HITSP Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS) Component

July 8, 2009

Version 1.2

HITSP Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS) Component

HITSP/C38

Healthcare Information Technology Standards Panel (HITSP) logo

Submitted to:

Healthcare Information Technology Standards Panel

Submitted by:

Care Management and Health Records Domain Technical Committee

Document Change History

Version Number	Description of Change	Name of Author	Date Published
0.0.1	Review Copy	Population Health Technical Committee	September 8, 2007
0.0.2	Review Copy	Population Health Technical Committee	December 5, 2007
1.0	Released for Implementation	Population Health Technical Committee	December 13, 2007
1.0.1	Review Copy	Care Management and Health Records Domain Technical Committee	August 20, 2008
1.1	Released for Implementation	Care Management and Health Records Domain Technical Committee	August 27, 2008
	Template V2.5	Project Team	June 30, 2009
1.1.1	Review Copy	Care Management and Health Records Domain Technical Committee	June 30, 2009
1.2	Released for Implementation	Care Management and Health Records Domain Technical Committee	July 8, 2009

Table of Contents

1.0 Introduction. 5

1.1 Overview. 5

1.2 Copyright Permissions. 5

1.3 Reference Documents. 5

1.4 Conformance. 5

1.4.1 Conformance Criteria. 6

1.4.2 Conformance Scoping, Subsetting and Options. 6

2.0 Component Definition. 7

2.1 Context Overview. 7

2.1.1 Component Constraints. 7

2.1.2 Component Dependencies. 7

2.2 Rules for Implementing. 7

2.2.1 Data Mapping. 7

2.2.1.1 Cross Reference Table Key. 7

2.2.1.2 Patient Level Quality Data Message Data Set 7

2.2.1.3 Mapping Table. 21

2.2.2 Guidelines and Examples. 34

2.3 Standards. 34

2.3.1 Regulatory Guidance. 34

2.3.2 Selected Standards. 34

2.3.3 Informative Reference Standards. 36

3.0 Appendix. 37

Document Updates. 38

3.1 December 5, 2007. 38

3.2 December 13, 2007. 38

3.3 August 20, 2008. 38

3.4 August 27, 2008. 38

3.5 June 30, 2009. 38

3.6 July 8, 2009. 38

Figures and Tables

Table 1-1 Reference Documents. 5

Table 2-1 Component Constraints. 7

Table 2-2 Component Dependencies. 7

Table 2-3 Data Element Cross Reference. 7

Table 2-4 Data Element Cross Reference. 8

Table 2-5 Base Facility Data Elements. 8

Table 2-6 Patient Data Elements. 8

Table 2-7 Clinical Data Elements Problem Data. 10

Table 2-8 Clinical Data Elements Adverse Event Entry. 11

Table 2-9 Clinical Data Elements Product in Support of Adverse Event Data. 12

Table 2-10 Clinical Data Elements Reaction in Support of Adverse Event Data. 12

Table 2-11 Clinical Data Elements Severity in Support of Adverse Event Data. 12

Table 2-12 Clinical Data Elements Diagnosis Data. 13

Table 2-13 Clinical Data Elements Vital Signs. 13

Table 2-14 Clinical Data Elements Procedures and Diagnostic Tests. 14

Table 2-15 Clinical Data Elements Other Clinical Data Elements. 15

Table 2-16 Clinical Data Elements Medication Data. 16

Table 2-17 Clinical Data Elements Study Findings/Test Results Laboratory. 20

Table 2-18 Clinical Data Elements Study Findings/Test Results Radiology and Other Studies. 20

Table 2-19 Patient Data Mapping. 21

Table 2-20 Data Mapping Problem Data. 23

Table 2-21 Data Mapping Diagnosis Data. 26

Table 2-22 Data Mapping Vital Signs. 26

Table 2-23 Data Mapping - Procedures and Diagnostic Tests. 27

Table 2-24 Data Mapping Other Clinical Data Elements. 28

Table 2-25 Data Mapping Medication Data. 29

Table 2-26 Data Mapping - Study Findings/Test Results Laboratory. 32

Table 2-27 Data Mapping - Study Findings/Test Results Radiology and Other Studies. 33

Table 2-28 Regulatory Guidance. 34

Table 2-29 Selected Standards. 34

Table 2-30 Informative Reference Standards. 36