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The following sections provide the details of updates made to this document.
Added mapping to HITEP-identified data elements or TC-identified elements to support the HITSP Use Case
Added data elements to round out concepts for problems, medications, and adverse events and to align with HITSP/C32
Updated vocabularies to use V3 vocabulary sets as should be done for V3 CDA
Upon approval by the HITSP Panel on December 13, 2007, this document is now Released for Implementation.
This document has been modified to reflect the updated HITSP approach to categorizing standards as Regulatory Guidance, Selected Standards, and Informative References.
Deleted the following from the standards listing:
Consolidated Health Informatics (CHI)
Digital Imaging and Communications in Medicine (DICOM) Attribute Level Confidentiality Supplement: # 55
Added the following Selected Standard:
Integrating the Healthcare Enterprise (IHE) Patient Care Coordination (PCC), Revision 3.0, 2007-2008, Cross-Enterprise Sharing of Medical Summaries (XDS-MS) Integration Profile
Upon approval by the HITSP Panel on August 27, 2008, this document is now Released for Implementation.
Minor editorial changes were made to this document. Removed boilerplate text for simplification. The term actor was replaced with interface.
Upon approval by the HITSP Panel on July 8, 2009, this document is now Released for Implementation.
[1] We recognize the existence of CPT II as a new administrative coding system to collect measurement required data elements. The long-term goal for interoperability is to use clinical terminology allowing the repurposing of data created as part of routine clinical care delivery. For the short term, CPT II codes may be useful to capture required data for measurement calculation, especially with respect to exclusion criteria inherent in many measures. The Technical Committee has recommended standards and terminologies to enable clinical data element standardization which will require work effort by EHRs, receiving systems and clinical measurement and guideline developers. Such standardization will support repurposing of routine clinical care data for quality measurement without interposition of additional coding schema such as CPT II.
[2] The location in the Destination column can be considered to be pseudo-XPath. While not properly formed XPath expressions in all cases, these destinations should allow a reader familiar with XPath notation to identify the location of the data element in a CDA document. Descriptions are included next to LOINC and SNOMED codes to aid comprehension.
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