Western Canada Chronic Disease Management Infostructure Initiative

Transcription

1 Western Health Information Collaborative (WHIC) Western Canada Chronic Disease Management Infostructure Initiative - 07/06/2005 2:39 PM Prepared by Western Health Information Collaborative Data Standards and HL7 Messaging Project Team June 29, 2005 Version 7.1

2 Page i Disclaimer: The contents of this document are in a DRAFT state. As such, the reader should be aware that the contents are still undergoing revision. The WHIC Chronic Disease Management (CDM) project is sharing this document for information purposes, and we would request that the document not be distributed further at this time. Once the final version of the document is completed and approved by the WHIC CDM Steering Committee, it will be posted to the CDM page at the WHIC public web site at

3 Page ii TABLE OF CONTENTS 1. Introduction Clinical Data Attributes Type Procedure type Medication / Vaccine type Observation type Diagnostic image type Planned procedure type Planned observation type Planned diagnostic image type Goal type Identifier Procedure identifier Medication / Vaccine prescription or dispense identifier Observation identifier Diagnostic image identifier Referral identifier Observation Value Observation Interpretation Method Code Observation method code Diagnostic image method code Date (Measured, Performed) Procedure date Observation date Diagnostic image date Date (Entered, Recorded) Y/N Indicator Procedure occurred indicator Medication / Vaccine occurred indicator Observation occurred indicator Diagnostic image occurred indicator... 10

4 Page iii 2.9. Non Performance Reason Code Procedure non performance reason Medication / Vaccine not given reason Observation non performance reason Diagnostic image non performance reason Referral reason code Referral encounter occurred indicator Referral encounter date Referral encounter non performance reason Observation Normal Range Details Procedure details Medication / Vaccine details Observation details Diagnostic image details Referral details Medication / Vaccine name Medication / Vaccine dose Medication / Vaccine frequency Medication / Vaccine route Medication / Vaccine flag Goal value Goal value target date Reassessment date Medication / Vaccine dispense date Date Ordered Planned observation diagnosis value... 16

5 Page 1 1. INTRODUCTION The primary purpose of the Western Canada Chronic Disease Management (CDM) Infostructure Initiative is to develop chronic disease management data standards and information interchange messages, and to support the implementation of this infostructure within the four participating western provinces (British Columbia, Alberta, Saskatchewan, and Manitoba). The CDM Data Standards have been prepared to describe in clinical terms the scope, content and details of the CDM Data Standards developed for the Western Canada CDM Infostructure Initiative. This document is intended primarily for a clinical / business audience 1. The CDM Data Standards have been organized as follows: CDM Data Standards Introduction This document provides background information on the Western Canada CDM Infostructure Initiative, provides an overview of the Phase 2 Data Standards and HL7 Messaging project, describes the Chronic Disease Model, and provides an overview of the record and clinical data elements. Appendix A Coding Systems Includes an overview of the coding systems considered for the CDM Data Standards, describes the criteria and process for selection, and identifies special considerations and explanations for the selected code systems. Appendix B Record Level Data The record level data or structural data elements are generic data elements that are fixed and are provided regardless of the type of chronic disease. This appendix provides the data definition, and identifies the data type and valid values for each of the data elements. Appendix C Clinical Data Clinical data elements are specific data elements that pertain to chronic diseases. These data elements provide clinical information to assist clinicians in managing individuals with 1 For more technical documentation on the CDM HL7 Message Specifications, please refer to the CDM HL7 Message Specifications Implementation Guide.

6 Page 2 chronic diseases. This appendix provides the data definition, and identifies the data type (type code, type code value, type code name) and code table for each of the data elements. Appendix D Detail Data The detailed data attributes give additional specifics on the clinical data elements. The attributes describe the characteristics or details to be captured on person history, physical exams, lab tests, medications, procedures, etc. This appendix provides the data definition, and identifies the data type and valid values for each of the data elements. Appendix E Code Tables This appendix provides the details for the defined code sets that will be used for the CDM data elements (e.g. Code table name, source, codes, descriptions, print names, etc.).

7 Page 3 2. CLINICAL DATA ATTRIBUTES 2.1. Type Includes TYPE The form of procedure, observation, diagnostic image, etc. Procedure type Medication / Vaccine type Observation type Diagnostic image type Planned procedure type Planned observation type Planned diagnostic image type Goal type Procedure type Procedure type Indicates the type of procedure(s) performed. See Appendix E for Procedure Type Medication / Vaccine type Medication / Vaccine type A code uniquely identifying the medication or vaccine. See Appendix E for Medication / Vaccine Type

8 Page Observation type Observation type Indicates what sort of test or observation was actually performed. See Appendix E for Observation Type Diagnostic image type Diagnostic image type Identifies the type of image that was taken. See Appendix E for Diagnostic Image Type Planned procedure type Planned procedure type Indicates the type of procedure to be performed (e.g. kind of education, type of surgery etc.). See Appendix E for Procedure Type Planned observation type Planned observation type A code specifying the type of clinical observation planned to be made at some time in the future (e.g. height, weight, a particular lab test etc.). See Appendix E for Observation Type Planned diagnostic image type Planned diagnostic image type Indicates what type of image is to be taken. See Appendix E for Diagnostic Image Type

9 Page Goal type Goal type The type of measurement for which the target is being set e.g. BMI. See Appendix E for Goal Type 2.2. Identifier Includes IDENTIFIER A unique identifier (numeric, alpha or alpha-numeric) used for reference purposes Procedure identifier Medication / Vaccine prescription or dispense identifier Observation identifier Diagnostic image identifier Referral identifier Procedure identifier Procedure identifier A unique identifier assigned to a particular occurrence of a procedure. II Instance Identifier Medication / Vaccine prescription or dispense identifier Medication / Vaccine prescription or dispense identifier A unique identifier assigned to the prescription or dispensing record. II Instance Identifier Observation identifier Observation identifier A unique identifier for the observation. II Instance Identifier

10 Page Diagnostic image identifier Diagnostic image identifier A unique identifier for the diagnostic image II Instance Identifier Referral identifier Referral identifier A unique identifier for the referral. II Instance Identifier 2.3. Observation Value OBSERVATION VALUE The observed value of the variable being tested. May be expressed as a numeric quantity, as a code, or as free text, or in some other ways depending on the particular test. ANY 2.4. Observation Interpretation OBSERVATION INTERPRETATION Many times in addition to (or possibly instead of) reporting a physical measurement, a laboratory will indicate that the reported value is high, low, normal, or some other coded interpretation. Even when there is a value, interpretation is often offered to help convey the significance of a particular result. See Appendix E for Observation Interpretation and Retinopathy Interpretation

11 Page Method Code Includes METHOD CODE A unique code number that describes a way of doing something or obtaining information. In the CDM project, method code may refer to whether information on the person or chronic condition was reported by the person or observed by the service provider; or whether the approach to taking a physical measurement such as blood pressure was done with the person sitting or lying down, etc. Observation method code Diagnostic image method code Observation method code Observation method code Indicates the means or technique used to perform the test or observation. See Appendix E for Observation Method Code Diagnostic image method code Diagnostic image method code Indicates the means or technique used to perform the imaging. See Appendix E for Diagnostic Image Method Code 2.6. Date (Measured, Performed) Includes DATE (MEASURED, PERFORMED) Date when a lab test, procedure, examination, etc. was measured or performed on the person. Procedure date Observation date Diagnostic image date

12 Page Procedure date Procedure date The calendar date on which the person received health services by a provider. TS.DATE Timestamp Limited to date only, may be YYYY, YYYYMM or YYYYMMDD Observation date Observation date The biologically relevant date at which the observation was measured / performed / collected. In the case of a lab test this refers to the date the specimen was collected. (e.g., the date the blood was collected / drawn for testing). In the case of an examination the date refers to when the exam was performed (e.g., systolic and diastolic blood pressure). In the case of a diagnosis the date refers to when the condition is believed to have been diagnosed (e.g., depression). TS.DATE Timestamp Diagnostic image date Limited to date only, may be YYYY, YYYYMM or YYYYMMDD Diagnostic image date The date the diagnostic image was actually performed. TS.FULLDATE Timestamp Limited to date only, must specify all of YYYYMMDD 2.7. Date (Entered, Recorded) DATE (ENTERED, RECORDED) The date the information was actually entered / recorded. TS.DATE Timestamp Limited to date only, may be YYYY, YYYYMM or YYYYMMDD

13 Page Y/N Indicator Includes Y/N INDICATOR A code that indicates whether information is available or not on the specific clinical area of interest, i.e., procedure, medication, lab test, etc. in the CDM record. Procedure occurred indicator Medication / Vaccine occurred indicator Observation occurred indicator Diagnostic image occurred indicator Procedure occurred indicator Procedure occurred indicator An indication whether the procedure occurred or not. Used as a simple Yes / No indicator. BL Boolean True or False Medication / Vaccine occurred indicator Medication / Vaccine occurred indicator An indication as to whether the medication is being taken or not, or whether the vaccine was administered or not. It is used as a simple Yes / No indicator. BL Boolean True or False Observation occurred indicator Observation occurred indicator An indication that a clinical observation was made or not (e.g., I have not observed an allergic reaction). BL Boolean True or False

14 Page Diagnostic image occurred indicator Diagnostic image occurred indicator An indication that the diagnostic image was done or not done e.g. a particular image of interest does not exist. BL Boolean True or False 2.9. Non Performance Reason Code Includes NON PERFORMANCE REASON CODE An explanation as to why an administrative correction, change in condition or referral occurred or why a procedure, observation, diagnostic image, etc. did not occur. Procedure non performance reason Medication / Vaccine not given reason Observation non performance reason Diagnostic image non performance reason Procedure non performance reason Procedure non performance reason The reason the procedure wasn't performed as expected. See Appendix E for Non Performance Reason Medication / Vaccine not given reason Medication / Vaccine not given reason The reason the Medication / Vaccine wasn't taken. See Appendix E for Non Performance Reason

15 Page Observation non performance reason Observation non performance reason The reason the action wasn't performed. See Appendix E for Non Performance Reason Diagnostic image non performance reason Diagnostic image non performance reason The reason the action wasn't performed. See Appendix E for Non Performance Reason Referral reason code REFERRAL REASON CODE The reason the referral was made according to the guidelines. See Appendix E for Reason Referral Code Referral encounter occurred indicator REFERRAL ENCOUNTER OCCURRED INDICATOR An indication whether the referral encounter occurred or did not occur. BL Boolean True or False Referral encounter date REFERRAL ENCOUNTER DATE Indicates the date of the first "point of contact" between the referred-to provider and the person with the chronic condition, as initiated by the referral. IVL.LOW<TS.FULLDATE> Lower-bounded date-range (includes start-date but duration and end-time are unspecified)

16 Page Referral encounter non performance reason REFERRAL ECNOUNTER NON PERFORMANCE REASON The reason the referral encounter did not occur. See Appendix E for Non Performance Reason Observation Normal Range OBSERVATION NORMAL RANGE Indicates the expected range for the observation in a healthy person. IVL<PQ> Details Includes DETAILS Additional information provided in a textual or narrative form regarding a lab test, procedure, medication, etc. Procedure details Medication / Vaccine details Observation details Diagnostic image details Referral details Procedure details Procedure details Provides additional detail about the procedure, such as how the procedure was performed (e.g., the modality), the body-site involved and other descriptive information. ST String

17 Page Medication / Vaccine details Medication / vaccine details Additional details about the medication therapy. ST String Observation details Observation details Additional details about the observation. ST String Diagnostic image details Diagnostic image details Additional details about the diagnostic image result that may affect its clinical interpretation for instance how the image was taken, what body part was imaged and the orientation the person assumed. ST String Referral details Referral details Additional details about the referral. ST String Medication / Vaccine name MEDICATION / VACCINE NAME A generic drug name is humanly readable for the medication, which is necessary in order to communicate effectively between service providers in respect of the person s medications. ST String

18 Page Medication / Vaccine dose MEDICATION / VACCINE DOSE The amount of medication prescribed by the service provider, for the person, intended to be consumed during a single administration. The quantity specified by the dose is intended to be taken once for each repetition indicated by the frequency. URG<PQ.MASSVOL> Medication / Vaccine frequency MEDICATION / VACCINE FREQUENCY Indicates the frequency with which a vaccine dose is administered (e.g., annually for influenza vaccine) and with which a medication is consumed (e.g., daily for aspirin). PIVL<TS> Repeating Interval Medication / Vaccine route MEDICATION / VACCINE ROUTE The route of administration of the medication. Common examples include "oral", "s.c.", (subcutaneous) or via continuous pump. See Appendix E Medication / Vaccine Route Medication / Vaccine flag MEDICATION / VACCINE FLAG An indicator of whether with the record represents a medication or a vaccine. See Appendix E for Medication / Vaccine Flag

19 Page Goal value GOAL VALUE The value of the measurement targeted to be achieved. May be expressed as a range (e.g., blood glucose between X and Y), or in comparison to a particular target number (e.g., BMI <25). ANY Goal value target date GOAL VALUE TARGET DATE The specific date the target should be achieved. IVL.HIGH<TS.FULLDATE> Interval Timestamp Limited to end date only, must specify all of YYYYMMDD Reassessment date REASSESSMENT DATE Indicates when a particular planned activity or type of activity is intended to be reviewed. For example, review medications on Mar. 1, TS.DATE Timestamp Limited to date only, may be YYYY, YYYYMM or YYYYMMDD Medication / Vaccine dispense date MEDICATION / VACCINE DISPENSE DATE The date the medication was dispensed to the person by a service provider, or the date the vaccine was actually injected into a person by the service provider delivering the vaccination services. TS.FULLDATE Timestamp Limited to date only, must specify all of YYYYMMDD

20 Page Date Ordered DATE ORDERED Indicates when the order for the specified event was created. TS.FULLDATE Timestamp Limited to date only, must specify all of YYYYMMDD Planned observation diagnosis value PLANNED OBSERVATION DIAGNOSIS VALUE This identifies the specific diagnosis to be reviewed. See Appendix E for Planned Observation Diagnosis Value