Medical Document Binding to XDS, XDM and XDR
Medical Document Binding to XDS, XDM and XDR
This binding defines a transformation that generates metadata for the XDSDocumentEntry element of appropriate transactions from the XDS, XDM and XDR profiles given a medical document and information from other sources. The medical document refers to the document being stored in a repository that will be referenced in the registry. The other sources of information include the configuration of the Document Source actor, the Affinity Domain, the site or facility, local agreements, other documents in the registry/repository, and this Content Profile.
XDSDocumentEntry Metadata
| XDSDocumentEntry Attribute |
Optional? | Constrained? |
Extended Discussion? | Source Type | Source/ Value |
| authorSpecialty | R2 | 4.1.2.1 | CAD | ||
| authorInstitution | R2 | SA | /ClinicalDocument/author /assignedAuthor /representedOrganization/name | ||
| authorPerson | R2 | 4.1.2.2 | SAT | $person <= /ClinicalDocument/author | |
| classCode | R | 4.1.2.3 | CADT | Must be consistent with /ClinicalDocument/code/@code | |
| classCodeDisplayName | R | 4.1.2.4 | CADT | Must be Consitent with /ClinicalDocument/code/@code | |
| confidentialityCode | R | 4.1.2.5 | CADT | /ClinicalDocument/ confidentialityCode/@code | |
| creationTime | R | SA | /ClinicalDocument/effectiveTime | ||
| eventCodeList | O |
4.1.2.6 | CADT | ||
| eventCodeDisplay NameList |
R (if event Code is valued) |
CADT | |||
| formatCode | R | 4.1.2.7 | FM | /ClinicalDocument/templateId | |
| healthcareFacility TypeCode |
R |
4.1.2.8 | O | Must be concistent with /clinicalDocument/code | |
| healthcareFacility TypeCodeDisplay Name |
R | 4.1.2.8 | O | Must be concistent with /clinicalDocument/code | |
| intendedRecipient | R2 | 4.1.2.2 | SAT | $person <= /ClinicalDocument/intendedRecipient | |
| languageCode | R | SA | /ClinicalDocument/languageCode | ||
| legalAuthenticator | O | 4.1.2.2 | SAT | $person <= /ClinicalDocument/ legalAuthenticator | |
| mimeType | R | FM | text/xml | ||
| parentDocument Relationship |
R (when applicable) |
SA | /ClinicalDocument/relatedDocument/@typeCode | ||
| parentDocumentId | R (when parent Document Relationship is present) |
4.1.2.9 | SAT | $docID <= /ClinicalDocument/ relatedDocument/parentDocument/ id | |
| patientId | R | 4.1.2.10 | SAT | $patID <= /ClinicalDocument/recordTarget/ patientRole/id | |
| practiceSettingCode | R |
4.1.2.11 | CAD | ||
| practiceSettingCode DisplayName | R | 4.1.2.10 | CAD | ||
| serviceStartTime | R2 | SA | /ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value | ||
| serviceStopTime | R2 | SA | /ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value | ||
| sourcePatientId | R | DS | |||
| sourcePatientInfo | R | DS | |||
| Title | O | SA | /ClinicalDocument/title | ||
| typeCode | R |
SA | /ClinicalDocument/code/@code | ||
| typeCodeDisplay Name |
R | SA | /ClinicalDocument/code/@displayName | ||
| uniqueId | R | 4.1.2.12 | SAT | $docID <= /ClinicalDocument/id |
Extended Discussion of XDSDocumentEntry Metadata
authorSpecialty
This metadata element should be based on a detailed defined classification system for healthcare providers such as those found in SNOMED-CT, or the HIPPA Healthcare Provider Taxonomy.
authorPerson, legalAuthenticator and intendedRecipient
The author, legal authenticator or intendedRecipient can be formatted using the following XPath expression, where $person in the expression below represents /ClinicalDocument/author, /ClinicalDocument/legalAuthenticator or /ClinicalDocument/intendedRecipient respectively.
concat(
$person/id/@extension,"^",
$person/assignedPerson/name/family,"^",
$person/assignedPerson/name/given,"^",
$person/assignedPerson/name/middle,"^",
$person/assignedPerson/name/suffix,"^",
$person/assignedPerson/name/prefix,"^",
$person/assignedPerson/name/degree,"^^&",
$person/id/@root,"&ISO"
)
classCode
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].
classCodeDisplayName
DisplayName of the classCode derived.Derived from a mapping of /ClinicalDocument/code/@code to the appropriate Display Name based on the Type of Service.
ConfidentialityCode
Derived from a mapping of /ClinicalDocument/confidentialityCode/@code to an Affinity Domain specified coded value and coding system.
EventCodeList and eventCodeDisplayNameList
These values express a collection of keywords that may be relevant to the consumer of the documents in the registry. Public comment is sought on what value sets would be of use.
formatCode
The format code shall be the OID associated with the template identifier used to identify the content module that the document conforms to. See PCC TF-2:5.1.2 for a list of values that can be used as format codes.
healthcareFacilityTypeCode and healthcareFacilityTypeCodeDisplayName
A fixed value assigned to the Document Source and configured form a set of Affinity Domain defined values.
parentDocumentId and uniqueId
The parentDocumentId and/or uniqueId can be formatted using the following XPath expression, where $docID in the expression below represents the appropriate identifier.
concat($docID/@root,"^", $docID/@extension)
patientId
The patientId can be formatted using the following XPath expression, where $patID in the expression below represents the appropriate identifier.
concat($patID/@extension,"^^^&", $patID/@root, "&ISO")
practiceSettingCode and practiceSettingCodeDisplayName
These elements should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.
uniqueId
concat($docID/@root,"^", $docID/@extension)
XDSSubmissionSet Metadata
| XDSSubmissionSet attribute |
Optional? | Constrained? | Extended Discussion? | Source Type | Source/ Value |
| authorDepartment | R2 | Yes | CAD | See 1.4.1.2.1 | |
| authorInstitution | R2 | SA | /ClinicalDocument/author/assignedAuthor /representedOrganization/name | ||
| authorPerson | O | R2 | Yes | SAT | $person <= /ClinicalDocument/author See 1.4.1.2.2 |
| comments | R2 | Yes | string(//section[@code='42349-1']/text) This is the reason for referral if present. | ||
| contentTypeCode | R | CAD | |||
| contentTypeCode DisplayName |
R | CAD | |||
| patientId | R | Yes | SAT | $patID <= /ClinicalDocument/recordTarget /patientRole/id See 1.4.1.2.6 | |
| sourceId | R | DS | |||
| submissionTime | R | DS | |||
| uniqueId | R |
Use of XDS Submission Set
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.
Use of XDS Folders
No specific requirements identified.
Configuration
This Medical Summary Content Profile requires that Content Creators and Content Consumers using these documents be configured 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 medication summaries (See PCC TF-2: 5.4.1.1.2.1).