PCC TF-1/PHLAB/XDSLAB Harmonization

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Intro

The use of explicit content modules in XDS-LAB will help other domains that are incorporating laboratory data be consistent.

• Provide purpose to section of CDA (see annotation comment)
• Provide context to section of CDA (see intended recipient)

Annotation Comment (PCC)

Laboratory reports come with a multi-tier of possible comments. We would like to adopt the PCC-TF template for comments in XDS-Lab.

• Specimen level
• Test level
• Result level

Test level comment

XDS-Lab is quiet on test (observation or organizer) level comments. I placed them within the

block using <tfoot> blocks. For consistency, we recommend re-use of the existing PCC Annotation Comment content module within Level 3 Entry linked to the Report_Entry <entry><act> and <><> as shown in this example.

<ClinicalDocument
  ...
  <component typeCode="COMP">
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component typeCode="COMP">
        <section classCode="DOCSECT">
          ...
          <text>
            ...
            <paragraph ID="sComment">Report level comment goes here.</paragraph>
            ...
          </text>
          ...
          <entry typeCode="DRIV">
            <templateId extension="Lab.Report.Data.Processing.Entry" root="1.3.6.1.4.1.19376.1.3"/>
            <act classCode="ACT" moodCode="EVN">
             ...
              <entryRelationship typeCode="COMP">
                <observation classCode="OBS" moodCode="EVN">
                  <code code="C58990" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Rabies Test">
                    <originalText><reference value="rabiesTest"/></originalText>
                  </code>
                  <text>Reagent lot 34</text>
                  <statusCode code="completed"/>
                  <effectiveTime value="20071108000000.0000-0500"/>
                  <value xsi:type="CE" code="59881000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" displayName="Rabies Virus"/>
                  <entryRelationship typeCode="COMP">
                    <act classCode="ACT" moodCode="EVN">
                      <templateId root='2.16.840.1.113883.10.20.1.40'/>
                      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
                      <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment">
                        <originalText><reference value="cRabiesTest"/></originalText>
                      </code>
                      <text>Repeat confirmed negative</text>
                    </act>
                  </entryRelationship>
                </observation>
              </entryRelationship>

Report level comment

XDS-Lab report level comments are placed within the <text> block using <paragraph> blocks. For consistency, we recommend re-use of the existing PCC Annotation Comment content module within Level 3 Entry linked to the Report_Entry <entry><act> as shown in this example.

<ClinicalDocument
  ...
  <component typeCode="COMP">
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component typeCode="COMP">
        <section classCode="DOCSECT">
          ...
          <text>
            ...
            <paragraph ID="sComment">Report level comment goes here.</paragraph>
            ...
          </text>
          ...
          <entry typeCode="DRIV">
            <templateId extension="Lab.Report.Data.Processing.Entry" root="1.3.6.1.4.1.19376.1.3"/>
            <act classCode="ACT" moodCode="EVN">
             ...
             <entryRelationship typeCode="COMP">
               <act classCode="ACT" moodCode="EVN">
                 <templateId root='2.16.840.1.113883.10.20.1.40'/>
                 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
                 <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment">
                   <originalText><reference value="sComment"/></originalText>
                 </code>
                 <text>Report level comment goes here.</text>
                 <statusCode code='completed' />
               </act>
             </entryRelationship>

Intended Recipient

The intended recipients of a laboratory document are intended for a reason which is not currently conveyed in the standard mark up.

• Per request of ordering physician
  • unknown relationship to patient
  • patient's primary care provider (PCP)
  • patient's specialist
• Per requirement
  • infection control
  • notifiable to public health program

Laboratory Observation

• sondra to fill in here

Laboratory Organizer

• sondra to fill in here

Laboratory Organizer - Isolate Organizer

• sondra to fill in here

Notifiable Condition

• sondra to fill in here

Referral Ordering Physician

• sondra to fill in here

Specimen

• sondra to fill in here

Specimen Collection DateTime

• sondra to fill in here

Specimen Receive DateTime

• sondra to fill in here