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Primary Health Care

Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0

Business View

Who We AreEstablished in 1994, CIHI is an independent, not-for-profit corporation that provides essential information on Canada’s health system and the health of Canadians. Funded by federal, provincial and territorial governments, we are guided by a Board of Directors made up of health leaders across the country.

Our VisionTo help improve Canada’s health system and the well-being of Canadians by being a leading source of unbiased, credible and comparable information that will enable health leaders to make better-informed decisions.

Table of Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

About the Canadian Institute for Health Information . . . . . . . . . . . . . . . . .viii

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Benefits to Patient Care and the Health System . . . . . . . . . . . . . . . . . . . . . 7

Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Business Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Use Case Category 1: PHC Clinic Visits and Program Management . . . . . . . . 19

Use Case Category 2: Referral to a Specialist and Wait Times Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Use Case Category 3: Patient Self-Reporting and Chronic Disease Prevention and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Data Elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Adoption, Maintenance and Governance . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Contact Information and Links . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Appendix A: Draft Conceptual Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Appendix B: Data Element Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Appendix C: Pan-Canadian Primary Health Care Indicators . . . . . . . . . . . 89

Appendix D: Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

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Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View

AcknowledgementsThe Canadian Institute for Health Information (CIHI) would like to acknowledge and thank the many individuals and organizations that contributed to the development of this product. In particular, CIHI would like to acknowledge and express its appreciation to the members of the Jurisdictional Advisory Group (JAG) and the Content Standards Working Group (CSWG), who provided invaluable guidance in developing the core content for the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard. As of September 1, 2010, these groups consisted of the following members:

Jurisdictional Advisory Group Members

Mr. Jeff AitkenDirector, First Nations eHealth, BC Ministry of Health Services (December 2009–September 2010)

Mr. Thomas P. AlteenProject Manager,Newfoundland and Labrador Centre for Health Information (December 2009–September 2010)

Ms. Pat BoothManager of Information Management Unit, Information Services Division, Department of Health and Social Services, Government of the Northwest Territories (February 2010–June 2010)

Ms. Claire BernatchezSenior Program Manager, Federal Healthcare Partnership (December 2009–September 2010)

Ms. Sandra CascaddenChief Information Officer, Nova Scotia Department of Health (December 2009–September 2010)

Mr. Neil GardnerChief Information Officer, Saskatchewan Health (December 2009–September 2010)

Mr. Dennis GiokasChief Technology Officer, Canada Health Infoway (December 2009–September 2010)

Ms. Cheryl HansenExecutive Director, Innovation, New Brunswick Department of Health (December 2009–September 2010)

Mr. Richard Johnstone Senior Delivery Manager, Shared Health Network, Alberta Health and Wellness (December 2009–June 2010)

Mr. Martin JoyActing Director, Nunavut Department of Health and Social Services (December 2009–September 2010)

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Ms. Heather E. N. CooperHealth Information Standards Coordinator, Alberta Health and Wellness (June 2010–September 2010)

Mr. Tom Fogg (Co-Chair)Director of Strategy and Planning, Manitoba eHealth (December 2009–September 2010)

Mr. Randy FrancisDirector, Program Management, Prince Edward Island Department of Health (December 2009–September 2010)

Mr. John McKinleyAssistant Deputy Minister, Ontario Ministry of Health and Long-Term Care (December 2009–July 2010)

Ms. Janet NybergChief Information Officer, Yukon Department of Health (December 2009–September 2010)

Mr. Greg Webster (Co-Chair) Director, Primary Health Care Information, Canadian Institute for Health Information (December 2009–September 2010)

Content Standards Working Group Members

Mr. Jeff AitkenDirector, First Nations Health, British Columbia Ministry of Health Services(February 2010–September 2010)

Mr. Thomas P. AlteenProject Manager, EHR Projects, Health Information Network, Newfoundland and Labrador Centre for Health Information (February 2010–September 2010)

Ms. Claire BernatchezSenior Program Manager, Federal Healthcare Partnership (February 2010–September 2010)

Dr. Richard BirtwhistleDirector of Centre for Studies in Primary Care, Queen’s University and Principal Investigator, Canadian Primary Care Sentinel Surveillance Network (February 2010–April 2010)

Ms. Mary Ann JuurlinkeHealth Standards, Lead,eHealth Ontario (February 2010–September 2010)

Ms. Beverly KnightTerminology Services Manager, Canada Health Infoway (February 2010–September 2010)

Ms. Jan LabovichManager, Information Architecture, Manitoba eHealth (February 2010–September 2010)

Dr. Marion LyverPresident, Healthy Futures Inc.; Associate Clinical Professor, McMaster University Faculty of Medicine (February 2010–September 2010)

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Ms. Pat BoothManager of Information Management Unit, Information Services Division, Department of Health and Social Services, Government of the Northwest Territories (February 2010–June 2010)

Dr. Denise Campbell-SchererAssociate Professor, Department of Family Medicine, University of Alberta (February 2010–September 2010)

Ms. Heather E. N. CooperHealth Information Standards Coordinator, Alberta Health and Wellness (February 2010–September 2010)

Dr. Sisira De SilvaElectronic Health Record Standards Specialist, Newfoundland and Labrador Centre for Health Information (February 2010–September 2010)

Mr. Finnie FloresSenior Standards Analyst, eHealth Ontario (April 2010–September 2010)

Ms. Irene A. K. GillisHealth Information Specialist, Prince Edward Island Department of Health (February 2010–September 2010)

Ms. Beverly GreenePrimary Health Care Consultant, New Brunswick Department of Health (February 2010–September 2010)

Ms. Michelina MancusoExecutive Director of Performance Management, New Brunswick Health Council (February 2010–September 2010)

Mr. Ken MartinSenior Data Manager, CPCSSN Project, Queen’s University (April 2010–September 2010)

Ms. Patti McManusNurse Practitioner, Federal Healthcare Partnership and First Nations and Inuit (April 2010–September 2010)

Ms. Lynn MillerNurse Practitioner, Cumberland North Rural Practice Network (April 2010–September 2010)

Ms. Lisa NapierPHIM Program Manager, Nova Scotia Department of Health (February 2010–September 2010)

Dr. Ray SimkusPhysician, Brookswood Family Practice Biomedical Informatics, British Columbia (February 2010–September 2010)

Ms. Karen OldfordPHC Nurse Practitioner, Labrador–Grenfell Health (April 2010–September 2010)

Mr. Pavel PlatonovSenior EMR Technical Specialist, Manitoba eHealth (February 2010–September 2010)

Dr. Morgan PriceUniversity of British Columbia, Department of Family Practice (February 2010–September 2010)

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Dr. Roger HamiltonPhysician, Nova Scotia (February 2010–September 2010)

Ms. Cindy HollisterClinical Leader, Clinical Adoption, Canada Health Infoway (February 2010–September 2010)

Dr. R. Liisa JaakkimainenFamily Physician; Scientist, Institute for Clinical Evaluative Sciences, Ontario (February 2010–September 2010)

Ms. Brenda JackmanClinical Business Analyst, Primary Health Care, Health Information Solutions, Saskatchewan Ministry of Health (February 2010–September 2010)

Ms. Donna ShanleyPhysician eHealth Program, eHealth Ontario (February 2010–September 2010)

Ms. Cynthia SmithSenior Manager, Primary Health Care Unit, Alberta Health and Wellness (February 2010–September 2010)

Ms. Patricia Sullivan-Taylor (Chair)Manager, Primary Health Care Information, Canadian Institute for Health Information (February 2010–September 2010)

Ms. Valerie RossActing Manager,Information Management, Department of Health and Social Services, Northwest Territories(June 2010–September 2010)

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Canada Health Infoway

CIHI would like to thank Canada Health Infoway (Infoway) for its collaboration on this project, with special thanks to Sukhi Burgen, Linda Dentay, Shari Dworkin, Dennis Giokas, Beverly Knight, Alex Mair, Julie Richards and Lynne Zucker. CIHI would also like to thank members of the Infoway Standards Collaborative Strategic and Coordinating Committees and Working Groups 2, 3 and 9 for their input and contributions to various phases of the project.

CIHI Project Team

The core CIHI project team responsible for developing the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0 included

Mr. Louis Barré, Vice President, Strategy, Planning and Outreach

Mr. Ted Harrison, Project Lead, Primary Health Care Information

Mr. Scott Murray, Vice President and Chief Technology Officer, Information Technology and Services

Ms. Patricia Sullivan-Taylor, Manager, Primary Health Care Information

Mr. Gavin Tong, Project Manager, Primary Health Care Information

Mr. Greg Webster, Director, Primary Health Care Information

Significant project contributions were also made by Zee Hua Cheung, Tanya Flanagan, Azra Kulenovic, Shaheena Mukhi, Marco Neri, Dawn Nicholson, Christine Proietti, Michael Terner, Christina Tomsa, Jennifer Trebell and Vicky Walker.

This product could not have been completed without the generous support and assistance of many other CIHI staff members, including classifications, information technology and services, CIHI standards working group, layout and design, translation, communications and distribution, who provided ongoing support to the core team.

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About the Canadian Institute for Health Information The Canadian Institute for Health Information (CIHI) collects and analyzes information on health and health care in Canada and makes it publicly available. Canada’s federal, provincial and territorial governments created CIHI as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI’s goal: to provide timely, accurate and comparable information. CIHI’s data and reports inform health policies, support the effective delivery of health services and raise awareness among Canadians of the factors that contribute to good health.

For more information, visit our website at www.cihi.ca.

Executive SummaryPrimary health care (PHC) is the most common type of health care experienced by Canadians. Efforts to improve PHC hold the greatest potential to positively impact the health of Canadians and the sustainability of the health care system. Stakeholders across Canada are facing increased demands to improve primary health care (PHC) and to demonstrate fiscal responsibility. However, there is relatively little high-quality information available with which to guide efforts to prevent chronic diseases and to improve the quality, efficiency and accessibility of PHC. Across Canada, jurisdictions and clinicians are increasingly using Electronic Medical Records (EMRs) to support improvements in PHC.

Interoperable EMRs will play a key role in ensuring that PHC clinicians have the information they need to deliver, coordinate and administer care. Using EMR information to support clinicians at the point of service is generally considered its primary use. However, the information generated at the point of service can also be used to support quality improvement initiatives, such as clinical program management, research, and monitoring the health of the population, as well as to improve the efficiency of the health care system overall. The use of information for these purposes is often referred to as “health system use.”

The availability of high-quality information to support PHC improvements can be achieved only if a subset of priority, standardized data is present in PHC EMRs. With increased funds going toward the adoption of EMRs, it has become imperative that standardized data capture is occurring in order to support the priority information needs now and into the future. At present, most EMRs support free text data capture, with little regard for aligning

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with common content standards. This approach limits the EMR’s ability to provide point of care benefits, such as patient safety reminders and alerts for patients who require close monitoring. The absence of standardized PHC data compromises the quality and comparability of all forms of information that can be created—an issue that affects all stakeholders, regardless of type (for example, clinician or health system planner) and regardless of their intended use of that information.

To support the EMR adoption initiatives, stakeholders identified the need for a pan-Canadian PHC EMR content standard that would define a common approach to capturing a priority set of data elements in a structured manner that supports both primary and health system uses of the data. Supporting a single pan-Canadian standard was seen by stakeholders as a way to maximize the value and efficiency associated with development, implementation and maintenance.

In collaboration with stakeholders from across the country, the Canadian Institute for Health Information (CIHI) led the project to establish the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0 (PHC EMR CS). The PHC EMR CS is composed of 106 data elements that are commonly captured in EMRs and that support both primary uses of EMR data, such as reminders and alerts for patients with chronic conditions, and health system uses, such as a jurisdictional diabetes management registry. These data elements are required to support the many facets of PHC, including treatment of illnesses, as well as health promotion and disease prevention.

The creation of the PHC EMR CS marks a key milestone on the path to improving PHC in Canada. The next step along this path is to ensure that the PHC EMR CS is properly and widely implemented in EMRs. Two future steps involve ensuring that implementation of the PHC EMR CS supports care delivery and PHC system improvements in a privacy-sensitive manner; and ensuring that PHC EMR data is privacy-protected when employed for health system uses.

CIHI will continue to work with stakeholders to establish additional products and services to facilitate the adoption and implementation of the PHC EMR CS. In parallel, strategies and plans for the longer-term governance and maintenance of the PHC EMR CS will be established to ensure it remains clinically and technically relevant to meet evolving stakeholder needs in the years to come.

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Introduction

The Challenge

Primary health care (PHC) is the most common type of health care experienced by Canadians. Efforts to improve PHC hold the greatest potential to positively impact the health of Canadians and the sustainability of the health care system.1 As health care costs continue to rise, all stakeholders are increasingly accountable to demonstrate value for health care spending while improving the quality and outcomes of care. Accountabilities in this area are far-reaching and extend to jurisdictions, i PHC clinicians and electronic medical records (EMR) vendors. At the same time that stakeholders are experiencing a greater demand to demonstrate improvements in health care delivery and fiscal responsibility, information on PHC remains limited. Currently, there is limited evidence-based information to inform better practice and health system management on how to improve the quality, effectiveness and efficiency of patient care.

Across Canada, the increased use of EMRs has been promoted to support improvements in PHC quality and efficiency. However, in the absence of a pan-Canadian PHC EMR content standard, multiple EMR standards have been developed to support jurisdictional needs. The lack of a pan-Canadian approach to EMR standards to date has resulted in

Increased costs to the system associated with developing, implementing • and maintaining multiple standards;

Fewer benefits realized from EMRs, including limited information to support • clinical decision-making at the point of care; and

Limited comparable information to support health system evaluation and • management across the country.

i. The term “jurisdiction” broadly refers to the provincial and territorial ministries of health, as well as the Federal Healthcare Partnership, which comprises Citizenship and Immigration Canada, Correctional Service Canada, Department of National Defence, Health Canada, Public Health Agency of Canada, Royal Canadian Mounted Police and Veterans Affairs Canada.

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The Solution

Stakeholders from across the country developed a set of priority data elements to ensure that the necessary subset of standardized information is available to improve access, quality, outcomes and chronic disease prevention and management across Canada. These priority data elements formed the core content of the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0, henceforth referred to as the PHC EMR CS.

The PHC EMR CS is composed of 106 data elements that are commonly captured in EMRs and support primary uses, such as reminders and alerts for patients with chronic conditions and health system uses of EMR data, such as a jurisdictional diabetes management registry. These data elements are required to support the many facets of PHC, which include not only treatment of illnesses but also include health promotion and disease prevention activities.

About This Document

This document is intended for clinicians and decision-makers from public and private sector organizations with an interest in effective PHC EMRs, with a goal of aiding these stakeholders in understanding the purpose and development process of the PHC EMR CS. To this end, the document has been written from a business perspective as opposed to a technical one. ii

ii. Technical information that is of interest to implementers and standards experts is available on CIHI’s Primary Health Care Information Program website at www.cihi.ca/phc.

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Background

Primary Health Care Indicators to Support Measurement for Improvement

Primary health care (PHC) has been called the foundation of Canada’s health system and is the most common type of health care that Canadians experience.2 Currently, we know little about the way services are delivered, the results that these services yield or how our PHC system is evolving. Broadly, PHC indicators and the data required to report on these indicators contribute to the measurement and management of PHC in Canada. Measuring PHC in Canada will require harnessing and enhancing data sources at the local, regional, provincial/territorial and pan-Canadian levels.

In 2005, the Canadian Institute for Health Information (CIHI) received funding from the Primary Health Care Transition Fund and partnered with a broad range of PHC experts across Canada to develop an agreed-upon set of pan-Canadian indicators that could be used to measure PHC at multiple levels within jurisdictions across Canada. The resulting 105 indicators were published in the two-volume report Pan-Canadian Primary Health Care Indicators in 2006. A companion report recommended options for enhancing the infrastructure required to collect the data associated with the PHC indicators. CIHI built on this work in 2007 by exploring the feasibility of various options to improve PHC data sources, including data on quality and outcomes from clinical sources.

CIHI PHC Indicators EMR Content Standards, Version 1.1 to Support Quality Measurement and Improvement

In 2007, CIHI conducted an environmental scan to assess the feasibility of collecting data on these 105 PHC indicators from a variety of sources, including electronic medical records (EMRs), existing CIHI databases and other administrative databases, as well as patient, provider and organizational surveys.

The environmental scan found that data for the PHC quality indicators—representing approximately one-third of the 105—could potentially be collected from EMRs plus diagnostic imaging, prescription drug and lab data sources. However, the scan also highlighted the need to establish EMR content standards in order to standardize data collection across PHC settings. In response to provincial, territorial and federal needs, CIHI led the PHC Indicators EMR Content Standards Project, which included pan-Canadian collaboration with PHC clinicians, researchers, standards experts and health system managers to identify the priority data elements for the preliminary

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standard (Version 1.1). The focus of the project was to establish a new pan-Canadian data stream for populating and reporting on a subset of the PHC quality indicators in order to improve the understanding of PHC across the country and inform health policy and decision-making at various levels.

In early 2009, CIHI issued Version 1.1 of the PHC Indicators EMR Content Standards to facilitate the standardized capture of a priority subset of EMR data associated with 12 quality PHC indicators. Over the past year, pilot testing in PHC settings informed the need for a subsequent iteration of the standard.

Draft Pan-Canadian PHC EMR Content Standard, Version 2.0 to Support Primary and Health System Use

In the fall of 2009, stakeholders identified the need to expand the scope of Version 1.1 to include both primary and health system uses of EMR data and to improve alignment of the data elements with the pan-Canadian Electronic Health Record (EHR) Messaging and Terminology Standards, as well as with Infoway’s Physician Office System Requirements.3 In response to the needs of the jurisdictions promoting the use of PHC EMRs, CIHI launched a project to work with stakeholders to develop Version 2.

Two Types of “Use”

Primary useThe data are currently and commonly required to support the delivery and/or administration of primary health care.

Health system useThe data are commonly required to support PHC clinical program management, health system management, research and monitoring the health of the population.

To achieve this goal, a jurisdictional advisory group (JAG)—with representation from the jurisdictions, Infoway and CIHI—was established to help set the strategic direction for the project. The JAG was supported by a pan-Canadian Content Standards Working Group (CSWG), which provided input and advice on the data elements to ensure that they were clinically relevant, aligned with existing standards where appropriate, met the needs of stakeholders and were implementable. The JAG and CSWG were also responsible for informing strategies and plans for the longer term adoption, governance and maintenance of the PHC EMR CS.

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The collaborative approach was intended to reduce duplication of effort in the development of EMR content standards at the jurisdictional level and to minimize the burden on EMR vendors who would otherwise have to incorporate and maintain multiple standards in their EMRs. The draft standard was given a slightly different name than its predecessor to reflect the fact that it is a pan-Canadian standard that supports both primary and health system uses of EMR data.

Content Standard Naming Convention

The PHC EMR CS is considered a “draft pan-Canadian standard” because it meets the following criteria:

It is governed by a body with pan-Canadian representation.•

Its scope is to meet pan-Canadian requirements.•

It was developed with pan-Canadian input on clinical content, jurisdictional • priorities and standards expertise.

It was established by a pan-Canadian, consensus-based approval process.•

It is considered “draft” because it has not yet been implemented and there • are areas for further refinement that require implementation experience.

In this context, the term “pan-Canadian” means “across Canada”; generally, in the health field, the term often implies representation from the majority of the health jurisdictions and other stakeholder categories from across Canada. The title “Draft Pan-Canadian Standard” was recommended by the CSWG in order to avoid confusion with labels used by the Infoway Standards Collaborative (“Canadian Draft for Use”) and other standards bodies, such as HL7 (“Draft Standard for Trial Use”).

ScopeThe purpose of the PHC EMR CS is to provide a minimum data set that, when implemented in PHC EMRs, will yield data that enables EMR functionality and provides information that will lead to quality improvements in patient care and the broader health care system.

Once the PHC EMR CS has been implemented, PHC EMRs can make better use of EMR data to drive application functionality—such as the functions described in Infoway’s Physician Office System Requirements (e.g. the EMR can graph lab results over time)—and to generate information. They can also extract data to support a variety of needs ranging from interoperating with a jurisdictional EHR to providing data to a chronic disease management repository.

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Scope Criteria

The main criterion for the inclusion of a data element in the PHC EMR CS was its ability to support both primary and health system uses of EMR data.

Examples of data elements that support both primary and health system uses of EMR data are shown in Figure 1. Data elements that appear in the overlapping area of the two circles support both uses, and are therefore deemed to be in scope for the PHC EMR CS.

Figure 1: PHC EMR CS Scope

Patient StreetNumber and Name

ClinicianBilling Number

Number of PrescribedMedication Refills

PatientPostal Code

ClinicianRole Type

PrescribedMedication

Patient Socio-EconomicNeighbourhood

Clinician HighestDegree Obtained

DispensedMedication Cost

Primary Use Health System Use

In Scope

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Benefits to Patient Care and the Health SystemThe PHC EMR CS directly supports patient care improvements by enabling EMR functionality (for example, clinical decision support) and providing information that clinicians and health care system decision-makers can use to improve quality of care (for example, prevention, outcomes and access to care). Without the PHC EMR CS, it would not be possible to efficiently monitor and evaluate efforts to improve PHC across the country in a comparable way.

“Data standards allow comparisons between patients within the practice, as well as comparisons across practices, and facilitate surveillance and a population health approach to primary health care.”

Dr. Alan KatzFamily PhysicianWinnipeg, Manitoba

A pan-Canadian approach to the PHC EMR CS mitigates duplication of effort to develop jurisdictional-specific standards, which otherwise increases costs to EMR vendors who would have to support the implementation of multiple standards in their products. By supporting both primary and health system uses of EMR data, the PHC EMR CS will reduce data collection costs by reusing data captured at the point of care for clinical program management, health system management, research, and monitoring the health of the population.

“Collecting information in a structured way helps manage our precious resources in the most effective way.”

Dr. Roger HamiltonFamily PhysicianWolfville, Nova Scotia

While clinicians, jurisdictions and PHC EMR vendors receive the benefits described above, they also derive unique benefits from the adoption of the PHC EMR CS. These benefits can only be fully realized through incorporation into software and systems that are properly designed and used by all stakeholders.

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Clinician BenefitsImprove patient care and safety• through the use of clinical decision support functions in their PHC EMR. Examples of clinical decision support functions include, but are not limited to, drug-to-drug interaction alerts, reminders for follow-up care and suggested treatment plans for specific conditions.

Facilitate patient care coordination• through electronic communications with other clinicians via interoperable systems, such as electronic referrals, and ordering of lab tests using standardized, comparable and clinician-friendly terms.

Improve the quality of care and efficiency in their PHC practice • by examining reports on their patient population and quality of care indicators over time. Understanding trends in patient demographics, quality of care, patient-centred care and disease prevalence can help clinicians plan for quality improvement and optimize resource allocation in their practice.

“Standardized data in the EMR helps those of us working in primary health care to work more collaboratively as a team. The easy retrieval of information in the EMR also gives me more time to deal with issues that my patients have.”

Denise MossRegistered Nurse andCertified Diabetes EducatorAlgoma Diabetes Education and Care ProgramSault Ste. Marie, Ontario

Jurisdiction Benefits

Improve availability of comparable, standardized data in order to

Evaluate and monitor chronic disease prevention and management • (CDPM) initiatives. Improvements to CDPM will not only improve the lives of patients but also decrease costs to the jurisdictional health care system.

Analyze PHC delivery and administration to identify areas to improve• quality, outcomes, safety and efficiency and to ensure that patients have optimal access to care.

Monitor the health of the population to identify, prevent and contain• outbreaks of disease.

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“This standard enables the consistent capture of information in EMRs that will help inform efforts to better manage the health system.”

Tom FoggDirector of Strategy and Planning, Manitoba eHealth Co-chair of the Pan-Canadian EMR Content Standard Jurisdictional Advisory Group

PHC EMR Vendor BenefitsLower the implementation and maintenance costs of EMRs• through support of a single standard. Otherwise, vendors must consume considerable resources in evaluating jurisdictional requirements that conform to different standards. The vendors then have to expend resources to maintain each of these standards in their products and support mapping between these standards.

Improve product offerings• by providing innovative features and functionality that rely on the underlying standardized data (clinical decision-support tools, quality indicator reporting).

Increase the speed• at which products can be brought to the market by decreasing development and conformance-testing efforts.

When properly implemented, the PHC EMR CS offers numerous benefits to stakeholders, such as ensuring that PHC clinicians have the information they need to deliver, coordinate and administer optimal care, and providing the information required to manage the PHC system in an efficient and effective manner.

“I want to know how I can get good data out of my EMR without disrupting the work flow. Pan-Canadian standardized data allows you to identify work flow issues and patients’ needs and gives you an opportunity to compare models of care not only within your own province, but models operating across Canada.”

Dr. Lewis O’BrienFamily Physician Sault Ste. Marie, Ontario

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ApproachThe PHC EMR CS project followed a robust framework to ensure that stakeholders were actively engaged in every step, from establishing the project’s strategic directions to approving the final deliverables. The following diagram depicts the project framework, which is described in further detail below.

Figure 2: PHC EMR CS Project Framework

Clinicians

Researchers

Other EHR Standards

Vendors

Standards Experts

Jurisdictions

Infoway

Ongoing Development

and Maintenance

Jurisdictions

Clinicians

Vendors

StakeholderInputs

1. Education

2. Implementation Support

3. Conformance and Quality Testing

Stakeholder engagement strategy and plan

Communication material

Conceptual data model

Use cases

Specifications for each data element

Terminologies options analysis andrecommendations report

Implementation planning

Work Packages

CIHI

Promotion, Adoption and Implementation

Information Requirements Gathering

1. Conduct gap analysis of other EHR/ EMR standards

2. Identify agreed list of PHC data elements

3. Develop options for clinical concept lists and explore mappings to clinical terminologies and classification systems for clinical data

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Stakeholder Inputs

The stakeholder engagement process was initiated by the creation of a Jurisdictional Advisory Group (JAG) that was formed with senior representatives from the provinces and territories, Infoway and the Federal Healthcare Partnership. The role of the JAG was to provide strategic direction to the project and inform the stakeholder engagement and communication strategies. These strategies engaged the most influential and interested representatives from the jurisdictions, clinicians, standards organizations, vendors, researchers, Infoway and CIHI to contribute to the requirements and content of project deliverables. A key component of the stakeholder engagement strategy was the creation of the Content Standards Working Group (CSWG), which consisted of subject matter experts representing the key stakeholders from across the country. The CSWG was ultimately responsible for ensuring that the core content of the PHC EMR CS reflected stakeholders’ needs.

The JAG and CSWG members were also tasked with acting as liaisons to their stakeholders to create awareness and solicit input on various aspects of the project. In support of these efforts, the PHC EMR CS project team collaborated with JAG and CSWG members to deliver several jurisdictional face-to-face workshops, which resulted in the identification of additional requirements for the PHC EMR CS.

The PHC EMR CS project team presented to standards bodies, such as the Infoway Standards Collaborative Working Groups, Coordinating Committee, Clinical Sub-Committee and Partnership Conferences. In addition, jurisdictional health information standards councils were directly engaged in collaboration with CSWG members.

A face-to-face workshop with PHC EMR vendors was held in June 2010 to discuss adoption challenges and solutions for the PHC EMR CS. The workshop provided an opportunity to deliver consistent messaging regarding the alignment of the project with other jurisdictional and national EMR standards initiatives. JAG and CSWG representatives also contributed to the in-depth discussions on the best methods for facilitating adoption of the PHC EMR CS.

In an effort to increase the project’s exposure to an even broader range of stakeholders, the PHC EMR CS project information was also presented at conferences such as eHealth 2010 and the Canadian Institutes of Health Research Primary Healthcare Summit.

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Information Gathering and Priority Setting

A baseline set of data elements was compared with EMR and EHR jurisdictional and national standards to assess the size of the alignment gap. The gap analysis also identified opportunities to reuse existing standards, particularly from the pan-Canadian EHR messaging and terminology standards. This information was coupled with the input from the stakeholder engagement process, described above, to form the core requirements and scope of the PHC EMR CS.

The CSWG acted as the main body for reviewing and agreeing on requirements and solutions for meeting stakeholders’ needs. The CSWG held three review cycles of iterative drafts of the PHC EMR CS. Each cycle generated additional requirements and solutions, which were tracked to completion using a defined methodology and supporting database. This process allowed CSWG members to track the evolution of the PHC EMR CS against their proposed requirements and solutions to ensure that their needs were being met.

The CSWG review cycles resulted in a priority list consisting of 106 data elements, which formed the core content of the PHC EMR CS and were recommended to the JAG for approval. The JAG endorsed the CSWG recommendations regarding the data elements to be included in the PHC EMR CS. During the requirements review process, stakeholders identified the need to analyze options for selecting terminologies for six high-priority clinical concepts, including diagnoses, reason for encounter and interventions. In response to this need, CIHI launched a parallel project to identify and assess options regarding the development or adaptation of one or more standard sets of terminology or coding standards for use in PHC EMRs.

Work Packages

As previously discussed, the stakeholder engagement strategy and plan were the first project deliverables. It should be noted that the strategy and plans were refined throughout the project based on stakeholder feedback. Bilingual communication materials, such as a one-page project overview and a list of frequently asked questions, were developed to assist stakeholders in promoting the project within their respective areas. These materials are available from CIHI’s Primary Health Care Information Program website, at www.cihi.ca/phc.


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A conceptual model was developed to help stakeholders understand how PHC business concepts referenced by the 106 data elements related to each other. (See Appendix A: Draft Conceptual Model.)

High-level use cases were developed to clarify how data that had been collected to support the delivery and administration of PHC could be reused to support quality improvement, policy development and health system management. (See the Business Context section for more information on the use cases.)

The 106 data elements that form the core of the PHC EMR CS are summarized in the Data Elements section. (See Appendix B: Data Element Matrix for a complete list.) A data extract specification was in development at the time of writing this document. The purpose of the data extract specification is to provide the additional information that implementers need in order to be able to extract EMR data for health system use.

The report regarding the terminology options analysis and recommendations was one of the final project deliverables. At the time of writing this document, the recommendations were under review. Similarly, implementation support planning was just being launched at the time of writing. Initial plans on the type of implementation support that may be required to facilitate adoption of the PHC EMR CS are discussed later on in this document. (See the Adoption, Maintenance and Governance section.)

Promotion, Adoption and Implementation

The benefits of the PHC EMR CS will be fully realized only if it is implemented in vendors’ products, such as PHC EMRs and PHC data repositories, and if these products are ultimately used by clinicians and jurisdictions. Promotion and education efforts are therefore required to ensure that stakeholders are aware of the PHC EMR CS and its benefits. Once stakeholders have made the decision to adopt the PHC EMR CS, they will need guidance and support to facilitate the efficient and accurate implementation of the PHC EMR CS. Finally, conformance and quality testing will be required on vendors’ products to ensure that the PHC EMR CS has been implemented correctly.

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Business Context

Background

At the point of service, the primary use of EMR information is to support clinical decision-making and interdisciplinary collaboration in the delivery and administration of PHC. However, the same data is essential to improving patient care through research and clinical program management, and will support monitoring the health of the population and the overall effectiveness of the health care system. The reuse of PHC EMR data for these purposes is often referred to as “health system use.” The types of PHC EMR data that can serve dual purposes include, among others,

Patient and clinician demographics;•

Patient health status and history;•

Lab orders and results;•

Medication prescription and fills; and•

Diagnostic imaging orders and results.•

This section provides examples—in the form of high-level use cases—of how a common set of data elements collected at the point of service can directly support both patient care and health system uses of PHC EMR data. The use cases illustrate a future state of standardized PHC EMR data flow to support patient care coordination and integration of services, and generate aggregate reports for use by clinicians and by jurisdictions to aid with population planning for chronic disease prevention and management.

What Is a Use Case?

Use cases provide one or more scenarios that convey electronic transmission points of a common set of data elements between an end user and another system to link knowledge and achieve a specific business goal. For example, connecting clinical knowledge to prompt alerts or reminders facilitates clinicians in achieving their goal of improving the quality of care for their patients.

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Chronic disease prevention and management forms the overarching context for the use cases described in this section. Within this context, three use case categories are provided:

Use Case Category 1: PHC Clinic Visits and Program Management1.

Use Case Category 2: Referral to a Specialist and Wait Times Management2.

Use Case Category 3: Patient Self-Management and Chronic Disease 3. Prevention and Management

Each category consists of a primary use case and a health system use case. As a whole, each category demonstrates how data collected at the point of service for the purpose of delivering and administrating care can also be used by clinicians and health system managers to help improve patient care and the broader health care system. Figure 3 shows the relationship between the three use case categories and their corresponding use cases.

Figure 3: Use Case Categories

Health SystemManagement

Referral WaitTimes Management

Referral to a Specialist

Use Case Category 2: Referral to a Specialist and Wait Times Management

Research/Monitoringthe Health of

the Population

Patient Self-Management

Chronic Disease Prevention and Management

Use Case Category 3:Patient Self-Management

and Chronic Disease Prevention and Management

Prim

ary

Use

Heal

th S

yste

m U

se

Clinical ProgramManagement

PHC Clinic Visit

PHC ClinicalProgram

Management

Use Case Category 1: PHC Clinic Visits and Program Management

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Each use case is composed of three parts:

Narrative:1. A brief story about people’s interactions with specific aspects of the PHC system.

Swim lane diagram: 2. A picture of the people, systems and EMR data involved in specific aspects of the PHC systems. Each swim lane represents the action of a person or a system (called an “Actor”). In each lane, actions are initiated by an Actor and result in data outputs or inputs to the system.

Flow of events sidebar:3. A sequential flow of actions derived from the narrative that corresponds to key points in the swim lane diagram. Each step in the sequential flow of actions is referenced in the diagram as red numbered circles.

Caveats

The following caveats should be kept in mind while reading the use cases:

The example data shown in the use cases represent a business view of 1. the data elements in the PHC EMR CS. Please note that the use cases reference the common names of the data elements, which are non-technical labels that are easily understood by a broad audience. Each data element also has a standard name, which in many cases may be a longer but more precise label than the common name. Appendix B includes both the common and standard names for cross-referencing.

The Electronic Health Records swim lane depicts a simplified 2. representation of the systems that constitute the EHR; it is not a comprehensive list of all potential jurisdictional systems.

Jurisdictions are at different stages of development of their EHR system; 3. therefore, no assumptions are made regarding the existence or lack thereof of EHR system components. As a result, the diagrams depict information flows directly between Point of Service (PoS) systems as well as flows between PoS systems and other systems.

The use cases assume that all the necessary consent, privacy and security 4. measures that are required to use the data for multiple purposes have been adhered to.

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Use Case Example: From Primary to Health System Use of EMR Data

The following use case example introduces the reader to the swim lane diagrams while providing a holistic view of how EMR data that is used in the delivery and administration of care (primary use) can also support various health system uses.

Narrative

At the point of service, clinicians capture clinical information on risk factors, symptoms and assessment measurements in an EMR and use this information to support care coordination activities electronically. In this example, a clinician is electronically issuing a lab requisition, referral and prescription to facilitate care for a single patient.

The data collected by the various point of service systems can be aggregated and presented to clinicians in the form of practice-level feedback reports on their population, which can help clinicians to assess clinical quality of care, utilization and care coordination. This is an example of a health system use for PHC clinical program management.

The same data is used to support PHC health system management. It is used to inform improvements in access, coordination, delivery models, resource and service utilization, and quality of care outcomes. Ultimately, the data can be used to inform policy for PHC and to support sound decision-making. Overall, standardized PHC EMR data collection will expand the country’s understanding of emerging PHC information needs through monitoring the health of the population and research.

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Figure 4: Example Swim Lane Diagram

PATI

ENT

PHC

CLIN

ICIA

N(S)

PHC

EMR

(Dat

a St

ore)

EHR

EXTE

RNAL

PO

INT

OF S

ERVI

CEHE

ALTH

SYS

TEM

US

E (H

SU)

AlternativeData Flow

Data Store

PHARMACY• Medication

Dispense Date

SPECIALIST • Consult Note

Nurse assesses patient

Physicianassesses patient

Patient calls to book appointment for

annual assessment

• Patient Name• Patient Identification Number• Identification Issuer• Date of Birth• Gender• Reason for Encounter• Postal Code• Encounter Date

• Blood Pressure• Symptoms• Family History• Vitals, etc

• Diagnosis• Prescription• Lab Request• Referral• Intervention

SYMPTOMS EXAMINATION

Jurisdictional Lab Information System

e-Lab

PHC EMR

Jurisdictional Shared Health Record System

e-Referral

Jurisdictional Drug Information System

e-Prescription

RESEARCHCLINICAL PROGRAMMANAGEMENT

HEALTH SYSTEMMANAGEMENT

• Provider Level Feedback Report

• Practice Level Feedback Report (Includes PHC Indicator and Utilization Analysis)

• Access and Coordination of Care to PHC Services

• Wait Times and Referral Patterns

• Drug Prescription Patterns• Patient Outcomes

• Diabetes Management• Wait Times

• Diabetes and Hypertension Incidence and Prevalence Rates

MONITORING THE HEALTH OF THE POPULATION

RISK FACTORS

Patient arrivesat PHC clinic

• Excessive Thirst

• Fatigue• Frequent

Urination

• Height• Weight• Blood

Pressure

• Physical Inactivity

• Advanced Age • Obesity

Report

SwimLanes

Data Flow

PATIENT AND ENCOUNTER DETAILS

• Lab Test Performed Date• Lab Test Result Value• Lab Test Result Low Range• Lab Test Result High Range

LAB FACILITY/ LAB REPOSITORY

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Figure 4: Example Swim Lane Diagram (cont’d)

Flow of Events

The Patient arrives at a PHC clinic for a scheduled appointment.1.

The Nurse assesses the Patient and captures risk factor data 2. in the EMR.

The Physician reviews the pre-assessment information in the EMR.3.

The Physician performs an examination on the Patient. 4. The Physician notes that the Patient has risk factors and symptoms that suggest the patient may have diabetes.

The Physician enters the Patient’s health status in the EMR and 5. electronically orders a lab test and a prescription medication, and creates a referral to a specialist.

The data from the point of service systems is aggregated to 6. create information that supports clinical program management, health system management, research or monitoring of the health of the population.

Use Case Category 1: PHC Clinic Visits and Program ManagementThe following use cases demonstrate how data that is created at the point of service during an encounter (primary use) can also be used to support clinical program management (health system use).

PHC Clinic Visit (Primary Use)

At an annual medical appointment, the Patient describes frequent episodes of excessive thirst, fatigue and urination. The Nurse assesses the Patient and captures risk factors (such as the Patient’s physical inactivity and obesity) and symptoms in a standardized manner in the EMR. Subsequently, a risk factor alert is generated by the EMR and prompts the Physician to review the clinical information that suggests a potential diagnosis of diabetes. To confirm this clinical assessment, the Physician electronically issues a lab test for fasting blood glucose levels and HbA1C.

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Figure 5: PHC Clinic Visit

PATI

ENT

LAB

FACI

LITY

PHC

CLIN

ICIA

N(S)

PHC

EMR

(Dat

a St

ore)

EHR

Nurse assesses Patient

Physicianassesses Patient

Patient calls to book appointment for

annual assessment

• Patient Identifier• Patient Date of Birth• Patient Gender• Patient Postal Code• Reason for Encounter• Encounter Date

• Blood Pressure• Symptoms• Family History• Vitals, etc.

• Immunizations• Diagnosis• Prescriptions• Lab request• Intervention

SYMPTOMS EXAMINATION

Jurisdictional Lab Information System (JLIS)

e-Lab

PHC EMR

LAB

• Lab Test Name Ordered• Lab Test Ordered Date

RISK FACTORS

Patient arrivesat PHC clinic

• Excessive Thirst

• Fatigue• Frequent

Urination

• Height• Weight• Blood

Pressure

• Physical Inactivity

• Advanced Age • Obesity

PATIENT AND ENCOUNTER DETAILS

Flow of Events


The Nurse assesses the Patient and captures risk factor data 2. in the EMR.

The Physician reviews the Nurse’s assessment information in the EMR.3.

The Physician performs an examination on the Patient. The Physician 4. notes that the Patient has risk factors and symptoms that suggest the Patient may have diabetes.

The Physician enters the Patient’s health status in the EMR and 5. electronically orders a lab test for fasting blood glucose levels and Hemoglobin A1c (HbA1C).

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PHC Clinical Program Management (Health System Use)

The PHC EMR data captured during a face-to-face encounter between a patient and a PHC provider can be used by the PHC clinic or other organizations to generate a variety of reports, such as provider feedback reports and practice level feedback reports that include PHC indicators and utilization analysis.

Through the PHC clinic, a number of quality improvement initiatives are coordinated to monitor and manage patients with chronic diseases, including those with diabetes. To support care coordination efforts, the PHC Clinic Administrator routinely extracts EMR data from a local server and generates provider-level feedback reports. In this example, the Physician receives and reviews the provider feedback report to determine the percentage of adult Patients with diabetes who have not had their routine assessment for HbA1C, blood pressure, weight, full fasting lipid profile and nephropathy screening. Subsequently, the Clinic Administrator organizes follow-up calls (or emails) to Patients to schedule reassessment visits. The Clinic Administrator also organizes a meeting of the interdisciplinary team to discuss modifiable risk factors in adults with diabetes that can help improve their quality of life and prevent additional health complications. The report also supports improvements to practice efficiency by identifying resourcing needs required to optimally care for the patient population within the clinic’s catchment area and to maximize jurisdictional incentives for vulnerable patient populations.

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Figure 6: PHC Clinical Program Management

PHC

CLIN

ICIA

N(S)

PHC

EMR

(Dat

a St

ore)

Automatically Extracts Data

Automated Automated

Physician enters Patient’s health

concern data into EMR

Performs Data Quality and Statistical Analysis

Automatically Generates Provider-Level Feedback

Report (Annual Comparative Reports)

PHC

DATA

SER

VICE

S

Provider-Level Feedback Report (Annual

Comparative Reports)

PHC EMR

• Diagnosis

HEALTH CONCERNS

PHC ClinicAdministrator

Flow of Events


Patient data is captured in the EMR by Clinicians throughout the 2. course of delivering care.

The PHC Clinic Administrator extracts aggregated patient data 3. from the EMR and generates the provider-level feedback report.

The Physician reviews the provider-level feedback report to 4. determine the percentage of adult patients with diabetes who have not had their annual assessments.

The Physician asks the PHC Clinic Administrator to contact patients 5. who have not had their annual assessments in the last 12 months in order to remind them to schedule an appointment.

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Use Case Category 2: Referral to a Specialist and Wait Times Management

Referral to a Specialist (Primary Use)

The Physician accesses a centralized, real-time patient referral system to coordinate care for a Patient with diabetes who would benefit from a consultation with a Specialist. The generated wait list from the patient referral system provides a range of waiting periods with corresponding names of available Specialists. Upon retrieving this information, the Physician reviews the list with the Patient and confirms the Patient’s preferred wait time and location. The Patient chooses to see the first available Specialist with a six-week wait time. Immediately, the Physician processes the referral and secures an appointment time with a Specialist.

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Figure 7: Referral to a Specialist

PHC

CLIN

ICIA

N(S)

PHC

EMR

(Dat

a St

ore)

SPEC

IALI

ST

Physician diagnoses Patient with type 2 diabetes mellitus

EHR

Physician looks for a Specialist with the

shortest wait timePhysician recommends

Specialist and discusses availability options

Physician processes referral and books

referral appointment

PHC EMR

EHR Data and Services

Specialist EMR

SPECIALIST

• Consult Note

Available SpecialistWait Times Report

• Referral Service• Referral Requested Date

REFERRAL

Flow of Events

After reviewing the Patient’s lab test results, the Physician diagnoses 1. the Patient with type 2 diabetes mellitus and recommends that the Patient see a Specialist (diabetes educator) for a follow-up visit.

The Physician uses the EMR to check a centralized, real-time, 2. Patient referral system to find a Specialist with the shortest wait time.

The Physician receives an immediate feedback report indicating that 3. the first available Specialist has a wait time of six weeks.

The Physician discusses the Specialist options with the Patient 4. based on wait times and locations. The Patient chooses to see the first available Specialist with a six-week wait time.

The Physician uses the EMR to book the appointment.5.

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Referral Wait Times Management (Health System Use)

The PHC EMR data captured during a face-to-face encounter and a subsequent referral to a Specialist by a PHC provider to a Patient can be aggregated and used by the jurisdictions and CIHI to generate a variety of reports, such as wait times for specific services and referral patterns. Primary health care information can be used by jurisdictions for health system management to support improvements in access, coordination, delivery models, resource and service utilization and quality of care outcomes. To support the country’s need to manage health systems and set benchmarks, the PHC Clinic Administrator extracts data on a quarterly basis in accordance with privacy and security guidelines and submits the data to the jurisdiction and/or CIHI for analysis. Data quality and statistical analysis is performed to generate health service access and utilization reports. The reports identify average patient wait times for an appointment with a Specialist, referral patterns and utilization of health services. Next, the health service access and utilization reports are confidentially disseminated to individual jurisdictions. The jurisdictions use the information to evaluate health policies, inform PHC improvement efforts and allocate resources.

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Figure 8: Referral Wait Times Management

JURI

SDIC

TION

(S)

PHC

DATA

SER

VICE

SPH

C EM

R(D

ata

Stor

e)JU

RISD

ICTI

ON/C

IHI P

HC

REPO

SITO

RYEH

R

AutomaticallyExtracts Data

Compresses and Encrypts Data File

Submits/Uploads Data Files via Electronic Data Submission Process (eDSS)

De-Identifies Data

Automated Automated

Retrieves, Verifies and PerformsData Quality and Statistical Analysis

Generates Referral to ServicesWait-Times/Referral Patterns Reports

PHC EMR

Jurisdictional/CIHIPHC Repository

Jurisdictional SharedHealth Record

• Referral to Services Wait-Times Reports• Referral Patterns Reports

• Referral Service• Referral Requested • Date

REFERRAL


Jurisdictional Health System Administrator

Jurisdictional/CIHIData Administrator

Flow of Events

The PHC Clinic Administrator extracts aggregated patient data from 1. the EMR and electronically submits the data to the jurisdictional/CIHI PHC repository.

The Jurisdictional/CIHI Data Administrator retrieves the submitted 2. data files, performs data quality and statistical analysis, and generates the health service access and utilization reports.

The Jurisdictional/CIHI Data Administrator disseminates the health 3. service access and utilization reports to Jurisdictional Health System Administrators.

The Jurisdictional Health System Administrators receive the health 4. service access and utilization reports.

The Jurisdictional Health System Administrators use the reports to 5. help inform decisions on how to improve access to care.

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Use Case Category 3: Patient Self-Reporting and Chronic Disease Prevention and Management

Patient Self-Management (Primary Use)

During the Patient’s previous diabetes follow-up visit at the PHC clinic, the Physician asked the Patient a number of questions regarding her family health history, social behaviours and other potential risk factors. But due to a combination of nervousness and lack of knowledge of her family’s health history, the Patient was unable to answer all of the Physician’s questions.

The Physician requests that the Patient speak to family members regarding the family history of other diseases and to enter this information into her Personal Health Record (PHR) as it becomes available. Over the course of the next three months, the Patient learns that there is a history of hypertension and heart disease in the family. She enters her family health history, social behaviours and other risk factor information into the PHR web portal. The data in the PHR is shared electronically with the Physician’s EMR for verification and discussion at a subsequent visit.

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Figure 9: Patient Self-Reporting

PHR

(Dat

a St

ore)

PATI

ENT

EMR

(Dat

a St

ore)

PHC

CLIN

ICIA

NSEH

R

Patient entershealth history and

risk factor data

Physician reviews health history and risk factor data with patient

PHR

EMR


• Patient Identifier• Patient Date of Birth• Family Health History• Social Behaviours

PATIENT HEALTH HISTORY

Flow of Events

The Patient enters health history and risk factor data into the PHR.1.

The data in the PHR is shared electronically with the Physician’s EMR. 2.

The Physician discusses the Patient’s risk factors and health history 3. at a follow-up appointment.

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Chronic Disease Prevention and Management(Health System Use)

The Physician is asked to join a voluntary research collaborative that uses EMR data to better understand chronic diseases and to improve care and prevention for Patients with chronic conditions. The Physician works with the PHC Clinic Administrator to contribute anonymized data to a centralized repository on a routine basis.

A Researcher is investigating correlations between the health status of Patients with diabetes and risk factors for hypertension and heart disease. The Researcher queries the repository to identify populations of people with diabetes who also have a family history of hypertension and heart disease. The Researcher then queries the repository to determine how many Patients within the population have received nutrition and exercise counselling to help prevent hypertension and heart disease. The findings are published as part of a comprehensive report on the quality of care for people living with chronic diseases.

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Figure 10: Chronic Disease Prevention and Management

PHC

DATA

SER

VICE

SPH

C EM

R(D

ata

Stor

e)RE

SEAR

CHRE

POSI

TORY

CPDM

REP

ORT

EHR

AutomaticallyExtracts Data

Compresses and Encrypts Data File

Submits/Uploads Data Files via Electronic Data Submission Process (eDSS)

De-Identifies Data

Automated Automated

Retrieves, Verifies and PerformsData Quality and Statistical Analysis

PHC EMR

ResearchRepository


CPDM Quality of Care Report

• Health Concerns• Family Health History• Interventions

HEALTH STATUS AND HISTORY


Researcher

Flow of Events

The PHC Clinic Administrator extracts the anonymized data 1. for submission to the voluntary research collaborative.

The Researcher queries the repository to identify populations 2. of people with diabetes who also have a family history of hypertension and heart disease.

The findings are published as part of a comprehensive report 3. on the quality of care for people living with chronic diseases.

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Summary

The preceding high-level use cases demonstrate how data captured at the point of service for primary uses can also support health system uses. However, the reuse of PHC EMR data can be achieved only if it is captured and shared in a standardized manner.

Data ElementsThe data elements listed in Table 1 form the core (normative) content for the PHC EMR CS. Table 1 provides a simplified view of the data elements by using their common names (meaning the names that are recognizable from a business perspective). Please see Appendix B: Data Element Matrix for a detailed view of the 106 data elements, including their standard name, definition, domain values and alignment to pan-Canadian EHR Messaging and Terminology standards and Physician Office System Requirements.

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Table 1: PHC EMR CS Business View

Demographics

Patient Clinician Clinic

Identifier Identifier Identifier

Identifier Type Identifier Type Name

Identifier Assigning Authority Identifier Assigning Authority Type of Services

Date of Birth Status Last Name Postal Code

Gender Date of Death First Name

Highest Education Rostered (Start/End Date) Middle Name

Housing Status Ethnicity Role

Primary Language Postal/Zip Code Expertise

Patient Care Activities

Patient

Health Concern(s) (Date of Onset/Resolution Date)

Social Behaviour(s) (Date of Onset/Resolution Date)

Allergy/Intolerance Type Agent Severity Status (Date of Onset/Resolution Date)

Vaccine Administered Date Administered Lot # Reason Not Given

Encounter Specific

Appointment Requested Date Reason for Visit Visit Date Visit Type

Systolic/Diastolic Blood Pressure Site Position Representative

Height* Weight* Waist Circumference*

Intervention (Treatment) Date Reason for Refusing Intervention

Clinician Assessment Payment Source Payment Type Billing Code

Medications

Prescribed Prescribed DateEstimated Completed Date

Stop Date Repeat

Strength* Dosage* Form Frequency Route

Reason Not Prescribed Medication Compliance

Medication Dispensed

Dispensed Date

Lab

Lab Test Name Ordered

Order Date Performed Date

Result Name Result Value* Low/High Range*

Diagnostic Imaging

Diagnostic Imaging Test Ordered Order Date Performed Date

Referral

Referral Service Request Date Occurred Date

Family History

Relationship to Patient Ethnicity Deceased Date Cause of Death

Health History Concern(s) (Age at Onset or [Start/End Date])

Social Behaviour(s) (Age at Onset or [Start/End Date])

Intervention (Treatments) (Age at Onset or [Start/End Date])

Note* These data elements are associated with additional data elements to express Unit of Measure (e.g. cm, kg).

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The data elements listed in Table 1: PHC EMR CS Business View do not represent mandatory or optional data elements. Requirements for mandatory and optional data elements will be specific to implementations of the PHC EMR CS and are expected to vary somewhat by jurisdiction.

Adoption, Maintenance and Governance

Adoption

Three stakeholder groups need to collaborate in their adoption of the PHC EMR CS in order to achieve its maximum benefits:

PHC EMR Vendors: • Need to incorporate the PHC EMR CS in their products in a user-friendly manner so that there are no additional burdens for data collection placed on clinicians and that tools are intuitive and easy to use.

PHC Clinicians:• Need to use the EMRs to capture and exchange PHC data to enable EMR functionality and generate information.

Jurisdictions:• Need to ensure that the PHC EMR CS are included in their vendor requirements and subsequently use information generated from PHC EMR data to help manage the health care system and monitor the health of the population and inform future versions.

Each of these groups has unique adoption goals and challenges. CIHI will continue to collaborate with stakeholders to provide implementation support products and services that will assist them in the adoption of the PHC EMR CS as described above. At the time of writing this document, the following implementation support resources are expected to be available from CIHI’s Primary Health Care Information Program website at www.cihi.ca/phc:

A data extraction specification to support health system uses of EMR data;•

Detailed use cases depicting primary and health system uses of • PHC EMR data;

A logical data model; and•

Known challenges and suggested resolutions.•


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The implementation support resources will be established through the CSWG and JAG, with input from other stakeholders. It is expected that some of the implementation resources will be packaged with the 106 data elements to form the final publication of the PHC EMR CS. Additional implementation support services are also anticipated and may include workshops, e-learning and implementation help desk.

Maintenance

Maintenance of the PHC EMR CS is required to ensure that it remains clinically and technically relevant as stakeholders’ needs evolve. Broadly speaking, maintenance of the PHC EMR CS encompasses four interdependent processes.4

Problem Management: 1. Recording and managing feedback/comments/issues;

Change Management:2. Managing requests for changes to the PHC EMR CS and related artefacts;

Configuration Management: 3. Ensuring that the PHC EMR CS and its related artefacts remain in sync as changes are made; and

Release Management: 4. Implementing and releasing changes to the PHC EMR CS and related artefacts.

These processes will apply to interim “hot fixes” to support the immediate needs of implementers, as well as new versions of the PHC EMR CS.

Governance

PHC is a strategic priority for CIHI. To this end, CIHI will continue to support the PHC EMR CS to ensure that it remains clinically and technically relevant as stakeholders’ needs evolve over time. This will entail engaging stakeholders through the same (or similar) governance structure and processes described in the Approach section.

CIHI’s Primary Health Care Information Program website (www.cihi.ca/phc) will be updated with information on the adoption, maintenance and governance of the PHC EMR CS as it becomes available. If you would like to participate in a working group to refine future versions of the PHC EMR CS, please send an email to [email protected].


mailto:[email protected]

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Next StepsThe PHC EMR CS will be shared with stakeholders, and efforts will be made to support its adoption and uptake through meetings with Infoway, jurisdictions, standards collaborative working groups, vendor forums, PHC organizations, researchers and clinicians. CIHI will also conduct a privacy impact assessment of the PHC EMR CS to guide implementers on privacy considerations when using PHC EMR data for health system use. Ancillary communication and education materials will be developed to support stakeholders’ awareness and understanding of the PHC EMR CS. The PHC EMR CS will also be shared at international levels where it can be compared with other initiatives in an attempt to refine and improve future releases.

It will be necessary to continue to update the PHC EMR CS based on information gathered through pilot testing and implementations and on indicator refinements, and as clinical guidelines change. The evolution of e-health projects, provincial registries, EMRs and care delivery practices will also necessitate changes to the PHC EMR CS over time, based on priority information needs. Maintenance and publication release processes will be defined and implemented in order to support stakeholders’ evolving needs for the PHC EMR CS.

CIHI will continue to work with stakeholders to determine the ideal approach and necessary resources to establish standard value sets for use with priority clinical data elements. This work will include examination of the value propositions for clinical user interface terminologies and mappings from the terminology value sets to classifications.

Contact Information and LinksFor more information on the PHC EMR CS or to learn more about PHC in Canada, please contact CIHI’s Primary Health Care Information program via email ([email protected]) or visit the website at www.cihi.ca/phc. This online resource provides easy access to important pan-Canadian PHC information, including the Primary Health Care Indicators Chartbook and recent analyses (for example, Diabetes Care Gaps and Disparities in Canada and Experiences With Primary Health Care in Canada).



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Appendix A: Draft Conceptual Model A draft conceptual model was developed to provide an overview of primary health care business entities (for example, Clients, Health Service Events) and the relationships between these entities. A conceptual model is independent of technology (databases, files, etc.) and usage context.5 It was developed by examining the business processes illustrated in the Business Context section of this document and after receiving input from a variety of subject matter experts.

The draft conceptual model was structured with the Client at the centre to reflect the needs of patient-centric health care.

How to Read the Model

Boxes represent business entities, and lines connecting the boxes represent the relationships between the business entities. Solid lines denote mandatory relationships whereas dashed lines denote optional relationships. The symbols described in the legend below represent the number of times a business entity can participate in a relationship with another business entity.6

Figure 11: Draft Conceptual Model

Client

Organization

Health Service Event

MedicationPrescribed

ReferralRequest

DI RequestLab RequestInterventionObservationEncounter Immunization

MeasuredObservation

MedicationDispensedReferral ResultDI ResultLab Result

CodedObservation

ProviderService Delivery Location

One or Many to One or Many(e.g. an Organization may have one or more Providers and the Providers may belong to one or more Organizations)

Represents a supertype/subtype relationship. A subtype is subordinate to a supertypeand inherits attributes and relationships of the supertype.

One to Zero, One, or Many (e.g. one Organization may have zero, one or many Service Delivery Locations)

38


The conceptual model contains the following business entities:

Client: A person that has received, is receiving or is eligible to receive health care–related services or goods. A Client can have many Providers and can participate in zero, one or multiple Health Service Events. A Client is dependent on a Provider to receive a Health Service Event. A Client also has a relationship with an Organization because Clients can be eligible to receive health services even though they may not have actually received any.

Health Service Event: The act that is being done, has been done, can be done or is intended/requested to be done for a Client. This entity is effectively a “supertype” of the following business entities: Encounter, Observation, Intervention, Lab Request and Result, Diagnostic Imaging Request and Result, Referral Request and Result, Prescribed and Dispensed Medications, and Immunizations. A Health Service Event (and its subtypes) can have none, one or multiple relationships with other Health Service Events.

Encounter:• An interaction between a Client and one or more Providers for the purpose of providing one or more health care–related services or goods.

Observation:• Information derived from performance of a health-related activity. This business entity is effectively a supertype of the following business entities: Coded Observation and Measured Observation.

Coded Observation: – Information derived from the performance of a health-related activity that is represented by predefined symbols associated with a specific value or meaning. A codified recording of a Client’s allergy to shellfish is an example of a Coded Observation.

Measured Observation: – Information derived from the performance of a health-related activity that is represented by a numeric value. Recordings of a Client’s height, weight and blood pressure are examples of Measured Observations (they can be expressed as numerical values).

Intervention:• An activity that is intended to assess and/or change the state of a Client’s health.

Laboratory Orders:• A request for analytical services, typically performed by medical laboratories in areas such as chemistry, serology, haematology, microbiology, histology, anatomic pathology, cytology and virology.

Laboratory Results:• The results of analytical services typically performed by medical laboratories in areas such as chemistry, serology, haematology, microbiology, histology, anatomic pathology, cytology and virology.

Diagnostic Imaging Orders:• Requests for diagnostic imaging services to be performed on a Client.

Diagnostic Imaging Results:• The results of diagnostic imaging services performed on a Client.

39


Referral Request:• A request from one Provider to another to deliver one or more health services for a Client. The scope of referrals includes requests for clinical care or evaluation, as well as requests for community services such as home care.

Referral Result:• A description of the health services performed for the Client in response to a referral request; can include additional information such as subjective and objective notes about the Client and the recommended treatment plan.

Prescribed Medication:• The medication ordered by a Provider for a Client.

Dispensed Medication:• The medication dispensed by a Provider to a Client.

Immunization:• The administration of vaccines to a Client for the purpose of preventing the spread of infectious disease.

Organization: A formalized group of people with a common purpose or function. An Organization can have none, one or multiple Providers, Clients and Service Delivery Locations.

Provider: A person who has delivered, is delivering or has the potential to deliver health care–related services or goods. A Provider can have many Clients and can participate in many Health Service Events. A Provider can belong to many Organizations.

Service Delivery Location: A Place, administered by an Organization, that assembles the resources required for the provision of health care–related services or goods. A Service Delivery Location can be the site of none, one or multiple Health Service Events.

Each business entity described above has specific attributes. For example, a Client has attributes such as a date of birth and gender. Some attributes have a finite set of values (for example, gender can only be male, female or unknown). The complete set of all values for an attribute is often called the “domain values.”7 The instantiation of a business entity with an attribute and its domain values results in a data element such as Client Gender. The list of data elements in Appendix B: Data Element Matrix reflects the instantiation of business entities in the conceptual model with their attributes and domain values. It should be noted that Appendix B: Data Element Matrix does not describe every possible attribute and domain value required to fully describe each of the business entities; only attributes that support both primary and health system uses of PHC EMR data were examined. Attributes are not normally displayed on a conceptual model, therefore data elements presented in Appendix B: Data Element Matrix are not displayed as attributes in the conceptual model.

41


Ap

pen

dix

B: D

ata

Ele

men

t Mat

rixTa

ble

2 p

rovi

des

a d

etai

led

vie

w o

f the

106

dat

a el

emen

ts th

at c

omp

rise

the

core

con

tent

of t

he P

HC

EM

R C

S. T

he ta

ble

is

div

ided

into

thre

e se

ctio

ns:

Info

rmat

ive

Co

nte

nt:

XR

ef—

1.

This

sec

tion

cont

ains

a U

niq

ue Id

entif

ier

(for

exa

mp

le, A

1) a

nd th

e C

omm

on D

ata

Ele

men

t Nam

e fo

r ea

ch o

f the

dat

a el

emen

ts.

No

rmat

ive

Co

nte

nt:

2.

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd

Ext

ract

ed f

or

Hea

lth

Sys

tem

Use

—Th

is s

ectio

n co

ntai

ns th

e co

re c

onte

nt o

f the

PH

C E

MR

CS

—th

e D

ata

Ele

men

t Sta

ndar

d N

ame,

Def

initi

on, E

xam

ple

of P

rimar

y U

se, P

HC

Ind

icat

or

Map

pin

g, iii a

nd T

erm

inol

ogy

or D

ata

Typ

e N

ame

and

Exa

mp

le V

alue

s. N

ote

that

con

tent

in th

e ce

lls u

nder

the

colu

mn

Term

inol

ogy

or D

ata

Typ

e N

ame

and

Exa

mp

le V

alue

s us

ually

sta

rts

with

the

nam

e of

the

root

cod

e sy

stem

(fo

r ex

amp

le,

SN

OM

ED

CT®

, HL7

v3,

pC

LOC

D),

follo

wed

by

the

nam

e of

the

corr

esp

ond

ing

con

cep

t dom

ain

in th

e S

tand

ard

s C

olla

bor

ativ

e M

aste

r Te

rmin

olog

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orks

heet

, and

follo

wed

by

an e

xam

ple

val

ue. T

he p

atte

rn is

rep

eate

d if

the

dat

a el

emen

t val

ue d

omai

n co

vers

mor

e th

an o

ne c

once

pt d

omai

n. A

ltern

ativ

ely,

the

appr

opria

te H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Typ

e S

pec

ifica

tion

refe

renc

e is

pro

vid

ed, f

ollo

wed

by

an e

xam

ple

val

ue.

Info

rmat

ive

Co

nte

nt:

Alig

nm

ent

to t

he

Pan

-Can

adia

n E

HR

—3.

Th

is s

ectio

n co

ntai

ns r

efer

ence

s to

the

pan

-Can

adia

n E

HR

mes

sag

es a

nd te

rmin

olog

y th

at th

e d

ata

elem

ent s

upp

orts

, as

wel

l as

a re

fere

nce

to th

e P

hysi

cian

Off

ice

Sys

tem

R

equi

rem

ents

(P

OS

R) iv

that

the

dat

a el

emen

t sup

por

ts.

Man

y of

the

stan

dar

ds

refe

renc

ed in

the

Dat

a E

lem

ent M

atrix

are

acc

essi

ble

from

the

Info

way

Sta

ndar

ds

Col

lab

orat

ive.

For

mor

e in

form

atio

n on

how

to a

cces

s th

ese

stan

dar

ds,

con

tact

the

Sta

ndar

ds

Col

lab

orat

ive

Info

des

k vi

a em

ail a

t sta

ndar

ds@

info

way

-in

foro

ute.

ca o

r vi

sit t

he w

ebsi

te a

t htt

p://w

ww

.info

way

-info

rout

e.ca

/lang

-en/

stan

dar

ds-

colla

bor

ativ

e.

iii.

See

Ap

pen

dix

C fo

r th

e na

mes

and

def

initi

ons

of t

he in

dic

ato

rs s

upp

ort

ed b

y th

e P

HC

EM

R C

S.

iv.

See

Ap

pen

dix

D fo

r m

ore

info

rmat

ion

abo

ut P

OS

R, i

nclu

din

g a

sta

tem

ent r

egar

din

g p

ote

ntia

l lim

itatio

ns o

f use

.

http://www.infoway-inforoute.ca/lang-en/standards-collaborative


42


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

Co

ntex

t: C

lient

Def

initi

on:

A p

erso

n w

ho

has

rec

eive

d, i

s re

ceiv

ing

or

is e

ligib

le t

o r

ecei

ve h

ealth

car

e–re

late

d s

ervi

ces

or

go

od

s.

A1

Pat

ient

Id

entif

ier

Clie

nt

Iden

tifie

rR

epre

sent

s a

uniq

ue

iden

tifie

r as

sign

ed to

th

e C

lient

.

Use

d in

the

prov

isio

n an

d ad

min

istr

atio

n of

ca

re. C

an b

e us

ed to

as

soci

ate

adm

inis

trat

ive

(e.g

. dem

ogra

phic

s)

and

heal

th in

form

atio

n (e

.g. l

ab r

esul

ts)

with

th

e C

lient

.

13, 3

6,

39–4

4,

48–6

0,

62 a

nd 6

3

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 4—

Iden

tifie

rs +

C

odes

Exa

mpl

e:66

1116

8070

NN

Foun

d in

:R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l Mar

ch 1

6, 2

009.

Rec

ord

38, P

atie

nt

look

-ups

can

be

done

by

last

nam

e, fi

rst

nam

e, m

iddl

e na

me,

P

HN

, cha

rt n

umbe

r, da

te o

f birt

h, te

leph

one

num

ber,

alte

rnat

e ID

, al

ias,

pho

netic

sea

rch,

pa

rtia

l sea

rche

s an

d m

ultip

le c

ombi

natio

ns.

A2

Pat

ient

Id

entif

ier

Type

Clie

nt

Iden

tifie

r Ty

pe C

ode

Rep

rese

nts

the

type

of

Clie

nt Id

entif

ier

(e.g

. Jur

isdi

ctio

nal

Hea

lthca

re Id

entif

ier,

Pas

spor

t).

Use

d in

the

prov

isio

n an

d ad

min

istr

atio

n of

ca

re. H

elps

diff

eren

tiate

th

e ty

pe o

f ide

ntifi

er

used

to id

entif

y th

e C

lient

. In

conj

unct

ion

with

the

Clie

nt Id

entif

ier,

can

be u

sed

to

asso

ciat

e ad

min

istr

ativ

e (e

.g. d

emog

raph

ics)

an

d he

alth

info

rmat

ion

(e.g

. lab

res

ults

) w

ith

the

Clie

nt.

13, 3

6,

39–4

4,

48–6

0,

62 a

nd 6

3

MTW

—In

fow

ay

Sta

ndar

ds C

olla

bora

tive

(SC

TEM

P)

Con

cept

Dom

ain:

Oth

erId

entif

iers

Rol

eTyp

e

Exa

mpl

e:JH

N (J

uris

dict

iona

l H

ealth

Num

ber)

Foun

d in

:R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l Mar

ch 1

6, 2

009.

Rec

ord

38, P

atie

nt

look

-ups

can

be

done

by

last

nam

e, fi

rst

nam

e, m

iddl

e na

me,

P

HN

, cha

rt n

umbe

r, da

te o

f birt

h, te

leph

one

num

ber,

alte

rnat

e ID

, al

ias,

pho

netic

sea

rch,

pa

rtia

l sea

rche

s an

d m

ultip

le c

ombi

natio

ns.

43


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceA

3P

atie

nt

Iden

tifie

r A

ssig

ning

A

utho

rity

Clie

nt

Iden

tifie

r A

ssig

ning

A

utho

rity

Cod

e

Rep

rese

nts

the

lega

l en

tity

resp

onsi

ble

for

assi

gnin

g th

e C

lient

Id

entif

ier.

Use

d in

the

prov

isio

n an

d ad

min

istr

atio

n of

ca

re. H

elps

iden

tify

the

orga

niza

tion

that

is

sued

the

iden

tifie

r w

hen

a C

lient

can

hav

e m

ultip

le id

entif

iers

. In

conj

unct

ion

with

the

Clie

nt Id

entif

ier,

can

be u

sed

to a

ssoc

iate

ad

min

istr

ativ

e (e

.g.

dem

ogra

phic

) an

d he

alth

info

rmat

ion

(e.g

. la

bora

tory

res

ults

) w

ith

the

Clie

nt.

13, 3

6,

39–4

4,

48–6

0, 6

2 an

d 63

MTW

—In

fow

ay

Sta

ndar

ds C

olla

bora

tive

(SC

TEM

P)

Con

cept

Dom

ain:

Juris

dict

ionT

ypeC

ode

Exa

mpl

e:A

B (

Alb

erta

)

Foun

d in

:P

RPA

_MT1

0110

1CA

—Q

uery

by

Clie

nt ID

M

arch

16,

200

9.

Rec

ord

38, P

atie

nt

look

-ups

can

be

done

by

last

nam

e, fi

rst

nam

e, m

iddl

e na

me,

P

HN

, cha

rt n

umbe

r, da

te o

f birt

h, te

leph

one

num

ber,

alte

rnat

e ID

, al

ias,

pho

netic

sea

rch,

pa

rtia

l sea

rche

s an

d m

ultip

le c

ombi

natio

ns.

A4

Pat

ient

D

ate

of

Birt

h

Clie

nt

Birt

h D

ate

Rep

rese

nts

the

Clie

nt’s

da

te o

f birt

h.U

sed

in b

oth

the

prov

isio

n an

d ad

min

istr

atio

n of

car

e.

Birt

h D

ate

is u

sed

to

valid

ate

the

iden

tity

of

the

Clie

nt.

It is

als

o us

ed to

ens

ure

that

the

right

dru

g an

d la

b re

fere

nce

rang

es

are

used

for

the

Clie

nt.

13, 3

6,

39–4

4,

48–6

0 an

d 63

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1010

01

Foun

d in

:R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l Mar

ch 1

6, 2

009.

Rec

ord

38, P

atie

nt

look

-ups

can

be

done

by

last

nam

e, fi

rst

nam

e, m

iddl

e na

me,

P

HN

, cha

rt n

umbe

r, da

te o

f birt

h, te

leph

one

num

ber,

alte

rnat

e ID

, al

ias,

pho

netic

sea

rch,

pa

rtia

l sea

rche

s an

d m

ultip

le c

ombi

natio

ns.

A5

Pat

ient

G

ende

rC

lient

A

dmin

istr

ativ

e G

ende

r C

ode

Rep

rese

nts

a re

port

ed

gend

er c

ateg

ory

of

the

Clie

nt a

t a g

iven

po

int i

n tim

e us

ed

for

adm

inis

trat

ive

purp

oses

.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

C

an b

e us

ed to

filte

r dr

ugs,

lab

test

and

re

fere

nce

rang

es.

49–5

3H

L7 v

3

Con

cept

Dom

ain:

A

dmin

istr

ativ

eGen

der

Exa

mpl

e:M

(M

ale)

Foun

d in

:R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l Mar

ch 1

6, 2

009.

Rec

ord

57, D

ispl

ay

patie

nt’s

gen

der

at

poin

t of s

ched

ulin

g.

44


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceA

6P

atie

nt

Hig

hest

E

duca

tion

Clie

nt H

ighe

st

Edu

catio

n C

ode

Rep

rese

nts

the

high

est

leve

l of e

duca

tion

com

plet

ed b

y th

e C

lient

.

Use

d in

the

adm

inis

trat

ion

of c

are.

O

n av

erag

e, th

e m

ore

educ

atio

n a

pers

on

has,

the

mor

e lik

ely

they

are

to u

nder

stan

d he

alth

cho

ices

.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

SN

OM

ED

CT®

cod

es

unde

r th

e fin

ding

of

educ

atio

n re

ceiv

ed in

th

e pa

st (

findi

ng)

Exa

mpl

e:22

4300

008

(rec

eive

d un

iver

sity

edu

catio

n)

Not

foun

d in

any

of

the

pan-

Can

adia

n E

HR

Mes

sagi

ng a

nd

Term

inol

ogy

Sta

ndar

ds.

Not

cur

rent

ly r

equi

red

to s

uppo

rt a

ny o

f the

P

OS

R r

ecor

ds.

A7

Pat

ient

H

ousi

ng

Sta

tus

Clie

nt

Hou

sing

S

tatu

s C

ode

Rep

rese

nts

the

hous

ing

stat

us o

f the

Clie

nt.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Hou

sing

sta

tus

is im

port

ant s

ince

it

can

also

dire

ctly

rel

ate

to h

ealth

out

com

es.

Clie

nts

who

are

ho

mel

ess

or w

ithou

t a

perm

anen

t add

ress

(r

ente

rs) a

re m

uch

mor

e lik

ely

to b

e de

pres

sed

and

unab

le to

affo

rd

a he

alth

y lif

esty

le.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

SN

OM

ED

CT®

cod

es

unde

r th

e fin

ding

of

hous

ing

owne

rshi

p an

d te

nure

(fin

ding

)

Exa

mpl

e:32

9110

00 (

hom

eles

s)

Not

foun

d in

any

of

the

pan-

Can

adia

n E

HR

Mes

sagi

ng a

nd

Term

inol

ogy

Sta

ndar

ds.

Not

cur

rent

ly r

equi

red

to s

uppo

rt a

ny o

f the

P

OS

R r

ecor

ds.

A8

Pat

ient

P

rimar

y La

ngua

ge

Clie

nt P

rimar

y La

ngua

ge

Cod

e

Rep

rese

nts

the

pref

erre

d sp

oken

la

ngua

ge o

f the

C

lient

.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

La

ngua

ge is

ass

ocia

ted

with

hea

lth c

are

acce

ss

and

com

plia

nce

issu

es.

If a

Clie

nt c

an fi

nd a

P

rovi

der

that

they

can

co

mm

unic

ate

with

, it

can

redu

ce s

igni

fican

t ba

rrie

rs th

at m

ay

prev

ent a

nd/o

r im

prov

e th

eir

over

all h

ealth

.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

ISO

639-

3

Con

cept

Dom

ain:

Hum

anLa

ngua

ge

Exa

mpl

e:en

g (E

nglis

h)

Foun

d in

:P

RPA

_MT1

0100

1CA

—A

dd C

lient

M

arch

16,

200

9.

Rec

ord

202,

Abi

lity

to

sele

ctiv

ely

pre-

popu

late

re

ferr

al r

eque

st le

tters

w

ith a

min

imum

set

of

exi

stin

g pa

tient

da

ta w

ithin

the

patie

nt

reco

rd, i

nclu

ding

de

mog

raph

ics,

m

edic

atio

ns, a

llerg

ies,

pr

oble

m li

st, m

edic

al

and

surg

ical

his

tory

, an

d vi

sit n

otes

.

45


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceA

9P

atie

nt

Sta

tus

Clie

nt

Sta

tus

Cod

eR

epre

sent

s w

heth

er

or n

ot th

e P

HC

P

rovi

der

cons

ider

s th

e C

lient

to b

e ac

tivel

y se

ekin

g P

HC

ser

vice

s th

roug

h th

em.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Ens

ures

that

in

appr

opria

te r

emin

ders

ar

e no

t sen

t to

Clie

nts

with

a s

tatu

s of

inac

tive

for

the

Pro

vide

r.

13, 3

6,

39–4

4,

48–6

0, 6

2 an

d 63

TBD

Exa

mpl

es:

Act

ive

Inac

tive

Not

foun

d in

any

of

the

pan-

Can

adia

n E

HR

Mes

sagi

ng a

nd

Term

inol

ogy

Sta

ndar

ds.

Rec

ord

27, P

rovi

des

abili

ty to

doc

umen

t pa

tient

–pro

vide

r re

latio

nshi

ps.

A10

Pat

ient

D

ate

of

Dea

th

Clie

nt

Dec

ease

d D

ate

Rep

rese

nts

the

Clie

nt’s

da

te o

f dea

th.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Rec

ords

can

be

arch

ived

bas

ed o

n th

is

date

plu

s a

num

ber

of

days

as

dete

rmin

ed

by th

e C

linic

ian/

Org

aniz

atio

n. E

nsur

es

that

Clie

nt d

oes

not

rece

ive

appo

intm

ent

rem

inde

rs in

the

futu

re.

13, 3

6,

39–4

4,

48–6

0, 6

2 an

d 63

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

:P

RPA

_MT1

0100

1CA

—A

dd C

lient

M

arch

16,

200

9.

Rec

ord

52,

App

oint

men

ts

upda

ted

base

d on

sta

tus

of th

e pa

tient

from

act

ive

to d

ecea

sed.

A11

Pat

ient

R

oste

red

Sta

rt D

ate

Clie

nt

Ros

tere

d S

tart

Dat

e

Rep

rese

nts

the

date

the

Clie

nt w

as in

clud

ed o

n th

e ro

ster

.

Use

d in

the

adm

inis

trat

ion

of c

are.

Use

d by

P

rovi

ders

to s

uppo

rt

pay-

for-

perfo

rman

ce

prog

ram

s, p

hysi

cian

’s

billi

ng q

ualit

y ch

eck

and

accu

racy

.

36, 3

9–41

, 49

, 52

and

54–5

9

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

n S

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

foun

d in

any

of

the

pan-

Can

adia

n E

HR

Mes

sagi

ng a

nd

Term

inol

ogy

Sta

ndar

ds.

Rec

ord

50, A

bilit

y to

rec

ord

that

a

patie

nt is

ros

tere

d.

46


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceA

12P

atie

nt

Ros

tere

d E

nd D

ate

Clie

nt

Ros

tere

d E

nd

Dat

e

Rep

rese

nts

the

date

th

e C

lient

was

rem

oved

fro

m th

e ro

ster

.

Use

d in

the

adm

inis

trat

ion

of c

are.

Use

d by

P

rovi

ders

to s

uppo

rt

pay-

for-

perfo

rman

ce

prog

ram

s, p

hysi

cian

’s

billi

ng q

ualit

y ch

eck

and

accu

racy

.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

foun

d in

any

of

the

pan-

Can

adia

n E

HR

Mes

sagi

ng a

nd

Term

inol

ogy

Sta

ndar

ds.

Rec

ord

50, A

bilit

y to

rec

ord

that

a

patie

nt is

ros

tere

d.

A13

Pat

ient

E

thni

city

Clie

nt

Adm

inis

trat

ive

Eth

nici

ty

Cod

e

Rep

rese

nts

the

Clie

nt’s

sel

f-rep

orte

d et

hnic

gro

up to

whi

ch

he o

r sh

e be

long

s,

for

adm

inis

trat

ive

purp

oses

. The

refo

re,

the

ethn

ic o

rigin

re

fers

to a

per

son’

s “r

oots

” an

d sh

ould

no

t be

conf

used

with

hi

s or

her

citi

zens

hip

or n

atio

nalit

y.

Use

d in

the

adm

inis

trat

ion

of c

are

to h

elp

unde

rsta

nd th

e de

mog

raph

ic p

rofil

e of

a P

rovi

der’s

clie

nt

base

. Not

e: k

now

ing

a C

lient

’s e

thni

city

ca

n al

so a

ssis

t in

the

prov

isio

n of

car

e.

How

ever

, the

pro

visi

on

of c

are

need

s sh

ould

be

met

thro

ugh

the

Fam

ily H

isto

ry F

amili

al

Eth

nici

ty C

ode

in th

e Fa

mily

His

tory

sec

tion,

w

hich

allo

ws

for

the

expr

essi

on o

f add

ition

al

deta

ils s

uch

as th

e et

hnic

ity o

f mul

tiple

fa

mily

mem

bers

and

th

eir

fam

ilial

rel

atio

nshi

p w

ith th

e C

lient

.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Sta

tistic

s C

anad

a 20

06 C

ensu

s—et

hnic

ca

tego

ries

and

subc

ateg

orie

s

Exa

mpl

e:In

uit

An

equi

vale

nt c

once

pt

was

not

foun

d in

th

e pa

n-C

anad

ian

EH

R M

essa

ging

and

Te

rmin

olog

y S

tand

ards

.

This

dat

a el

emen

t do

es n

ot c

urre

ntly

su

ppor

t any

of t

he

PO

SR

rec

ords

.

47


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceA

14P

atie

nt

Pos

tal/Z

ip

Cod

e

Clie

nt

Res

iden

ce

Pos

tal C

ode

Rep

rese

nts

the

post

al

code

of t

he C

lient

’s

perm

anen

t res

iden

ce.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

P

art o

f the

Clie

nt’s

ad

dres

s, w

hich

can

be

use

d to

hel

p fin

d se

rvic

e de

liver

y lo

catio

ns th

at a

re c

lose

to

the

Clie

nt’s

hom

e.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 7—

Dem

ogra

phic

s x_

FullA

ddre

ssP

artT

ype

Exa

mpl

e C

anad

ian

Pos

tal C

ode:

K0K

3R

0

Exa

mpl

e A

mer

ican

Zi

p C

ode:

2000

3

Foun

d in

:R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l Mar

ch 1

6, 2

009.

Rec

ord

57, P

art o

f pa

tient

’s a

ddre

ss.

Co

ntex

t: P

rovi

der

Def

initi

on:

An

ind

ivid

ual w

ho

has

del

iver

ed, i

s d

eliv

erin

g o

r h

as t

he

po

tent

ial t

o d

eliv

er h

ealth

car

e–re

late

d s

ervi

ces

or

go

od

s.

B1

Clin

icia

n La

st N

ame

Pro

vide

r Fa

mily

Nam

e Te

xt

Rep

rese

nts

the

Pro

vide

r’s le

gal

fam

ily n

ame.

Use

d in

the

prov

isio

n of

ca

re. T

he fa

mily

nam

e of

the

Pro

vide

r th

at

asse

ssed

the

Clie

nt

durin

g an

enc

ount

er.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 7—

Dem

ogra

phic

sx_

Bas

icP

erso

nNam

eP

artT

ype

Exa

mpl

e:D

oe

Foun

d in

:S

C-2

003-

EN

—R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l—20

0903

16.

Rec

ord

102,

Abi

lity

to

man

age

a ph

ysic

ian

on-

call

sche

dule

, inc

ludi

ng

docu

men

ting

nam

e an

d co

ntac

t inf

orm

atio

n of

w

ho is

pro

vidi

ng a

fter-

ho

urs

call

for

prac

tice.

B2

Clin

icia

n Fi

rst n

ame

Pro

vide

r G

iven

Nam

e Te

xt

Rep

rese

nts

the

Pro

vide

r’s le

gal

give

n na

me.

Use

d in

the

prov

isio

n of

car

e. N

ame

of th

e P

rovi

der

used

on

refe

rral

req

uest

s.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 7—

Dem

ogra

phic

sx_

Bas

icP

erso

nNam

eP

artT

ype

Exa

mpl

e:Jo

hn

Foun

d in

:S

C-2

003-

EN

—R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l—20

0903

16

as H

ealth

care

.

Rec

ord

102,

Abi

lity

to

man

age

a ph

ysic

ian

on-

call

sche

dule

, inc

ludi

ng

docu

men

ting

nam

e an

d co

ntac

t inf

orm

atio

n of

w

ho is

pro

vidi

ng a

fter-

ho

urs

call

for

prac

tice.

48


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceB

3C

linic

ian

Mid

dle

Nam

e

Pro

vide

r M

iddl

e N

ame

Text

Rep

rese

nts

the

Pro

vide

r’s m

iddl

e na

me.

Use

d in

the

prov

isio

n of

car

e. N

ame

of th

e P

rovi

der

used

on

refe

rral

req

uest

s.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 7—

Dem

ogra

phic

sx_

Bas

icP

erso

nNam

eP

artT

ype

Exa

mpl

e:E

dwar

d

Foun

d in

:S

C-2

003-

EN

—R

EP

C_

MT5

0000

4CA

—C

are

Com

posi

tion

Det

ail—

2009

0316

.

Rec

ord

102,

Abi

lity

to

man

age

a ph

ysic

ian

on-

call

sche

dule

, inc

ludi

ng

docu

men

ting

nam

e an

d co

ntac

t inf

orm

atio

n of

w

ho is

pro

vidi

ng a

fter

- ho

urs

call

for

prac

tice.

B4

Clin

icia

n Id

entif

ier

Pro

vide

r Id

entif

ier

Rep

rese

nts

the

uniq

ue

iden

tifie

r as

sign

ed to

th

e P

rovi

der.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

C

an b

e us

ed to

link

C

lient

rec

ords

and

bi

lling

info

rmat

ion

to a

sp

ecifi

c P

rovi

der.

Can

be

use

d to

sup

port

au

thor

izat

ion

acce

ss to

se

nsiti

ve r

ecor

ds.

13, 3

6,

39–4

4,

48–6

0, 6

2 an

d 63

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 4—

Iden

tifie

rs +

C

odes

Exa

mpl

e:82

3567

43

Foun

d in

:S

C-2

003-

EN

—P

RP

M_

MT3

0101

0CA

—A

dd

Pro

vide

r—20

0903

16.

Rec

ord

186,

Gen

erat

e pa

per

pres

crip

tion

with

pr

ovid

er d

etai

ls.

B5

Clin

icia

n Id

entif

ier

Type

Pro

vide

r Id

entif

ier

Type

C

ode

Rep

rese

nts

the

type

of

Pro

vide

r Id

entif

ier.

Use

d in

bot

h th

e ad

min

istr

atio

n an

d pr

ovis

ion

of c

are.

In

con

junc

tion

with

th

e P

rovi

der

Iden

tifie

r, it

can

be u

sed

to li

nk

Clie

nt r

ecor

ds a

nd

billi

ng in

form

atio

n to

a s

peci

fic P

rovi

der.

Can

be

used

to s

uppo

rt

auth

oriz

atio

n ac

cess

to

sen

sitiv

e re

cord

s.

58TB

D—

a co

de s

et n

eeds

to

be

iden

tifie

d

Exa

mpl

e:B

illin

g N

umbe

r

Not

foun

d in

any

of

the

pan-

Can

adia

n E

HR

Mes

sagi

ng a

nd

Term

inol

ogy

Sta

ndar

ds.

Rec

ord

356,

Acc

ess

cont

rol m

anag

ed b

y ro

le ty

pes.

49


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceB

6C

linic

ian

Iden

tifie

r A

ssig

ning

A

utho

rity

Pro

vide

r Id

entif

ier

Ass

igni

ng

Aut

horit

y C

ode

Rep

rese

nts

the

lega

l en

tity

resp

onsi

ble

for

assi

gnin

g th

e un

ique

id

entif

ier

to th

e P

rovi

der.

Use

d in

bot

h th

e ad

min

istr

atio

n an

d pr

ovis

ion

of c

are.

In

con

junc

tion

with

th

e P

rovi

der

Iden

tifie

r, it

can

be u

sed

to li

nk

Clie

nt r

ecor

ds a

nd

billi

ng in

form

atio

n to

a s

peci

fic P

rovi

der.

Can

be

used

to s

uppo

rt

auth

oriz

atio

n ac

cess

to

sen

sitiv

e re

cord

s.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

MTW

—In

fow

ay

Sta

ndar

ds C

olla

bora

tive

(SC

TEM

P)

Con

cept

Dom

ain:

Juris

dict

ionT

ypeC

ode

Exa

mpl

e:A

B (

Alb

erta

)

Foun

d in

: S

C-2

003-

EN

—R

EP

C_

MT5

0000

4CA

—C

are

Com

posi

tion

Det

ail—

2009

0316

.

Rec

ord

356,

Acc

ess

cont

rol m

anag

ed b

y ro

le ty

pes.

B7

Clin

icia

n R

ole

Pro

vide

r R

ole

Type

Cod

eR

epre

sent

s th

e ro

le

of th

e P

rovi

der

in

rela

tion

to h

is/h

er

part

icip

atio

n in

a

spec

ific

heal

th c

are

even

t.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

U

sed

to d

istin

guis

h ro

les

with

in a

hea

lth

care

set

ting,

can

be

used

to r

estr

ict a

cces

s to

Clie

nt d

ata

by r

ole

type

, and

can

be

used

for

iden

tifyi

ng

spec

ialis

ts.

13, 3

6,

39–4

4,

48–6

0, 6

2 an

d 63

MTW

—In

fow

ay

Sta

ndar

ds C

olla

bora

tive

(SC

PTY

PE

)

Con

cept

Dom

ain:

H

ealth

Car

ePro

vide

rR

oleT

ype

Exa

mpl

e:R

N (

Reg

iste

red

Nur

se)

Foun

d in

:S

C-2

003-

EN

—R

EP

C_

MT5

0000

4CA

—C

are

Com

posi

tion

Det

ail—

2009

0316

.

Rec

ord

356,

Acc

ess

cont

rol m

anag

ed b

y ro

le ty

pes.

B8

Clin

icia

n E

xper

tise

Pro

vide

r E

xper

tise

Cod

e

Rep

rese

nts

the

expe

rtis

e or

qua

lific

atio

ns

of th

e P

rovi

der.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

U

sed

to d

istin

guis

h ex

pert

ise

with

in a

hea

lth

care

set

ting.

Use

d to

id

entif

y th

e pa

rtic

ular

ex

pert

ise

requ

ired

for

a re

ferr

al.

13, 3

6,

39–4

4,

48–6

0, 6

2 an

d 63

MTW

—In

fow

ay

Sta

ndar

ds C

olla

bora

tive

(SC

PQ

UA

L)

Con

cept

Dom

ain:

Q

ualif

iedR

oleT

ype

Exa

mpl

e:30

5 (C

ardi

ovas

cula

r an

d Th

orac

ic S

urge

ry)

Foun

d in

: PR

PM

_M

T301

010C

A—

Add

P

rovi

der—

2009

0316

.

Not

cur

rent

ly r

equi

red

to s

uppo

rt a

ny o

f the

P

OS

R r

ecor

ds.

50


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceC

ont

ext:

Ser

vice

Del

iver

y Lo

catio

nD

efin

itio

n: A

loca

tion

wh

ere

the

pro

visi

on

of

hea

lth c

are

rela

ted

ser

vice

s o

r g

oo

ds

may

occ

ur.

C1

Ser

vice

D

eliv

ery

Iden

tifie

r

Ser

vice

D

eliv

ery

Loca

tion

Iden

tifie

r C

ode

Rep

rese

nts

the

uniq

ue

iden

tifie

r of

the

PH

C

prac

tice

(Ser

vice

D

eliv

ery

Loca

tion)

w

here

the

Clie

nt

rece

ived

car

e.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

N

ame

of th

e S

ervi

ce

Del

iver

y Lo

catio

n is

re

fere

nced

on

lette

rs

sent

to C

lient

s.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 4—

Iden

tifie

rs +

C

odes

Exa

mpl

e:A

46B

7356

743

Foun

d in

:P

RLO

_MT2

0201

5CA

—U

pdat

e S

ervi

ce D

eliv

ery.

Rec

ord

55,

Sch

edul

ing

feat

ures

al

low

use

r-de

finab

le

appo

intm

ent t

ypes

th

at c

an b

e de

fined

by

crit

eria

: ser

vice

, pr

ogra

m, p

rovi

der,

equi

pmen

t, lo

catio

n.

C2

Ser

vice

D

eliv

ery

Nam

e

Ser

vice

D

eliv

ery

Loca

tion

Nam

e Te

xt

Rep

rese

nts

the

nam

e of

the

PH

C p

ract

ice

(Ser

vice

Del

iver

y Lo

catio

n) w

here

the

Clie

nt r

ecei

ved

care

.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

N

ame

of th

e S

ervi

ce

Del

iver

y Lo

catio

n is

re

fere

nced

in le

tters

se

nt to

Clie

nts.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

N/A

Exa

mpl

e:G

lend

ale

Fam

ily H

ealth

C

linic

Foun

d in

: S

C-2

003-

EN

—P

RLO

_M

T000

002C

A—

Ser

vice

Del

iver

y Lo

catio

n D

etai

l—20

0903

16.

Rec

ord

55,

Sch

edul

ing

feat

ures

al

low

use

r-de

finab

le

appo

intm

ent t

ypes

th

at c

an b

e de

fined

by

crit

eria

: ser

vice

, pr

ogra

m, p

rovi

der,

equi

pmen

t, lo

catio

n.

C3

Ser

vice

D

eliv

ery

Type

of

Ser

vice

s

Ser

vice

D

eliv

ery

Loca

tion

Type

C

ode

Rep

rese

nts

the

type

of

PH

C (

Ser

vice

Del

iver

y Lo

catio

n) lo

catio

n w

here

the

Clie

nt

rece

ived

car

e.

Use

d in

the

adm

inis

trat

ion

of c

are.

In

dica

tes

the

type

of

faci

lity

whe

re c

are

is

prov

ided

to a

Clie

nt.

13, 3

6,

39–4

4,

48–6

0, 6

2 an

d 63

HL7

v3

Con

cept

Dom

ain:

S

ervi

ceD

eliv

eryL

ocat

ion

Rol

eTyp

e

Exa

mpl

e:P

C (

Prim

ary

care

clin

ic)

Foun

d in

:S

C-2

003-

EN

—P

RLO

_MT0

0000

2CA

—S

ervi

ce D

eliv

ery

Loca

tion

Det

ail—

2009

0316

.

Rec

ord

55,

Sch

edul

ing

feat

ures

al

low

use

r-de

finab

le

appo

intm

ent t

ypes

th

at c

an b

e de

fined

by

crit

eria

: ser

vice

, pr

ogra

m, p

rovi

der,

equi

pmen

t, lo

catio

n.

51


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceC

4S

ervi

ce

Del

iver

y P

osta

l C

ode

Ser

vice

D

eliv

ery

Loca

tion

Pos

tal C

ode

Rep

rese

nts

the

post

al c

ode

whe

re

the

Clie

nt r

ecei

ved

the

PH

C s

ervi

ce.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

P

art o

f the

Ser

vice

D

eliv

ery

Loca

tion

Add

ress

, whi

ch h

elps

C

lient

s kn

ow w

here

to

go fo

r th

e se

rvic

e.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 7—

Dem

ogra

phic

s x_

FullA

ddre

ssP

artT

ype

Exa

mpl

e C

anad

ian

Pos

tal C

ode:

K0K

3R

0

Foun

d in

:R

EP

C_M

T610

001C

A—

Pro

fess

iona

l Ser

vice

P

roce

dure

Rec

ord

May

8, 2

007.

Rec

ord

55,

Sch

edul

ing

feat

ures

al

low

use

r-de

finab

le

appo

intm

ent t

ypes

th

at c

an b

e de

fined

by

crit

eria

: ser

vice

, pr

ogra

m, p

rovi

der,

equi

pmen

t, lo

catio

n.

Co

ntex

t: E

nco

unte

rD

efin

itio

n: A

per

iod

of

hea

lth c

are

bet

wee

n a

clie

nt(s

) an

d a

pro

vid

er(s

).A

dditi

onal

dat

a el

emen

ts th

at m

ay b

e re

quire

d to

sup

port

the

use

and

extr

actio

n of

Enc

ount

er d

ata

in P

HC

EM

Rs:

Pro

vide

r(s)

(e.

g. th

e P

rovi

der[

s] in

volv

ed in

the

Enc

ount

er):

Pro

vide

r Id

entif

ier

Cod

e, P

rovi

der

Iden

tifie

r A

ssig

ning

Aut

horit

y, P

rovi

der

Rol

e Ty

pe a

nd P

rovi

der

Exp

ertis

e ex

pres

sed

in th

e co

ntex

t of t

he E

ncou

nter

.C

lient

(s)

(e.g

. the

Clie

nt[s

] in

volv

ed in

the

Enc

ount

er):

Clie

nt Id

entif

ier

Cod

e, C

lient

Iden

tifie

r Ty

pe a

nd C

lient

Iden

tifie

r A

ssig

ning

Aut

horit

y ex

pres

sed

in th

e co

ntex

t of t

he E

ncou

nter

.S

ervi

ce D

eliv

ery

Loca

tion

(e.g

. the

pla

ce w

here

an

in-p

erso

n E

ncou

nter

occ

urre

d): S

ervi

ce D

eliv

ery

Loca

tion

Iden

tifie

r C

ode

and

Ser

vice

Del

iver

y Lo

catio

n N

ame

in

the

cont

ext o

f the

Enc

ount

er.

Enc

ount

er Id

entif

ier:

A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e E

ncou

nter

.

D1

App

oint

-m

ent

Cre

atio

n D

ate

Enc

ount

er

Req

uest

Dat

eR

epre

sent

s th

e da

te o

n w

hich

an

appo

intm

ent

was

cre

ated

for

the

Clie

nt b

y th

e P

rovi

der

(or

his/

her

staf

f).

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

H

elps

iden

tify

wai

t tim

es

for

spec

ific

prov

ider

s.

55–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

Sta

ndar

ds—

Dat

a Ty

pe S

peci

ficat

ion

Sec

tion

3—D

ates

+

Tim

ing

Exa

mpl

e:20

1004

30

Not

Fou

nd: N

ot

curr

ently

in th

e se

t of

iEH

R m

essa

ges.

Rec

ord

93, R

etai

ns

a co

mpl

ete

patie

nt

appo

intm

ent h

isto

ry

and

audi

t tra

il.

52


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceD

2R

easo

n fo

r V

isit

Clie

nt

Enc

ount

er

Rea

son

Cod

e

Rep

rese

nts

reas

on

for

the

Enc

ount

er a

s co

nvey

ed b

y th

e C

lient

.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

C

an b

e us

ed to

giv

e th

e P

rovi

der

adva

nce

notic

e of

info

rmat

ion

that

may

ne

ed to

be

addr

esse

d w

ith th

e C

lient

dur

ing

the

enco

unte

r. C

an

assi

st in

sch

edul

ing

the

amou

nt o

f tim

e a

Clie

nt m

ay n

eed

with

th

e P

rovi

der.

63S

NO

ME

D C

T®C

once

pt D

omai

n:

Dia

gnos

isVa

lue

Exa

mpl

e:23

7734

007

(AC

TH-

depe

nden

t Cus

hing

’s

synd

rom

e)

Con

cept

Dom

ain:

Sym

ptom

Valu

e

Exa

mpl

e:43

3640

01 (

Abd

omin

al

disc

omfo

rt)

Con

cept

Dom

ain:

A

ctP

rofe

ssio

nal

Ser

vice

Cod

e

Exa

mpl

e:40

8952

002

(Acu

te p

ain

cont

rol a

sses

smen

t)

Not

e: W

hile

con

cept

do

mai

ns h

ave

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Rec

ord

59, D

ocum

ent

reas

on fo

r vi

sit w

hen

book

ing

appo

intm

ent.

D3

Vis

it D

ate

Enc

ount

er

Dat

eR

epre

sent

s th

e da

te th

e C

lient

had

an

Enc

ount

er

with

the

Pro

vide

r.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Can

rep

ort o

n C

lient

wai

t tim

es fo

r sc

hedu

led

Clie

nts

and

trac

k th

e co

ntin

uum

of

car

e pr

ovid

ed to

C

lient

s.

13, 3

6, 3

9,

40, 4

9,

54–6

0 an

d 63

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

: R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l May

8, 2

007.

Rec

ord

37, C

an fi

lter

on a

dat

e ra

nge

and

prin

t the

cha

rt b

ased

on

dat

e ra

nge.

D4

Vis

it Ty

peE

ncou

nter

M

ode

Cod

eA

des

crip

tion

of th

e ty

pe o

f con

tact

bet

wee

n th

e P

rovi

der

and

the

Clie

nt fo

r a

regi

ster

ed

Enc

ount

er o

r vi

sit.

Use

d in

the

adm

inis

trat

ion

of c

are.

C

an b

e us

ed to

trac

k se

rvic

es p

rovi

ded

that

m

ay r

equi

re s

peci

al

billi

ng p

roce

sses

.Tr

ack

perc

enta

ge o

f C

lient

s tr

eate

d th

roug

h va

rious

mod

es o

f vis

its.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

MTW

—In

fow

ay

Sta

ndar

ds C

olla

bora

tive

(SC

TE

MP

)

Con

cept

Dom

ain:

Act

Car

eEve

ntTy

pe

Exa

mpl

e:W

LKIN

(W

alk-

in C

linic

)

Foun

d in

:C

OC

T_M

T011

001C

A—

Car

e E

vent

iden

tifie

d—M

arch

16,

200

9.

Rec

ord

212,

Allo

ws

trac

king

of t

elep

hone

ca

ll or

con

tact

atte

mpt

s in

the

patie

nt r

ecor

d.

53


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceD

5P

aym

ent

Sou

rce

Enc

ount

er

Pay

or S

ourc

e C

ode

Rep

rese

nts

the

sour

ce

of p

aym

ent f

or th

e E

ncou

nter

.

Use

d in

the

adm

inis

trat

ion

of c

are

for

billi

ng p

urpo

ses.

D

eter

min

es th

e so

urce

of p

aym

ent f

or

Enc

ount

er.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

TBD

Exa

mpl

e:P

rovi

ncia

l or

terr

itoria

l in

sura

nce

Not

Fou

nd: L

ikel

y P

OS

-spe

cific

due

to

adm

inis

trat

ive

natu

re.

Rec

ord

289,

Fee

sc

hedu

le lo

ok-u

p by

co

de, d

escr

iptio

n an

d al

tern

ate

desc

riptio

n.

D6

Pay

men

t Ty

peE

ncou

nter

R

emun

erat

ion

Mod

e C

ode

Rep

rese

nts

the

type

of

reim

burs

emen

t pai

d to

the

Pro

vide

r fo

r th

e E

ncou

nter

.

Use

d in

the

adm

inis

trat

ion

of c

are

for

billi

ng p

urpo

ses.

D

eter

min

e ty

pe

of p

aym

ent t

o th

e P

rovi

der.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Nat

iona

l Phy

sici

an

Dat

abas

e D

ata

Sub

mis

sion

S

peci

ficat

ion

Vers

ion

4.0

Exa

mpl

e:00

(Fe

e fo

r S

ervi

ce)

Not

Fou

nd: L

ikel

y P

OS

-spe

cific

due

to

adm

inis

trat

ive

natu

re.

Rec

ord

289,

Fee

sc

hedu

le lo

ok-u

p by

co

de, d

escr

iptio

n an

d al

tern

ate

desc

riptio

n.

D7

Bill

ing

Cod

eE

ncou

nter

B

illin

g (F

ee)

Cod

e

Rep

rese

nts

the

Juris

dict

iona

l Bill

ing

Cod

e.

Use

d in

the

adm

inis

trat

ion

of c

are

for

billi

ng p

urpo

ses.

D

eter

min

es th

e so

urce

of p

aym

ent f

or

Enc

ount

er.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

N/A

As

per

juris

dict

ion-

spec

ific

set o

f val

ues

Not

Fou

nd: L

ikel

y P

OS

spe

cific

due

to

adm

inis

trat

ive

natu

re.

Rec

ord

289,

fee

sche

dule

look

up b

y co

de, d

escr

iptio

n an

d al

tern

ate

desc

riptio

n.

54


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceC

ont

ext:

Ob

serv

atio

nD

efin

itio

n: A

Hea

lth S

ervi

ce E

vent

th

at is

inte

nded

to

res

ult

in n

ew in

form

atio

n ab

out

th

e su

bje

ct. (

So

urce

HL7

v3)

. Th

e m

ain

diff

eren

ce b

etw

een

ob

serv

atio

ns

and

inte

rven

tions

as

des

crib

ed in

th

e P

HC

EM

R C

ont

ent

Sta

ndar

ds

is t

hat

ob

serv

atio

ns h

ave

a re

sult

(val

ue)

wh

erea

s in

terv

entio

ns d

o n

ot.

Add

ition

al d

ata

elem

ents

that

may

be

requ

ired

to s

uppo

rt th

e us

e an

d ex

trac

tion

of O

bser

vatio

n da

ta in

PH

C E

MR

s:P

rovi

der(

s) (

e.g.

the

Pro

vide

r[s]

who

per

form

ed th

e O

bser

vatio

n[s]

): P

rovi

der

Iden

tifie

r C

ode,

Pro

vide

r Id

entif

ier

Ass

igni

ng A

utho

rity,

Pro

vide

r R

ole

Type

and

Pro

vide

r E

xper

tise

expr

esse

d in

the

cont

ext o

f the

Obs

erva

tion.

Clie

nt (

e.g.

the

Clie

nt w

ho w

as th

e su

bjec

t of t

he O

bser

vatio

n): C

lient

Iden

tifie

r C

ode,

Clie

nt Id

entif

ier

Type

and

Clie

nt Id

entif

ier

Ass

igni

ng A

utho

rity

expr

esse

d in

the

cont

ext o

f the

Obs

erva

tion.

Enc

ount

er Id

entif

ier:

A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e en

coun

ter

in w

hich

the

Obs

erva

tion

took

pla

ce.

E1

Fam

ily

Mem

ber

Hea

lth

Con

cern

Obs

erva

tion

Fam

ily

His

tory

Hea

lth

Con

cern

C

ode

Rep

rese

nts

the

rele

vant

he

alth

con

cern

s of

a

pers

on s

harin

g co

mm

on a

nces

try

with

th

e C

lient

.

Use

d in

the

prov

isio

n of

car

e. F

amily

His

tory

H

ealth

Con

cern

is

ofte

n re

cord

ed to

not

e th

at th

e C

lient

may

ha

ve a

ris

k fa

ctor

for

dise

ases

. For

exa

mpl

e,

a w

oman

who

se m

othe

r ha

d br

east

can

cer

may

be

at h

ighe

r ris

k of

dev

elop

ing

brea

st c

ance

r.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

SN

OM

ED

CT®

Con

cept

Dom

ain:

D

iagn

osis

Valu

e

Exa

mpl

e:23

7734

007

(AC

TH-d

epen

dent

C

ushi

ng’s

syn

drom

e)

Con

cept

Dom

ain:

Sym

ptom

Valu

e

Exa

mpl

e:24

9543

005

(Abd

omen

sof

t)

Not

e: W

hile

a c

once

pt

dom

ain

has

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle

sum

mar

y vi

ew

(def

ault

view

and

ab

ility

to c

usto

miz

e).

55


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

2Fa

mily

M

embe

r S

ocia

l B

ehav

iour

(s)

Obs

erva

tion

Fam

ily

His

tory

Soc

ial

Beh

avio

ur

Cod

e

Rep

rese

nts

the

rele

vant

so

cial

beh

avio

urs

of a

per

son

shar

ing

com

mon

anc

estr

y w

ith

the

Clie

nt. T

his

can

incl

ude

risk

fact

ors,

su

ch a

s to

bacc

o us

e,

alco

hol u

se, a

buse

of

illic

it or

pre

scrip

tion

drug

s, a

nd o

ccup

atio

n.

Use

d in

the

prov

isio

n of

car

e. F

amily

His

tory

S

ocia

l Beh

avio

ur is

of

ten

reco

rded

to n

ote

that

the

Clie

nt m

ay h

ave

a ris

k fa

ctor

for

soci

al

beha

viou

rs a

nd/o

r di

seas

es. F

or e

xam

ple,

st

udie

s ha

ve s

how

n th

at

peop

le w

hose

par

ents

w

ere

alco

holic

s ha

ve a

hi

gher

ris

k of

bec

omin

g al

coho

lics

them

selv

es.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

SN

OM

ED

CT®

Con

cept

Dom

ain:

Com

mon

Clin

ical

Obs

er-

vatio

nAss

ertio

nVal

ue

Exa

mpl

e:56

4520

08 (

Adu

lt D

ysso

cial

Beh

avio

ur)

Nat

iona

l Occ

upat

ion

Cla

ssifi

catio

n (N

OC

)

Exa

mpl

e:

2211

(C

hem

ical

Te

chno

logi

sts

and

Tech

nici

ans)

Not

e: W

hile

a c

once

pt

dom

ain

has

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

E3

Fam

ilyM

embe

r In

-te

rven

tions

(T

reat

men

ts)

Obs

erva

tion

Fam

ily H

isto

ry

Inte

rven

tion

Cod

e

Rep

rese

nts

the

rele

vant

in

terv

entio

ns p

erfo

rmed

on

a p

erso

n sh

arin

g co

mm

on a

nces

try

with

the

Clie

nt.

Use

d in

the

prov

isio

n of

car

e. F

amily

His

tory

In

terv

entio

ns is

ofte

n re

cord

ed to

not

e th

at

the

Clie

nt m

ay h

ave

a ris

k fa

ctor

for

dise

ases

. In

som

e ca

ses,

Clie

nts

may

kno

w th

at th

e fa

mily

mem

ber

had

a sp

ecifi

c in

terv

entio

n bu

t not

kno

w th

e he

alth

con

cern

beh

ind

the

inte

rven

tion.

For

ex

ampl

e, a

Clie

nt m

ight

kn

ow th

at h

is/h

er fa

ther

ha

d a

trip

le b

y-pa

ss

surg

ery

but n

ot k

now

th

e ex

act u

nder

lyin

g he

alth

con

cern

that

the

surg

ery

was

atte

mpt

ing

to tr

eat.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

SN

OM

ED

CT®

Con

cept

Dom

ain:

A

ctP

rofe

ssio

nalS

ervi

ce-

Cod

e

Exa

mpl

e:40

8952

002

(Acu

te p

ain

cont

rol a

sses

smen

t)

Not

e: W

hile

a c

once

pt

dom

ain

has

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

56


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

4Fa

mily

M

embe

r R

elat

ions

hip

to P

atie

nt

Obs

erva

tion

Fam

ily H

isto

ry

Fam

ilial

R

elat

ions

hip

Cod

e

Rep

rese

nts

the

rela

tions

hip

betw

een

the

Clie

nt a

nd

a pe

rson

who

sha

res

a co

mm

on a

nces

try.

Use

d in

the

prov

isio

n of

car

e. F

amily

His

tory

Fa

mili

al R

elat

ions

hip

is

ofte

n re

cord

ed to

not

e th

at th

e C

lient

may

hav

e a

risk

fact

or fo

r dis

ease

s an

d so

cial

beh

avio

urs.

Fo

r ex

ampl

e, s

tudi

es

have

sho

wn

that

peo

ple

who

se p

aren

ts w

ere

alco

holic

s ha

ve a

hi

gher

ris

k of

bec

omin

g al

coho

lics

as w

ell.

Sim

ilarly

, a w

oman

w

hose

mot

her

had

brea

st c

ance

r m

ay

be a

t hig

her

risk

of

deve

lopi

ng it

.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

HL7

v3

Con

cept

Dom

ain:

Fa

mily

Mem

berR

elat

ion-

ship

Rol

eTyp

e

Exa

mpl

e:N

FTH

(N

atur

al F

athe

r)

Not

e: W

hile

a c

once

pt

dom

ain

has

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

E5

Fam

ily

Mem

ber

Hea

lth

Con

cern

, In

terv

entio

n or

Soc

ial

Beh

avio

ur

Age

at

Ons

et

Obs

erva

tion

Fam

ily H

isto

ry

Effe

ctiv

e O

nset

Age

N

umbe

r

Rep

rese

nts

the

age

of th

e fa

mily

mem

ber

(in y

ears

) w

hen

the

heal

th c

once

rn,

inte

rven

tion

or s

ocia

l be

havi

our

star

ted.

Use

d in

the

prov

isio

n of

car

e. F

amily

His

tory

E

ffect

ive

End

Dat

e is

ofte

n re

cord

ed to

no

te th

at th

e C

lient

m

ay b

e at

a h

ighe

r ris

k of

dev

elop

ing

a he

alth

con

cern

or

soc

ial b

ehav

iour

at

a c

erta

in a

ge.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

N/A

Exa

mpl

e:82

Not

e: T

he p

an-

Can

adia

n E

HR

M

essa

ging

Sta

ndar

ds

do n

ot c

urre

ntly

con

tain

an

y m

essa

ges

that

use

th

is d

ata

elem

ent.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

57


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

6Fa

mily

M

embe

r H

ealth

C

once

rn,

Inte

rven

tion

or S

ocia

l B

ehav

iour

S

tart

Dat

e

Obs

erva

tion

Fam

ily H

isto

ry

Effe

ctiv

e S

tart

D

ate

Rep

rese

nts

the

date

on

whi

ch th

e he

alth

co

ncer

n, in

terv

entio

n or

so

cial

beh

avio

ur s

tart

ed

for

the

fam

ily m

embe

r.

Use

d in

the

prov

isio

n of

car

e. F

amily

His

tory

E

ffect

ive

End

Dat

e is

ofte

n re

cord

ed to

no

te th

at th

e C

lient

m

ay b

e at

a h

ighe

r ris

k of

dev

elop

ing

a he

alth

con

cern

or

soc

ial b

ehav

iour

at

a c

erta

in a

ge.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

e: T

he p

an-

Can

adia

n E

HR

M

essa

ging

Sta

ndar

ds

do n

ot c

urre

ntly

con

tain

an

y m

essa

ges

that

use

th

is d

ata

elem

ent.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

E7

Fam

ily

Mem

ber

Hea

lth

Con

cern

, In

terv

entio

n or

Soc

ial

Beh

avio

ur

End

Dat

e

Obs

erva

tion

Fam

ily H

isto

ry

Effe

ctiv

e E

nd

Dat

e

Rep

rese

nts

the

date

on

whi

ch th

e he

alth

co

ncer

n, in

terv

entio

n or

so

cial

beh

avio

ur e

nded

fo

r th

e fa

mily

mem

ber.

Use

d in

the

prov

isio

n of

car

e. F

amily

His

tory

E

ffect

ive

End

Dat

e is

ofte

n re

cord

ed to

no

te th

at th

e C

lient

m

ay b

e at

a h

ighe

r ris

k of

dev

elop

ing

a he

alth

con

cern

or

soc

ial b

ehav

iour

at

a c

erta

in a

ge.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

e: T

he p

an-

Can

adia

n E

HR

M

essa

ging

Sta

ndar

ds

do n

ot c

urre

ntly

con

tain

an

y m

essa

ges

that

use

th

is d

ata

elem

ent.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

E8

Fam

ily

Mem

ber

Dec

ease

d D

ate

Obs

erva

tion

Fam

ily H

isto

ry

Effe

ctiv

e D

ecea

sed

Dat

e

Rep

rese

nts

the

date

on

whi

ch th

e fa

mily

m

embe

r di

ed.

Use

d in

the

prov

isio

n of

car

e. F

amily

His

tory

E

ffect

ive

End

Dat

e is

ofte

n re

cord

ed to

no

te th

at th

e C

lient

m

ay b

e at

a h

ighe

r ris

k of

dev

elop

ing

a he

alth

con

cern

or

soc

ial b

ehav

iour

at

a c

erta

in a

ge.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

e: T

he p

an-

Can

adia

n E

HR

M

essa

ging

Sta

ndar

ds

do n

ot c

urre

ntly

con

tain

an

y m

essa

ges

that

use

th

is d

ata

elem

ent.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

58


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

9Fa

mily

M

embe

r C

ause

of

Dea

th

Obs

erva

tion

Fam

ily H

isto

ry

Dea

th C

ause

C

ode

Rep

rese

nts

the

clin

ical

ca

use

of d

eath

for

the

fam

ily m

embe

r.

Use

d in

the

prov

isio

n of

car

e. F

amily

His

tory

D

eath

Cau

se C

ode

is

ofte

n re

cord

ed to

not

e th

at th

e C

lient

may

ha

ve a

ris

k fa

ctor

for

dise

ases

. For

exa

mpl

e,

a w

oman

who

se m

othe

r di

ed o

f bre

ast c

ance

r m

ay b

e at

hig

her

risk

of d

evel

opin

g it.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

SN

OM

ED

CT®

Con

cept

Dom

ain:

Dia

gnos

isVa

lues

Exa

mpl

e:23

7734

007

(AC

TH-

depe

nden

t Cus

hing

’s

synd

rom

e)

Not

e: W

hile

a c

once

pt

dom

ain

has

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

E10

Fam

ily

Mem

ber

Eth

nici

ty

Obs

erva

tion

Fam

ily H

isto

ry

Fam

ilial

E

thni

city

C

ode

Rep

rese

nts

the

ethn

icity

of

the

fam

ily m

embe

r.U

sed

in th

e pr

ovis

ion

of c

are.

Fam

ily H

isto

ry

Fam

ilial

Eth

nici

ty C

ode

is o

ften

reco

rded

to

note

that

the

Clie

nt

may

hav

e a

risk

fact

or

for

dise

ases

and

so

cial

beh

avio

urs.

Fo

r ex

ampl

e, s

ome

heal

th c

ondi

tions

are

m

ore

prom

inen

t in

cert

ain

ethn

ic g

roup

s su

ch a

s si

ckle

cel

l an

aem

ia in

peo

ple

with

Afri

can

orig

ins.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Sta

tistic

s C

anad

a 20

06 C

ensu

s—et

hnic

ca

tego

ries

and

subc

ateg

orie

s

Exa

mpl

e:H

ispa

nic

An

equi

vale

nt c

once

pt

was

not

foun

d in

th

e pa

n-C

anad

ian

EH

R M

essa

ging

and

Te

rmin

olog

y S

tand

ards

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

59


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

11H

ealth

C

once

rnO

bser

vatio

n H

ealth

C

once

rn

Cod

e

Rep

rese

nts

the

Clie

nt’s

re

leva

nt c

linic

al

prob

lem

s, c

ondi

tions

, di

agno

ses,

sym

ptom

s,

findi

ngs

and

com

plai

nts.

Use

d in

the

prov

isio

n of

car

e. P

rovi

des

a lo

ngitu

dina

l rec

ord

of

prob

lem

s or

sym

ptom

s fo

r a

Clie

nt. C

linic

ians

ca

n us

e th

is in

form

atio

n to

mon

itor

the

heal

th

of th

eir

clie

nts,

re

com

men

d tr

eatm

ents

an

d as

sist

in th

e fo

rmat

ion

of d

iagn

oses

.

36, 3

9, 4

0,

50, 5

5–60

, 62

and

63

SN

OM

ED

CT®

Con

cept

Dom

ain:

Dia

gnos

isVa

lue

valu

es

Exa

mpl

e:23

7734

007

(AC

TH-

depe

nden

t Cus

hing

’s

synd

rom

e)

Con

cept

Dom

ain:

S

ympt

omVa

lue

Exa

mpl

e:24

9543

005

(Abd

omen

sof

t)

Foun

d in

:R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l May

8, 2

007.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

E12

Hea

lth

Con

cern

D

ate

of

Ons

et

Obs

erva

tion

Hea

lth

Con

cern

Sta

rt

Dat

e

Rep

rese

nts

the

date

on

whi

ch th

e C

lient

’s

heal

th c

once

rn s

tart

ed.

Use

d in

the

prov

isio

n of

car

e. P

rovi

des

a lo

ngitu

dina

l rec

ord

of

prob

lem

s or

sym

ptom

s fo

r a

Clie

nt. C

linic

ians

ca

n us

e th

is in

form

atio

n to

mon

itor

the

heal

th

of th

eir

Clie

nts,

re

com

men

d tr

eatm

ents

an

d as

sist

in th

e fo

rmat

ion

of d

iagn

oses

.

36, 3

9, 4

0,

55–5

8, 6

2 an

d 63

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

:S

C-2

003-

EN

—R

EP

C_M

T000

003C

A—

Hea

lth C

ondi

tion

Rec

ord—

2009

0316

.doc

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

60


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

13H

ealth

C

once

rn

Dat

e of

R

esol

utio

n

Obs

erva

tion

Hea

lth

Con

cern

End

D

ate

Rep

rese

nts

the

date

on

whi

ch th

e C

lient

’s

heal

th c

once

rn e

nded

.

Use

d in

the

prov

isio

n of

car

e. P

rovi

des

a lo

ngitu

dina

l rec

ord

of

prob

lem

s or

sym

ptom

s fo

r a

Clie

nt. C

linic

ians

ca

n us

e th

is in

form

atio

n to

mon

itor

the

heal

th

of th

eir

clie

nts,

re

com

men

d tr

eatm

ents

an

d as

sist

in th

e fo

rmat

ion

of d

iagn

oses

.

36, 3

9, 4

0,

55–5

8 an

d 63

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

:S

C-2

003-

EN

—R

EP

C_

MT0

0000

3CA

—H

ealth

C

ondi

tion

Rec

ord—

2009

0316

.doc

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

E14

Soc

ial

Beh

avio

urO

bser

vatio

n S

ocia

l B

ehav

iour

C

ode

Rep

rese

nts

a ty

pe o

f C

lient

soc

ial b

ehav

iour

th

at in

crea

ses

the

poss

ibili

ty o

f dis

ease

or

inju

ry fo

r th

e C

lient

. Th

is c

an in

clud

e ris

k fa

ctor

s su

ch a

s to

bacc

o us

e, a

lcoh

ol u

se, a

buse

of

illic

it or

pre

scrip

tion

drug

s, a

nd o

ccup

atio

n.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to id

entif

y C

lient

be

havi

ours

that

, if

trea

ted,

cou

ld le

ad to

im

prov

emen

ts in

the

Clie

nt’s

hea

lth a

nd

wel

lnes

s. F

or e

xam

ple,

th

e id

entif

icat

ion

and

trea

tmen

t of d

rug

and

alco

hol p

robl

ems

can

impr

ove

a C

lient

’s

men

tal a

nd p

hysi

cal

heal

th a

nd s

ocia

l fu

nctio

ning

.

13 a

nd 4

3S

NO

ME

D C

T®

Con

cept

Dom

ain:

Com

mon

Clin

ical

Obs

er-

vatio

nAss

ertio

nVal

ue

Exa

mpl

e:56

4520

08 (

Adu

lt D

ysso

cial

Beh

avio

ur)

Nat

iona

l Occ

upat

ion

Cla

ssifi

catio

n (N

OC

)

Exa

mpl

e:

2211

(C

hem

ical

Te

chno

logi

sts

and

Tech

nici

ans)

Exa

mpl

e N

OC

Val

ue:

2211

(C

hem

ical

Te

chno

logi

sts

and

Tech

nici

ans)

Not

e: W

hile

a c

once

pt

dom

ain

has

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

61


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

15S

ocia

l B

ehav

iour

D

ate

of

Ons

et

Obs

erva

tion

Soc

ial

Beh

avio

ur

Sta

rt D

ate

Rep

rese

nts

the

effe

ctiv

e da

te th

e C

lient

sta

rted

th

e so

cial

beh

avio

ur.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to id

entif

y C

lient

be

havi

ours

that

, if

trea

ted,

cou

ld le

ad to

im

prov

emen

ts in

the

Clie

nt’s

hea

lth a

nd

wel

lnes

s. F

or e

xam

ple,

th

e id

entif

icat

ion

and

trea

tmen

t of d

rug

and

alco

hol p

robl

ems

can

impr

ove

a C

lient

’s

men

tal a

nd p

hysi

cal

heal

th a

nd s

ocia

l fu

nctio

ning

.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

e: W

hile

a d

ata

type

ha

s be

en r

efer

ence

d,

this

exa

ct d

ata

elem

ent

does

not

cur

rent

ly e

xist

in

the

pan-

Can

adia

n E

HR

Mes

sagi

ng

Sta

ndar

ds.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

E16

Soc

ial

Beh

avio

ur

Dat

e of

R

esol

utio

n

Obs

erva

tion

Soc

ial

Beh

avio

ur

End

Dat

e

Rep

rese

nts

the

effe

ctiv

e da

te th

e C

lient

cea

sed

the

soci

al b

ehav

iour

.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to id

entif

y C

lient

be

havi

ours

that

, if

trea

ted,

cou

ld le

ad to

im

prov

emen

ts in

the

Clie

nt’s

hea

lth a

nd

wel

lnes

s. F

or e

xam

ple,

th

e id

entif

icat

ion

and

trea

tmen

t of d

rug

and

alco

hol p

robl

ems

can

impr

ove

a C

lient

’s

men

tal a

nd p

hysi

cal

heal

th a

nd s

ocia

l fu

nctio

ning

.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

e: W

hile

a d

ata

type

ha

s be

en r

efer

ence

d,

this

exa

ct d

ata

elem

ent

does

not

cur

rent

ly e

xist

in

the

pan-

Can

adia

n E

HR

Mes

sagi

ng

Sta

ndar

ds.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

(d

efau

lt vi

ew a

nd

abili

ty to

cus

tom

ize)

.

62


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

17A

llerg

y/In

tole

ranc

e Ty

pe

Obs

erva

tion

Alle

rgy/

Into

lera

nce

Type

Cod

e

Rep

rese

nts

the

type

of

alle

rgy

or in

tole

ranc

e a

Clie

nt h

as.

Use

d in

the

prov

isio

n of

ca

re. U

sed

to p

reve

nt

adve

rse

reac

tions

an

d ca

n be

use

d fo

r re

min

ders

and

ale

rts.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

SN

OM

ED

CT®

Con

cept

Dom

ain:

O

bser

vatio

nInt

oler

an-

ceTy

pe

Exa

mpl

e:23

5719

002

(Foo

d In

tol-

eran

ce)

Foun

d in

:R

EP

C_M

T000

001C

A—

Alle

rgy

Into

lera

nce—

2009

0316

.

Rec

ord

347,

Pro

vide

s au

tom

ated

dec

isio

n su

ppor

t rem

inde

rs o

r ru

les

from

alle

rgie

s.

E18

Alle

rgy/

Into

lera

nce

Age

nt

Obs

erva

tion

Alle

rgy/

Into

lera

nce

Age

nt C

ode

Rep

rese

nts

the

spec

ific

alle

rgen

or

othe

r ag

ent/

subs

tanc

e to

whi

ch th

e C

lient

has

an

alle

rgic

re

actio

n or

into

lera

nce.

Use

d in

the

prov

isio

n of

car

e. U

sed

to p

reve

nt

adve

rse

reac

tions

an

d al

lerg

y to

dru

g in

tera

ctio

ns a

nd c

an

be u

sed

for

rem

inde

rs

and

aler

ts.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

SN

OM

ED

CT®

Con

cept

Dom

ain:

Non

Dru

gAge

ntE

ntity

Exa

mpl

e:22

7150

003

(Mus

sels

)

HC

-AIG

C, H

C-A

IGN

, H

C-D

IN, H

C-N

PN

, G

TIN

, SN

OM

ED

CT®

Con

cept

Dom

ain:

Clin

ical

Dru

g

Exa

mpl

e:37

3270

004

(Pen

icill

in)

Foun

d in

:R

EP

C_M

T000

001C

A—

Alle

rgy

Into

lera

nce—

2009

0316

.

Rec

ord

347,

Pro

vide

s au

tom

ated

dec

isio

n su

ppor

t rem

inde

rs o

r ru

les

from

alle

rgie

s.

E19

Alle

rgy/

Into

lera

nce

Sev

erity

Obs

erva

tion

Alle

rgy/

Into

lera

nce

Sev

erity

Cod

e

Rep

rese

nts

the

leve

l of

seve

rity

a C

lient

has

in

rela

tion

to a

n al

lerg

y or

in

tole

ranc

e.

Use

d in

the

prov

isio

n of

ca

re. U

sed

to p

reve

nt

adve

rse

reac

tions

an

d ca

n be

use

d fo

r re

min

ders

and

ale

rts.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

SN

OM

ED

CT®

Con

cept

Dom

ain:

S

ever

ityO

bser

vatio

n

Exa

mpl

e:24

4840

00 (

Sev

ere)

Foun

d in

SC

-200

3-E

N—

RE

PC

_MT0

0000

1CA

—A

llerg

y In

tole

ranc

e—20

0903

16.

Rec

ord

347,

Pro

vide

s au

tom

ated

dec

isio

n su

ppor

t rem

inde

rs o

r ru

les

from

alle

rgie

s.

63


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

20A

llerg

y/In

tole

ranc

e S

tatu

s

Obs

erva

tion

Alle

rgy/

Into

lera

nce

Sta

tus

Cod

e

Rep

rese

nts

whe

ther

an

alle

rgy/

into

lera

nce

is

“act

ive”

or

”com

plet

ed”

(indi

catin

g no

long

er

activ

e).

Use

d in

the

prov

isio

n an

d ad

min

istr

atio

n of

ca

re. A

n E

MR

can

be

prog

ram

med

to p

rovi

de

aler

ts fo

r al

lerg

ies/

into

lera

nces

that

ar

e ac

tive.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

HL7

v3

Con

cept

Dom

ain:

A

ctS

tatu

s

Exa

mpl

e:A

CTI

VE

Foun

d in

:R

EP

C_M

T000

001C

A—

Alle

rgy

Into

lera

nce—

Mar

ch 1

6, 2

009.

Rec

ord

347,

Pro

vide

s au

tom

ated

dec

isio

n su

ppor

t rem

inde

rs o

r ru

les

from

alle

rgie

s.

E21

Alle

rgy/

Into

lera

nce

Dat

e of

O

nset

Obs

erva

tion

Alle

rgy

and/

or In

tole

ranc

e S

tart

Dat

e

Rep

rese

nts

the

date

on

whi

ch th

e re

cord

ed

alle

rgy/

into

lera

nce

is

cons

ider

ed a

ctiv

e.

Use

d in

the

prov

isio

n an

d ad

min

istr

atio

n of

ca

re. A

n E

MR

can

be

prog

ram

med

to p

rovi

de

aler

ts fo

r al

lerg

ies/

into

lera

nces

that

ar

e ac

tive.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

:R

EP

C_M

T000

001C

A—

Alle

rgy

Into

lera

nce—

Mar

ch 1

6, 2

009.

Rec

ord

347,

Pro

vide

s au

tom

ated

dec

isio

n su

ppor

t rem

inde

rs o

r ru

les

from

alle

rgie

s.

E22

Alle

rgy/

Into

lera

nce

Dat

e of

R

esol

utio

n

Obs

erva

tion

Alle

rgy

and/

or In

tole

ranc

e E

nd D

ate

Rep

rese

nts

the

date

on

whi

ch th

e re

cord

ed

alle

rgy/

into

lera

nce

is

no lo

nger

con

side

red

activ

e.

Use

d in

the

prov

isio

n an

d ad

min

istr

atio

n of

ca

re. A

n E

MR

can

be

prog

ram

med

to p

rovi

de

aler

ts fo

r al

lerg

ies/

into

lera

nces

that

ar

e ac

tive.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

:R

EP

C_M

T000

001C

A—

Alle

rgy

Into

lera

nce—

Mar

ch 1

6, 2

009.

Rec

ord

347,

Pro

vide

s au

tom

ated

dec

isio

n su

ppor

t rem

inde

rs o

r ru

les

from

alle

rgie

s.

64


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

23S

ysto

lic

Blo

od

Pre

ssur

e

Obs

erva

tion

Sys

tolic

Blo

od

Pre

ssur

e N

umbe

r

Rep

rese

nts

the

Clie

nt’s

sy

stol

ic b

lood

pre

ssur

e va

lue

(in m

mH

g)

mea

sure

d. T

he u

nit

of m

easu

re (

mm

Hg)

is

impl

ied

whe

n re

pres

entin

g th

e va

lue.

Use

d in

the

prov

isio

n of

car

e. A

dis

cret

e va

lue

prov

ides

the

abili

ty to

gra

ph a

nd

tren

d va

lues

ove

r tim

e. A

mea

sure

men

t th

at s

uppo

rts

clin

ical

de

cisi

ons.

40 a

nd

54–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

Sta

ndar

ds—

Dat

a Ty

pe S

peci

ficat

ion

Sec

tion

6—N

umer

icP

Q.B

AS

IC .

Bas

ic

Phy

sica

l Qua

ntity

Exa

mpl

e:12

0

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d M

arch

16,

200

9.

Rec

ord

127,

Gra

ph

and

prin

t cod

ed a

nd

mea

sure

d el

emen

ts

over

tim

e.

E24

Dia

stol

ic

Blo

od

Pre

ssur

e

Obs

erva

tion

Dia

stol

ic

Blo

od

Pre

ssur

e N

umbe

r

Rep

rese

nts

the

Clie

nt’s

di

asto

lic b

lood

pre

ssur

e va

lue

(in m

mH

g)

mea

sure

d. T

he u

nit

of m

easu

re (

mm

Hg)

is

impl

ied

whe

n re

pres

entin

g th

e va

lue.

Use

d in

the

prov

isio

n of

car

e. A

dis

cret

e va

lue

prov

ides

the

abili

ty to

gra

ph a

nd

tren

d va

lues

ove

r tim

e. A

mea

sure

men

t th

at s

uppo

rts

clin

ical

de

cisi

ons.

40 a

nd

54–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

Sta

ndar

ds—

Dat

a Ty

pe S

peci

ficat

ion

Sec

tion

6—N

umer

icP

Q.B

AS

IC. B

asic

P

hysi

cal Q

uant

ity

Exa

mpl

e:80

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d M

arch

16,

200

9.

Rec

ord

127,

Gra

ph

and

prin

t cod

ed a

nd

mea

sure

d el

emen

ts

over

tim

e.

E25

Blo

od

Pre

ssur

e B

ody

Loca

tion

Obs

erva

tion

Blo

od

Pre

ssur

e M

easu

rem

ent

Ana

tom

ical

Lo

catio

n C

ode

Rep

rese

nts

the

anat

omic

al lo

catio

n of

whe

re th

e bl

ood

pres

sure

was

mea

sure

d on

the

Clie

nt’s

bod

y.

Use

d in

the

prov

isio

n of

car

e. Id

entif

ies

whe

re

the

bloo

d pr

essu

re

was

take

n.

40 a

nd

55–5

7S

NO

ME

D C

T®

Con

cept

Dom

ain:

O

bser

vatio

nMet

hod

Exa

mpl

e:50

7692

010

(rig

ht u

pper

ar

m s

truc

ture

)

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d—20

0903

16.d

oc.

Not

cur

rent

ly r

equi

red

to s

uppo

rt a

ny o

f the

P

OS

R r

ecor

ds.

65


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

26B

lood

P

ress

ure

Bod

y P

ositi

on

Obs

erva

tion

Blo

od

Pre

ssur

e M

easu

rem

ent

Bod

y P

ositi

on

Cod

e

Rep

rese

nts

the

posi

tion

the

Clie

nt’s

bod

y w

as

in w

hen

bloo

d pr

essu

re

was

mea

sure

d (e

.g.

stan

ding

, sitt

ing,

lyin

g).

Use

d in

the

prov

isio

n of

car

e. Id

entif

ies

the

posi

tion

the

Clie

nt w

as

in w

hen

bloo

d pr

essu

re

was

take

n.

40 a

nd

55–5

7S

NO

ME

D C

T®

Con

cept

Dom

ain:

O

bser

vatio

nMet

hod

Exa

mpl

e:16

3035

008

(sitt

ing

bloo

d pr

essu

re)

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d—20

0903

16.d

oc.

Not

cur

rent

ly r

equi

red

to s

uppo

rt a

ny o

f the

P

OS

R r

ecor

ds.

E27

Blo

od

Pre

ssur

e R

epre

-se

ntat

ive

Rea

ding

Obs

erva

tion

Rep

rese

nta-

tive

Blo

od

Pre

ssur

e R

eadi

ng

Cod

e

Rep

rese

nts

whe

ther

th

e C

lient

’s b

lood

pr

essu

re r

eadi

ng is

re

pres

enta

tive

of th

e C

lient

’s c

urre

nt h

ealth

co

nditi

on.

Use

in th

e pr

ovis

ion

of c

are.

Iden

tifie

s a

bloo

d pr

essu

re r

eadi

ng

that

app

ears

to b

e no

n-re

pres

enta

tive

at th

e tim

e th

e re

adin

g w

as ta

ken.

40 a

nd

55–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

Sta

ndar

ds—

Dat

a Ty

pe S

peci

ficat

ion

Sec

tion

8.4—

BL—

Boo

lean

Exa

mpl

e:F

(Fal

se)

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d—20

0903

16.

Rec

ord

127,

Gra

ph

and

prin

t cod

ed a

nd

mea

sure

d el

emen

ts

over

tim

e.

E28

Hei

ght

Obs

erva

tion

Hei

ght

Num

ber

Rep

rese

nts

the

heig

ht o

f the

Clie

nt

as m

easu

red.

Use

d in

the

prov

isio

n of

car

e. A

dec

reas

e in

fem

ale

heig

ht

coul

d be

an

early

si

gn o

f ost

eopo

rosi

s an

d tr

igge

r a

need

fo

r a

bone

min

eral

de

nsity

test

.

13 a

nd

55–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

Sta

ndar

ds—

Dat

a Ty

pe S

peci

ficat

ion

Sec

tion

6.9—

PQ

.H

EIG

HTW

EIG

HT

Hei

ght

or W

eigh

t Qua

ntity

Exa

mpl

e:1.

25

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d M

arch

16,

200

9.

Rec

ord

127,

Gra

ph

and

prin

t cod

ed a

nd

mea

sure

d el

emen

ts

over

tim

e.

66


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceE

29H

eigh

t Uni

t of

Mea

sure

Obs

erva

tion

Hei

ght U

nit

of M

easu

re

Cod

e

Rep

rese

nts

the

Clie

nt

heig

ht u

nit o

f mea

sure

ca

ptur

ed.

Use

d in

the

prov

isio

n of

car

e. A

dec

reas

e in

fem

ale

heig

ht

coul

d be

an

early

si

gn o

f ost

eopo

rosi

s,

and

trig

ger

a ne

ed

for

a bo

ne m

iner

al

dens

ity te

st.

13 a

nd

55–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

Sta

ndar

ds—

Dat

a Ty

pe S

peci

ficat

ion

Sec

tion

6.9—

PQ

.H

EIG

HTW

EIG

HT

Hei

ght

or W

eigh

t Qua

ntity

Exa

mpl

e:m

(m

eter

)

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d M

arch

16,

200

9.

Rec

ord

6, U

ser

can

ente

r an

d di

spla

y bo

th

met

ric a

nd im

peria

l m

easu

rem

ents

.

E30

Wei

ght

Obs

erva

tion

Wei

ght

Num

ber

Rep

rese

nts

the

wei

ght o

f the

Clie

nt

as m

easu

red.

Use

d in

the

prov

isio

n of

car

e. W

eigh

t use

d to

ca

lcul

ate

body

mas

s in

dex

(BM

I).

13 a

nd

55–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.9—

PQ

.H

EIG

HTW

EIG

HT

Hei

ght o

r W

eigh

t Q

uant

ity

Exa

mpl

e:75

.6

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d M

arch

16,

200

9.

Rec

ord

200,

Dis

play

co

nsis

tent

and

ac

cura

te d

osag

e w

hen

calc

ulat

ing

the

dose

ba

sed

on w

eigh

t.

E31

Wei

ght

Uni

t of

Mea

sure

Obs

erva

tion

Wei

ght U

nit

of M

easu

re

Cod

e

Rep

rese

nts

the

Clie

nt

wei

ght u

nit o

f mea

sure

ca

ptur

ed.

Use

d in

the

prov

isio

n of

car

e. W

eigh

t use

d to

cal

cula

te B

MI.

13 a

nd

55–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.9—

PQ

.H

EIG

HTW

EIG

HT

Hei

ght o

r W

eigh

t Q

uant

ity

Exa

mpl

e:kg

(ki

logr

am)

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d M

arch

16,

200

9.

Rec

ord

6, U

ser

can

ente

r an

d di

spla

y bo

th

met

ric a

nd im

peria

l m

easu

rem

ents

.

67


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

E32

Wai

st

Circ

um-

fere

nce

Obs

erva

tion

Wai

st C

ir-cu

mfe

renc

e N

umbe

r

Rep

rese

nts

the

wai

st

circ

umfe

renc

e of

the

Clie

nt a

s m

easu

red.

Use

d in

the

prov

isio

n of

car

e. U

sed

to

mon

itor

and

prev

ent

onse

t of c

hron

ic

dise

ases

for

Clie

nts

with

a fa

mily

hea

lth

hist

ory

of a

spe

cific

ch

roni

c di

seas

e.

13 a

nd

55–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

Sta

ndar

ds—

Dat

a Ty

pe S

peci

ficat

ion

Sec

tion

6.6—

PQ

.BA

SIC

—B

asic

P

hysi

cal Q

uant

ity

Exa

mpl

e:70

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d M

arch

16,

200

9.

Rec

ord

127,

Abi

lity

to g

raph

and

prin

t co

ded

and

mea

sure

d el

emen

ts fo

r a

patie

nt’s

ch

art o

ver

time

from

la

bora

tory

, cod

ed

hist

oric

al e

lem

ents

, co

ded

phys

ical

ex

am fi

ndin

gs, a

nd

med

icat

ions

to o

bser

ve

tren

ds. P

ropo

nent

to

desc

ribe

the

abili

ty

to d

ispl

ay m

ultip

le

elem

ents

on

one

grap

h.

E33

Wai

st

Circ

um-

fere

nce

Uni

t of

Mea

sure

Obs

erva

tion

Wai

st C

ircum

-fe

renc

e U

nit

of M

easu

re

Cod

e

Rep

rese

nts

the

Clie

nt

Wai

st C

ircum

fere

nce

unit

of m

easu

re

capt

ured

.

Use

d in

the

prov

isio

n of

car

e. U

sed

to

mon

itor

and

prev

ent

onse

t of c

hron

ic

dise

ases

for

Clie

nts

with

a fa

mily

hea

lth

hist

ory

of a

spe

cific

ch

roni

c di

seas

e.

13 a

nd

55–5

7D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

Sta

ndar

ds—

Dat

a Ty

pe S

peci

ficat

ion

Sec

tion

6.6—

PQ

.BA

SIC

—B

asic

P

hysi

cal Q

uant

ity

Foun

d in

:R

EP

C_M

T410

001C

A—

Mea

sure

d O

bser

vatio

n R

ecor

d M

arch

16,

200

9.

Rec

ord

6, U

ser

can

ente

r an

d di

spla

y bo

th

met

ric a

nd im

peria

l m

easu

rem

ents

.

68


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

E34

Clin

icia

n A

sses

s-m

ent

Obs

erva

tion

Enc

ount

er

Clin

ical

A

sses

smen

t C

ode

Rep

rese

nts

the

Pro

vide

r’s p

rofe

ssio

nal

opin

ion

of th

e m

ost

rele

vant

clin

ical

find

ings

re

late

d to

the

Clie

nt’s

E

ncou

nter

. The

mos

t re

leva

nt c

linic

al fi

ndin

g fo

r th

e E

ncou

nter

can

in

clud

e di

agno

ses,

sy

mpt

oms

and

prof

essi

onal

ser

vice

s.

Use

d in

the

prov

isio

n an

d ad

min

istr

atio

n of

car

e. T

he c

linic

al

asse

ssm

ent o

f the

E

ncou

nter

can

be

used

to

hel

p tr

ack

epis

odes

of

car

e. C

an a

lso

supp

ort s

hado

w b

illin

g.

13, 3

6, 3

9,

40, 4

3, 4

9,

55–6

0 an

d 63

SN

OM

ED

CT®

Con

cept

Dom

ain:

Dia

gnos

isVa

lue

Exa

mpl

e:23

7734

007

(AC

TH-

depe

nden

t Cus

hing

’s

synd

rom

e)

SN

OM

ED

CT®

Con

cept

Dom

ain:

Sym

ptom

Valu

e

Exa

mpl

e:43

3640

01 (

Abd

omin

al

disc

omfo

rt)

SN

OM

ED

CT®

Con

cept

Dom

ain:

Act

Pro

fess

iona

lSer

vice

-C

ode:

Exa

mpl

e:40

8952

002

(Acu

te p

ain

cont

rol a

sses

smen

t)

Not

e: W

hile

con

cept

do

mai

ns h

ave

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Rec

ord

num

ber

122,

S

umm

ary

of p

atie

nt

info

rmat

ion

rela

ted

to a

hea

lth c

ondi

tion

(pro

blem

or

diag

nosi

s).

69


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceC

ont

ext:

Inte

rven

tion

Def

initi

on:

An

activ

ity p

erfo

rmed

by

one

or

mo

re p

rovi

der

s o

f a

ther

apeu

tic o

r o

ther

hea

lth c

are–

rela

ted

ser

vice

fo

r a

clie

nt.

Add

ition

al d

ata

elem

ents

that

may

be

requ

ired

to s

uppo

rt th

e us

e an

d ex

trac

tion

of In

terv

entio

n da

ta in

PH

C E

MR

s:P

rovi

der

(e.g

. the

Pro

vide

r w

ho p

erfo

rmed

the

Inte

rven

tion)

: Pro

vide

r Id

entif

ier

Cod

e, P

rovi

der

Iden

tifie

r A

ssig

ning

Aut

horit

y, P

rovi

der

Rol

e Ty

pe a

nd P

rovi

der

Exp

ertis

e ex

pres

sed

in th

e co

ntex

t of t

he In

terv

entio

n.C

lient

(e.

g. th

e C

lient

who

was

the

subj

ect o

f the

Inte

rven

tion)

: Clie

nt Id

entif

ier

Cod

e, C

lient

Iden

tifie

r Ty

pe a

nd C

lient

Iden

tifie

r A

ssig

ning

Aut

horit

y ex

pres

sed

in th

e co

ntex

t of t

he In

terv

entio

n.E

ncou

nter

Iden

tifie

r: A

bus

ines

s id

entif

ier

that

uni

quel

y id

entif

ies

the

Enc

ount

er in

whi

ch th

e In

terv

entio

n to

ok p

lace

.

F1In

terv

entio

n (T

reat

men

t)In

terv

entio

n C

ode

Rep

rese

nts

the

serv

ices

/act

iviti

es

perfo

rmed

by

the

Pro

vide

r fo

r th

e C

lient

.

Use

d in

the

prov

isio

n of

car

e. T

rack

ed

Inte

rven

tions

pe

rform

ed o

n a

Clie

nt c

an h

elp

guid

e fu

ture

Inte

rven

tions

. U

sed

to tr

ack

Clie

nt’s

pro

gres

sive

im

prov

emen

t on

the

cont

inuu

m o

f car

e tim

elin

e. C

ouns

ellin

g fo

r sm

okin

g ce

ssat

ion

deliv

ered

in 2

008,

bl

ood

pres

sure

, and

dr

ug a

dmin

iste

red

show

pos

itive

im

prov

emen

t tod

ay.

13, 4

3, 4

9 an

d 50

SN

OM

ED

CT®

Con

cept

Dom

ain:

A

ctP

rofe

ssio

nalS

ervi

ce-

Cod

e

Exa

mpl

e:40

8952

002

(Acu

te p

ain

cont

rol a

sses

smen

t)

Foun

d in

:R

EP

C_M

T610

001C

A—

Pro

fess

iona

l Ser

vice

.

Rec

ord

342,

Pro

vide

us

er-d

efin

ed p

atie

nt

info

rmat

ion

for c

omm

on

inte

rven

tions

.

70


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

F2In

terv

entio

n(T

reat

men

t)

Dat

e

Inte

rven

tion

Dat

eR

epre

sent

s th

e da

te

the

Inte

rven

tion

was

pe

rform

ed b

y th

e P

rovi

der

for

the

Clie

nt.

Use

d in

the

prov

isio

n of

car

e to

trac

k th

e da

te

a pa

rtic

ular

inte

rven

tion

was

per

form

ed b

y th

e P

rovi

der.

13, 4

9 an

d 50

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng

Sta

ndar

ds—

Dat

a Ty

pe

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

:R

EP

C_M

T610

001C

A—

Pro

fess

iona

l Ser

vice

A

ctP

rofe

ssio

nalS

ervi

ce-

Cod

e.

Rec

ord

342,

Pro

vide

us

er-d

efin

ed p

atie

nt

info

rmat

ion

for c

omm

on

inte

rven

tions

.

F3In

terv

entio

n (T

reat

men

t)

Ref

usal

R

easo

n

Inte

rven

tion

Ref

usal

R

easo

n C

ode

Rep

rese

nts

the

reas

on

the

Clie

nt r

efus

ed a

n In

terv

entio

n.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to p

reve

nt in

appr

opria

te

rem

inde

rs a

nd a

lert

s fo

r C

lient

s.

13, 4

3, 4

9 an

d 50

TBD

—co

de s

et n

eeds

to

be

iden

tifie

d. P

o-te

ntia

l to

use

HL7

v3.

P

oten

tial t

o us

e va

lues

fro

m th

e co

ncep

t do

mai

n:A

ctN

oIm

mun

izat

ion-

Rea

son

Exa

mpl

e:R

ELI

G (

Rel

igio

us

Obj

ectio

n)

Not

foun

d in

any

of

the

pan-

Can

adia

n E

HR

Mes

sagi

ng a

nd

Term

inol

ogy

Sta

ndar

ds.

Not

cur

rent

ly r

equi

red

to s

uppo

rt a

ny o

f the

P

OS

R r

ecor

ds.

71


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

Co

ntex

t: L

abo

rato

ry O

rder

sD

efin

itio

n: R

eque

sts

for

the

pro

visi

on

of

anal

ytic

al s

ervi

ces

typ

ical

ly p

erfo

rmed

by

lab

ora

tori

es in

are

as s

uch

as

chem

istr

y, h

aem

ato

log

y, s

ero

log

y, h

isto

log

y,

cyto

log

y, a

nato

mic

pat

ho

log

y, m

icro

bio

log

y an

d v

iro

log

y. (

So

urce

HL7

v3)

. A

dditi

onal

dat

a el

emen

ts th

at m

ay b

e re

quire

d to

sup

port

the

use

and

extr

actio

n of

Lab

orat

ory

Ord

er d

ata

in P

HC

EM

Rs:

Pro

vide

r(e.

g. th

e P

rovi

der

who

aut

hore

d th

e or

der

for

the

lab

test

[s])

: Pro

vide

r Id

entif

ier

Cod

e, P

rovi

der

Iden

tifie

r A

ssig

ning

Aut

horit

y, P

rovi

der

Rol

e Ty

pe a

nd P

rovi

der

Exp

ertis

e ex

pres

sed

in th

e co

ntex

t of t

he L

abor

ator

y O

rder

.C

lient

(e.

g. th

e C

lient

who

was

the

subj

ect o

f the

Lab

orat

ory

Ord

er):

Clie

nt Id

entif

ier

Cod

e, C

lient

Iden

tifie

r Ty

pe a

nd C

lient

Iden

tifie

r A

ssig

ning

Aut

horit

y ex

pres

sed

in th

e co

ntex

t of

the

Labo

rato

ry O

rder

.E

ncou

nter

Iden

tifie

r: A

bus

ines

s id

entif

ier

that

uni

quel

y id

entif

ies

the

Enc

ount

er a

ssoc

iate

d w

ith th

e La

bora

tory

Ord

er.

Labo

rato

ry O

rder

Iden

tifie

r: A

bus

ines

s id

entif

ier

that

uni

quel

y id

entif

ies

the

Labo

rato

ry O

rder

.

G1

Lab

Test

O

rder

edLa

bora

tory

Te

st N

ame

Ord

ered

C

ode

Rep

rese

nts

the

lab

test

or

dere

d by

the

Pro

vide

r fo

r th

e C

lient

.

Use

d in

the

prov

isio

n of

car

e. L

ab te

sts

are

orde

red

in th

e pr

ovis

ion

of c

are

for

man

y re

ason

s, in

clud

ing

conf

irmat

ion

of

susp

ecte

d di

agno

ses.

Th

e la

b te

st n

ame

is

requ

ired

to k

now

wha

t te

st is

bei

ng o

rder

ed.

Cle

ar id

entif

icat

ion

of la

b te

st n

ame

and

valu

e.

48, 5

2, 5

3 an

d 55

–57

pCLO

CD

Con

cept

Dom

ain:

O

bser

vatio

nOrd

erab

le-

LabT

ype

(for

Ord

ered

Te

st)

Exa

mpl

e:24

358-

4 (H

emog

ram

pa

nel)

Foun

d in

:P

OLB

_MT0

0100

0CA

—La

bora

tory

Pla

cer

Ord

er—

2009

0316

.

Rec

ord

4, R

econ

cile

s te

st r

esul

ts w

ith o

rder

s us

ing

disc

rete

dat

a el

emen

ts s

o th

at

mis

sing

, non

-res

ulte

d or

ders

are

hig

hlig

hted

.

G2

Lab

Test

O

rder

ed

Dat

e

Labo

rato

ry

Test

Ord

er

Dat

e

Rep

rese

nts

the

date

the

lab

test

was

ord

ered

by

the

Pro

vide

r.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Sch

edul

e fu

ture

ap

poin

tmen

t bas

ed o

n th

e tr

ack

turn

arou

nd

time

of la

b te

st.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng

Sta

ndar

ds—

Dat

a Ty

pe

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

:S

C-2

003-

EN

—P

OLB

_MT0

0100

0CA

—La

bora

tory

Pla

cer

Ord

er—

2009

0316

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

.

72


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

Co

ntex

t: L

abo

rato

ry R

esul

tsD

efin

itio

n: T

he

resu

lts o

f an

alyt

ical

ser

vice

s ty

pic

ally

per

form

ed b

y la

bo

rato

ries

in a

reas

suc

h a

s ch

emis

try,

hae

mat

olo

gy,

ser

olo

gy,

his

tolo

gy,

cyt

olo

gy,

ana

tom

ic

pat

ho

log

y, m

icro

bio

log

y an

d v

iro

log

y. (

So

urce

HL7

v3)

.A

dditi

onal

dat

a el

emen

ts th

at m

ay b

e re

quire

d to

sup

port

the

use

and

extr

actio

n of

Lab

orat

ory

Res

ult d

ata

in P

HC

EM

Rs:

Pro

vide

r(e.

g. th

e P

rovi

der

who

aut

hore

d th

e or

der

for

the

lab

test

[s])

: Pro

vide

r Id

entif

ier

Cod

e, P

rovi

der

Iden

tifie

r A

ssig

ning

Aut

horit

y, P

rovi

der

Rol

e Ty

pe a

nd P

rovi

der

Exp

ertis

e ex

pres

sed

in th

e co

ntex

t of t

he L

abor

ator

y O

rder

that

re

late

s to

the

Lab

Res

ults

. Clie

nt (

e.g.

the

Clie

nt w

ho w

as th

e su

bjec

t of t

he L

abor

ator

y O

rder

): C

lient

Iden

tifie

r C

ode,

Clie

nt Id

entif

ier

Type

and

Clie

nt Id

entif

ier

Ass

igni

ng A

utho

rity

expr

esse

d in

the

cont

ext o

f the

Lab

orat

ory

Ord

er. L

abor

ator

y O

rder

Iden

tifie

r: A

bus

ines

s id

entif

ier

that

uni

quel

y id

entif

ies

the

Labo

rato

ry O

rder

that

the

Labo

rato

ry R

esul

ts fu

lfills

. La

bora

tory

Res

ult I

dent

ifier

: A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e La

bora

tory

Res

ults

.

H1

Lab

Test

P

erfo

rmed

D

ate

Labo

rato

ry

Test

P

erfo

rmed

D

ate

Rep

rese

nts

the

date

the

lab

test

was

per

form

ed.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Sch

edul

e fu

ture

ap

poin

tmen

t bas

ed o

n th

e tr

ack

turn

arou

nd

time

of la

bora

tory

test

.

39, 4

8, 5

2,

53 a

nd

55–5

7

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng

Sta

ndar

ds—

Dat

a Ty

pe

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

: P

OLB

_MT0

0400

0CA

—La

bora

tory

Res

ult

Eve

nt—

2009

0316

1.6

.3

Res

ult O

bser

vatio

n D

ate/

Tim

e.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

.

H2

Lab

Test

N

ame

Labo

rato

ry

Test

Res

ult

Nam

e C

ode

Rep

rese

nts

the

nam

e of

th

e la

b te

st p

erfo

rmed

.U

sed

in b

oth

the

prov

isio

n an

d ad

min

istr

atio

n of

car

e to

ens

ure

that

the

nam

e of

the

test

per

form

ed

is u

nder

stoo

d by

the

Pro

vide

r, re

sear

cher

s, e

tc.

39pC

LOC

D

Con

cept

Dom

ain:

O

bser

vatio

nRes

ulta

ble-

LabT

ype

Exa

mpl

e:71

8-7

(Hae

mog

lobi

n)

Foun

d in

:P

OLB

_MT0

0400

0CA

—La

bora

tory

Res

ult

Eve

nt—

2009

0316

.

Rec

ord

4, R

econ

cile

s te

st r

esul

ts w

ith o

rder

s us

ing

disc

rete

dat

a el

emen

ts s

o th

at

mis

sing

, non

-res

ulte

d or

ders

are

hig

hlig

hted

.

73


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

H3

Lab

Test

R

esul

t Va

lue

Labo

rato

ry

Test

Res

ult

Valu

e Te

xt

(Num

ber,

Cod

e)

Rep

rese

nts

the

resu

lt of

the

lab

test

.U

sed

in th

e pr

ovis

ion

of c

are.

Lab

test

s ar

e or

dere

d in

the

prov

isio

n of

car

e fo

r m

any

reas

ons,

incl

udin

g co

nfirm

atio

n of

su

spec

ted

diag

nose

s.

Blo

od-s

ugar

mon

itorin

g (A

ccu-

Che

k) v

alue

s ar

e tr

acke

d ov

er ti

me

and

com

pare

d w

ith y

early

H

b1A

c te

st r

esul

ts a

t a

Cen

tral

Lab

.

39S

NO

ME

D C

T®

(for

cod

ed r

esul

ts)

Con

cept

Dom

ain:

La

bora

tory

Res

ultC

ode-

Valu

e

Exa

mpl

e:16

4020

00 (

Sic

kle

cell

trai

t)

Foun

d in

:P

OLB

_MT0

0400

0CA

—La

bora

tory

Res

ult

Eve

nt—

2009

0316

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

.

H4

Lab

Test

R

esul

t Uni

t of

Mea

sure

Labo

rato

ry

Test

Res

ult

Valu

e U

nit

of M

easu

re

Cod

e

Rep

rese

nts

the

unit

of m

easu

re o

f the

lab

resu

lt fo

r th

e la

b te

st

perfo

rmed

.

Use

d in

the

prov

isio

n of

car

e. E

nsur

es th

at

the

unit

of m

easu

re

asso

ciat

ed w

ith th

e va

lue

is p

rovi

ded.

39D

ata

Type

Ref

eren

ce

(for

num

eric

res

ults

):H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng

Sta

ndar

ds—

Dat

a Ty

pe

Spe

cific

atio

nS

ectio

n 6.

11—

PQ

.LA

B

Labo

rato

ry Q

uant

ity

Exa

mpl

e:m

g/m

ol

Foun

d in

:P

OLB

_MT0

0400

0CA

—La

bora

tory

Res

ult

Eve

nt—

2009

0316

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

.

74


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

H5

Lab

Test

R

esul

t Low

R

ange

Labo

rato

ry

Test

Res

ult

Ref

eren

ce

Ran

ge L

ow

Num

ber

Rep

rese

nts

the

low

end

of a

nor

mal

re

fere

nce

rang

e la

b re

sult

for

a pa

rtic

ular

te

st p

erfo

rmed

in

a pa

rtic

ular

lab.

Use

d in

the

prov

isio

n of

car

e. L

ab te

sts

are

orde

red

in th

e pr

ovis

ion

of c

are

for

man

y re

ason

s, in

clud

ing

conf

irmat

ion

of

susp

ecte

d di

agno

ses.

Th

e re

fere

nce

rang

e is

re

quire

d to

det

erm

ine

whe

ther

the

lab

test

re

sult

is n

orm

al o

r no

t. Fl

ag a

nd a

lert

pro

vide

r. H

bA1C

is 6

.5 b

ut C

lient

ha

s a

fam

ily h

isto

ry o

f di

abet

es. P

reve

ntiv

e m

easu

res

are

initi

ated

.

39D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.11

—P

Q.L

AB

La

bora

tory

Qua

ntity

Exa

mpl

e:0.

5

Foun

d in

:S

C-2

003-

EN

—P

OLB

_M

T004

000C

A—

Labo

rato

ry R

esul

t E

vent

—20

0903

16.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

.

H6

Lab

Test

R

esul

t Uni

t of

Mea

sure

Labo

rato

ry

Test

Res

ult

Ref

eren

ce

Ran

ge

Low

Uni

t of

Mea

sure

C

ode

Rep

rese

nts

the

unit

of

mea

sure

ass

ocia

ted

with

the

Lab

Test

Res

ult

Ref

eren

ce R

ange

Low

N

umbe

r.

Use

d in

the

prov

isio

n of

car

e. E

nsur

es th

at

the

unit

of m

easu

re

is a

ssoc

iate

d w

ith th

e va

lue

as p

rovi

ded.

39D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.11

—P

Q.L

AB

La

bora

tory

Qua

ntity

Exa

mpl

e:m

g

Foun

d in

:P

OLB

_MT0

0400

0CA

—La

bora

tory

Res

ult

Eve

nt—

2009

0316

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

.

75


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

H7

Lab

Test

R

esul

t H

igh

Ran

ge

Labo

rato

ry

Test

Res

ult

Ref

eren

ce

Ran

ge H

igh

Num

ber

Rep

rese

nts

the

high

en

d of

a n

orm

al

refe

renc

e ra

nge

lab

resu

lt fo

r a

part

icul

ar

test

per

form

ed in

a

part

icul

ar la

b.

Use

d in

the

prov

isio

n of

car

e. L

ab te

sts

are

orde

red

in th

e pr

ovis

ion

of c

are

for

man

y re

ason

s, in

clud

ing

conf

irmat

ion

of

susp

ecte

d di

agno

ses.

Th

e re

fere

nce

rang

e is

re

quire

d to

det

erm

ine

whe

ther

the

lab

test

re

sult

is n

orm

al o

r no

t. Fl

ag a

nd a

lert

pro

vide

r. H

bA1C

is 6

.5 b

ut C

lient

ha

s a

fam

ily h

isto

ry o

f di

abet

es. P

reve

ntiv

e m

easu

res

are

initi

ated

.

39D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.11

—P

Q.L

AB

La

bora

tory

Qua

ntity

Exa

mpl

e:2.

5

Foun

d in

:S

C-2

003-

EN

—P

OLB

_M

T004

000C

A—

Labo

rato

ry R

esul

t E

vent

—20

0903

16.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

.

H8

Lab

Test

R

esul

t R

ange

Uni

t of

Mea

sure

Labo

rato

ry

Test

Res

ult

Ref

eren

ce

Ran

ge

Hig

h U

nit

of M

easu

re

Cod

e

Rep

rese

nts

the

unit

of m

easu

re a

ssoc

iate

d w

ith th

e La

b Te

st R

esul

t R

efer

ence

Ran

ge H

igh

Num

ber.

Use

d in

the

prov

isio

n of

car

e. E

nsur

es th

at

the

unit

of m

easu

re

is a

ssoc

iate

d w

ith th

e va

lue

as p

rovi

ded.

39D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.11

—P

Q.L

AB

La

bora

tory

Qua

ntity

Exa

mpl

e:m

g

Foun

d in

:P

OLB

_MT0

0400

0CA

—La

bora

tory

Res

ult

Eve

nt—

2009

0316

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

.

76


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

Co

ntex

t: D

iag

nost

ic Im

agin

g O

rder

sD

efin

itio

n: R

eque

sts

for

dia

gno

stic

imag

ing

ser

vice

s, w

hic

h t

ypic

ally

res

ult

in im

agin

g p

roce

dur

es p

erfo

rmed

to

th

e C

lient

. (S

our

ce H

L7 v

3).

Add

ition

al d

ata

elem

ents

that

may

be

requ

ired

to s

uppo

rt th

e us

e an

d ex

trac

tion

of D

iagn

ostic

Imag

ing

Ord

er d

ata

in P

HC

EM

Rs:

Pro

vide

r (e

.g. t

he P

rovi

der

who

aut

hore

d th

e or

der

for

the

diag

nost

ic im

agin

g te

st[s

]): P

rovi

der

Iden

tifie

r C

ode,

Pro

vide

r Id

entif

ier

Ass

igni

ng A

utho

rity,

Pro

vide

r R

ole

Type

and

P

rovi

der

Exp

ertis

e ex

pres

sed

in th

e co

ntex

t of t

he D

iagn

ostic

Imag

ing

Ord

er.

Clie

nt (

e.g.

the

Clie

nt w

ho w

as th

e su

bjec

t of t

he D

iagn

ostic

Imag

ing

Ord

er):

Clie

nt Id

entif

ier

Cod

e, C

lient

Iden

tifie

r Ty

pe a

nd C

lient

Iden

tifie

r A

ssig

ning

Aut

horit

y ex

pres

sed

in th

e co

ntex

t of t

he D

iagn

ostic

Imag

ing

Ord

er.

Enc

ount

er Id

entif

ier:

A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e E

ncou

nter

ass

ocia

ted

with

the

Dia

gnos

tic Im

agin

g O

rder

.D

iagn

ostic

Imag

ing

Ord

er Id

entif

ier:

A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e D

iagn

ostic

Imag

ing

Ord

er.

I1D

iagn

ostic

Im

agin

g Te

st

Ord

ered

Dia

gnos

tic

Imag

ing

Test

O

rder

ed

Cod

e

Rep

rese

nts

the

type

of

diag

nost

ic im

agin

g te

st

orde

red

by th

e P

rovi

der

for

the

Clie

nt.

Use

d in

the

prov

isio

n of

ca

re. D

iagn

ostic

imag

es

can

be u

sed

to a

ssis

t in

the

conf

irmat

ion

of

susp

ecte

d di

agno

sis.

49 a

nd 5

1S

NO

ME

D C

T®

Con

cept

Dom

ain:

Act

Pro

fess

iona

lSer

vice

-C

ode

Exa

mpl

e:36

3000

009

(car

diov

as-

cula

r di

agno

stic

ima-

ging

pro

cedu

re)

Not

e: W

hile

con

cept

do

mai

ns h

ave

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Rec

ord

108,

C

onso

lidat

es p

atie

nt

hist

ory,

rec

ent t

est

resu

lts a

nd in

form

atio

n di

spla

yed

in a

sin

gle,

su

mm

ary

view

.

I2D

iagn

ostic

Im

agin

g Te

st

Ord

ered

D

ate

Dia

gnos

tic

Imag

ing

Test

O

rder

ed D

ate

Rep

rese

nts

the

date

th

e di

agno

stic

imag

ing

test

was

ord

ered

by

the

Pro

vide

r.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Sch

edul

e fu

ture

ap

poin

tmen

t bas

ed o

n th

e tr

ack

turn

arou

nd

time

of d

iagn

ostic

im

agin

g te

st.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng S

tand

ards

—D

ata

Type

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

e: W

hile

a d

ata

type

ha

s be

en r

efer

ence

d,

this

exa

ct d

ata

elem

ent

does

not

cur

rent

ly e

xist

in

the

pan-

Can

adia

n E

HR

Mes

sagi

ng

Sta

ndar

ds.

Rec

ord

267,

Abi

lity

to

disp

lay,

sor

t and

sea

rch

hist

oric

al D

I dat

a us

ing

a us

er-d

efin

ed s

elec

tion

crite

ria.

77


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

Co

ntex

t D

iag

nost

ic Im

agin

g R

esul

tsD

efin

itio

n: T

he

resu

lts o

f d

iag

nost

ic im

agin

g s

ervi

ces,

wh

ich

are

typ

ical

ly t

he

resu

lts o

f im

agin

g p

roce

dur

es p

erfo

rmed

on

the

Clie

nt. (

So

urce

HL7

v3)

.A

dditi

onal

dat

a el

emen

ts th

at m

ay b

e re

quire

d to

sup

port

the

use

and

extr

actio

n of

Dia

gnos

tic Im

agin

g R

esul

ts d

ata

in P

HC

EM

Rs:

Pro

vide

r (e

.g. t

he P

rovi

der

who

aut

hore

d th

e or

der

for

the

diag

nost

ic im

agin

g te

st[s

]): P

rovi

der

Iden

tifie

r C

ode,

Pro

vide

r Id

entif

ier

Ass

igni

ng A

utho

rity,

Pro

vide

r R

ole

Type

and

Pro

vide

r E

xper

tise

expr

esse

d in

the

cont

ext

of th

e D

iagn

ostic

Imag

ing

Ord

er th

at r

elat

es to

the

Dia

gnos

tic Im

agin

g R

esul

ts. C

lient

(e.

g. th

e C

lient

who

was

the

subj

ect o

f the

Dia

gnos

tic Im

agin

g O

rder

): C

lient

Iden

tifie

r C

ode,

C

lient

Iden

tifie

r Ty

pe a

nd C

lient

Iden

tifie

r A

ssig

ning

Aut

horit

y ex

pres

sed

in th

e co

ntex

t of t

he D

iagn

ostic

Imag

ing

Ord

er th

at r

elat

es to

the

Dia

gnos

tic Im

agin

g R

esul

ts.

J1D

I Tes

t P

erfo

rmed

D

ate

Dia

gnos

tic

Imag

ing

Test

P

erfo

rmed

D

ate

Rep

rese

nts

the

date

the

diag

nost

ic im

agin

g te

st

was

per

form

ed.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Sch

edul

e fu

ture

ap

poin

tmen

t bas

ed o

n th

e tr

ack

turn

arou

nd

time

of d

iagn

ostic

im

agin

g te

st.

49D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

3—D

ates

+

Tim

ing

Exa

mpl

e:20

1004

30

Not

e: W

hile

a d

ata

type

ha

s be

en r

efer

ence

d,

this

exa

ct d

ata

elem

ent

does

not

cur

rent

ly e

xist

in

the

pan-

Can

adia

n E

HR

Mes

sagi

ng

Sta

ndar

ds.

Rec

ord

267,

Abi

lity

to

disp

lay,

sor

t and

sea

rch

hist

oric

al D

I dat

a us

ing

a us

er-d

efin

ed

sele

ctio

n cr

iteria

.

78


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceC

ont

ext:

Ref

erra

l Req

uest

Def

initi

on:

A r

eque

st f

rom

one

Pro

vid

er t

o a

noth

er t

o d

eliv

er o

ne o

r m

ore

hea

lth s

ervi

ces

for

a C

lient

. Th

e sc

op

e in

clud

es r

efer

rals

fo

r cl

inic

al c

are

or

eval

uatio

n,

as w

ell a

s re

ferr

als

for

com

mun

ity s

ervi

ces

such

as

mea

ls o

n w

hee

ls o

r h

om

e ca

re. (

So

urce

HL7

v3)

.A

dditi

onal

dat

a el

emen

ts th

at m

ay b

e re

quire

d to

sup

port

the

use

and

extr

actio

n of

Ref

erra

l Req

uest

dat

a in

PH

C E

MR

s:R

efer

ring

Pro

vide

r (e

.g. t

he a

utho

r of

the

refe

rral

): P

rovi

der

Iden

tifie

r C

ode,

Pro

vide

r Id

entif

ier

Ass

igni

ng A

utho

rity,

Pro

vide

r R

ole

Type

and

Pro

vide

r E

xper

tise

expr

esse

d in

the

cont

ext o

f the

Ref

erra

l Req

uest

.R

efer

red

to P

rovi

der

(e.g

. the

targ

et o

f the

ref

erra

l): P

rovi

der

Iden

tifie

r C

ode,

Pro

vide

r Id

entif

ier

Ass

igni

ng A

utho

rity,

Pro

vide

r R

ole

Type

and

Pro

vide

r E

xper

tise

expr

esse

d in

the

cont

ext o

f the

Ref

erra

l Req

uest

.C

lient

(e.

g. th

e su

bjec

t of t

he r

efer

ral):

Clie

nt Id

entif

ier

Cod

e, C

lient

Iden

tifie

r Ty

pe a

nd C

lient

Iden

tifie

r A

ssig

ning

Aut

horit

y ex

pres

sed

in th

e co

ntex

t of t

he R

efer

ral R

eque

st.

Enc

ount

er Id

entif

ier:

A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e E

ncou

nter

ass

ocia

ted

with

the

Ref

erra

l Req

uest

.R

efer

ral R

eque

st Id

entif

ier:

A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e R

efer

ral R

eque

st.

K1

Ref

erra

l R

efer

ral

Ser

vice

Cod

eR

epre

sent

s th

e ty

pe

of s

ervi

ce r

equi

red

for

the

Clie

nt.

Cod

es th

at id

entif

y di

ffere

nt ty

pes

of

refe

rral

req

uest

s.

Iden

tify

the

gene

ral

type

of c

are

or c

ateg

ory

of s

ervi

ces

requ

este

d.

Not

use

d to

rep

rese

nt

the

indi

catio

n or

di

agno

sis

that

trig

gere

d th

e ne

ed fo

r th

e re

ferr

al.

58S

NO

ME

D C

T®

Con

cept

Dom

ain:

A

ctC

areP

rovi

sion

Re-

ques

tTyp

e

Exa

mpl

e:31

0149

003

(Ear

, Nos

e an

d Th

roat

Ser

vice

)

Foun

d in

:R

EP

C_M

T210

001C

A—

Ref

erra

l Rec

ord—

Mar

ch 1

6, 2

009.

Rec

ord

105,

Allo

w

docu

men

tatio

n of

cr

iteria

for

acce

ptan

ce

of r

efer

rals

and

to

docu

men

t crit

eria

ag

ains

t eac

h re

ferr

al r

ecei

ved.

K2

Ref

erra

l R

eque

sted

D

ate

Ref

erra

l R

eque

sted

D

ate

Rep

rese

nts

the

date

the

Ref

erra

l Req

uest

was

cr

eate

d by

the

Prim

ary

Hea

lth C

are

Pro

vide

r.

Use

d in

pro

visi

on o

f ca

re a

nd a

dmin

istr

atio

n of

car

e. A

ssis

ts

Pro

vide

rs in

trac

king

w

hen

a re

ques

t to

obta

in a

con

sult

was

fir

st r

eque

sted

.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng

Sta

ndar

ds—

Dat

a Ty

pe

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

e: W

hile

a d

ata

type

ha

s be

en r

efer

ence

d,

this

exa

ct d

ata

elem

ent

does

not

cur

rent

ly e

xist

in

the

pan-

Can

adia

n E

HR

Mes

sagi

ng

Sta

ndar

ds.

Rec

ord

275,

Abi

lity

to

log

whe

n a

refe

rral

has

be

en s

ent a

nd w

hich

pr

ovid

er(s

) ha

ve b

een

sent

the

refe

rral

lette

r;

incl

udes

dat

e an

d tim

e st

amp.

79


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

Co

ntex

t: R

efer

ral R

esul

tD

efin

itio

n: A

des

crip

tion

of

the

hea

lth s

ervi

ces

per

form

ed f

or

the

Clie

nt in

res

po

nse

to t

he

Ref

erra

l Req

uest

; oft

en in

clud

es a

dd

itio

nal i

nfo

rmat

ion

such

as

the

sub

ject

ive

and

ob

ject

ive

note

s ab

out

th

e C

lient

and

th

e re

com

men

ded

tre

atm

ent

pla

n.A

dditi

onal

dat

a el

emen

ts th

at m

ay b

e re

quire

d to

sup

port

the

use

and

extr

actio

n of

Ref

erra

l Res

ult d

ata

in P

HC

EM

Rs:

Ref

errin

g P

rovi

der

(e.g

. the

aut

hor

of th

e re

ferr

al):

Pro

vide

r Id

entif

ier

Cod

e, P

rovi

der

Iden

tifie

r A

ssig

ning

Aut

horit

y, P

rovi

der

Rol

e Ty

pe a

nd P

rovi

der

Exp

ertis

e ex

pres

sed

in th

e co

ntex

t of t

he R

efer

ral R

eque

st th

at r

elat

es to

the

resu

lts.

Ref

erre

d to

Pro

vide

r (e

.g. t

he ta

rget

of t

he r

efer

ral):

Pro

vide

r Id

entif

ier

Cod

e, P

rovi

der

Iden

tifie

r A

ssig

ning

Aut

horit

y, P

rovi

der

Rol

e Ty

pe a

nd P

rovi

der

Exp

ertis

e ex

pres

sed

in th

e co

ntex

t of t

he R

efer

ral R

eque

st th

at r

elat

e to

the

resu

lts. C

lient

(e.

g. th

e su

bjec

t of t

he r

efer

ral):

Clie

nt Id

entif

ier

Cod

e, C

lient

Iden

tifie

r Ty

pe a

nd C

lient

Iden

tifie

r A

ssig

ning

Aut

horit

y ex

pres

sed

in th

e co

ntex

t of t

he R

efer

ral R

eque

st th

at r

elat

e to

the

resu

lts. R

efer

ral R

eque

st Id

entif

ier:

A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e R

efer

ral R

eque

st th

at is

as

soci

ated

with

the

Ref

erra

l Res

ult.

Ref

erra

l Res

ult I

dent

ifier

: A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e R

efer

ral R

esul

t.

L1R

efer

ral

Occ

urre

d D

ate

Ref

erra

l O

ccur

red

Dat

e

Rep

rese

nts

the

actu

al

date

the

Clie

nt h

ad

the

Enc

ount

er w

ith th

e re

ferr

ed to

Pro

vide

r.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

A

ssis

ts p

rovi

ders

in

unde

rsta

ndin

g w

hich

re

ferr

al p

artn

ers

have

lo

nger

wai

t tim

es.

Det

erm

ine

the

wai

t tim

e of

Clie

nts

and

deve

lop

accu

rate

futu

re

sche

dulin

g tim

es fo

r se

lect

ed r

easo

ns fo

r vi

sit a

nd r

efer

rals

.

58D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

Sta

ndar

ds—

Dat

a Ty

pe S

peci

ficat

ion

Sec

tion

3—D

ates

+

Tim

ing

Exa

mpl

e:20

1004

30

To b

e de

term

ined

. Th

e da

te o

f the

ref

erra

l E

ncou

nter

cou

ld s

how

in

sev

eral

mes

sage

s de

pend

ing

on w

hat

the

refe

rral

is fo

r. R

EP

C_M

T500

004C

A—

Car

e C

ompo

sitio

n D

etai

l May

8, 2

007.

Rec

ord

279,

Mai

ntai

n hi

stor

ical

pat

ient

-bas

ed

reco

rd o

f ref

erra

ls, s

ent

and/

or r

ecei

ved

and

disp

ositi

on/o

utco

me.

A

ble

to v

iew

/prin

t lis

t.

80


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ceC

ont

ext:

Pre

scri

bed

Med

icat

ion

Def

initi

on:

Th

e m

edic

atio

n o

rder

ed f

or

a C

lient

by

a P

rovi

der

. (S

our

ce H

L7 v

3).

Add

ition

al d

ata

elem

ents

that

may

be

requ

ired

to s

uppo

rt th

e us

e an

d ex

trac

tion

of P

resc

ribed

Med

icat

ion

data

in P

HC

EM

Rs:

Pro

vide

r (e

.g. t

he P

rovi

der

who

pre

scrib

ed th

e m

edic

atio

n): P

rovi

der

Iden

tifie

r C

ode,

Pro

vide

r Id

entif

ier

Ass

igni

ng A

utho

rity,

Pro

vide

r R

ole

Type

and

Pro

vide

r E

xper

tise

expr

esse

d in

the

cont

ext o

f pre

scrib

ing

med

icat

ion.

Clie

nt (

e.g.

the

Clie

nt th

at is

pre

scrib

ed th

e m

edic

atio

n): C

lient

Iden

tifie

r C

ode,

Clie

nt Id

entif

ier

Type

and

Clie

nt Id

entif

ier

Ass

igni

ng A

utho

rity

expr

esse

d in

the

cont

ext

of p

resc

ribin

g m

edic

atio

n.E

ncou

nter

Iden

tifie

r: A

bus

ines

s id

entif

ier

that

uni

quel

y id

entif

ies

the

Enc

ount

er a

ssoc

iate

d w

ith th

e pr

escr

iptio

n.M

edic

atio

n P

resc

riptio

n Id

entif

ier:

A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e m

edic

atio

n pr

escr

iptio

n.

M1

Pre

scrib

ed

Med

icat

ion

Med

icat

ion

Pre

scrib

ed

Nam

e C

ode

Rep

rese

nts

the

med

icat

ions

pre

scrib

ed

(or

inte

nded

to b

e pr

escr

ibed

) to

the

Clie

nt.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to c

reat

e a

long

itudi

nal

med

icat

ion

reco

rd to

su

ppor

t the

pro

visi

on

of c

are.

59, 6

0, 6

2 an

d 63

MTW

—In

fow

ay

Sta

ndar

ds C

olla

bora

tive

(SN

OM

ED

CT®

HC

-AIG

C, H

C-A

IGN

, H

C-D

IN, H

C-N

PN

, G

TIN

)

Con

cept

Dom

ain:

C

linic

alD

rug

Exa

mpl

e:03

741

(Am

oxic

illin

)

Foun

d in

:P

OR

X_M

T010

120C

A—

Rx

Dru

g O

rder

—20

0903

16.

Rec

ord

169,

Mai

ntai

n ea

ch m

edic

atio

n fo

r a

give

n pa

tient

as

disc

rete

dat

a el

emen

ts.

M2

Pre

scrip

-tio

n D

ate

Med

icat

ion

Pre

scrib

ed

Dat

e

Rep

rese

nts

the

date

th

e pr

escr

iptio

n fo

r th

e m

edic

atio

n w

as c

reat

ed

for

the

Clie

nt.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to c

reat

e a

long

itudi

nal

med

icat

ion

reco

rd to

su

ppor

t the

pro

visi

on

of c

are.

59, 6

0, 6

2 an

d 63

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng

Sta

ndar

ds—

Dat

a Ty

pe

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Rep

rese

nts

the

first

da

te in

the

inte

rval

de

fined

by

the

“Dis

pens

ing

Allo

wed

P

erio

d” fo

und

in:

PO

RX

_MT0

1012

0CA

—R

x D

rug

Ord

er—

2009

0316

.

Rec

ord

169,

Mai

ntai

n ea

ch m

edic

atio

n fo

r a

give

n pa

tient

as

disc

rete

dat

a el

emen

ts.

81


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

M3

Pre

scrip

-tio

n E

xpec

ted

Com

ple-

tion

Dat

e

Med

icat

ion

Pre

scrib

ed

Exp

ecte

d C

ompl

etio

n D

ate

Rep

rese

nts

the

last

da

te th

e P

resc

ribed

M

edic

atio

n is

exp

ecte

d to

fini

sh.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to c

reat

e a

long

itudi

nal

med

icat

ion

reco

rd to

su

ppor

t the

pro

visi

on

of c

are.

62D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

3—D

ates

+

Tim

ing

Exa

mpl

e:20

1004

30

Rep

rese

nts

the

last

da

te in

the

inte

rval

de

fined

by

the

“Dis

pens

ing

Allo

wed

P

erio

d” fo

und

in:

PO

RX

_MT0

1012

0CA

—R

x D

rug

Ord

er—

2009

0316

.

Rec

ord

169,

Mai

ntai

n ea

ch m

edic

atio

n fo

r a

give

n pa

tient

as

disc

rete

dat

a el

emen

ts.

M4

Pre

scrip

-tio

n S

top

Dat

e

Med

icat

ion

Pre

scrib

ed

Sto

pped

Dat

e

Rep

rese

nts

the

last

da

te th

e C

lient

took

the

Pre

scrib

ed M

edic

atio

n.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

P

rovi

des

hist

oric

al a

nd

curr

ent m

edic

atio

n pr

ofile

for

the

clie

nt.

59, 6

0, 6

2 an

d 63

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng

Sta

ndar

ds—

Dat

a Ty

pe

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Not

e: W

hile

a d

ata

type

re

fere

nce

has

been

pr

ovid

ed, t

his

exac

t da

ta e

lem

ent d

oes

not

curr

ently

exi

st in

the

pan-

Can

adia

n E

HR

M

essa

ging

Sta

ndar

ds.

Rec

ord

169,

Mai

ntai

n ea

ch m

edic

atio

n fo

r a

give

n pa

tient

as

disc

rete

dat

a el

emen

ts.

M5

Med

icat

ion

Str

engt

hM

edic

atio

n P

resc

ribed

S

tren

gth

Num

ber

Rep

rese

nts

the

pote

ncy

of th

e dr

ug/c

hem

ical

, us

ually

mea

sure

d in

m

etric

wei

ght (

e.g.

m

icro

gram

s, m

illig

ram

s,

gram

s) a

nd d

escr

ibed

as

the

stre

ngth

of

the

prod

uct’s

act

ive

(med

icin

al)

ingr

edie

nt.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Con

veys

the

pote

ncy

of th

e dr

ug to

be

dis

pens

ed fo

r th

e C

lient

’s tr

eatm

ent.

59D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.7—

PQ

.DR

UG

Exa

mpl

e:10

0

Rep

rese

nts

the

num

eric

co

mpo

nent

of t

he

“Dru

g In

gred

ient

Q

uant

ity”

foun

d in

:C

OC

T_M

T220

200C

A—

Med

icat

ion

adm

inis

trab

le—

2009

0316

.

Rec

ord

180,

Pro

vide

s su

ppor

t to

pres

crip

tion

writ

ing

incl

udin

g:

reco

mm

ende

d do

sage

, rou

te, r

efill

s,

repe

ats,

etc

.

82


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

M6

Med

icat

ion

Str

engt

h U

nit o

f M

easu

re

Med

icat

ion

Pre

scrib

ed

Str

engt

h U

nit

of M

easu

re

Cod

e

Rep

rese

nts

the

units

of

mea

sure

for

Pre

scrib

ed

Med

icat

ion

Str

engt

h.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

C

onve

ys th

e un

it of

mea

sure

for

the

Str

engt

h (p

oten

cy)

of th

e dr

ug to

be

disp

ense

d fo

r th

e C

lient

’s tr

eatm

ent.

59D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.7—

PQ

.DR

UG

Exa

mpl

e:m

g

Rep

rese

nts

the

unit

of

mea

sure

com

pone

nt

of th

e “D

rug

Ingr

edie

nt

Qua

ntity

” fo

und

in:

CO

CT_

MT2

2020

0CA

—M

edic

atio

n ad

min

istr

able

—20

0903

16.

Rec

ord

180,

Pro

vide

s su

ppor

t to

pres

crip

tion

writ

ing

incl

udin

g:

reco

mm

ende

d do

sage

, rou

te, r

efill

s,

repe

ats,

etc

.

M7

Med

icat

ion

Dos

age

Med

icat

ion

Pre

scrib

ed

Dos

e N

umbe

r

Rep

rese

nts

the

mea

sure

d po

rtio

n of

a

drug

to b

e ta

ken

at a

ny

one

time

that

per

tain

s to

the

drug

pre

scrib

ed.

Use

d in

the

prov

isio

n of

car

e. U

sed

with

C

lient

wei

ght a

nd a

ge

to d

eter

min

e id

eal d

ose

for

the

Clie

nt.

59D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.7—

PQ

.DR

UG

Exa

mpl

e:10

0

Foun

d in

:P

OR

X_M

T010

120C

A—

Rx

Dru

g O

rder

—20

0903

16.

Rec

ord

180,

Pro

vide

s su

ppor

t to

pres

crip

tion

writ

ing

incl

udin

g:

reco

mm

ende

d do

sage

, rou

te, r

efill

s,

repe

ats,

etc

.

M8

Med

icat

ion

Dos

e U

nit

of M

easu

re

Med

icat

ion

Pre

scrib

ed

Dos

e U

nit

of M

easu

re

Cod

e

Rep

rese

nts

the

unit

of

mea

sure

of a

dru

g do

se

take

n at

any

one

tim

e.

Use

d in

the

prov

isio

n of

car

e. U

sed

with

C

lient

wei

ght a

nd a

ge

to d

eter

min

e id

eal d

ose

for

the

Clie

nt.

59D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.7—

PQ

.DR

UG

Exa

mpl

e:m

g

Foun

d in

:P

OR

X_M

T010

120C

A—

Rx

Dru

g O

rder

—20

0903

16.

Rec

ord

180,

Pro

vide

s su

ppor

t to

pres

crip

tion

writ

ing

incl

udin

g:

reco

mm

ende

d do

sage

, rou

te, r

efill

s,

repe

ats,

etc

.

83


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

M9

Med

icat

ion

Form

Med

icat

ion

Pre

scrib

ed

Form

Cod

e

The

phys

ical

co

nfig

urat

ion,

pr

esen

tatio

n of

sta

te

of m

atte

r of

any

gi

ven

drug

pro

duct

. Th

e do

sage

form

in

whi

ch th

e m

edic

atio

n is

adm

inis

tere

d (e

.g. t

able

t, liq

uid,

su

ppos

itory

, sol

utio

n).

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of c

are.

E

nsur

es th

at th

e rig

ht

form

of t

he P

resc

ribed

M

edic

atio

n is

pro

vide

d to

the

Clie

nt a

s re

quire

d fo

r tr

eatm

ent.

59H

L7 v

3

Con

cept

Dom

ain:

O

rder

able

Dru

gFor

m

Exa

mpl

e:N

DR

OP

(N

asal

Dro

ps)

Foun

d in

:P

OR

X_M

T010

120C

A—

Rx

Dru

g O

rder

—20

0903

16.

Rec

ord

180,

Pro

vide

s su

ppor

t to

pres

crip

tion

writ

ing

incl

udin

g:

reco

mm

ende

d do

sage

, rou

te, r

efill

s,

repe

ats,

etc

.

M10

Med

icat

ion

Freq

uenc

yM

edic

atio

n P

resc

ribed

Fr

eque

ncy

Text

Rep

rese

nts

the

num

ber

of o

ccur

renc

es w

ithin

a

give

n tim

e pe

riod

that

a

dose

of a

dru

g is

to b

e ad

min

iste

red.

Use

d in

the

prov

isio

n of

car

e to

ens

ure

that

th

e C

lient

take

s th

e m

edic

atio

n as

req

uire

d du

ring

a sp

ecifi

ed

perio

d of

tim

e, h

elpi

ng

to e

nsur

e th

e ef

ficie

ncy

of th

e tr

eatm

ent a

nd to

pr

even

t any

uni

nten

ded

med

icat

ion

over

dose

.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng

Sta

ndar

ds—

Dat

a Ty

pe

Spe

cific

atio

nS

ectio

n 6.

14—

Dru

g Q

uant

ity p

er T

ime

Dur

atio

n

Exa

mpl

e:2

tabl

ets/

24 h

ours

Foun

d in

:P

OR

X_M

T010

120C

A—

Rx

Dru

g O

rder

—20

0903

16.

Rec

ord

180,

Pro

vide

s su

ppor

t to

pres

crip

tion

writ

ing

incl

udin

g:

reco

mm

ende

d do

sage

, rou

te, r

efill

s,

repe

ats,

etc

.

M11

Med

icat

ion

Rou

teM

edic

atio

n P

resc

ribed

R

oute

Cod

e

Rep

rese

nts

the

part

of

the

body

on

whi

ch,

thro

ugh

whi

ch o

r in

to

whi

ch a

dru

g pr

oduc

t is

to b

e in

trod

uced

. A

drug

pro

duct

can

hav

e m

ore

than

one

rou

te o

f ad

min

istr

atio

n.

Use

d in

the

prov

isio

n of

car

e. P

rovi

de

inst

ruct

ions

to th

e C

lient

reg

ardi

ng h

ow

the

med

icat

ion

is to

be

take

n (a

s a

supp

osito

ry

vers

us o

rally

).

59H

L7 v

3

Con

cept

Dom

ain:

R

oute

ofA

dmin

istr

atio

n

NA

SIN

HL

(nas

al

inha

lant

)

Foun

d in

:P

OR

X_M

T010

120C

A—

Rx

Dru

g O

rder

—20

0903

16.

Rec

ord

180,

Pro

vide

s su

ppor

t to

pres

crip

tion

writ

ing

incl

udin

g:

reco

mm

ende

d do

sage

, rou

te, r

efill

s,

repe

ats,

etc

.

84


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

M12

Med

icat

ion

Num

ber

of R

epea

t/R

efill

(s)

Med

icat

ion

Pre

scrib

ed

Rep

eat

Num

ber

Rep

rese

nts

the

num

ber

of ti

mes

th

e pr

escr

iptio

n ca

n be

use

d to

ref

ill th

e P

resc

ribed

Med

icat

ion.

Use

d in

the

prov

isio

n of

car

e. P

rovi

de

inst

ruct

ions

on

how

of

ten

a pa

rtic

ular

pr

escr

iptio

n ca

n be

ref

illed

and

the

pote

ntia

l nee

d fo

r a

follo

w-u

p re

min

der

to th

e P

rovi

der

for

this

Clie

nt.

59D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

6.2—

Non

-ne

gativ

e In

tege

r

Exa

mpl

e:2

Foun

d in

:P

OR

X_M

T010

120C

A—

Rx

Dru

g O

rder

—20

0903

16.

Rec

ord

180,

Pro

vide

s su

ppor

t to

pres

crip

tion

writ

ing

incl

udin

g:

reco

mm

ende

d do

sage

, rou

te, r

efill

s,

repe

ats,

etc

.

M13

Med

icat

ion

Not

P

resc

ribed

R

easo

n

Med

icat

ion

Pre

scrib

ed

Not

Giv

en

Rea

son

Cod

e

Rep

rese

nts

the

reas

on

why

a p

refe

rred

m

edic

atio

n w

as n

ot

pres

crib

ed to

a C

lient

.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Exp

lain

s w

hy

a P

rovi

der

was

not

ab

le to

pre

scrib

e a

med

icat

ion

at th

e tim

e of

an

enco

unte

r. C

an

serv

e as

a r

emin

der

for

futu

re p

rovi

sion

of

car

e as

to w

hy a

pa

rtic

ular

med

icat

ion

may

not

be

suita

ble

for

an in

divi

dual

.

62H

L7 v

3

Con

cept

Dom

ain:

Sub

stan

ceA

dmin

istr

a-tio

nPer

mis

sion

Ref

usal

-R

easo

nCod

e

Exa

mpl

e:PA

TIN

ELI

G (

patie

nt n

ot

elig

ible

)

HL7

v3

Con

cept

Dom

ain:

Act

Det

ecte

dIss

ue

Exa

mpl

e:A

GE

(A

ge A

lert

)

Not

e: W

hile

con

cept

do

mai

ns h

ave

been

re

fere

nced

, thi

s ex

act

data

ele

men

t doe

s no

t cu

rren

tly e

xist

in th

e pa

n-C

anad

ian

EH

R

Mes

sagi

ng S

tand

ards

.

Not

cur

rent

ly r

equi

red

to s

uppo

rt a

ny o

f the

P

OS

R r

ecor

ds.

85


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

M14

Med

icat

ion

Com

pli-

ance

Med

icat

ion

Pre

scrib

ed

Adh

eren

ce

Cod

e

Rep

rese

nts

whe

ther

or

not

the

Clie

nt h

as

been

adm

inis

terin

g th

e pr

escr

ibed

m

edic

atio

n(s)

as

inst

ruct

ed.

Use

d in

bot

h th

e pr

ovis

ion

and

adm

inis

trat

ion

of

care

. Doc

umen

ts

that

a C

lient

did

not

ta

ke th

e pr

escr

ibed

dr

ug a

nd c

an b

e us

ed

to in

form

sub

sequ

ent

prov

isio

n of

car

e.

Exa

mpl

e: U

pon

taki

ng

Pre

vaci

d, a

Clie

nt

deve

lope

d di

arrh

ea

and

disc

ontin

ued

use

of th

e dr

ug.

60 a

nd 6

3D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

8.4—

BL—

Boo

lean

Exa

mpl

e:T

(Tru

e)

Not

e: W

hile

a d

ata

type

ha

s be

en r

efer

ence

d,

this

exa

ct d

ata

elem

ent

does

not

cur

rent

ly e

xist

in

the

pan-

Can

adia

n E

HR

Mes

sagi

ng

Sta

ndar

ds.

Rec

ord

170,

Mai

ntai

ns

patie

nt m

edic

atio

nlis

t, in

clud

ing

pres

crib

ing

and

disp

ensi

ng e

vent

s.

Co

ntex

t: D

isp

ense

d M

edic

atio

nD

efin

itio

n: T

he

med

icat

ion

dis

pen

sed

to

a C

lient

by

a P

rovi

der

. (S

our

ce H

L7 v

3).

Add

ition

al d

ata

elem

ents

that

may

be

requ

ired

to s

uppo

rt th

e us

e an

d ex

trac

tion

of D

ispe

nsed

Med

icat

ion

data

in P

HC

EM

Rs:

Pro

vide

r (e

.g. t

he P

rovi

der

who

pre

scrib

ed th

e m

edic

atio

n): P

rovi

der

Iden

tifie

r C

ode,

Pro

vide

r Id

entif

ier

Ass

igni

ng A

utho

rity,

Pro

vide

r R

ole

Type

and

Pro

vide

r E

xper

tise

expr

esse

d in

the

cont

ext o

f the

Pre

scrib

ed M

edic

atio

n th

at

rela

tes

to th

e D

ispe

nsed

Med

icat

ion.

Clie

nt (

e.g.

the

Clie

nt th

at is

pre

scrib

ed th

e m

edic

atio

n): C

lient

Iden

tifie

r C

ode,

Clie

nt Id

entif

ier

Type

and

Clie

nt Id

entif

ier

Ass

igni

ng A

utho

rity

expr

esse

d in

the

cont

ext o

f the

Pre

scrib

ed M

edic

atio

n th

at r

elat

es to

the

Dis

pens

ed M

edic

atio

n. M

edic

atio

n P

resc

riptio

n Id

entif

ier:

A b

usin

ess

iden

tifie

r th

at u

niqu

ely

iden

tifie

s th

e m

edic

atio

n pr

escr

iptio

n. M

edic

atio

n D

ispe

nsed

Iden

tifie

r: A

bus

ines

s id

entif

ier

that

uni

quel

y id

entif

ies

the

med

icat

ion

disp

ense

d.

N1

Med

icat

ion

Dis

pens

edM

edic

atio

n D

ispe

nsed

C

ode

Rep

rese

nts

the

med

icat

ion

that

was

di

spen

sed

to th

e C

lient

.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to c

reat

e a

long

itudi

nal

med

icat

ion

reco

rd to

su

ppor

t the

pro

visi

on

of c

are.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

HC

-DIN

[H

C-N

PN

]

Con

cept

Dom

ain:

M

anuf

actu

redD

rug

Exa

mpl

e:02

2377

22 (

gen-

aceb

utol

ol 2

00 m

g)

Foun

d in

:P

OR

X_M

T020

070C

A—

Dru

g D

ispe

nse—

2009

0316

.

Rec

ord

170,

Mai

ntai

ns

patie

nt m

edic

atio

n lis

t, in

clud

ing

pres

crib

ing

and

disp

ensi

ng e

vent

s.

86


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

N2

Med

icat

ion

Dis

pens

ed

Dat

e

Med

icat

ion

Dis

pens

ed

Dat

e

Rep

rese

nts

the

date

th

e m

edic

atio

n w

as

disp

ense

d to

the

Clie

nt.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to c

reat

e a

long

itudi

nal

med

icat

ion

reco

rd to

su

ppor

t the

pro

visi

on

of c

are.

59, 6

0 an

d 63

Dat

a Ty

pe R

efer

ence

:H

L7 v

3 pa

n-C

anad

ian

Mes

sagi

ng

Sta

ndar

ds—

Dat

a Ty

pe

Spe

cific

atio

nS

ectio

n 3—

Dat

es +

Ti

min

g

Exa

mpl

e:20

1004

30

Foun

d in

:P

OR

X_M

T020

070C

A—

Dru

g D

ispe

nse—

2009

0316

.

Rec

ord

170,

Mai

ntai

ns

patie

nt m

edic

atio

n lis

t, in

clud

ing

pres

crib

ing

and

disp

ensi

ng e

vent

s.

Co

ntex

t: Im

mun

izat

ion

Def

initi

on:

Th

e ad

min

istr

atio

n o

f va

ccin

es (

and

/or

antis

era)

to

Clie

nts

to p

reve

nt in

fect

ious

dis

ease

. (S

our

ce H

L7 v

3).

Add

ition

al d

ata

elem

ents

that

may

be

requ

ired

to s

uppo

rt th

e us

e an

d ex

trac

tion

of Im

mun

izat

ion

data

in P

HC

EM

Rs:

Pro

vide

r (e

.g. t

he P

rovi

der

who

per

form

s th

e Im

mun

izat

ion)

: Pro

vide

r Id

entif

ier

Cod

e, P

rovi

der

Iden

tifie

r A

ssig

ning

Aut

horit

y, P

rovi

der

Rol

e Ty

pe a

nd P

rovi

der

Exp

ertis

e ex

pres

sed

in th

e co

ntex

t of t

he Im

mun

izat

ion.

Clie

nt (

e.g.

the

Clie

nt th

at r

ecei

ves

the

Imm

uniz

atio

n): C

lient

Iden

tifie

r C

ode,

Clie

nt Id

entif

ier

Type

and

Clie

nt Id

entif

ier

Ass

igni

ng A

utho

rity

expr

esse

d in

the

cont

ext o

f the

Imm

uniz

atio

n.E

ncou

nter

Iden

tifie

r: A

bus

ines

s id

entif

ier

that

uni

quel

y id

entif

ies

the

Enc

ount

er a

ssoc

iate

d w

ith th

e Im

mun

izat

ion.

O1

Vacc

ine

Adm

inis

-te

red

Vacc

ine

Adm

inis

tere

d N

ame

Cod

e

Rep

rese

nts

the

nam

e of

the

vacc

ine

that

w

as a

dmin

iste

red

to th

e C

lient

.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to c

reat

e re

min

ders

to

offe

r a

vacc

ine,

or

to fl

ag th

at a

vac

cine

ha

s al

read

y be

en g

iven

an

d do

es n

ot n

eed

to

be r

e-ad

min

iste

red

until

a

spec

ific

futu

re d

ate.

41, 4

2, 4

4S

NO

ME

D C

T®

Con

cept

Dom

ain:

Va

ccin

eEnt

ityTy

pe

3964

2500

6 (In

fluen

za

viru

s va

ccin

e [s

ubst

ance

])

Foun

d in

:P

OIZ

_MT0

3005

0CA

—Im

mun

izat

ion—

Febr

uary

7, 2

008.

Rec

ord

224,

Pro

vide

a

quer

y te

mpl

ate

that

ca

n ge

nera

te a

list

of

patie

nts

who

rec

eive

d a

vacc

ine.

87


Tab

le 2

: Dat

a E

lem

ent M

atrix

(con

t’d)

Info

rmat

ive

Co

nten

t: X

Ref

No

rmat

ive

Co

nten

t:

Ava

ilab

le in

EM

R f

or

Pri

mar

y U

se a

nd E

xtra

cted

fo

r H

ealth

Sys

tem

Use

Info

rmat

ive

Co

nten

t:A

lignm

ent

to t

he

Pan

-Can

adia

n E

HR

UI

Dat

a E

lem

ent

Com

mon

N

ame

Dat

a E

lem

ent

Sta

ndar

d N

ame

Dat

a E

lem

ent

Def

initi

onE

xam

ple

of P

rimar

y U

se

PH

C

Indi

cato

r M

appi

ng

Term

inol

ogy

or D

ata

Type

Nam

e an

d E

xam

ple

Valu

esE

HR

MS

G a

nd T

erm

S

tand

ards

PO

SR

Ref

eren

ce

O2

Vacc

ine

Adm

inis

-te

red

Dat

e

Vacc

ine

Adm

inis

tere

d D

ate

Rep

rese

nts

the

date

the

vacc

ine

was

adm

inis

tere

d to

the

Clie

nt.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed to

en

sure

that

onl

y C

lient

s w

ho h

ave

not r

ecei

ved

an o

ffer

to v

acci

nate

re

ceiv

e re

min

ders

, or

to fl

ag th

at a

vac

cine

ha

s al

read

y be

en g

iven

an

d do

es n

ot n

eed

to

be r

e-ad

min

iste

red

until

a

spec

ific

futu

re d

ate.

41, 4

2, 4

4D

ata

Type

Ref

eren

ce:

HL7

v3

pan-

Can

adia

n M

essa

ging

S

tand

ards

—D

ata

Type

S

peci

ficat

ion

Sec

tion

3—D

ates

+

Tim

ing

Exa

mpl

e:20

1004

30

Foun

d in

:P

OIZ

_MT0

3005

0CA

—Im

mun

izat

ion—

Febr

uary

7, 2

008.

Rec

ord

26, A

bilit

y to

do

cum

ent m

edic

atio

ns

pres

crib

ed,

imm

uniz

atio

ns g

iven

an

d pr

oced

ures

pe

rform

ed o

utsi

de th

e ph

ysic

ian’

s cl

inic

to

capt

ure

a co

mpl

ete

patie

nt r

ecor

d.

O3

Vacc

ine

Adm

inis

-te

red

Lot

Num

ber

Vacc

ine

Adm

inis

tere

d Lo

t Num

ber

Rep

rese

nts

the

batc

h id

entif

icat

ion

num

ber

of th

e va

ccin

e.

Use

d in

the

prov

isio

n of

car

e. C

an b

e us

ed

to c

onta

ct C

lient

s w

ho

rece

ived

a p

artic

ular

lo

t num

ber

of a

va

ccin

e su

bsta

nce.

Sup

ple-

men

tary

—us

ed fo

r an

alys

is

and

repo

rtin

g

HL7

v3

N/A

Foun

d in

:P

OIZ

_MT0

3005

0CA

—Im

mun

izat

ion.

Rec

ord

224,

Pro

vide

a

quer

y te

mpl

ate

that

ca

n ge

nera

te a

list

of

patie

nts

who

rec

eive

d a

vacc

ine.

O4

Rea

son

Vacc

ine

Not

Giv

en

Vacc

ine

Not

G

iven

Rea

son

Cod

e

Rep

rese

nts

the

reas

on a

vac

cine

w

as n

ot a

dmin

iste

red

to a

Clie

nt.

Use

d in

the

prov

isio

n of

car

e. E

xpla

ins

why

a

Clie

nt m

ay h

ave

been

of

fere

d a

vacc

inat

ion

but r

efus

ed o

r w

hy

the

vacc

ine

was

not

gi

ven

for

othe

r re

ason

s.

Can

be

requ

ired

for

phys

icia

ns w

ho

part

icip

ate

in p

ay-fo

r-pe

rform

ance

pro

gram

s.

41, 4

2, 4

4H

L7 v

3

Con

cept

Dom

ain:

Act

-N

oIm

mun

izat

ionR

easo

n

Exa

mpl

e:PA

TOB

J (P

atie

nt O

bjec

tion)

Foun

d in

:P

OIZ

_MT0

3005

0CA

—Im

mun

izat

ion—

Febr

uary

7, 2

008.

Not

cur

rent

ly r

equi

red

to s

uppo

rt a

ny o

f the

P

OS

R r

ecor

ds.

89


Appendix C: Pan-Canadian Primary Health Care IndicatorsSource Document: Pan-Canadian Primary Health Care Indicators, volume 2, www.cihi.ca/phc

Indicator Number Indicator Definition

13

% of PHC clients/patients, 12 years and over, who were screened by their PHC provider for the following common health risks over the past 12 months:• Tobacco use;• Unhealthy eating habits;• Problem drug use;• Physical inactivity;• Overweight status;• Problem alcohol drinking;• Unintentional injuries (home risk factors);• Unsafe sexual practices; and• Unmanaged psychosocial stress and/or depression.

36% of PHC clients/patients, ages 18 to 64, with established diabetes mellitus (type 1 and type 2) who have had an acute myocardial infarction or above or below knee amputation or began chronic dialysis within the past 12 months.

39% of PHC clients/patients,18 years and over, with diabetes mellitus in whom the last HbA1C was 7.0% or less (or equivalent test/reference range depending on local laboratory) in the last 15 months.

40 % of PHC clients/patients,18 years and over, with hypertension for duration of at least one year, who have blood pressure measurement control (i.e. less than 140/90 mmHg).

41 % of PHC clients/patients, 65 years and over, who received an influenza immunization within the past 12 months.

42 % of PHC clients/patients, 65 years and over, who have received a pneumococcal immunization.

43 % of PHC clients/patients who received screenings for congenital hip displacement, eye and hearing problems by 3 years of age.

44 % of PHC clients/patients who received required primary childhood immunizations by 7 years of age.

48 % of PHC clients/patients, 50 years and over, who received screening for colon cancer with Hemoccult test within the past 24 months.

49 % of women PHC clients/patients, ages 50 to 69, who received mammography and clinical breast examination within the past 24 months.

50 % of women PHC clients/patients, ages 18 to 69, who received a papanicolaou smear within the past 3 years.

51 % of women PHC clients/patients, 65 years and older, who received screening for low bone mineral density at least once.

52 % of women PHC clients/patients, 55 years and over, who had a full fasting lipid profile measured within the past 24 months.

53 % of men PHC clients/patients, 40 years and over, who had a full fasting lipid profile measured within the past 24 months.

54 % of PHC clients/patients, 18 years and over, who had their blood pressure measured within the past 24 months.


90


Indicator Number Indicator Definition

55

% of PHC clients/patients,18 years and over, with coronary artery disease (CAD) who received annual testing, within the past 12 months, for all of the following:• Fasting blood sugar;• Full fasting lipid profile screening;• Blood pressure measurement; and• Obesity/overweight screening.

56

% of PHC clients/patients,18 years and over, with hypertension who received annual testing, within the past 12 months, for all of the following:• Fasting blood sugar;• Full fasting lipid profile screening;• Test to detect renal dysfunction (e.g. serum creatinine);• Blood pressure measurement; and• Obesity/overweight screening.

57

% of PHC clients/patients,18 years and over, with diabetes mellitus who received annual testing, within the past 12 months, for all of the following:• Hemoglobin A1c testing (HbA1c);• Full fasting lipid profile screening;• Nephropathy screening (e.g. albumin/creatinine ratio, microalbuminuria);• Blood pressure (BP) measurement; and• Obesity/overweight screening.

58 % of PHC clients/patients, 18 to 75 years, with diabetes mellitus who saw an optometrist or ophthalmologist within the past 24 months.

59

% of PHC clients/patients, ages 6 to 55, with asthma, who were dispensed high amounts (greater than 4 canisters) of short-acting beta2-agonist (SABA) within the past 12 months and who received a prescription for preventer/controller medication (e.g. inhaled corticosteroid—ICS).

60 % of PHC clients/patients, 18 years and over, with CHF who are using ACE inhibitors or ARBs.

62 % of PHC clients/patients who have had an AMI and are currently prescribed a beta blocking drug.

63% of PHC clients/patients with depression who are taking antidepressant drug treatment under the supervision of a PHC provider68 who had follow-up contact by a PHC provider for review within two weeks of initiating antidepressant drug treatment.

91


Appendix D: Glossary of Terms v

TermAcronym(if applicable) Description

Canadian Institute for Health Information

CIHIThe Canadian Institute for Health Information is an independent, not-for-profit organization that provides essential data and analysis on Canada’s health system and the health of Canadians.

Clinical Data Warehouse CDW

An overarching term for Health Information Data Warehouse. This is an enterprise-level system to facilitate query and analysis of health care data.

Clinical Program Management

Use of data for direct management of health services and programs, including quality improvement and decision support (program level).

Electronic Health Record EHR

An electronic health record (commonly known as an EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health care providers.8

Electronic Medical Record EMR

The electronic medical record is provider-centric, focuses on medical or physician-specific information and is configured to reflect the needs of individual physicians or groups of physicians who are directly caring for a patient. The EMR is a record of each and every patient encounter and will detail encounter information. This is also the system where patient results (such as laboratory, diagnostic imaging and other reports ordered by a provider) are delivered to that provider’s electronic in-box (that is, this information is pushed to the provider, negating the need for the provider to go out and seek it).9

Health Level 7 HL7

A comprehensive framework and related standards for the exchange, integration, sharing and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services.10

Health System Use HSU

Health system use of information refers to the use of health information to monitor, manage and improve the health of Canadians and the health care system. Health system use of information also supports the delivery of care and patient outcomes.

International Organization for Standardization

ISOISO is an international developer and publisher of standards and consists of a network of national standards institutes in 163 countries.11

Master Terminology Worksheet

MTW

An Excel file developed and maintained by the Infoway Standards Collaborative that provides the classification and status for all coded Concept Domains and Value Sets for the following pan-Canadian EHR HL7 v3 messaging domains:Infrastructure, Shared Interactions, Client Registry, Provider Registry, Location Registry, Shared Health Record, Pharmacy, Laboratory, Immunization, Claims and Record Access (includes Consent) domains.12

Pan-Canadian Laboratory Observation Code Database

pCLOCD

The pan-Canadian LOINC Observation Code Database (pCLOCD) Nomenclature Standard was created using the LOINC® records and attributes that specifically meet Canadian laboratory-ordering and -reporting requirements.13

v. All definitions are from CIHI unless otherwise noted.

92


TermAcronym(if applicable) Description

Physician Office System Requirements

POSR

The purpose of the pan-Canadian “physician office system requirements (POSR)” exercise was to collaboratively identify core requirements based on experiences from across the country to assist jurisdictions in the management of electronic medical record (EMR) specifications. Stakeholders for this initiative include individual physicians and jurisdictions that are preparing for or are in the midst of the procurement process.14

The Standards Collaborative Strategic Committee recommended that, due to known POSR limitations, stakeholders should be aware of these limitations and exercise diligence in use of POSR. For more information, contact the Standards Collaborative Infodesk at [email protected] or call 1-877-595-3417 (toll free) or 416-595-3417 (local).

Point of Service PoS Refers to clinical systems used by a clinical provider at the point of care.

Secondary UseExpression sometimes employed to describe the use of data for additional purposes other than the primary reason for its collection, adding value to this data.

Statistics CanadaStatistics Canada is a federal organization responsible for producing statistics that help Canadians better understand characteristics of Canada’s population, resources, economy, society and culture.15

Surveillance Use of data for population health surveillance.

Systematized Nomenclature of Medicine-Clinical Terms

SNOMED CT®

SNOMED CT® provides the core general terminology for the electronic health record (EHR) and contains over 311,000 concepts with unique meanings and formal logic-based definitions organized into hierarchies. When implemented in software applications, SNOMED CT® can be used to represent clinically relevant information consistently, reliably and comprehensively as an integral part of producing electronic health records.16

Unified Code for Units of Measure UCUM A code system intended to include all units of measure currently

in use in international science.17


93


ReferencesHealth Canada, 1. Primary Health Care and Health System Renewal, accessed on October 27, 2010, from <http://www.hc-sc.gc.ca/hcs-sss/prim/renew-renouv-eng.php>.

Health Council of Canada, 2. Primary Health Care: A Background Paper to Accompany Health Care Renewal in Canada—Accelerating Change (Toronto, Ont: Health Council of Canada, 2005).

Canada Health Infoway, 3. Physician Office System Requirements (August 24, 2009), pp. 3–5, accessed on October 27, 2010, from < http://forums.infoway-inforoute.ca/POSR/Physician%20Office%20System%20Requirements%20(POSR).pdf>.

Canada Health Infoway, 4. Product Release Management White Paper (July 7, 2007), p. 7, accessed on October 27, 2010, from <http://forums.infoway-inforoute.ca/[email protected]@.ef03d69>.

DAMA International, 5. The DAMA Guide to The Data Management Body of Knowledge, 1st Edition (Bradley Beach, New Jersey: Technics Publications, 2009).



Canada Health Infoway, 8. EHRS Blueprint: An Interoperable EHR Framework (April 2006), pp. 10–13, accessed on October 27, 2010, from <http://www2.infoway-inforoute.ca/Documents/EHRS-Blueprint-v2-Exec-Overview.pdf>.

The College of Family Physicians of Canada, 9. Primary Care Toolkit for Family Physicians, accessed on October 27, 2010, from <http://toolkit.cfpc.ca/en/information-technology/electronic-medical-record.php>.

Health Level 7, 10. About HL7, accessed on October 27, 2010, from <http://www.hl7.org/about/index.cfm>.

International Organization for Standardization, 11. About ISO, accessed on October 27, 2010, from <http://www.iso.org/iso/about.htm>.

Canada Health Infoway, 12. R02.04.00 Read Me (2009), p. 14, accessed on October 27, 2010, from <http://forums.infoway-inforoute.ca/[email protected]@.ef098ed>.

Canada Health Infoway, 13. Pan Canadian LOINC Observation Code Database (April 14, 2009), pp. 3–6, accessed on October 27, 2010, from <http://forums.infoway-inforoute.ca/[email protected]@.ef0cff6>.

Canada Health Infoway, 14. Physician Office System Requirements (August 24, 2009), pp. 3–5, accessed on October 27, 2010, from <http://forums.infoway-inforoute.ca/POSR/Physician%20Office%20System%20Requirements%20(POSR).pdf>.

http://www.hc-sc.gc.ca/hcs-sss/prim/renew-renouv-eng.php

http://forums.infoway-inforoute.ca/POSR/Physician%20Office%20System%20Requirements%20(POSR).pdf

http://forums.infoway-inforoute.ca/[email protected]@.ef03d69

<http://toolkit.cfpc.ca/en/information-technology/electronic-medical-record.php

http://www.hl7.org/about/index.cfm

http://www.iso.org/iso/about.htm

http://forums.infoway-inforoute.ca/[email protected]@.ef098ed

http://forums.infoway-inforoute.ca/[email protected]@.ef0cff6

http://forums.infoway-inforoute.ca/POSR/Physician%20Office%20System%20Requirements%20(POSR).pdf

94


Statistics Canada, 15. About Us, accessed on October 27, 2010, from <http://www.statcan.gc.ca/about-apercu/about-apropos-eng.htm>.

International Health Terminology Standards Development Organisation, 16. SNOMED CT, accessed on October 27, 2010, from <http://www.ihtsdo.org/snomed-ct/>.

Regenstrief Institute, 17. The Unified Codes for Units of Measure, accessed on October 27, 2010, from <http://www.unitsofmeasure.org/wiki/WikiStart>.

http://www.statcan.gc.ca/about-apercu/about-apropos-eng.htm

http://www.ihtsdo.org/snomed-ct/

http://www.unitsofmeasure.org/wiki/WikiStart

Production of this report is made possible by financial contributions from Health

Canada and provincial and territorial governments. The views expressed herein

do not necessarily represent the views of Health Canada or any provincial or

territorial government.

The contents of this publication may be reproduced in whole or in part, provided

the intended use is for non-commercial purposes and full acknowledgement is

given to the Canadian Institute for Health Information.

Canadian Institute for Health Information

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Phone: 613-241-7860

Fax: 613-241-8120

www.cihi.ca

[email protected]

ISBN 978-1-55465-874-9 (PDF)

© 2011 Canadian Institute for Health Information

How to cite this document:

Canadian Institute for Health Information, Draft Pan-Canadian Primary Health

Care Electronic Medical Record Content Standard, Version 2.0—Business View

(Ottawa, Ont.: CIHI, 2011).

Cette publication est aussi disponible en français sous le titre Norme pancanadienne

provisoire relative au contenu du dossier médical électronique en lien avec les soins

de santé primaires, version 2.0 — perspective opérationnelle.

ISBN 978-1-55465-876-3 (PDF)

http://www.cihi.ca


Talk to UsCIHI Ottawa495 Richmond Road, Suite 600Ottawa, Ontario K2A 4H6Phone: 613-241-7860

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