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Appendix

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A - Acronyms and Abbreviations

Acronym	Description
ADL	Activities of Daily Living
C-CDA R1, R1.1, R2	Consolidated CDA (Release 1, 1.1, and 2)
CCD	Continuity of Care Document
CDA, CDA R2	Clinical Document Architecture (Release 2)
CDC	Centers for Disease Control and Prevention
CFR	Code of Federal Regulations
CID	content identifier
CPT	Current Procedural Terminology
CVX	Codes for Vaccine Administered
DAM	Domain Analysis Model
DI	device identifier
DICOM	Digital Imaging and Communications in Medicine
CMET	Common Message Element Type
DIR	Diagnostic Imaging Report
DME	durable medical equipment
DRIV	is derived from
DSTU	Draft Standard for Trial Use
EHR	electronic health record
EMR	electronic medical record
EVN	event
FDA	Food and Drug Administration
FIPS	Federal Information Processing Standards
GOL	goal
H&P	History and Physical
HCT/P	Human Cell & Tissue Products
HHPoC	Home Health Plan of Care
HIBCC	Health Industry Business Communications Council
HIE	health information exchange
HISP	health information service provider
HIT	healthcare information technology
HITSP	Health Information Technology Standards Panel
HL7	Health Level Seven
HTML	Hypertext Markup Language
IADL	Instrumental Activities of Daily Living
ICCBBA	International Council for Commonality in Blood Banking Automation, Inc.
ICD	International Classification of Diseases
ICF	International Classification of Functioning, Disability and Health
IG	implementation guide
IHE	Integrating the Healthcare Enterprise
PCC	Patient Care Coordination
IHTSDO	International Health Terminology Standard Development Organisation
RFC	Request for Comments
ITI	information technology infrastructure
LCC	Longitudinal Care Coordination
LCP	Longitudinal Care Plan
LOINC	Logical Observation Identifiers Names and Codes
LTPAC	Long-Term Post-Acute Care
MHTML	MIME HTML
MIME	Multipurpose Internet Mail Extensions
MPHO	Medical Products of Human Origin
NA	not applicable
NDC	National Drug Code
NDFRT	National Drug File Reference Terminology
NEMA	National Electrical Manufacturers Association
NHSN	National Healthcare Safety Network
NI	no information
NLM	National Library of Medicine
NPI	National Provider Identifier
NPO	nothing by mouth
NPP	non-physician provider
NUBC	National Uniform Billing Committee
NUCC	National Uniform Claim Committee
OID	object identifier
ONC	Office of National Coordinator
OTH	not an element in the value domain
PCDATA	Parsed Character Data
PCWG	Patient Care Work Group
PDF	Portable Document Format
PGD	Patient Generated Document
PGP	Pretty Good Privacy
PHQ	Patient Health Questionnaire
PHR	personal health record
PI	Production Identifier
PKCS#7	public-key cryptography standard seven (Cryptographic Message Syntax Standard
RFC	request for comment
RIM	Reference Information Model
RMIM	Refined Message Information Model
RQO	request
RSNA	Radiological Society of North America
S&I	Standards and Interoperability
sdtc	Standard Duty Title Code
SDWG	Structured Documents Working Group
SMART	Substitutable Medical Applications & Reusable Technology
SNF	Skilled Nursing Facility
SNOMED CT	Systemized Nomenclature for Medicine – Clinical Terms
SOP	Service Object Pair
SPL	Structured Product Labeling
SR	Structured Report
SSN	Social Security Number
SWG	Sub Work Group
TPN	Total Parenteral Nutrition
UCUM	Unified Code for Units of Measure
UD	Unstructured Document
UDI	Unique Device Identification
UML	Unified Modeling Language
UNII	Unique Ingredient identifier
UNK	unknown
URL	uniform resource locator
URN	uniform resource name
UUID	universally unique identifier
VIS	Vaccine Information Statement
WADO	Web Access to Persistent DICOM Objects
XDS-SD	Cross Enterprise Sharing of Scanned Documents
XML	eXtensible Markup language
XML-DSIG	XML digital signature
XPath	XML Path Language

B - High-Level Change Log

This implementation guide builds on HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm), Release 2.0. (NOV 2014).

C - Extensions to CDA R2

Where there is a need to communicate information for which there is no suitable representation in CDA R2, extensions to CDA R2 have been developed. These extensions are described above in the context of the section where they are used. This section serves to summarize the extensions and provide implementation guidance. Extensions created for this guide include:

• sdtc:raceCode - The raceCode extension allows for multiple races to be reported for a patient.
• sdtc:ethnicGroupCode - The ethnicGroupCode extension allows for additional ethnicity groups for the recordTarget or subjectPerson.
• sdtc:id - The id extension in the family history organizer on the related subject allows for unique identification of the family member(s).
• sdtc:deceasedInd - The deceasedIndextension (= “true” or “false”) in the family history organizer on the related subject is used inside to indicate if a family member is deceased.
• sdtc:deceasedTime - The deceasedTime extension in the family history organizer on the related subject allows for reporting the date and time a family member died.
• sdtc:birthTime - The birthTime extension allows for the birth date of any person to be recorded. The purpose of this extension is to allow the recording of the subscriber or member of a health plan in cases where the health plan eligibility system has different information on file than the provider does for the patient.
• sdtc:dischargeDispositionCode - The dischargeDispositionCode extension allows the provider to record a discharge disposition in an encounter activity.
• sdtc:signatureText - The signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 Implementation Guide for CDA® Release 2: Digital Signatures and Delegation of Rights, Release 1.

To resolve issues that need to be addressed by extension, the developers of this guide chose to approach extensions as follows:

• An extension is a collection of element or attribute declarations and rules for their application to the CDA Release 2.0.
• All extensions are optional. An extension may be used, but need not be under this guide.
• A single namespace for all extension elements or attributes that may be used by this guide will be defined.
• The namespace for extensions created by the HL7 Structured Documents Working Group (formerly Structured Documents Technical Committee) shall be urn:hl7-org:sdtc.
• This namespace shall be used as the namespace for any extension elements or attributes that are defined by this implementation guide.
• Each extension element shall use the same HL7 vocabularies and data types used by CDA Release 2.0.
• Each extension element shall use the same conventions for order and naming as is used by the current HL7 tooling.
• An extension element shall appear in the XML where the expected RIM element of the same name would have appeared had that element not been otherwise constrained from appearing in the CDA XML schema.

D - Mime Multipart/Related Messages

The following text is taken from the Claims Attachments Implementation Guide (AIS00000) in Section 2.4.15 For up-to-date guidance, refer to the latest edition of that specification.

MIME Multipart/Related Messages

An attachment is comprised of the CDA document, including any supporting files necessary to render the attested content of the document. Two Internet request for comments (RFCs) are needed to properly construct the mime multipart message. When supporting files are needed, the collection of information shall be organized using a MIME multipart/related package constructed according to RFC 2557. Within the MIME package, supporting files must be encoded using Base-64. RFC-4648 should be used when encoding the contents of the MIME package using Base-64. Finally, RFC-2392 may be used to reference other content that appears in the same X12 transaction to use the same content to answer multiple questions for a single claim. Internet RFCs can be downloaded from the RFC editor page at http://www.rfc-editor.org.

RFC-2557 MIME Encapsulation of Aggregate Documents, Such as HTML (MHTML)

This RFC describes how to construct a MIME multipart/related package, and how URLs are resolved within content items of that package. RFC-2557 can be obtained at: http://www.rfc-editor.org/rfc/rfc2557.txt

A MIME multipart/related package is made up of individual content items. Each content item has a MIME header identifying the item. Each content item is delimited from other content items using a string of application specified text. In addition, there must be an ending boundary. The actual content is recorded between these delimiter strings using a BASE-64 encoding of the content item. There is also a MIME header for the entire package.

The first content item of a multipart/related message supporting attachments is the CDA document, containing the header and structured or non-structured body. Subsequent content items included in this package will contain additional content that appears within the body of the document. The CDA document will reference these additional content items by their URLs.

Referencing Supporting Files in Multipart/Related Messages

Because the CDA document and its supporting files may have already existed in a clinical information system, references may already exist within the CDA document to URLs that are not accessible outside of the clinical information system that created the document. When the CDA document is sent via attachments, these URLs may no longer be accessible by the receiving information system. Therefore, each content item that is referenced by a URL within the CDA document must be included as a content item in the MIME package. Each content item may specify the URL by which it is known using the Content-Location header. The receiver of this MIME package shall translate URL references according the RFC-2557. This will ensure resolution of the original URL to the correct content item within the MIME package. Thus, URL references contained within an original document need not be rewritten when the CDA package is transmitted. Instead, these URLs are simply supplied as the value of the Content-Location header in the MIME package.

This capability allows for the same content item to be referred to more than once in a MIME multipart/related package without requiring the content item to be supplied twice. However, it does not allow a separate MIME multipart/related package to contain references to information sent in a previously recorded package.

Referencing Documents from Other Multiparts within the Same X12 Transactions

RFC-2392 is used when referencing content across MIME package boundaries, but still contained within the same X12 transaction (ST to SE). This can occur when the same document answers multiple questions for a single claim. Each component of a MIME package may be assigned a content identifier using the Content-ID header for the content item. For example, this header would appear as:

Content-ID: <07EE4DAC-76C4-4a98-967E-F6EF9667DED1>

This content identifier is a unique identifier for the content item, which means it must never be used to refer to any other content item. RFC-2392 defines the cid: URL scheme (http: and ftp: are two other URL schemes). This URL scheme allows for references by the Content-ID header to be resolved. The URL for the content item identified above would be:

cid:07EE4DAC-76C4-4a98-967E-F6EF9667DED1

Receivers of the MIME multipart message must be able to resolve a cid: URL to the content item that it identifies. Senders must ensure that they only refer to items that have already been transmitted to the receiver by their cid: URL. Thus, this implementation guide prohibits forward URL references using the cid: URL scheme.

Content items shall not be referenced across X12 transactions using the cid: URL scheme. For example, if the payer previously requested information using a 277, and the provider returned that information in a MIME multipart/related package in a 275, and then the payer requested additional information in another 277, the provider may not refer to the content item previously returned in the prior 275 transaction.

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