PCC TF-1/PHLAB/XDSLAB Harmonization

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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 as they incorporate relevant laboratory data into their own content profiles.

Benefits:

  • Consistency with work done in other domains (example annotation comment)
  • Provide guidance to other domains incorporating laboratory data (example PCC)
  • Provide context to section of CDA (example intended recipient)

CDA Document Content Modules

CDA Header Content Modules

CDA Section Content Modules

CDA and HL7 Version 3 Entry Content Modules





Laboratory Organizer - Isolate Organizer

XDS-Lab Current Specification: <organizer><specimen><specimenRole> block

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">
              ...
              <entryRelationship typeCode="COMP">
                <organizer classCode="CLUSTER" moodCode="EVN">
                  <templateId root="TBD"/>
                  <statusCode code="completed"/>
                  <effectiveTime value="20071108000000.0000-0500"/>
                  <specimen>
                    <specimenRole classCode="ISLT">
                      <specimenPlayingEntity>
                        <code code="79153007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" 
                              displayName="Salmonella tennessee 6,7,14;z29;1,2,7">
                          <translation xsi:type="CE" code="L-17601" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" 
                                                     displayName="Salmonella tennessee 6,7,14;z29;1,2,7"/>


Laboratory Observation

XDS-Lab Current Specification: <observation> block

Proposed Specification: no change

Reason for template: re-usability

Note that Simple Observation cannot be used as is, XDS-LAB does not require an id. 

<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">
                  <code code="23749-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" 
                        displayName="Lead Measurement, Quantitative">
                    <originalText><reference value="pbTest"/></originalText>
                  </code>
                  <statusCode code="completed"/>
                  <effectiveTime value="20071108000000.0000-0500"/>
                  <value xsi:type="PQ" unit="mg/dL" value="7.4"/>
                  <interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/>

Annotation Comment (PCC)

We would like XDS-Lab to adopt the Annotation Comment content module for comments.


Reason for template: consistency with existing content module

Change Proposals: PCC Change Proposal Wiki List 


<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 ID="rabiesTestComment">
                <tr>
                  <td>Repeat confirmed negative</td>
                </tr>
              </tfoot>
              <tbody>
                <tr>
                  <td>Rabies virus not found.</td>
                  <td>ferret</td>
                  <td ID="rabiestTestR1Comment">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>
                  <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><reference value="rabiestTestR1Comment"/></text>
                      <statusCode code='completed'/>
                    </act>
                  </entryRelationship>
                  <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><reference value="rabiestTestTComment"/></text>
                      <statusCode code='completed'/>
                    </act>
                  </entryRelationship>
                </observation>
              </entryRelationship>
              ...
              <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><reference value="sComment"/></text>
                  <statusCode code='completed'/>
                </act>
              </entryRelationship>

Differed for later discussion

Specimen

XDS-Lab Current Specification: <specimen> block

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"/>
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