HITSP CDA Content Modules

The changes in this construct address the following comments received during the Public Comment and Inspection Testing period (September 29 October 24, 2008).

5081, 5082, 5109, 5192, 5468, 5473, 5485, 5489, 5621, 5623, 5631, 5463, 5028, 5626, 5624

The full text of the comments along with the Technical Committees disposition can be reviewed on the HITSP Public Web Site.

4.1.1 Global

The following changes were applies through-out the document for consistency with the HITSP suite of Interoperability Specifications

Many Entry Content Modules contained descriptions pertaining to related Section Content Modules. This text has been moved to the appropriate Section Content Module and re-worded when needed. The sections modified are:

- 2.2.2.3, 2.2.2.5, 2.2.1.1, 2.2.2.6, 2.2.1.2, 2.2.2.7, 2.2.2.8, 2.2.1.12, 2.2.2.16, 2.2.1.27, 2.2.2.19

- NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

Added text and removed requirements in Entry data elements in the Entry Content Modules

- Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications), for:

2.2.2.5, 2.2.2.6, 2.2.2.7, 2.2.2.8, 2.2.2.9, 2.2.2.12, 2.2.2.13, 2.2.2.14, 2.2.2.15,2.2.2.16, 2.2.2.17, 2.2.2.18, 2.2.2.19

4.1.2 Section 2.1 Contect Overview

Added text to describe why Template IDs may have changed from HITSP/C32 to HITSP/C83

4.1.3 Section 2.2 Rules for Implementing

Added constraints that were previously specified in HITSP/C32 but now apply to all HITSP CDA based documents. Added C[83] 4 11.

4.1.4 Section 2.2.1.x Section Content Modules

4.1.5 Section 2.2.1.23 Assessments and Plan Section

4.1.6 Section 2.2.1.28 Medical equipment Section

4.1.7 Section 2.2.2.5 Insurance Provider

This section is based upon HL7 CCD and HITSP cannot lower a field requirement if required by the CCD, thus two requirements have been modified.

4.1.8 Section 2.2.2.7 Condition

Removed text related to Registration and Medication History. This information is part of IS03.

4.1.9 Section 2.2.2.11 Comment

4.1.10 Section 2.2.2.15.2 Results Type

4.1.11 Section 2.2.2.17 Procedure

Deleted and moved text to TN901 that described standards overlap for procedure terminologies.

4.1.12 Section 2.2.2.18 Family History

Clarified that Family Member Relationships (18.04) can reference beyond 2^nd degree

4.1.13 Section 2.2.2.19 Social History

4.1.14 Section 2.3.2 Selected standards

Corrected the reference to the Integrating the Healthcare Enterprise (IHE) Patient Care Coordination (PCC) from version 3 to version 4

4.2 December 18, 2008

Upon approval by the HITSP Panel on December 18, 2008, this document is now Released for Implementation.

4.3 June 30, 2009

7071, 7078, 7079, 7080, 7081, 7086, 7089, 7090, 7091, 7094, 7096, 7097, 7098, 7112, 7116, 7117, 7118, 7126, 7122

The full text of the comments along with the Technical Committees disposition can be reviewed on the HITSP Public Web Site.

Minor editorial changes were made to this construct. Removed boilerplate text for simplification. The term actor was replaced with interface.

- Added this section, which now contains the Data Element Definitions previously found in the Entry Content Modules Section.

- Moved common value set constraints from the Entry Content Modules Section to this section where these constraints should be applied across exchanges using different selected standards.

- Change the name of the Rules for Implementing Components to Rules for Implementing Components in CDA to reflect the purpose of this section.

- Change the Constraint Numbers to reflect the numbering scheme agreed upon by the Data Architecture Tiger Team.

- Reordered and re-titled the Mapping Tables to conform to material provided in TN903.

4.4 July 8, 2009

Upon approval by the HITSP Panel on July 8, 2009, this document is now Released for Implementation.

[1] Several HITSP selected standards use different code systems for this data element. The HITSP Foundations committee is working with the respective standards bodies to harmonize the standards. Until such time as harmonized standards are adopted, we recommend the use of a value set that is consistent with that specified by this constraint.

[2] Given that this is a U.S. Realm specification, the template id 2.16.840.1.113883.10.20.3 is already required by the PCC template for medical documents. We include this information here for completeness.

[3] NOTE : Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[4] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[5] Judgments about language proficiency are subjective, and could have a negative impact on consumers.

[6] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[7] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[8] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[9] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[10] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[11] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[12] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[13] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[14] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[15] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[16] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[17] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[18] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[19] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[20] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[21] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[22] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[23] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[24] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[25] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[26] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[27] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[28] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[29] NOTE : Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[30] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[31] NOTE: Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[32] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

[33] NOTE : Optionality = R for Required, R2 for Required if known, O for Optional and Repeat = Y for Yes or N for No

[34] Requirements for Entries are defined at a higher level than the Entry Content Module (i.e. Section Content Modules, HITSP CDA based constructs and Interoperability Specifications).

4.0 Document Updates

4.1 December 10, 2008