EFA XDS Document Metadata Binding

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(Author Person)
K (HealthcareFacilityTypeCode)
 
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<tt>Bitte markieren Sie [[cdaefa:Kommentierung_EFAv2.0|Kommentare]] zu diesem Abschnitt mit dem Code {EDoct.02.03}</tt>
 
<tt>Bitte markieren Sie [[cdaefa:Kommentierung_EFAv2.0|Kommentare]] zu diesem Abschnitt mit dem Code {EDoct.02.03}</tt>
  
The healthcare facility type code SHALL be encoded as a coded value acc to the ''KBV Schlüsseltabelle S_VDX_PRAXISTYP'' ([http://www.kbv.de/keytabs/ita/schluesseltabellen.asp?page=S_VDX_PRAXISTYP_V1.05.htm]). The root OID 1.2.276.0.76.3.1.1.5.1.4 SHALL be used.
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The healthcare facility type code SHALL be encoded as a coded value acc to the ''KBV Schlüsseltabelle S_VDX_PRAXISTYP'' ([http://applications.kbv.de/keytabs/ita/schluesseltabellen.asp?page=S_VDX_PRAXISTYP_V1.07.htm]). The root OID 1.2.276.0.76.3.1.1.5.1.4 SHALL be used.
  
 
'''Example:'''
 
'''Example:'''
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</syntaxhighlight>
 
</syntaxhighlight>
 
  
 
==== sourcePatientInfo ====
 
==== sourcePatientInfo ====

Aktuelle Version vom 16. August 2016, 13:06 Uhr

Dieses Material ist Teil des Leitfadens CDA für die elektronische Fallakte.
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Hinweise zum Kommentierungsverfahren einschließlich aller Formulare und Kontaktadressen finden Sie auf der Seite "Kommentierung EFAv2.0".


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.
1.2.276.0.76.4.188
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.
1.2.276.0.76.4.188
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.
1.2.276.0.76.4.188
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

Bitte markieren Sie Kommentare zu diesem Abschnitt mit dem Code {EDoct.02.02}

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.
1.2.276.0.76.4.188
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.