Electronic Health Record system used within an enterprise to deliver care (also called EHR-CR by IHE-XDS).
- Estimated Time of Arrival
- the time the patient being referred can be expected to arrive in the emergency department.
- Enterprise User Authentication Integration Profile.
- Expected Actions
- Actions which should occur as the result of a trigger event.
- Healthcare Information and Management Systems Society.
- Health Level Seven
- Hospital Information System.
- Integrating the Healthcare Enterprise.
- Interaction Diagram
- A diagram that depicts data flow and sequencing of events.
- Information Technology.
- Logical Observation Identifiers Names and Codes (LOINC®)
- A vocabulary developed by the Regenstrief Institute aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research. Additional information found at http://www.regenstrief.org/medinformatics/loinc/.
- Mode of Arrival
- The method of transportation used to transport the patient to the Emergency Department.
- Master Patient Index.
- Medical Record Number.
- Notification of Document Availability
- Object Identifier. (See also 'Globally Unique Identifier').
- Patient Identifier Cross-reference Domain
- Consists of a set of Patient Identifier Domains known and managed by a Patient Identifier Cross-reference Manager Actor. The Patient Identifier Cross-reference Manager Actor is responsible for providing lists of "alias" identifiers from different Patient Identifier Domains.
- Patient Identifier Domain
- A single system or a set of interconnected systems that all share a common identification scheme for patients. Such a scheme includes: (1) a single identifier-issuing authority, (2) an assignment process of an identifier to a patient, (3) a permanent record of issued patient identifiers with associated traits, and (4) a maintenance process over time. The goal of Patient Identification is to reduce errors.
- Portable Document Format.
- Patient Identifier Cross Referencing. An IHE ITI Profile.
- Patient Demographics Query. An IHE ITI Profile.
- Personal Health Record
- In the context of a "Pre-procedure History and Physical," the "procedure" is a surgery or an invasive examination of a patient that is required by quality review organizations to be preceded by a pre-procedure assessment of procedure risk and anesthesia risk. This assessment is typically referred to as a "Pre-operative" or "Pre-procedure History and Physical."
- Process Flow Diagram
- A graphical illustration of the flow of processes and interactions among the actors involved in a particular example.
- Proposed disposition
- the intended disposition (i.e. admission to ICU, discharge to home, transfer to psychiatric hospital), if known, that the referring provider expects the patient will end up after the emergency department intervention.
- Referral Source
- An individual, group, or agency that determined the patient should seek care at the ED. Referral source may be used to determine appropriate discharge referrals and services, or to provide surveillance data for program and service planning, or to examine referral patterns.
- The actions of an actor in a use case.
- Radiological Society of North America.
- A Latin abbreviation for signetur used to represent the instruction following the medication name.
- A brief description of the transaction.
SNOMED-CT® A comprehensive clinical terminology, originally created by the College of American Pathologists (CAP) and, as of April 2007, owned, maintained, and distributed by the International Health Terminology Standards Development Organisation (IHTSDO), a non-for-profit association in Denmark. The CAP continues to support SNOMED CT operations under contract to the IHTSDO and provides SNOMED-related products and services as a licensee of the terminology. More information available from http://www.ihtsdo.org/ or the United States National Library of Medicine at http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html
- Transport Mode
- the method the patient employs, or is provided to get to the emergency department.
- Trigger Event
- An event such as the reception of a message or completion of a process, which causes another action to occur.
- Unique Identifier (See also Globally Unique Identifier).
- Universal ID
- Unique identifier over time within the UID type. Each UID must belong to one of specifically enumerated species. Universal ID must follow syntactic rules of its scheme.
- Use Case
- A graphical depiction of the actors and operation of a system.
- Cross Enterprise User Authentication
- Cross Enterprise Document Sharing
HIMSS and RSNA
Integrating the Healthcare Enterprise
IHE Patient Care Coordination
Immunization Content (IC)
Technical Framework Supplement
- (PCC TF-2/Preface)Preface
- (PCC TF-2/Introduction)Introduction
Namespaces and Vocabularies
This section lists the namespaces and identifiers defined or referenced by the IHE PCC Technical Framework, and the vocabularies defined or referenced herein.
The following vocabularies are referenced in this document. An extensive list of registered vocabularies can be found at http://www.hl7.org/oid/.
|18.104.22.168.4.1.19322.214.171.124.1||IHE PCC Template Identifiers||This is the root OID for all IHE PCC Templates. A list of PCC templates can be found below in CDA Release 2.0 Content Modules.|
|126.96.36.199.4.1.193188.8.131.52.2||IHEActCode||See IHEActCode Vocabulary below|
|184.108.40.206.4.1.193220.127.116.11.3||IHE PCC RoleCode||See IHERoleCode Vocabulary below|
|18.104.22.168.4.1.19322.214.171.124.4||Namespace OID used for IHE Extensions to CDA Release 2.0|
|2.16.840.1.1138126.96.36.199||CCD Root OID||Root OID used for by ASTM/HL7 Continuity of Care Document|
|2.16.840.1.113883.5.112||RouteOfAdministration||See the HL7 RouteOfAdministration Vocabulary|
|2.16.840.1.113883.5.1063||SeverityObservation||See the HL7 SeverityObservation Vocabulary|
|2.16.840.1.113883.5.7||ActPriority||See the HL7 ActPriority Vocabulary|
|2.16.840.1.113883.6.1||LOINC||Logical Observation Identifier Names and Codes|
|2.16.840.1.113883.6.96||SNOMED-CT||SNOMED Controlled Terminology|
|2.16.840.1.113883.6.103||ICD-9CM (diagnosis codes)||International Classification of Diseases, Clinical Modifiers, Version 9|
|2.16.840.1.113883.6.104||ICD-9CM (procedure codes)||International Classification of Diseases, Clinical Modifiers, Version 9|
|2.16.840.1.113883.6.26||MEDCIN||A classification system from MEDICOMP Systems.|
|2.16.840.1.113883.6.63||FDDC||First DataBank Drug Codes|
|2.16.840.1.113883.6.12||C4||Current Procedure Terminology 4 (CPT-4) codes.|
|2.16.840.1.113883.6.257||Minimum Data Set for Long Term Care||The root OID for Minimum Data Set Answer Lists|
|1.2.840.10008.2.16.4||DCM||DICOM Controlled Terminology; PS 3.16 Content Mapping Resource, Annex D|
|2.16.840.1.113883.6.24||MDC||ISO/IEEE 11073 Medical Device Nomenclature|
|2.16.840.1.1138188.8.131.52.5||NDF-RT||National Drug File Reference Terminology (NCI version)|
|2.16.840.1.113883.11.19465||nuccProviderCodes||National Uniform Codes Council Healthcare Provider Terminology|
|2.16.840.1.1138184.108.40.2066||X12DE1336||Insurance Type Code (ASC X12 Data Element 1336)|
|2.16.840.1.113883.6.256||RadLex||RadLex (Radiological Society of North America)|
The IHE FormatCode vocabulary is now managed in an Implementation Guide published using FHIR.
- formal canonical URI http://ihe.net/fhir/ihe.formatcode.fhir/CodeSystem/formatcode
- formal publication URL http://profiles.ihe.net/fhir/ihe.formatcode.fhir/index.html
- FormatCode gitHub repository for source of the Implementation Guide can be used to register issues, or create pull requests for modifications. Formal governance is managed by ITI Technical Committee.
This FormatCode vocabulary represents:
- Code System 220.127.116.11.4.1.19318.104.22.168
- Value Set 22.214.171.124.4.1.193126.96.36.199.1
|CCD||ASTM/HL7 Continuity of Care Document|
|CCR||ASTM CCR Implementation Guide|
The IHEActCode vocabulary is a small vocabulary of clinical acts that are not presently supported by the HL7 ActCode vocabulary. The root namespace (OID) for this vocabulary is 188.8.131.52.4.1.193184.108.40.206.2. These vocabulary terms are based on the vocabulary and concepts used in the CCR and CCD standards listed above.
|COMMENT||This is the act of commenting on another act.|
|PINSTRUCT||This is the act of providing instructions to a patient regarding the use of medication.|
|FINSTRUCT||This is the act of providing instructions to the supplier regarding the fulfillment of the medication order.|
|IMMUNIZ||The act of immunization of a patient using a particular substance or class of substances identified using a specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of substances.|
|DRUG||The act of treating a patient with a particular substance or class of substances identified using a specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of substances.|
|INTOL||An observation that a patient is somehow intollerant of (e.g., allergic to) a particular substance or class of substances using a specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of substances.|
|SUBSTANCE||A qualifier that identifies the substance used to treat a patient in an immunization or drug treatment act. The substance is expected to be identified using a vocabulary such as RxNORM, SNOMED CT or other similar vocabulary and should be specific enough to identify the ingredients of the substance used.|
|SUBSTCLASS||A qualifier that identifies the class of substance used to treat a patient in an immunization or drug treatment act. The class of substances is expected to be identified using a vocabulary such as NDF-RT, SNOMED CT or other similar vocabulary, and should be broad enough to classify substances by mechanism of action (e.g., Beta Blocker), intended effect (Dieuretic, antibiotic) or ...|
|For Public Comment||What else needs to appear above for SUBSTCLASS?|
The IHERoleCode vocabulary is a small vocabulary of role codes that are not presently supported by the HL7 Role Code vocabulary. The root namespace (OID) for this vocabulary is 220.127.116.11.4.1.19318.104.22.168.3.
|EMPLOYER||The employer of a person.|
|SCHOOL||The school in which a person is enrolled.|
|AFFILIATED||An organization with which a person is affiliated (e.g., a volunteer organization).|
|PHARMACY||The pharmacy a person uses.|
PCC Content Modules
This chapter contains the various content modules and value sets that are used with IHE Patient Care Coordintation profiles and transactions.
Various tables used in this section will further constrain the content. Within this volume, the follow conventions are used.
- A "Required" data element is one that shall always be provided. If there is information available, the data element must be present. If there is no information available, or it cannot be transmitted, the data element must contain a value indicating the reason for omission of the data. (See PCC TF-2: 22.214.171.124 for a list of appropriate statements).
- A "Required if data present" data element is one that shall be provided when a value exists. If the information cannot be transmitted, the data element shall contain a value indicating the reason for omission of the data. If no such information is available to the creator or if such information is not available in a well identified manner (e.g. buried in a free form narrative that contains additional information relevant to other sections) or if the creator requires that information be absent, the R2 section shall be entirely absent. (See section PCC TF-2: 126.96.36.199 for a list of appropriate statements).
- An optional data element is one that may be provided, irrespective of whether the information is available or not. If the implementation elects to support this optional section, then its support shall meet the requirement set forth for the "Required if data present" or R2.
- A conditional data element is one that is required, required if known or optional depending upon other conditions. These will have further notes explaining when the data element is required, et cetera.
|Note:||The definitions of R, R2, and O differ slightly from other IHE profiles. This is due in part to the fact that local regulations and policies may in fact prohibit the transmission of certain information, and that a human decision to transmit the information may be required in many cases.|
Folder Content Modules
This section contains modules that describe the content requirements of Folders used with XDS, XDM or XDR. When workflows are completed normally, the folders will contain documents with the optionality specified in the tables shown below. Under certain circumstances, the folders will not meet the optionality requirements described below, for example, when the patient leaves before treatment is completed.
HL7 Version 3.0 Content Modules
This section contains content modules based upon the HL7 CDA Release 2.0 Standard, and related standards and/or implementation guides.
CDA Document Content Modules
- (188.8.131.52.4.1.193184.108.40.206.1.1.1)Medical Documents Specification
- (220.127.116.11.4.1.19318.104.22.168.22.214.171.124.2)Immunization Detail
CDA Header Content Modules
- (126.96.36.199.4.1.193188.8.131.52.1.2.5)PCC CDA Supplement 2:184.108.40.206 Authorization
CDA Section Content Modules
This list defines the sections that may appear in a medical document. It is intended to be a comprehensive list of all document sections that are used by any content profile defined in the Patient Care Coordination Technical Framework. All sections shall have a narrative component that may be freely formatted into normal text, lists, tables, or other appropriate human-readable presentations. Additional subsections or entry content modules may be required.
Other Condition Histories
The sections defined below provide historical information about the patient's conditions.
- (220.127.116.11.4.1.19318.104.22.168.1.3.6)PCC TF 2:22.214.171.124.3 Active Problems
- (126.96.36.199.4.1.193188.8.131.52.1.3.8)PCC TF 2:184.108.40.206.5 History of Past Illness
- (220.127.116.11.4.1.19318.104.22.168.1.3.13)PCC TF 2:22.214.171.124.11 Allergies and Other Adverse Reactions
- (126.96.36.199.4.1.193188.8.131.52.184.108.40.206.4)PCC TF 2:220.127.116.11.18 Pregnancy History
This section contains section content modules that describe activities surrounding the use of medication.
- (18.104.22.168.4.1.19322.214.171.124.1.3.19)PCC TF 2:126.96.36.199.1 Medications
- (188.8.131.52.4.1.193184.108.40.206.1.3.23)PCC TF 2:220.127.116.11.5 Immunizations
- (18.104.22.168.4.1.19322.214.171.124.1.3.25)PCC TF 2:126.96.36.199.4 Vital Signs
- (188.8.131.52.4.1.193184.108.40.206.220.127.116.11.2)PCC TF 2:18.104.22.168.5 Coded Vital Signs
- (22.214.171.124.4.1.193126.96.36.199.1.3.27)PCC TF 2:188.8.131.52.1 Results
- (184.108.40.206.4.1.193220.127.116.11.1.3.28)PCC TF 2:18.104.22.168.2 Coded Results
Plans of Care
This section provides content modules for sections that describe the plan of care intended for the patient.
- (22.214.171.124.4.1.193126.96.36.199.1.3.31)PCC TF 2:188.8.131.52.1 Care Plan
- (184.108.40.206.4.1.193220.127.116.11.1.3.34)PCC TF 2:18.104.22.168.5 Advance Directives
- (22.214.171.124.4.1.193126.96.36.199.1.3.35)PCC TF 2:188.8.131.52.6 Coded Advance Directives
- (184.108.40.206.4.1.193220.127.116.11.18.104.22.168.1)PCC CDA Supplement 2:22.214.171.124.13 Immunization Recommendation
- (126.96.36.199.4.1.193188.8.131.52.184.108.40.206.4)PCC CDA Supplement 2:220.127.116.11.7 Assessments
CDA and HL7 Version 3 Entry Content Modules
- (18.104.22.168.4.1.19322.214.171.124.1.4.1)PCC TF 2:126.96.36.199 Severity
- (188.8.131.52.4.1.193184.108.40.206.220.127.116.11)PCC TF 2:18.104.22.168 Problem Status Observation
- (22.214.171.124.4.1.193126.96.36.199.188.8.131.52)PCC TF 2:184.108.40.206 Health Status
- (220.127.116.11.4.1.19318.104.22.168.1.4.2)PCC TF 2:22.214.171.124 Comments
- (126.96.36.199.4.1.193188.8.131.52.1.4.3)PCC TF 2:184.108.40.206 Patient Medication Instructions
- (220.127.116.11.4.1.19318.104.22.168.22.214.171.124)PCC TF 2:126.96.36.199 Medication Fulfillment Instructions
- (188.8.131.52.4.1.193184.108.40.206.1.4.4)PCC TF 2:220.127.116.11 External References
- (18.104.22.168.4.1.19322.214.171.124.126.96.36.199)PCC TF 2:188.8.131.52 Internal References
- (184.108.40.206.4.1.193220.127.116.11.18.104.22.168)PCC TF 2:22.214.171.124 Concern Entry
- (126.96.36.199.4.1.193188.8.131.52.184.108.40.206)PCC TF 2:220.127.116.11 Problem Concern Entry
- (18.104.22.168.4.1.19322.214.171.124.126.96.36.199)PCC TF 2:188.8.131.52 Allergy and Intolerance Concern
- (184.108.40.206.4.1.193220.127.116.11.1.4.5)PCC TF 2:18.104.22.168 Problem Entry
- (22.214.171.124.4.1.193126.96.36.199.1.4.6)PCC TF 2:188.8.131.52 Allergies and Intolerances
- (184.108.40.206.4.1.193220.127.116.11.1.4.7)PCC TF 2:18.104.22.168 Medications
- (22.214.171.124.4.1.193126.96.36.199.1.4.12)PCC TF 2:188.8.131.52 Immunizations
- (184.108.40.206.4.1.193220.127.116.11.18.104.22.168)PCC TF 2:22.214.171.124 Supply Entry
- (126.96.36.199.4.1.193188.8.131.52.184.108.40.206)PCC TF 2:220.127.116.11 Product Entry
- (18.104.22.168.4.1.19322.214.171.124.1.4.13)PCC TF 2:126.96.36.199 Simple Observations
- (188.8.131.52.4.1.193184.108.40.206.220.127.116.11)PCC TF 2:18.104.22.168 Vital Signs Organizer
- (22.214.171.124.4.1.193126.96.36.199.188.8.131.52)PCC TF 2:184.108.40.206 Vital Signs Observation
- (220.127.116.11.4.1.19318.104.22.168.1.4.15)PCC TF 2:22.214.171.124 Family History Organizer
- (126.96.36.199.4.1.193188.8.131.52.184.108.40.206)PCC TF 2:220.127.116.11 Social History Observation
- (18.104.22.168.4.1.19322.214.171.124.126.96.36.199)PCC CDA Supplement 2:188.8.131.52 Family History Observation
- (184.108.40.206.4.1.193220.127.116.11.18.104.22.168)PCC CDA Supplement 2:22.214.171.124 Pregnancy Observation
- (126.96.36.199.4.1.193188.8.131.52.184.108.40.206)PCC CDA Supplement 2:220.127.116.11 Advance Directive Observation
- (18.104.22.168.4.1.19322.214.171.124.1.4.14)PCC CDA Supplement 2:126.96.36.199 Encounters
- (188.8.131.52.4.1.193184.108.40.206.1.4.19)PCC CDA Supplement 2:220.127.116.11 Procedure Entry
- (18.104.22.168.4.1.19322.214.171.124.126.96.36.199.1)PCC CDA Supplement 2:188.8.131.52 Pain Score Observation
- (184.108.40.206.4.1.193220.127.116.11.18.104.22.168)CDA Supplement 2:22.214.171.124 Immunization Recommendation
- (126.96.36.199.4.1.193188.8.131.52.184.108.40.206 )CDA Supplement 2:220.127.116.11 Antigen Dose
HL7 Version 2 Content Modules
This section contains content modules based upon the HL7 Version 2 Standard, and related standards and/or implementation guides.
- (18.104.22.168.4.1.19322.214.171.124.126.96.36.199.3)V2 Immunization Upate Message
PCC Value Sets
This section contains value sets used by Content Modules.
Appendix A - Examples Using PCC Content Profiles
Example documents conforming to each profile can be found on the IHE wiki at the following URLs.
|Profile and Content||URL|
|Referral Summary||XDSMS Example1|
|Discharge Summary||XDSMS Example1|
|XPHR Content||XPHR Example1|
|XPHR Update||XPHR Example2|
|(EDR) ED Referral||EDR Example|
|(APS) Antepartum Summary||APS Example|
|Triage Note||EDES Example1|
|ED Nursing Note||EDES Example2|
|Composite Triage and Nursing Note||EDES Example3|
|ED Physician Note||EDES Example4|
|(FSA) Functional Status Section||FSA Example|
Appendix B - Validating CDA Documents using the Framework
Many of the constraints specified by the content modules defined in the PCC Technical Framework can be validated automatically by software. Automated validation is a very desirable capability, as it makes it easier for implementers to test the correctness of their implementations. With regard to validation of the content module, the PCC Technical Framework narrative is the authoritative specification, not any automated software tool. Having said that, it is still very easy to create a validation framework for the IHE PCC Technical Framework using a XML validation tool such as Schematron. Since each content module has a name (the template identifier), any XML instance that reports itself to be of that "class" can be validated by creating assertions that must be true for each constraint indicated for the content module. In the XML representation, the <templateId> element is a child of the element that is claiming conformance to the template named. Thus the general pattern of a Schematron that validates a specific template is shown below:
<schema xmlns="http://www.ascc.net/xml/schematron" xmlns:cda="urn:hl7-org:v3"> <ns prefix="cda" uri="urn:hl7-org:v3" /> <pattern name='ReferralSummary'> <rule context='*[cda:templateId/@root="188.8.131.52.4.1.193184.108.40.206.1.1.3]"'> <!-- one or more assertions made by the content module --> </rule> </pattern> </schema>
For document content modules, the pattern can be extended to support common document content module constraints as shown below:
<schema xmlns="http://www.ascc.net/xml/schematron" xmlns:cda="urn:hl7-org:v3"> <ns prefix="cda" uri="urn:hl7-org:v3" /> <pattern name='ReferralSummary'> <rule context='*[templateId/@root="220.127.116.11.4.1.19318.104.22.168.1.1.3]"'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../ClinicalDocument'> Error: The referral content module can only be used on Clinical Documents. </assert> <!-- Verify that the parent templateId is also present. --> <assert test='templateId[@root="22.214.171.124.4.1.193126.96.36.199.1.1.2"]'> Error: The parent template identifier for medical summary is not present. </assert> <!-- Verify the document type code --> <assert test='code[@code = "34133-9"]'> Error: The document type code of a referral summary must be 34133-9 SUMMARIZATION OF EPISODE NOTE. </assert> <assert test='code[@codeSystem = "2.16.840.1.113883.6.1"]'> Error: The document type code must come from the LOINC code system (2.16.840.1.113883.6.1). </assert> <!-- Verify that all required data elements are present --> <assert test='.//templateId[@root = "188.8.131.52.4.1.193184.108.40.206.1.3.1"]'> Error: A referral summary must contain a reason for referral. </assert> <!-- Alert on any missing required if known elements --> <assert test='.//templateId[@root = "220.127.116.11.4.1.19318.104.22.168.1.3.8"]'> Warning: A referral summary should contain a list of history of past illnesses. </assert> <!-- Note any missing optional elements --> <assert test='.//templateId[@root = "22.214.171.124.4.1.193126.96.36.199.1.3.18"]'> Note: This referral summary does not contain the pertinent review of systems. </assert> </rule> </pattern> </schema>
The same pattern can be also applied to sections with just a few minor alterations.
<schema xmlns="http://www.ascc.net/xml/schematron" xmlns:cda="urn:hl7-org:v3"> <ns prefix="cda" uri="urn:hl7-org:v3" /> <pattern name='ReasonForReferralUncoded'> <rule context='*[templateId/@root="188.8.131.52.4.1.193184.108.40.206.1.3.1"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='section'> Error: The coded reason for referral module can only be used on a section. </assert> <assert test='false'> Manual: Manually verify that this section contains narrative providing the reason for referral. </assert> <!-- Verify that the parent templateId is also present. --> <assert test='templateId[@root="220.127.116.11.4.1.19318.104.22.168.1.3.1"]'> Error: The parent template identifier for the reason for referral module is not present. </assert> <!-- Verify the section type code --> <assert test='code[@code = "42349-1"]'> Error: The section type code of the reason for referral section must be 42349-1 REASON FOR REFERRAL. </assert> <assert test='code[@codeSystem = "2.16.840.1.113883.6.1"]'> Error: The section type code must come from the LOINC code system (2.16.840.1.113883.6.1). </assert> </pattern> <pattern name='ReasonForReferralCoded'> <rule context='*[templateId/@root="22.214.171.124.4.1.193126.96.36.199.1.3.2"]'> <!-- The parent template will have already verified the type of object --> <!-- Verify that the parent templateId is also present. --> <assert test='templateId[@root="188.8.131.52.4.1.193184.108.40.206.1.3.1"]'> Error: The parent template identifier for the reason for referral module is not present. </assert> <!-- Don't bother with the section type code, as the parent template caught it --> <!-- Verify that all required data elements are present --> <assert test='.//templateId[@root = "220.127.116.11.4.1.19318.104.22.168.1.4.13"]'> Error: A coded reason for referral section must contain an simple observation. </assert> <!-- Alert on any missing required if known elements --> <!-- Note any missing optional elements --> </rule> </pattern> </schema>
A similar pattern can also be followed for Entry and Header content modules, and these are left as an exercise for the reader.
Phases of Validation and Types of Errors
Note that each message in the Schematrons shown above start with a simple text string that indicates whether the message indicates one of the following conditions:
- An error, e.g., the failure to transmit a required element,
- A warning, e.g., the failure to transmit a required if known element,
- A note, e.g., the failure to transmit an optional element.
- A manual test, e.g., a reminder to manually verify some piece of content.
Schematron supports the capability to group sets of rules into phases by the pattern name, and to specify which phases of validation should be run during processing. To take advantage of this capability, one simply breaks each <pattern> element above up into separate patterns depending upon whether the assertion indicates an error, warning, note or manual test, and then associate each pattern with a different phase. This is shown in the figure below.
<schema xmlns="http://www.ascc.net/xml/schematron" xmlns:cda="urn:hl7-org:v3"> <ns prefix="cda" uri="urn:hl7-org:v3" /> <phase id="errors"> <active pattern="ReasonForReferralUncoded_Errors"/> <active pattern="ReasonForReferralCoded_Errors"/> </phase> <phase id="manual"> <active pattern="ReasonForReferralUncoded_Manual"/> </phase> <pattern name='ReasonForReferralUncoded_Errors'> <rule context='*[templateId/@root="22.214.171.124.4.1.193126.96.36.199.1.3.1"]'> <assert test='section'> Error: The coded reason for referral module can only be used on a section. </assert> <assert test='code[@code = "42349-1"]'> Error: The section type code of the reason for referral section must be 42349-1 REASON FOR REFERRAL. </assert> <assert test='code[@codeSystem = "2.16.840.1.113883.6.1"]'> Error: The section type code must come from the LOINC code system (2.16.840.1.113883.6.1). </assert> </rule> </pattern> <pattern name='ReasonForReferralUncoded_Manual'> <rule context='*[templateId/@root="188.8.131.52.4.1.193184.108.40.206.1.3.1"]'> <assert test='false'> Manual: Manually verify that this section contains narrative providing the reason for referral. </assert> </pattern> <pattern name='ReasonForReferralCoded_Errors'> <rule context='*[templateId/@root="220.127.116.11.4.1.19318.104.22.168.1.3.2"]'> <assert test='templateId[@root="22.214.171.124.4.1.193126.96.36.199.1.3.1"]'> Error: The parent template identifier for the reason for referral not present. </assert> <assert test='.//templateId[@root = "188.8.131.52.4.1.193184.108.40.206.1.4.13"]'> Error: A coded reason for referral section must contain an simple observation. </assert> </rule> </pattern> </schema>
Using these simple "templates" for template validation one can simply create a collection of Schematron patterns that can be used to validate the content modules in the PCC Technical Framework. Such Schematrons are expected to be made available as part of the MESA test tools that are provided to IHE Connectathon participants, and which will also be made available to the general public after connectathon.
Appendix C - Extensions to CDA Release 2.0
This section describes extensions to CDA Release 2.0 that are used by the IHE Patient Care Coordination Technical Framework.
IHE PCC Extensions
All Extensions to CDA Release 2.0 created by the IHE PCC Technical Committee are in the namespace urn:ihe:pcc:hl7v3.
The approach used to create extension elements created for the PCC Technical Framework is the same as was used for the HL7 Care Record Summary (see Appendix E) and the ASTM/HL7 Continuity of Care Document (see secion 7.2).
The <replacementOf> extension element is applied to a section appearing in a PHR Update Document to indicate that that section's content should replace that of a previously existing section. The identifier of the previously existing section is given so that the PHR Manager receiving the Update content will know which section to replace. The model for this extension is shown below.
Use of this extension is shown below. The <replacementOf> element appears after all other elements within the <section> element. The <id> element appearing in the <externalDocumentSection> element shall provide the identifier of the section being replaced in the parent document.
<section> <id root=' ' extension=' '/> <code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Name of the Section</title> <text>Text of the section</text> <entry></entry> <component></component> <pcc:replacementOf xmlns:pcc='urn:ihe:pcc:hl7v3'> <pcc:externalDocumentSection> <pcc:id root='58FCBE50-D4F2-4bda-BC1C-2105B284BBE3'/> <pcc:externalDocumentSection/> </pcc:replacementOf> </section>
Extensions Defined Elsewhere used by IHE PCC
There is often a need to record an identifer for an entity so that it can be subsequently referenced. This extension provides a mechnism to store that identifier. The element appears after any <realm>, <typeId> or <templateId> elements, but before all others in the entity where it is used:
<playingEntity classCode='ENT' determinerCode='INSTANCE'> <sdtc:id root='220.127.116.11.18.104.22.16835.2' extension='EntityID'/> : . </playingEntity>
There is a need to record the identifer by which a patient is known to another healthcare provider. This extension provides a role link between the assigned, related or associated entity, and the patient role.
Use of this extension to record the identifier under which the patient is known to a provider is shown below.
<assignedEntity> <id extension='1' root='22.214.171.124.126.96.36.19935.1'/> <code code='59058001' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT' displayName='General Physician'/> <addr> <streetAddressLine>21 North Ave</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>01803</postalCode> <country>USA</country> </addr> <telecom value='tel:(999)555-1212' use='WP'/> <assignedPerson> <name> <prefix>Dr.</prefix><given>Bernard</given><family>Wiseman</family><suffix>Sr.</suffix> </name> </assignedPerson> <sdtc:patient xmlns:sdtc='urn:hl7-org:sdtc' > <sdtc:id root='188.8.131.52.184.108.40.20635.2' extension='PatientMRN'/> </sdtc:patient> </assignedEntity>
The <patient> element records the link between the related, assigned or associated entity and the patient. The <id> element provides the identifier for the patient. The root attribute of the <id> should be the namespace used for patient identifiers by the entity. The extension attribute of the <id> element shall be the patient's medical record number or other identifier used by the entity to identify the patient.