1.3.6.1.4.1.19376.1.5.3.1.1.5

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PHR Extract Specification 1.3.6.1.4.1.19376.1.5.3.1.1.5

The PHR Extract module describes the document content that summarizes information contained within a Personal Health Record. While a PHR can contain a great deal more information (including clinical documents, lab reported, images, trend data, monitoring data) et cetera, this content module only deals with the format of the summary information from the PHR.

An PHR Extract Module is a type of medical summary, and incorporates the constraints defined for medical summaries found in PCC TF-2: 5.4.1.2 Medical Summary Content. While mappings have been provided to various standards, this content module conforms to the ASTM/HL7 Continuity of Care Document as well as this guide.

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown below:

  <ClinicalDocument xmlns='urn:hl7-org:v3'>
    <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.2"/>
      <templateId root="2.16.840.1.113883.10.20.1"/><!—conformance to HL7 CCD -->
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5"/>
        :

A CDA Document may conform to more than one template, and can therefore have more that one <templateId> element. The <templateId> elements shown in Figure 5.4 1 above must be present. Furthermore, a clinical document conforming to this guide must use the LOINC Code 34133-9 SUMMARIZATION OF EPISODE note .

       :
      <code code='34133-9' displayName='SUMMARIZATION OF EPISODE' 
        codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
       :

The following table describes the data elements that may be present in a PHR Extract. The first column of this table is drawn from the Common Data Elements in the PHR found in Appendix B of the AHIMA Report: The Role of the Personal Health Record in the EHR. Indented items in this column of the table provide more detail for the item they appear underneath.

These data elements were then mapped to the ASTM CCR, HL7 CDA, CRS and CCD and the implicit data elements referenced by the HL7 PHR Conformance Criteria.

A further requirement of transfers of information between PHR and EHR systems is that authorship of the information stored within the PHR shall be tracable through the various import/export cycles. PHR Manager Actors must be secure nodes, which requires logging of any updates to or accesses of PHR information. The DSG profile should be used to ensure that information coming into, or exiting these systems is verifiably authored.

Standards

AHIMA-PHR	AHIMA PHR Common Data Elements
CDAR2	Clinical Document Architecture, Release 2.0, 2005, HL7
CRS	Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm), 2006, HL7.
CCD	ASTM/HL7 Continuity of Care Document
HL7-PHR	HL7 PHR Functional Model (Draft)
LOINC	Logical Observation Identifier Names and Codes

Data Element Index

AHIMA Common Data Elements	ASTM Continuity of Care Record	HL7 Clincial Document Architecture, Care Record Summary or Continuity of Care Document	HL7 PHR Conformance Criteria
Personal Information	Patient	patientRole	Demographic Information
Name	Patient	patient/name	Demographic Information
Address	Patient	patientRole/addr	Contact Information
Contact Information	Patient	patientRole/telecom	Contact Information
Personal Identification	Patient	patientRole/id	Demographic Information
Information
Gender	Patient	patient/genderCode	Demographic Information
Date of Birth	Patient	patient/dateOfBirth	Demographic Information
Marital Status	Patient	patient/martitalStatusCode
Race	Patient	patient/raceCode
Ethnicity	Patient	patient/ethnicityCode	Demographic Information
(Religious Affiliation[1])	Patient	patient/religiousAffiliationCode	Spiritual Affiliation / Considerations
Languages Spoken	Patient	patient/languageCommunication
Employer and School Contacts	Social History	participant/associatedEntity[
Hazardous Working Conditions	Social History	HISTORY OF OCCUPATIONAL EXPOSURE
Emergency Contacts	Support	participant/associatedEntity[
	patient/guardian
Healthcare Providers	Practitioners	serviceEvent/performer	Healthcare Providers
Insurance Providers	Insurance	Health Insurance
	Pharmacy Insurance
Pharamacy	performer
Legal Documents and Medical Directives	Advance Directives	ADVANCE DIRECTIVES	Advance Directive
General Medical Information
Height, Weight	Vital Signs	VITAL SIGNS
Blood Type	Results	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Last Physical or Checkup	Encounters	HISTORY OF OUTPATIENT VISITS	Clinical Encounters and Procedures List
Allergies and Drug Sensitivies	Alerts	HISTORY OF ALLERGIES	Allergy and Reaction List
Conditions	Problems	HISTORY OF PAST ILLNESS - or - PROBLEM LIST	Problem List
Surgeries	Procedures	HISTORY OF SURGICAL PROCEDURES	Clinical Encounters and Procedures List
Medications – Prescription and Non-Prescription	Medications	HISTORY OF MEDICATION USE	Medication List
Immunizations	Immunizations	HISTORY OF IMMUNIZATIONS	Immunizations List
Doctor Visits	Encounters	HISTORY OF OUTPATIENT VISITS	Clinical Encounters and Procedures List
Hospitalizations	Encounters	HISTORY OF HOSPITALIZATIONS	Clinical Encounters and Procedures List
Other Healthcare Visits	Encounters	HISTORY OF OUTPATIENT VISITS	Clinical Encounters and Procedures List
Clinical Tests	Results	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA	Laboratory and Test Results
Pregnancies	HISTORY OF PREGNANCIES
Medical Devices	Medical Devices	HISTORY OF MEDICAL DEVICE USE
Family Member History	Family History	HISTORY OF FAMILY MEMBER DISEASES	Family History
Foreign Travel	HISTORY OF TRAVEL
Therapy	Plan of Care	TREATMENT PLAN	Care Plans, Goals and Disease Management
Vital Signs	Vital signs	VITAL SIGNS
(Functional Status[2])	Functional Status	FUNCTIONAL STATUS

-->>Data<<--

Specification

Data Element Name	Opt	Template ID
Personal Information	R	See Personal Information
Name	R	See Personal Information
Address	R2	See Personal Information
Contact Information	R2	See Personal Information
Personal Identification Information	R2	See Personal Information
Gender	R	See Personal Information
Date of Birth	R2	See Personal Information
Marital Status	R2	See Personal Information
Race	O	See Personal Information
Ethnicity	O	See Personal Information
(Religious Affiliation[2])	O	See Personal Information
Languages Spoken	R2	1.3.6.1.4.1.19376.1.5.3.1.2.1
Employer and School Contacts	O	1.3.6.1.4.1.19376.1.5.3.1.2.2
Hazardous Working Conditions	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
Emergency Contacts	R2	1.3.6.1.4.1.19376.1.5.3.1.2.3.1
Healthcare Providers	R	1.3.6.1.4.1.19376.1.5.3.1.2.3
Insurance Providers	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
Pharamacy	R2	1.3.6.1.4.1.19376.1.5.3.1.2.3
Legal Documents and Medical Directives	R2	1.3.6.1.4.1.19376.1.5.3.1.3.34
Allergies and Drug Sensitivities	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
Conditions	R	1.3.6.1.4.1.19376.1.5.3.1.3.8
Conditions (cont)	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Surgeries	R2	1.3.6.1.4.1.19376.1.5.3.1.3.12
Medications – Prescription and Non-Prescription	R	1.3.6.1.4.1.19376.1.5.3.1.3.19
Immunizations	R2	1.3.6.1.4.1.19376.1.5.3.1.3.23
Doctor Visits / Last Physical or Checkup	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Hospitalizations	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Other Healthcare Visits	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Clinical Tests / Blood Type	O	1.3.6.1.4.1.19376.1.5.3.1.3.28
Pregnancies	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Medical Devices	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5
Family Member History	O	1.3.6.1.4.1.19376.1.5.3.1.3.15
Foreign Travel	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6
Therapy	O	1.3.6.1.4.1.19376.1.5.3.1.3.31
Vital Signs	R	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Functional Status	O	1.3.6.1.4.1.19376.1.5.3.1.3.17

Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below.

Sample PHR Extract Document

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>PHR Extract</title> <effectiveTime value='20240419012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/> : <component><structuredBody>     </structuredBody></component> </ClinicalDocument>

 

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a PHR Extract must be {{{LOINC}}}
   </assert>
   <assert test='cda: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>

Constraints

The LOINC Document type code for this document is 34133-9 SUMMARY OF EPISODE NOTE.

The assignedAuthoring device shall be populated with information about the EHR and/or PHR which assisted in creation of the document.

All sections and entries within the document shall contain an <id> element.