Medical Document Binding to XDS, XDM and XDR/zh
针对XDS、XDM和XDR的医疗文档绑定
这种绑定(binding)规定的是一种转换机制(transformation)。在存在来自其他来源的某份医疗文档以及信息的情况下,这种转换机制所产生的是来自XDS、XDM和XDR概貌的适当交易的XDS文档条目元数据(XDSDocumentEntry)要素。医疗文档(medical document,医疗文书)指的是存储在某个储存库(repository)之中并将在注册库(registry)之中加以引用的文档。其他信息来源包括文档来源角色(Document Source actor)的配置、共享域、地点或设施、本地协议、注册库/储存库之中的其他文档以及这份内容概貌。
在许多的情况下,CDA文档的创建针对的是特定共享域(affinity domain)之内不同的共享目的。在这些情况下,CDA的语境与共享域的语境并无两样;此时,必须运用下列映射关系。
在其他情况下,CDA文档可能是事先已经为内部用途而创建的,而后来又要加以共享。在这些情况下,CDA的语境并不一定会与共享域的语境相符。因此,下列映射关系此时并不一定会适用。
请注意如下表格之中所给出的具体细节。
XDS文档条目元数据
XDSDocumentEntry Attribute | XDS文档条目属性 | 可选程度 | 来源类型 | 来源/取值 |
---|---|---|---|---|
availabilityStatus | R | DS | ||
authorInstitution | R2 | SAT |
$inst <=
/ClinicalDocument/author | |
authorPerson | R2 | SAT |
$person <= /ClinicalDocument/author
| |
authorRole | R2 | SAT | This metadata element should be based on a mapping of the participation function defined in the CDA document to the set of author roles configured for the affinity domain. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate: /ClincicalDocument/author/ participationFunction | |
authorSpecialty | R2 | SAT | This metadata element should be based on a mapping of the code associated with the assignedAuthor to detailed defined classification system for healthcare providers such configured in the affinitity domain. Possible classifications include those found in SNOMED-CT, or the HIPAA Healthcare Provider Taxonomy. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate: /ClinicalDocument/author/ assignedAuthor/code | |
classCode | R | CADT | Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code | |
classCodeDisplayName | R | CADT | DisplayName of the classCode derived. Derived from a mapping of /ClinicalDocument/code/@code to the appropriate Display Name based on the Type of Service. Must be Consitent with /ClinicalDocument/code/@code | |
confidentialityCode | R | CADT | Derived from a mapping of /ClinicalDocument/confidentialityCode/@code to an Affinity Domain specified coded value and coding system. When using the BPPC profile, the confidentialyCode may also be obtained from the <authorization> element.
| |
comments | O | DS | ||
creationTime | R | SAT | /ClinicalDocument/effectiveTime
| |
entryUUID | R | DS | ||
eventCodeList | O | CADT | These values express a collection of keywords that may be relevant to the consumer of the documents in the registry. They may come from anywhere in the CDA document, according to its purpose. | |
eventCodeDisplayNameList | R (if event Code is valued) |
CADT | These are the display names for the collection of keywords described above. | |
formatCode | R | FM | The format code for each PCC Document content profile is provided within the document specifications. | |
healthcareFacilityTypeCode | R | CAD | A fixed value assigned to the Document Source and configured form a set of Affinity Domain defined values. Must be concistent with /clinicalDocument/code | |
healthcareFacility TypeCodeDisplay Name |
R | CAD | Must be concistent with /clinicalDocument/code | |
intendedRecipient (for XDR, XDM) | O | SAT |
$person <=
/ClinicalDocument/intendedRecipient
"^^^^^&", | |
languageCode | R | SA | /ClinicalDocument/languageCode | |
legalAuthenticator | O | SAT | $person <= /ClinicalDocument/ legalAuthenticator
| |
mimeType | R | FM | text/xml | |
parentDocumentRelationship | R (when applicable) |
DS | Local document versions need not always be published, and so no exact mapping can be determined from the content of the CDA document. The parentDocumentRelationship may be determined in some configurations from the relatedDocument element present in the CDA dsocument. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate: /ClinicalDocument/relatedDocument/@typeCode | |
parentDocumentId | R (when parent Document Relationship is present) |
DS | Local document versions need not always be published, and so no exact mapping can be determined from the content of the CDA document. The parentDocumentId may be determined in some configurations from the relatedDocument element present in the CDA dsocument. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate: $docID <= /ClinicalDocument/ relatedDocument/parentDocument/id
| |
patientId | R | DS | The XDS Affinity Domain patient ID can be mapped from the patientRole/id element using transactions from the ITI PIX or PDQ profiles. See sourcePatientId below. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate:
| |
practiceSettingCode | R | CAD | This elements should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC. | |
practiceSettingCodeDisplayName | R | CAD | This element shall contain the display names associated with the codes described above. | |
serviceStartTime | R2 | SAT | /ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value
| |
serviceStopTime | R2 | SAT | /ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value
| |
sourcePatientId | R | SAT | $patID <= /ClinicalDocument/recordTarget/ patientRole/id
| |
sourcePatientInfo | R | SAT | /ClinicalDocument/recordTarget/ patientRole
| |
title | O | SA | /ClinicalDocument/title | |
typeCode | R | CADT | /ClinicalDocument/code/@code
| |
typeCodeDisplay Name |
R | CADT | /ClinicalDocument/code/@displayName | |
uniqueId | R | SAT | $docID <= /ClinicalDocument/id
|
XDS提交集元数据
The submission set metadata is as defined for XDS, and is not necessarily affected by the content of the clinical document. Metadata values in an XDSSubmissionSet with names identical to those in the XDSDocumentEntry may be inherited from XDSDocumentEntry metadata, but this is left to affinity domain policy and/or application configuration.
XDS提交集的使用
This content format uses the XDS Submission Set to create a package of information to send from one provider to another. All documents referenced by the Medical Summary in this Package must be in the submission set.
XDS文件夹的使用
No specific requirements identified.
配置
IHE Content Profiles using this binding require that Content Creators and Content Consumers be configurable with institution and other specific attributes or parameters. Implementers should be aware of these requirements to make such attributes easily configurable. There shall be a mechanism for the publishing and distribution of style sheets used to view clinical documents.