Note for the readers This template version represents the best representation of the original epSOS/EXPAND
specifications in ART DECOR. However the original epSOS/EXPAND specifications in Microsoft Word took the original IHE Templates and added constraints
in written language. This actually is not best practice in electronic Template Design because the
additional constraints are not assigned to the original IHE template but rather than
that are text only constraints. In order to make everything computable new Template
OIDs need to be assigned to the epSOS Templates in order to cover both, the original
IHE Template Design and the additional constraints from epSOS in the text and represent
them electronically. Caveat: for the above mentioned reasons this version cannot be used for (automatic) testing/validation purposes. It shall be used however as basis for refinement
(repository)
Note: there is a new version planned that covers all above and makes proper testing/validation
possible
epSOS Patient Summary Template
The implementers must be familiar with the context of the project, as it shall not
be repeated in this document. The implementers must also be familiar with the content
of the following documents:
CDA Release 2.0 Normative Web Edition, May, 2005
HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), HL7,
April 1, 2007.
Integrating the Healthcare Enterprise, Patient Care Coordination Technical Framework,
Volume 1 and Volume 2- Revision 10, IHE International, November 4, 2014.
Integrating the Healthcare Enterprise, Patient Care Coordination CDA Content Modules-
Trial Implementation Supplement, December 3, 2014.
HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, HL7,
July 16, 2008.
It must also be noted that although the guidelines are based on the above documents,
they contain specific developments particular to the project epSOS. This document
can be used as a standalone to develop the syntax of the epSOS documents; however
in order to achieve the full functionality of the epSOS Semantic Services, they are
to be used within the context of the deliverable 3.9.1.
Prescribed and dispensed medications, including a specification of the Medication
Summary section used in the Patient Summary document, have described in the previous
chapter. The following sub-paragraphs specify how other sections that may be present
in a Patient Summary are implemented.
According to requirements described in the Body Data Elements, the following sections
- at least - shall be present in a Patient Summary document:
The Medication Summary Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.3
The Allergies and Other Adverse Reactions Section 1.3.6.1.4.1.19376.1.5.3.1.3.13
The Coded List of Surgeries Section 1.3.6.1.4.1.19376.1.5.3.1.3.12
The Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6
The Medical Devices Coded Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.4
Appropriated codes and/or nullFlavor values will be used in these sections to express
for example that coded information is not available, either that an entry is not applicable
or that information is not known, ….. See the related paragraph for further details.
While the XML Schema Language allows a schema location to be associated with an XML
document by including a schemaLocation attribute associated with the http://www.w3.org/2001/XMLSchema-instance
namespace, this is explicitly PROHIBITED by [ITS§1.4], and thus by the CDA standard.
The ClinicalDocument/id element is an instance identifier data type. The root attribute is an OID. If there
is a value in @extension, then the root uniquely identifies the scope of the extension.
If there is no value in @extension then @root SHALL uniquely identify the document
UUIDs SHALL be represented in the form XXXXXXXX-XXXX-XXXX-XXXX-XXXXXXXXXXXX, where
each X is a character from the set [A-Fa-f0-9].
OIDs SHALL be represented in dotted decimal notation, where each decimal number is
either 0, or starts with a nonzero digit. More formally, an OID SHALL be in the form
([0-2])(.([1-9][0-9]*|0))+.
By definition, a Patient Summary document describes the Patient Summary at the time
of creation of the document, represented by the /ClinicalDocument/effectiveTime XML Element.
The time when this instance of the document has been authored may be instead recorded
by the /ClinicalDocument/author/time element. (e.g. when a “spider” has collected
information for generating this instance of the document; or a practitioner updated
its local summary document).
Finally, the latest summary update, intended as the last date documented by this summary
(e.g. the last update occurred to the PHR from which the PS data has been extracted)
can be represented by the /ClinicalDocument/documentationOf/serviceEvent/effectiveTime/high XML Element (see section 2.1, CONF-2, CONF-3 and CONF-4 of the CCD specification).
This identifier is used to link together different versions of the same document:
the CDA L3 document, the CDA PDF embedded document and the version in the national
infrastructure.
The patient address
element is required. If there is no information, the nullFlavor attribute shall have
a value of 'NI' and no address parts shall be present, otherwise there shall be no
nullFlavor attribute, and at least one of the address parts listed below shall be
present.
Patient’s telephone number / Patient e-mail address. The patient telephone or e-mail
element is required. If there is no information, the nullFlavor attribute shall have
a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the
nullFlavor attribute shall not be present, and the "value" and "use" attributes shall
be present Optionalities and Cardinalities of the following two items shall be interpreted
according to this rule: e.g. is not expected to have two nullFlavored telecom elements.
The guardians of a patient shall be recorded in the <guardian> element beneath the
/ClinicalDocument/recordTarget/patientRole/patient XML - <patient> element. Other
patient contacts are described using the /ClinicalDocument/participant structure.
The <associatedEntity> element defines the type of contact.
The relationship between the patient and the guardian or other contact should be recorded
in the <code> element. The code attribute is required and comes from the HL7 PersonalRelationshipRoleType
vocabulary (eHDSIPersonalRelationship value set).
The address of the guardian or other contact should be present, and shall be represented,
as any other address would be in CDA.
The phone number of the guardian or other contact should be present, and shall be
represented, as any other phone number would be in CDA.
The name of the guardian or other contact shall be present, and shall be represented,
as any other name would be in CDA.
R1.7.A
@classCode
cs
1 … 1
F
GUARD
@nullFlavor
cs
0 … 1
Use nullFlavor if unknown or if no information is applicable
Example
<guardianclassCode="GUARD"> <templateIdroot="1.3.6.1.4.1.19376.1.5.3.1.2.4"/><addr> <streetAddressLine>2222 Home Street</streetAddressLine><city>London</city><state>London</state><postalCode>A1B 2C3</postalCode><country>UK</country></addr><telecomvalue="tel:+452070256161"/><telecomvalue="mailto:jsmith@myprovider.co.uk"/><guardianPerson> <name> <given>John</given><family>Español Smith</family></name></guardianPerson></guardian>
The guardian’s address
element is required. If there is no information, the nullFlavor attribute shall have
a value of 'NI' and no address parts shall be present, otherwise there shall be no
nullFlavor attribute, and at least one of the address parts listed below shall be
present
R1.7.A
@nullFlavor
cs
0 … 1
F
NI
hl7:streetAddressLine
0 … *
R
Guardian's Number of Street/Guardian's Number of Street
R1.7.3.2
hl7:city
0 … 1
R
Guardian's City
R1.7.3.3
hl7:postalCode
0 … 1
R
Guardian's Postal Code
R1.7.3.4
hl7:state
0 … 1
R
Guardian's State or Province
R1.7.3.5
hl7:country
0 … 1
R
Guardian's Country. When used addr.country it is always bound to the epSOSCountry
value set
R1.7.3.6
Constraint
The content of this element SHALL be selected from ValueSet epSOSCountry urn:oid:1.3.6.1.4.1.12559.11.10.1.3.1.42.4
Guardian’s telephone number / Patient e-mail address. The guardian telephone or e-mail
element is required. If there is no information, the nullFlavor attribute shall have
a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the
nullFlavor attribute shall not be present, and the "value" and "use" attributes shall
be present Optionalities and Cardinalities of the following two items shall be interpreted
according to this rule: e.g. is not expected to have two nullFlavored telecom elements.
This element is derived from the IHE template LanguageCommunication (1.3.6.1.4.1.19376.1.5.3.1.2.1),
however this template does not need the element preferenceInd because the language
is already said to be the "preferred language".
The author/time element represents the start time of the author’s participation in
the creation of the clinical document. The author/time element SHALL be present.
If there is no information, the nullFlavor attribute shall have a value of 'NI' and
the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute
shall not be present, and the "value" and "use" attributes shall be present.
Optionalities and Cardinalities of the following two items shall be interpreted according
to this rule: e.g. is not expected to have two nullFlavored telecom elements.
The person taking responsibility for the medical content of the document. In Spain
this is the regional authority in healthcare. This regional authority healthcare organization
will send this to the NCP. The definition of the legal authenticator may vary accoriding
to the rules set up in the framework agreement particular to each state. It may be
a person or a regional authority, or an NCP.
If there is no information, the nullFlavor attribute shall have a value of 'NI' and
the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute
shall not be present, and the "value" and "use" attributes shall be present.
Optionalities and Cardinalities of the following two items shall be interpreted according
to this rule: e.g. is not expected to have two nullFlavored telecom elements.
The element identifies the type of contact. The classCode attribute shall be present,
and contains a value from the eHDSIRoleClass value set when used for the patient contacts;
‘PRS’ when used for “Preferred HP / Legal Organization”.
The relationship between the patient and the guardian or other contact should be recorded
in the element. The code attribute is required and comes from the HL7 PersonalRelationshipRoleType
vocabulary with codeSystem (2.16.840.1.113883.5.111). The codeSystem attribute is
required. The relationship between the patient and his preferred HP comes from the
the full RoleCode (2.16.840.1.113883.5.111) codeSystem
Patient Contact's / Preferred HP's/Legal Organization telephone or e-mail
element is required. If there is no information, the nullFlavor attribute shall have
a value of 'UNK' and the "value" and "use" attributes shall be omitted, otherwise
the nullFlavor attribute shall not be present, and the "value" and "use" attributes
shall be present
represents the healthcare providers involved in the current or pertinent historical
care of the patient. Preferably, the patient’s key healthcare providers would be listed,
particularly their primary physician and any active consulting physicians, therapists,
and counselors
(eHDary)
@typeCode
cs
1 … 1
R
CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601x_ServiceEventPerformer (DYNAMIC)
If there is no information, the nullFlavor attribute shall have a value of 'NI' and
the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute
shall not be present, and the "value" and "use" attributes shall be present.
Optionalities and Cardinalities of the following two items shall be interpreted according
to this rule: e.g. is not expected to have two nullFlavored telecom elements.
Template eHDSI Patient Summary
Clinical Data
Transaction
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