cdaefa:EFA XDS Document Metadata Binding

EFA XDS Document Metadata Binding

EFA XDS Document Metadata Binding

Implementierungsleitfaden

vorgelegt von:
February 2013
Jörg Caumanns, Raik Kuhlisch

Draft

Version:	0.9
Datum:	March 2013
Status:	xxx
Verfahren:	{{{Verfahren}}}
Realm:	Deutschland

Copyright © 2012-2013: HL7 Deutschland

Document Metadata

Unless stated otherwise in the following sub-sections, document metadata MUST be used as defined in table 4.1-5 of [IHE ITI TF Vol3 v9.0]. Further constraints MAY apply for EFA national profiles (see below for the German profile).

classCode

The document class SHALL be provided as a LOINC code.

Example:

 <rim:Classification 
    id="urn:uuid:c33ca26a-29b4-45be-a9b9-de60adca4c64"
    lid="urn:uuid:c33ca26a-29b4-45be-a9b9-de60adca4c64"
    objectType="urn:oasis:names:tc:ebxml-regrep:ObjectType:RegistryObject:Classification"
    classificationScheme="urn:uuid:41a5887f-8865-4c09-adf7-e362475b143a"
    classifiedObject="urn:uuid:fbf2ea29-3aa3-4bc5-9187-01d7b6b0f481" 
    nodeRepresentation="11520-4">
    <rim:Slot name="codingScheme">
        <rim:ValueList>
            <rim:Value>2.16.840.1.113883.6.1</rim:Value>
        </rim:ValueList>
    </rim:Slot>
    <rim:Name>
        <rim:LocalizedString xml:lang="de" charset="UTF-8" value="EKG Befund"/>
    </rim:Name>
 </rim:Classification>

Comments

This slot is optional. If given, it SHALL hold a summary of the document content.

Example:

<rim:Description>
   <rim:LocalizedString xml:lang="de" charset="UTF-8" value = "Befund zur Magenspiegelung vom 3.3.13"/>
</rim:Description>

eventCodeList

Example:

 <rim:Classification 
    id="urn:uuid:c33ca26a-29b4-45be-a9b9-de60adca4c64"
    lid="urn:uuid:c33ca26a-29b4-45be-a9b9-de60adca4c64"
    objectType="urn:oasis:names:tc:ebxml-regrep:ObjectType:RegistryObject:Classification"
    classificationScheme="urn:uuid:2c6b8cb7-8b2a-4051-b291-b1ae6a575ef4"
    classifiedObject="urn:uuid:fbf2ea29-3aa3-4bc5-9187-01d7b6b0f481" 
    nodeRepresentation="I21.0">
    <rim:Slot name="codingScheme">
        <rim:ValueList>
            <rim:Value>1.2.276.0.76.5.311</rim:Value>
        </rim:ValueList>
    </rim:Slot>
    <rim:Name>
        <rim:LocalizedString xml:lang="de" charset="UTF-8" value="Akuter transmuraler Myokardinfarkt der Vorderwand"/>
    </rim:Name>
 </rim:Classification>

Slot Name	Binding	Slot Value
Id	Attribute	Identifer of the document. This identifier MUST be the same for <rim:ExtrinsicObject/@id> and <ihe:Document/@id>.
mimeType	Attribute	…
objectType	Attribute	MUST be set acc. to section 4.3.1.2 of [IHE IT TF 3]
Status	Attribute	MUST be "urn:oasis:names:tc:ebxml-regrep:StatusType:Approved"
creationTime	rim:Slot	MUST be set to the document creation time. At least YYYYMMDD MUST be provided.
languageCode	rim:Slot	…
sourcePatientID	rim:Slot	MUST be of the same value as $XDSDocumentEntry.PatientId (see below)
healthcareFacilityTypeCode	Classification	…
practiceSettingCode	classification	…
confidentialityCode	classification	SHOULD always be set to “N”.
XDSDocumentClassCode	classification	…
XDSDocumentFormatCode	classification	…
XDSDocumentEntry.PatientId	External identifier	Equals to the patient identifier that was agreed on upon EFA instantiation (encoded as HL7 v3 II data type)
XDSDocument.UniqueId	External identifier	MUST refer to the OID of the document that is included within the <ihe:Document> element.

Other metadata than the ones listed above SHOULD NOT be used and MUST NOT be processed by EFA clients and providers.

German Profile

For using EFA within the German national healthcare IT infrastructure (Telematikinfrastruktur) the constraints listed below MUST be considered.

Author Institution

For the German healthcare system the following identification schemes MUST be used. If multiple schemes are available for an organization, the order in the table denotes the order of preference.

Organization	Scheme	Code System OID
Practice	Telematik ID This ID scheme MUST be preferred only if the Telematik ID is recorded within the SMC-B AUT certificate of the practice.	not defined yet
Practice	ID of the SMC-B AUT Certificate	1.2.276.0.76.4.77
Practice	»Institutskennzeichen (IK)« acc. to § 293 SGB V	1.2.276.0.76.4.5
Practice	KBV »Arztnummer Praxis«	1.2.276.0.76.4.10
Hospital department or faculty	Telematik ID This ID scheme MUST be preferred only if the Telematik ID is recorded within the SMC-B AUT certificate of the department/faculty.	not defined yet
Hospital department or faculty	ID of the SMC-B AUT Certificate	1.2.276.0.76.4.77
Hospital	Telematik ID This ID scheme MUST be preferred only if the Telematik ID is recorded within the SMC-B AUT certificate of the hospital.	not defined yet
Hospital	ID of the SMC-B AUT Certificate	1.2.276.0.76.4.77
Hospital	»Institutskennzeichen (IK)« acc. to § 293 SGB V	1.2.276.0.76.4.5

Example:

A resident practice with the Institutskennzeichen 260326822 would be encoded as:

<rim:Slot name="authorInstitution">
  <rim:ValueList>
    <rim:Value>Name der Praxis^^^^^&1.2.276.0.76.4.5&ISO^^^^260326822</rim:Value> 
  </rim:ValueList>
</rim:Slot>

Author Person

For the German healthcare system the following identification schemes MUST be used. If mul-tiple schemes are available for a role, the order in the table denotes the order of preference. If multiple IDs are known, at least the two SHOULD be provided.

Person Role	Scheme	Code System OID
Physician	Telematik ID This ID scheme MUST be preferred only if the Telematik ID is recorded within the HBA AUT certificate of the physician.	not defined yet
Physician	ID of the HBA AUT Certificate	1.2.276.0.76.4.75
Physician	Lebenslange Arztnummer KV	1.2.276.0.76.4.16
Hospital Staff Practice Staff	Any internal identification scheme that guarantees a unique identification within the scope of the identified organization. The <representedOrganization> and an <id> for this organization MUST be recorded.	local code system

Example:

A physician with the Arztnummer 12345678 would be encoded as:

<rim:Slot name="authorInstitution">
  <rim:ValueList>
    <rim:Value>Name des Arztes^^^^^&1.2.276.0.76.4.16&ISO^^^^12345678</rim:Value> 
  </rim:ValueList>
</rim:Slot>