CCDA ProblemAllergy Problem Status Observation Templates and Clinical
C-CDA: Problem/Allergy Problem Status Observation Templates and Clinical Status Updates from 2014 -09 Chicago WGM Stephen Chu, PCWG co-chair Russ Leftwich, PCWG co-chair Elaine Ayres, PCWG co-chair Laura Heermann Langford, PCWG co-chair Rob Hausam, vocab facilitator Lisa Nelson, PCWG Liaison from SDWG © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office.
Background n C-CDA r 2. 0 deprecated two clinical status related templates: Ø Ø Allergy status observation Problem status © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 2 10/30/2021
In C-CDA 2. 0 Allergy Status Observation and Problem Status templates are deprecated © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 3 10/30/2021
In C-CDA 2. 0 Allergy Status Observation and Problem Status templates are deprecated Note – the issue of using status. Code + effective. Time to represent condition status appears to go beyond just Allergy and Problem in C-CDA R 2. 0 If the need to separate and disambiguate ACT state and condition status is accepted, this decision can be applied to resolve other similar issues © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 4 10/30/2021
Decision to deprecate? ? ? Confusions often resulted from combined use of these two sets of codes (Act. Status + Problem. Status) in CDA © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 5 10/30/2021
n These templates are replaced by the problem. Concern. Act and problem. Observation classes and four sets of elements: © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 6 10/30/2021
What have been lost by deprecating Allergy Status Observation template? Table 126: Allergy Status Observation 7 © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 10/30/2021
What have been lost by deprecating Problem Status Observation template? n The Problem Observation in C-CDA 1. 1 Uses same HITSPProblem. Status values: * Active * Inactive * Resolved © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 8 10/30/2021
What are the implications? (of deprecating the status observation templates) Question: Are the four sets of elements adequate for representing complex and rich semantics of clinical and verification Status? The Act status of that outer problem. Concern. Act controls the state model of the Concern clinical statement These rules set out how the Act status for the clinical statement will work © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 9 10/30/2021
What are the implications? (of deprecating the status observation templates) problem. Concern. Act <status. Code> (value = “active”; “complete” <effective. Time> (start + end concern is followed) problem. Observation <status. Code> (value set to “completed”) <effective. Time> (when problem start + end for the patient) The state model of clinical statements that represent Problem Concern observation needs to use these RIM state concepts in the status. Code Problem Concern clinical statement in order to control the state model for the clinical statement information to be properly processed by a machine But … 10/30/2021 © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 10
What are the implications? (of deprecating the status observation templates) problem. Concern. Act <status. Code> (value = “active”; “complete” <effective. Time> (start + end concern is followed) problem. Observation <status. Code> (value set to “completed”) <effective. Time> (when problem start + end for the patient) But … * The status. Code is: - a mechanical representation of “clinical statement “state machine” - “is. Document. Property” of status. Code = true (≠ clinical property) - not human readable (RIM: the status. Code does not carry meaning that would be present in the human readable narrative) - inadequate for complex and semantically rich clinical status * The value element of the Problem Status observation is denoted with a code element set of LOINC code 33999 -4 (= status of diagnosis) 10/30/2021 © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 11
Semantics of clinical status: much more complex n Clinical statements on allergy and intolerance status need to be represented by one of the following values: Ø Active Ø Inactive (semantically different from resolved) Ø Resolved n Other clinical conditions status observations need additional status values … © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 12 10/30/2021
Semantics of clinical status: much more complex n Other clinical conditions (e. g. CVS, respiratory, cancer, behavioural problems etc), require additional status values: Ø Remission states n In remission n Partial remission n Full/complete remission n Early full/partial remission n Sustained full/partial remission Ø Relapse states n n Relapse Suspected relapse after partial remission relapse after full remission © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 13 Note: “relapse”, “suspected relapse” may also apply to certain infections, e. g. Ebola haemorrhagic fever 10/30/2021
Clinical verification status n Joint PCWG – FHIR clinical resource development works (e. g. : on condition, allergy / intolerance, clinical assessment/impression) identifies need to include clinical verification status for tracking clinical workflow related status: Ø Ø Ø Differential Provisional, working Confirmed Refuted Unknown Entered in error © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 14 10/30/2021
A simple clinical use case First encounter: • A 16 yo male high student presented at ED with: fever, sore throat cough, persistent headache, general malaise, nausea, chills • There was no joint pain, no neck rigidity, no photophobia, no SOB • Working diagnosis = Upper respiratory tract infection (URI); possible influenza • Lab workout: throat & nasal swab; CBC, blood culture • Management: antipyretic, analgesic, encourage fluids, education on cough etiquette, hand hygiene Patient discharge home and advised to see family doctor/return to ED if symptoms worsened • Discharge (confirmed) diagnosis • = URI, possible influenza (clinical verification status) • Clinical status = active © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 15 10/30/2021
A simple clinical use case Second encounter: • The next day, patient returned to ED with additional symptoms: worsen headache, photophobia, nuchal rigidity, reddish purple skin rash, photophobia, irritability, mild delirium • Diff/diagnosis: bacterial meningitis; viral encephalitis (verification status) • Lab workout results: Throat + nasal swab: N meningitidis Blood + CSF: N meningitidis, serogroup A • Confirmed diagnosis = meningococcal meningitis (verification status) Clinical status = active • Refuted diagnosis = influenza; viral encephalitis (verification status) • Management: admit + antibiotics; discharged after 5 days • Discharge (Confirmed) diagnosis = meningococcal meningitis (verification status) Clinical status = resolved © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 16 10/30/2021
Recommendations n n n Review and recommend how to use without causing confusion: Ø Allergy Status template and Problem Status template Review clinical status value set to include: Ø Active; Inactive Carrier; Resolved Ø Remission states (e. g. partial, full …) Ø Relapse states (Note – the review should consider other clinical status values, e. g. : exacerbation, pseudoexacerbation, refractory …) Review/update C-CDA templates and guidelines to implement verification status values © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 17 10/30/2021
Next step? Use cases n Analyse allergy status and problem status observation templates n Ø Update where appropriate, necessary Review, develop, approve new clinical status and verification status value sets n Develop guidelines on how to use these status value sets with Act Status values n © 2014 Health Level Seven ® International. All Rights Reserved. HL 7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 18 10/30/2021
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