cdaefa:EFA XDS Document Metadata Binding

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Document Metadata

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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]. This as well holds for cardinalities and optionalities of document metadata elements. Further constraints MAY apply for EFA national profiles (see below for the German profile).

classCode

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The document class shall be taken from a national catalogue. The national catalogue should be a value set on top of LOINC as a reference terminology.

typeCode

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The document type shall be provided as a LOINC code. Document types shall be more specific than document classes. They may be defined per Care Domain.

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

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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>

German Profile

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

Author Institution

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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
Practice	Any internal identification scheme that guarantees a unique identification within the scope of the affinity domain. Identifiers SHALL be resolvable to all EFA participants through public directory services (e.g. HPD, see IHE-Cookbook).	local code system
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 department or faculty	Any internal identification scheme that guarantees a unique identification within the scope of the affinity domain. Identifiers SHALL be resolvable to all EFA participants through public directory services (e.g. HPD, see IHE-Cookbook).	local code system
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
Hospital	Any internal identification scheme that guarantees a unique identification within the scope of the affinity domain. Identifiers SHALL be resolvable to all EFA participants through public directory services (e.g. HPD, see IHE-Cookbook).	local code system

Example:

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

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

Author Person

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For the German healthcare system the following identification schemes MUST be used. If multiple schemes are available for an author's ID, the order in the table denotes the order of preference. If multiple IDs are known, at least two SHOULD be provided (considering the order of preference). An author identifier SHALL NOT be used without additionally providing the full name of the author.

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
Physician Hospital Staff Practice Staff	Any internal identification scheme that guarantees a unique identification within the scope of the identified organization. The <authorInstitution> 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="authorPerson">
  <rim:ValueList>
    <rim:Value>Name des Arztes^^^^^&1.2.276.0.76.4.16&ISO^^^^12345678</rim:Value> 
  </rim:ValueList>
</rim:Slot>

HealthcareFacilityTypeCode

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The healthcare facility type code SHALL be encoded as a coded value acc to the KBV Schlüsseltabelle S_VDX_PRAXISTYP ([1]). The root OID 1.2.276.0.76.3.1.1.5.1.4 SHALL be used.

Example:

A hospital facility type would be encoded as:

<rim:Classification classificationScheme="urn:uuid:f33fb8ac-18af-42cc-ae0e-ed0b0bdb91e1"
                    classifiedObject="theDocument" id=”ID_050"
                    objectType="urn:oasis:names:tc:ebxml-regrep:ObjectType:RegistryObject:Classification"
                    nodeRepresentation="50">
    <rim:Name>
        <rim:LocalizedString xml:lang="de" value="Krankenhaus"/>
    </rim:Name>
    <rim:Slot name="codingScheme">
       <rim:ValueList>
           <rim:Value>1.2.276.0.76.3.1.1.5.1.4</rim:Value>
       </rim:ValueList>
    </rim:Slot>
</rim:Classification>

sourcePatientInfo

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For reasons of protecting the confidentiality of personal medical information this slot SHALL NOT be used. For the identifing the patient the sourcePatientId element SHALL be provided for all documents metadata.

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