Current Build
This page is part of the C-CDA on FHIR Implementation Guide (v1.8.0: STU 1 Ballot 2) based on FHIR v1.8.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
C-CDA is one of the most widely implemented implementation guides for CDA and covers a significant scope of clinical care. Its target of the 'common/essential' elements of healthcare is closely aligned with FHIR's focus on the '80%'. There is significant interest in industry and government in the ability to interoperate between CDA and FHIR and C-CDA is a logical starting point. Implementers and regulators have both expressed an interest in the ability to map between FHIR and C-CDA.
This Implementation Guide defines a series of FHIR profiles on the Composition resource to represent the various document types in C-CDA. This release does not directly map every C-CDA template to FHIR profiles, rather tries to accomplish the C-CDA use case using Composition resource profiles created under this project (the equivalent of Level 2 CDA documents), and linking to the profiles created under the Data Access Framework (DAF) project for any coded entries that would normally be included in C-CDA sections. The hope is that this results in a simpler, more streamlined standard that reuses existing work and focuses on the 80% that implementers actually need in production systems (the hope is that DAF represents that 80% needed for coded entries).
The Composition profiles in this IG do not require coded data in any section. This is a departure from C-CDA, which requires coded data for Problems, Results, Medications, etc. his departure is intentional, as the C-CDA requirement for one or more coded entries in these sections resulted in some very complicated workarounds using nullFlavors to handle the fact that sometimes a patient is not on any medications, or has no current problems. In general, FHIR takes the approach that if something is nullable, it should simply be optional to ease the burden on implementers, thus C-CDA on FHIR does not require any coded entries, but rather uses the "required if known" approach, meaning that if an implementer's system has data for a section that requires data under Meaningful Use, they need to sent it, but if they have no data there is no need for a null entry.
We encourage feedback on these Composition profiles, and the general approach to the project as a whole. We also encourage implementers who wish to see more of the coded data from C-CDA mapped to FHIR to comment on the DAF project and make their requests known there. Once DAF creates new profiles, this project can reference them.
To represent Consolidated CDA Templates for Clinical Notes (C-CDA) 2.1 templates using FHIR profiles.
This first stage of the
project defines all the C-CDA document-level profiles on the Composition resource and contained sections.
Any coded data
used by sections will be accomplished by referencing relevant U.S. Data Access Framework (DAF) FHIR profiles.
| Name | Definition |
| HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes | The Consolidated CDA (C-CDA) implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from Health Level Seven (HL7), Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It represents harmonization of the HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination (IHE PCC), and Continuity of Care (CCD). C-CDA Release 1 included all required CDA templates in Final Rules for Stage 1 Meaningful Use and 45 CFR Part 170 – Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Final Rule. |
| U.S. Core FHIR Implementation Guide (IG) | Data elements, extension, and terminology used based on the ONC 2015 Edition Common Clinical Data Set (CCDS) as well as providing essential administrative and conformance requirements for US usage. |
| U.S. Data Access Framework (DAF) FHIR Implementation Guide (IG) | A U.S. Realm guide for making use of FHIR resources to support queries between systems within an enterprise and across enterprises |
| Author Name | |
| Rick Geimer | rick.geimer@lantanagroup.com |
| Sarah Gaunt | sarah.gaunt@lantanagroup.com |
| Brett Marquard | brett@riverrockassociates.com |
| Sean McIllvena | sean.mcIllvena@lantanagroup.com |
| Lisa Nelson | lisarnelson@cox.net |
This guide defines the following profiles.
| Profile Name | Description |
| C-CDA on FHIR US Realm Header | This profile defines constraints that represent common administrative and demographic concepts for US Realm clinical documents. Further specification, such as type, are provided in document profiles that conform to this profile. |
| C-CDA on FHIR Continuity of Care Document | This profile was originally based on the Continuity of Care Document (CCD) Release 1.1 which itself was derived from HITSP C32 and CCD Release 1.0. The Continuity of Care Document (CCD) profile represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another to support the continuity of care. The primary use case for the CCD is to provide a snapshot in time containing the germane clinical, demographic, and administrative data for a specific patient. The key characteristic of a CCD is that the Composition.event.code is constrained to "PCPR". This means it does not function to report new services associated with performing care. It reports on care that has already been provided. The CCD provides a historical tally of the care over a range of time and is not a record of new services delivered. More specific use cases, such as a Discharge Summary, Transfer Summary, Referral Note, Consultation Note, or Progress Note, are available as alternative profiles. |
| C-CDA on FHIR Discharge Summary | The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary (http://www.jointcommission.org/): The reason for hospitalization (the admission) The procedures performed, as applicable The care, treatment, and services provided The patients condition and disposition at discharge Information provided to the patient and family Provisions for follow-up care The best practice for a Discharge Summary is to include the discharge disposition in the display of the header. |
| C-CDA on FHIR Consultation Note | The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter. A Consultation Note includes the reason for the referral, history of present illness, physical examination, and decision-making components (Assessment and Plan). |
| C-CDA on FHIR Referral Note | A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery. Examples of referral situations are: * When a patient is referred from a family physician to a cardiologist for cardiac evaluation. * When patient is sent by a cardiologist to an emergency department for angina. * When a patient is referred by a nurse practitioner to an audiologist for hearing screening. * When a patient is referred by a hospitalist to social services. |
| C-CDA on FHIR Care Plan | CARE PLAN FRAMEWORK A Care Plan (including Home Health Plan of Care (HHPoC)) is a consensus-driven dynamic plan that represents a patients and Care Team Members prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers and providers), to guide the patients care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions. A Care Plan represents one or more Plan(s) of Care and serves to reconcile and resolve conflicts between the various Plans of Care developed for a specific patient by different providers. While both a plan of care and a care plan include the patients life goals and require Care Team Members (including patients) to prioritize goals and interventions, the reconciliation process becomes more complex as the number of plans of care increases. The Care Plan also serves to enable longitudinal coordination of care. The Care Plan represents an instance of this dynamic Care Plan at a point in time. The composition itself is NOT dynamic. Key differentiators between a Care Plan profile and CCD profile (another snapshot in time document): * Requires relationships between various concepts: * Health Concerns * Interventions * Goals * Outcomes * Provides the ability to identify patient and provider priorities with each act * Provides a header participant to indicate occurrences of Care Plan review |
| C-CDA on FHIR Procedure Note | A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care. |
| C-CDA on FHIR History and Physical | A History and Physical (H & P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. The first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members. The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures. The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues. A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note. |
| C-CDA on FHIR Diagnostic Imaging | A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialists interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patients medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties. |
| C-CDA on FHIR Operative Note | The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care. |
| C-CDA on FHIR Progress Note | This profile represents a patients clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. Tabers medical dictionary defines a Progress Note as An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note. Mosbys medical dictionary defines a Progress Note as Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned. A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report. |
| C-CDA on FHIR Transfer Summary | This profile describes constraints for a Transfer Summary. The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between health care settings. Standardization of information used in this form will promote interoperability; create information suitable for reuse in quality measurement, public health, research, and for reimbursement. |
This guide references the following value sets.
| Name | Definition |
| v3-ConfidentialityClassification | http://hl7.org/fhir/ValueSet/v3-ConfidentialityClassification Set of codes used to value Act.Confidentiality and Role.Confidentiality attribute in accordance with the definition for concept domain "Confidentiality". |
| DischargeSummaryDocumentTypeCode | urn:oid:2.16.840.1.113883.11.20.4.1 A value set of LOINC document codes for discharge summaries. Specific URL Pending |
| ConsultDocumentType | urn:oid:2.16.840.1.113883.11.20.9.31 Specific URL Pending |
| ReferralDocumentType | urn:oid:2.16.840.1.113883.1.11.20.2.3 A referral note provides a consulting physician specified patient information about the patient referred. Specific URL Pending |
| ProcedureNoteDocumentTypeCodes | urn:oid:2.16.840.1.113883.11.20.6.1 A value set of LOINC document codes for Procedure Notes. Specific URL Pending |
| HPDocumentType | urn:oid:2.16.840.1.113883.1.11.20.22 Specific URL Pending |
| LOINC Imaging Document Codes | urn:oid:1.3.6.1.4.1.12009.10.2.5 A value set of LOINC document type codes for Diagnostic Imaging Reports. |
| DIRSectionTypeCodes | urn:oid:2.16.840.1.113883.11.20.9.59 The Section Type codes used by DIR are all narrative document sections. The codes in this table are drawn from LOINC (http://www.loinc.org/) and DICOM (http://medical.nema.org/). The section/code should be selected from LOINC or DICOM for sections not listed in this table. |
| SurgicalOperationNoteDocumentTypeCode | urn:oid:2.16.840.1.113883.11.20.1.1 Specific URL Pending |
| ProgressNoteDocumentTypeCode | urn:oid:2.16.840.1.113883.11.20.8.1 Specific URL Pending |
This guide references the following code systems.
This guide references the following extensions.
© HL7.org 2011+. FHIR STU3 Candidate (v1.8.0-10514) generated on Thu, Dec 8, 2016 06:39+1100. QA Page
Links: Search |
Version History |
Table of Contents |
|
Propose a change