1CDA Open Issues: (June 20, 2002)

1.1.1Model/Use of RIM

1.1.2HMD

1.1.3Vocab

1.1.4ITS

1.1.5Changes for Level One

1.1.6Required additions for Levels Two & Three

1.1.7Prose

1.1.8Sample XML Instance

1.1.9MISC

1.1.1Model/Use of RIM

  1. Identification of changes required due to current RIM and current data types -- ?
  2. Create body R-MIM: need requirements first, especially for rendering -- Bob, Calvin, Liora
  3. Review clones from other committees against our proposed models
  4. Include: caption with free text and link for each section; local_markup; link_CDA
  5. Medications – need to review modeling. These aren’t really “events”. In some cases, it is the patient saying what they are taking. In some cases the information comes from a pharmacy system. In some cases, a family member brings in bottles. Need to review how to express the “PRN” portion of a prescription.
  6. Allergies – need to review modeling. How to link the allergy to the associated reaction?
  7. Need to review the correct values for Act.cd in in the case of diagnoses, allergies, allergic reactions, etc (for instance, are these “prior diagnoses”, “findings”, etc)
  8. Should we indicate whether or not the structured data fully encodes the narrative?
  9. For CXR example – how to know you’re referring to some external object? (The example uses an Act_relationship with type_cd = “REFR”)
  10. Where/how do we inherit the date of an observation? Or do we need to include this for every observation?

1.1.2HMD

  1. replace HMD with merged MRM/CDA HMD (change db #21) -- Bob

1.1.3Vocab

  1. Evaluate our use of RIM vocabulary -- ?
  2. Role of participant: Should CDA convey the role or specialty of the author (attending, cardiology, …) (should we re-examine the use of the function_cd field?) -- Bob to call Steve Brown

1.1.4ITS

  1. General choices: 1) CDA-specific modifications to V3 ITS; 2) general modifications to V3 ITS; 3) modify CDA to work with V3 ITS
  2. Known discrepancies with V3 ITS:
  • CDA has nested sections that mix with nested entries
  • XML Lang attribute
  • act.txt is a highly specialized type, only defined by an XML DTD
  1. ITS(s): W3C Schema? DTD? RELAX NG? Decide normative status of each. Bob, Amnon
  2. Validation: Make sure the ID/IDREF for originator, etc are correct.Bob

1.1.5Changes for Level One

  1. Link CDA: 3.3.2.4.3: need to add proposal for “link_CDA”; potentially other link types: inserted decision from minutes of 11-15-01. (Bob, Simona)
  2. Target is another CDA document. Primary document is not complete without the presence of the target. Use case: BMT with disease insert. Disease document is generated elsewhere. In the summary document, you have to reference the disease insert document. When you receive the summary document, you need to also have the referenced document in order to fully interpret the summary document.
  3. If this is a semantic link, what is the value of Act_relationship.type_cd?
  4. Must the target be a CDA document, or can it be any OID?
  5. see notes in DRAFT section 3.3.2.4.3
  6. Cardinality of <fulfills_order>, should be changed (change db #20)
  7. Referenced coordinates: Modeled as a discreet observation that refers to the referenced coordinate. (If so, need to add an Act_relationship in the R-MIM); Also needs relationship to linked images (e.g. for x-rays); Need AR from Observation to A_Ref_Coord -- ?? ITS, rendering issue?
  8. consider change to MIME-packaging per Gunther’s suggestion

1.1.6Required additions for Levels Two & Three

  1. Coded_entry in Levels Two & Three? should we maintain the distinction between caption_cd and coded_entry?
  2. Need a better understanding of how all the pieces can or should fit together:
  3. Need to review SNOMED hierarchies: Findings, Context-dependent categories, Observable entities, Observations procedures, Interpretation of Findings, Qualifier values.
  4. Pre- vs. Post-coordination of codes (see Dolin RH, Spackman KA, Markwell D. Selective Retrieval of Pre- and Post-coordinated SNOMED Concepts. Fall AMIA 2002. In Press).
  5. Lab and Clinical LOINC codes.
  6. ICD-9-CM and other administrative mappings (since at times it may be preferable to use codes that map to ICD-9-CM)
  7. RIM attributes: Negation indicator, Context, Observation.cd vs. Observation.value.

1.1.7Prose

  1. Clarify use of confidentiality codes; (change db #21)
  2. Update:
  • DTD comments
  • appendices
  1. Add section on backward compatibility
  2. Update section on when to use MDM vs. ORU (Scott)
  3. Document XFRM to <document_relationship.type_cd> to indicate that document transforrmed from source (change db #17)
  4. Document that retired the Patient_encounter.practice_setting_cd attribute; Indicate that the PracticeSetting vocabulary domain can be used for the Role.cd attribute; Re-map the current CDA <practice_setting_cd> to be derived from Role.cd, using the PracticeSetting vocabulary domain; add Practice_setting values. (change db #21)
  5. Document organization as potential intended recipient (change db #19)

1.1.8Sample XML Instance

  1. The sample will be updated as decisions are made, to reflect what a valid and conformant instance will look like.
  2. Some of the LOINC section codes in Bob’s NG CDA are made up. Need to validate (and make sure needed section codes are in LOINC).
  3. Things to add:
  4. Calvin’s Vital signs table
  5. Section that starts off with entries before there is a nested section.
  6. Context/Inheritance
  7. An in-office procedure (e.g. suture removal)
  8. Review modeling of units within observation values.
  9. Flavor of NULL (e.g. for Chem-7)

1.1.9MISC

  1. What is the down-side to just using HTML in the Act.txt field?