cdaefa:EFA XDS Document Metadata Binding

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Hinweise zum Kommentierungsverfahren einschließlich aller Formulare und Kontaktadressen finden Sie auf der Seite "Kommentierung EFAv2.0".

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Document Metadata

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The table below shows how eCR folder attributes map onto IHE XDS Folder metadata and vice versa:

EFA Metadata	IHE documentEntry Attribute	Remarks and Usage Constraints
Verantwortliche Organisation	author	EFA demands for registering the organization that takes responsibility for providing a document while IHE only allows to register the person/device (and organisation) that created the document. As it is assumed that provider of a document either ist the author of the document or acts on behalf the author of the document, the EFA "responsible organization" object is mapped onto an IHE "documentEntry.author" element. In cases these semantics conflict, the IHE semantics of "documentEntry.author" according to IHE ITI TF-3#4.2.3.2.1 shall be followed.
Status	availabilityStatus	shall be used according to IHE ITI TF-3#4.2.3.2.2.
Dokumentklasse	classCode	see below
	comments	see below
	confidentialityCode	shall always be "N" for EFA
Zeitpunkt der Bereitstellung		EFA demands for registering the timestamp when a document was provided to an EFA. IHE XDS does not assign this information to single document entry but to the submissions set which was used for registering a set of documents with an XDS Document Registry. EFA implementations SHALL therefore map this logical attribute onto the XDS submission set's submissionTime attribute.
	creationTime	shall be used according to IHE ITI TF-3#4.2.3.2.6.
	entryUUID	shall be used according to IHE ITI TF-3#4.2.3.2.7.
	eventCodeList	shall be used according to IHE ITI TF-3#4.2.3.2.8.
	formatCode	shall be used according to IHE ITI TF-3#4.2.3.2.9.
Fehlererkennender Code	hash	shall be used according to IHE ITI TF-3#4.2.3.2.10.
	healthcareFacilityTypeCode	shall be used according to IHE ITI TF-3#4.2.3.2.11.
	homeCommunityId	shall be used according to IHE ITI TF-3#4.2.3.2.12.
	languageCode	shall be used according to IHE ITI TF-3#4.2.3.2.13.
	legalAuthenticator	shall be used according to IHE ITI TF-3#4.2.3.2.14. For consent documents this element shall record the person/organization that validated the patient's consent and registered it with EFA.
Dokumentformat	mimeType	shall be used according to IHE ITI TF-3#4.2.3.2.15.
patientID	patientId	shall be used according to IHE ITI TF-3#4.2.3.2.16. EFA Document Registry actors shall verify that the patient matches the person who gave consent to the respective EFA.
	practiceSettingCode	shall be used according to IHE ITI TF-3#4.2.3.2.17.
	repositoryUniqueId	shall be used according to IHE ITI TF-3#4.2.3.2.18.
Zeitliche Einordnung	serviceStartTime	shall be used according to IHE ITI TF-3#4.2.3.2.19.
	serviceStopTime	shall be used according to IHE ITI TF-3#4.2.3.2.20.
Dateigröße	size	shall be used according to IHE ITI TF-3#4.2.3.2.21.
	sourcePatientId	shall be used according to IHE ITI TF-3#4.2.3.2.22.
	sourcePatientInfo	This element shall not be used for EFA.
Titel	title	shall be used according to IHE ITI TF-3#4.2.3.2.24.
Dokumenttyp	typeCode	see below
documentID	uniqueId	shall be used according to IHE ITI TF-3#4.2.3.2.25.
	URI	shall be used according to IHE ITI TF-3#4.2.3.2.26.
	referenceIdList	shall be used according to IHE ITI TF-3#4.2.3.2.27.
	limitedMetadata	Limited metadata are not allowed for IHE XDS document sources and therefore the respective option SHALL NOT be used by EFA implementations.
	objectType	shall be used according to IHE ITI TF-3#4.2.3.2.29.
Signatur		Documents provided to an EFA may be digitally signed. In this case, the constraints and means defined by the IHE ITI DSG integration profile shall be considered.

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^^^^^&1.2.276.0.76.4.5&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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