PCC TF-1/PHLAB/XDSLAB Harmonization: Difference between revisions
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Benefits: | Benefits: | ||
* Consistency with work done in other domains ( | * Consistency with work done in other domains (example annotation comment) | ||
* Provide guidance to other domains incorporating laboratory data (example PCC - ?profile) | * Provide guidance to other domains incorporating laboratory data (example PCC - ?profile incorporating lab data) | ||
* Provide context to section of CDA ( | * Provide context to section of CDA (example intended recipient) | ||
| Line 124: | Line 124: | ||
= Intended Recipient = | = Intended Recipient = | ||
The intended recipients of a laboratory document are intended for a reason which is not currently conveyed in the standard mark up. | XDS-Lab Current Specification: 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 | * Per request of ordering physician | ||
** unknown relationship to patient | ** unknown relationship to patient | ||
** patient's primary | ** patient's primary provider | ||
** patient's specialist | ** patient's specialist | ||
* Per requirement | * Per laboratory requirement | ||
** infection control | ** infection control | ||
** notifiable to public health program | ** notifiable to public health program | ||
XDS-Lab Current Specification: see below | |||
Proposed Specification: no change | |||
Reason for template: content, re-usability | |||
<pre> | |||
<ClinicalDocument | |||
... | |||
<informationRecipient> | |||
<templateId root='TBD'/> | |||
<intendedRecipient> | |||
<id extension="0000" root="1.19.6.11.13"/> | |||
<addr> | |||
<streetAddressLine>1600 Clifton Road</streetAddressLine> | |||
<city>Atlanta</city> | |||
<state>GA</state> | |||
<postalCode>30333</postalCode> | |||
</addr> | |||
<telecom value="tel: 404-639-3535"/> | |||
<informationRecipient> | |||
<name><family>Angulo</family><given>Fred</given></name> | |||
</informationRecipient> | |||
<receivedOrganization> | |||
<id extension="0000" root="1.19.6.11.13"/> | |||
<name>FoodNet</name> | |||
<telecom value="tel: 404-639-3535"/> | |||
<addr> | |||
<streetAddressLine>1600 Clifton Road</streetAddressLine> | |||
<city>Atlanta</city> | |||
<state>GA</state> | |||
<postalCode>30333</postalCode> | |||
</pre> | |||
= Laboratory Observation = | = Laboratory Observation = | ||
XDS-Lab Current Specification: see below | |||
Proposed Specification: no change | |||
Reason for template: re-usability | |||
<pre> | |||
</pre> | |||
= Laboratory Organizer = | = Laboratory Organizer = | ||
XDS-Lab Current Specification: see below | |||
Proposed Specification: no change | |||
Reason for template: re-usability | |||
<pre> | |||
</pre> | |||
= Laboratory Organizer - Isolate Organizer = | = Laboratory Organizer - Isolate Organizer = | ||
XDS-Lab Current Specification: see below | |||
Proposed Specification: no change | |||
Reason for template: re-usability | |||
<pre> | |||
</pre> | |||
= Notifiable Condition = | = Notifiable Condition = | ||
XDS-Lab Current Specification: outstanding issue, not addressed today | |||
<pre> | |||
</pre> | |||
Proposed Specification: see below | |||
Reason for template: re-usability | |||
<pre> | |||
<ClinicalDocument | |||
... | |||
<component typeCode="COMP"> | |||
<structuredBody classCode="DOCBODY" moodCode="EVN"> | |||
<component typeCode="COMP"> | |||
<section classCode="DOCSECT"> | |||
... | |||
<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"> | |||
<templateId extension="Lab.Report.Data.Notifiable.Entry" root="TBD"/> | |||
<code code="P0-007BF" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Notification of Disease"> | |||
<qualifier> | |||
<name code="G-C186" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Source of Specimen"/> | |||
<value code="S-16000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Patient"/> | |||
</qualifier> | |||
</code> | |||
<value xsi:type="CE" code="27268008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" | |||
displayName="Salmonella"> | |||
<translation code="6463-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |||
<translation code="L-17100" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED"/> | |||
</value> | |||
</pre> | |||
= Referral Ordering Physician = | = Referral Ordering Physician = | ||
Revision as of 11:07, 4 December 2007
Back to: PCC_TF-1/PHLAB
Intro
The use of content modules in XDS-Lab helps lab remain consistent with what other domains have accomplished as well as insures that the lab domain provides guidance to the other domains that as they incorporate relevant laboratory data into their content profiles.
Benefits:
- Consistency with work done in other domains (example annotation comment)
- Provide guidance to other domains incorporating laboratory data (example PCC - ?profile incorporating lab data)
- Provide context to section of CDA (example intended recipient)
Annotation Comment (PCC)
Laboratory reports come with at least 3 tiers of comments (result, test, report). We would like XDS-Lab to adopt an adaptation (CP potential!) of [PCC-TF Annotation Comment content module] for test and report comments and to provide samples demonstrating Level 3 references to Level 2 content.
Result and Test level comments
XDS-Lab
- result - footNote
- test - similiar to PCC-TF Annotation comment with proposal to extend schema on the observation
We recommend placing test level comments them within the observation/
block using <tfoot> blocks. For consistency, we recommend re-use of the existing PCC-TF Annotation Comment content module within Level 3 Entry linked to the Report_Entry <entry><act> and <><> as shown in this example. This example provides a reason for adaptation to the current content module.<ClinicalDocument
...
<component typeCode="COMP">
<structuredBody classCode="DOCBODY" moodCode="EVN">
<component typeCode="COMP">
<section classCode="DOCSECT">
...
<text>
<table>
<thead ID="rabiesTest">
<tr>
<th>Rabies Virus</th>
<th>Subject</th>
<th>Comments</th>
</tr>
</thead>
<tfoot>
<tr>
<td>Repeat confirmed negative</td>
</tr>
</tfoot>
<tbody>
<tr>
<td>Rabies virus not found.</td>
<td>ferret</td>
<td>Reagent lot 34</td>
</tr>
</tbody>
</table>
<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"/>
<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
XDS-Lab Current Specification: 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 provider
- patient's specialist
- Per laboratory requirement
- infection control
- notifiable to public health program
XDS-Lab Current Specification: see below
Proposed Specification: no change
Reason for template: content, re-usability
<ClinicalDocument
...
<informationRecipient>
<templateId root='TBD'/>
<intendedRecipient>
<id extension="0000" root="1.19.6.11.13"/>
<addr>
<streetAddressLine>1600 Clifton Road</streetAddressLine>
<city>Atlanta</city>
<state>GA</state>
<postalCode>30333</postalCode>
</addr>
<telecom value="tel: 404-639-3535"/>
<informationRecipient>
<name><family>Angulo</family><given>Fred</given></name>
</informationRecipient>
<receivedOrganization>
<id extension="0000" root="1.19.6.11.13"/>
<name>FoodNet</name>
<telecom value="tel: 404-639-3535"/>
<addr>
<streetAddressLine>1600 Clifton Road</streetAddressLine>
<city>Atlanta</city>
<state>GA</state>
<postalCode>30333</postalCode>
Laboratory Observation
XDS-Lab Current Specification: see below
Proposed Specification: no change
Reason for template: re-usability
Laboratory Organizer
XDS-Lab Current Specification: see below
Proposed Specification: no change
Reason for template: re-usability
Laboratory Organizer - Isolate Organizer
XDS-Lab Current Specification: see below
Proposed Specification: no change
Reason for template: re-usability
Notifiable Condition
XDS-Lab Current Specification: outstanding issue, not addressed today
Proposed Specification: see below
Reason for template: re-usability
<ClinicalDocument
...
<component typeCode="COMP">
<structuredBody classCode="DOCBODY" moodCode="EVN">
<component typeCode="COMP">
<section classCode="DOCSECT">
...
<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">
<templateId extension="Lab.Report.Data.Notifiable.Entry" root="TBD"/>
<code code="P0-007BF" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Notification of Disease">
<qualifier>
<name code="G-C186" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Source of Specimen"/>
<value code="S-16000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Patient"/>
</qualifier>
</code>
<value xsi:type="CE" code="27268008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"
displayName="Salmonella">
<translation code="6463-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<translation code="L-17100" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED"/>
</value>
Referral Ordering Physician
XDS-Lab Current Specification: see below
Proposed Specification: no change
Reason for template: context, re-usability
<ClinicalDocument
...
<participant typeCode="REF">
<templateId root='TBD'/>
<time>
<low value="20071104055700.0000-0500"/>
<high value="20071104131600.0000-0500"/>
</time>
<associatedEntity classCode="PROV">
<id extension="90573" root="1.19.6.11.13"/>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<associatedPerson>
<name><family>Patel</family><given>Kiran</given><prefix>Dr.</prefix></name>
</associatedPerson>
<scopingOrganization>
<id extension="rm83747" root="1.19.6.11.13"/>
<name>Hospital</name>
<telecom nullFlavor="UNK"/>
<addr nullFlavor="UNK"/>
Specimen
XDS-Lab Current Specification: see below
Proposed Specification: no change
Reason for template: re-usability
<ClinicalDocument
...
<component typeCode="COMP">
<structuredBody classCode="DOCBODY" moodCode="EVN">
<component typeCode="COMP">
<section classCode="DOCSECT">
...
<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">
...
<specimen typeCode="SPC">
<templateId root='TBD'/>
<specimenRole classCode="SPEC">
<id extension="555847" root="1.19.6.11.13"/>
Specimen Collection DateTime
XDS-Lab Current Specification: CDA schema extension, lab:productOf
<ClinicalDocument
...
<component typeCode="COMP">
<structuredBody classCode="DOCBODY" moodCode="EVN">
<component typeCode="COMP">
<section classCode="DOCSECT">
...
<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">
...
<specimen typeCode="SPC">
<specimenRole classCode="SPEC">
<id extension="555847" root="1.19.6.11.13"/>
<specimenPlayingEntity classCode="MIC">
<code code="STL" codeSystem="2.16.840.1.113883.5.129" codeSystemName="HL7" displayName="Stool"/>
</specimenPlayingEntity>
<lab:productOf typeCode="PRD">
<lab:procedure classCode="PROC" moodCode="EVN">
<effectiveTime value="20071104000000.0000-0400"/>
<participant typeCode="PRF">
<participantRole>
<addr>
<streetAddressLine>7000 Hosptial Drive</streetAddressLine>
<city>Chicago</city>
<state>IL</state>
<postalCode>60622</postalCode>
</addr>
<telecom value="tel: 312-555-5555"/>
Proposed Specification: no CDA schema extension, alternative proposed by Keith Boone
Reason for template: re-usability
<ClinicalDocument
...
<component typeCode="COMP">
<structuredBody classCode="DOCBODY" moodCode="EVN">
<component typeCode="COMP">
<section classCode="DOCSECT">
...
<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='TBD'/>
<code code="SPC_COL_TBD" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Specimen Collected"/>
<effectiveTime value="20071108000000.0000-0500"/>
<participant typeCode="PRF">
<participantRole>
<addr>
<streetAddressLine>7000 Hosptial Drive</streetAddressLine>
<city>Chicago</city>
<state>IL</state>
<postalCode>60622</postalCode>
</addr>
<telecom value="tel: 312-555-5555"/>
Specimen Receive DateTime
XDS-Lab Current Specification: outstanding issue, not addressed today
Proposed Specification: alternative proposed by Keith Boone
Reason for template: re-usability
<ClinicalDocument
...
<component typeCode="COMP">
<structuredBody classCode="DOCBODY" moodCode="EVN">
<component typeCode="COMP">
<section classCode="DOCSECT">
...
<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='TBD'/>
<code code="SPC_REC_TBD" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Specimen Received"/>
<effectiveTime value="20071108000000.0000-0500"/>