Header - relatedDocument ActRelationship

July DPROV Draft Harmonization ProposalsProvenanceActRelationshipDocument value set [Slide 7]ProvenanceActRelationshipEntryRelationship value set [Slide 13]v:ProvenanceActRelationshipExternalReference [Slide 17]REVIEWER ParticipationFunction

Header - relatedDocument ActRelationshipWhich x_ActRelationshipDocumentpType codes to use aGap Fix proposalsNew Provenance Chaining Rules?

The Star and Swoosh, Putting the I in Health IT, the Putting the I in Health IT composite logo, HealthIT.gov, the HealthIT.gov composition logo, HealthITBuzz, and the HealthITBuzz composite logo are service marks or registered service marks of the U.S. Department of Health and Human Services.Office of the National Coordinator for Health Information Technology ParentDocument RelationshipsThe ParentDocument represents the source of a document revision, addenda, or transformation. ParentDocument.text is modeled as an ED data type - allowing for the expression of the MIME type of the parent document. It is not to be used to embed the related document, and thus ParentDocument.text.BIN is precluded from use. Allowable values for the intervening relatedDocument.typeCode are shown in the following table. Code DefinitionAPND (append)The current document is an addendum to the ParentDocument.RPLC (replace)The current document is a replacement of the ParentDocument.XFRM (transform)The current document is a transformation of the ParentDocument.Value set for relatedDocument.typeCode (CNE)Allowable Combinations of ParentDocument RelationshipsA conformant CDA document can have a single relatedDocument with typeCode "APND"; a single relatedDocument with typeCode "RPLC"; a single relatedDocument with typeCode "XFRM"; a combination of two relatedDocuments with typeCodes "XFRM" and "RPLC"; or a combination of two relatedDocuments with typeCodes "XFRM" and "APND". No other combinations are allowed

Header relatedDocumentProposed Extension to x_ActRelationshipDocumentPropose Value Set Extensions for x_ActRelationshipDocument for richer provenance semantics about a CDAs relationship to Predecessor DocumentsCOMP [component] - The target act is a component of the source act, with no semantics regarding composition or aggregation impliedPART [has part] - The source Act is a composite of the target Acts. The target Acts do not have an existence independent of the source Act.Usage Note: In UML 1.1, this is a "composition" defined as:"A form of aggregation with strong ownership and coincident lifetime as part of the whole. Parts with non-fixed multiplicity may be created after the composite itself, but once created they live and die with it (i.e., they share lifetimes). Such parts can also be explicitly removed before the death of the composite. Composition may be recursive.XCRPT [excerpts] The source is an excerpt from the target6Insert Kathleens slides bfore this one, walk through the existing values present proposal in plain langauge, then show the definitionsGap area these are new values to address gap6ProvenanceActRelationshipDocumentHarmonization Proposal Decision 1Does the DPROV TT approve submission of:3 existing codes to be added to existing x_ActRelationshipDocument value set named ProvenanceActRelationshipDocument value setCOMPPARTXCRPT

EntryRelationshipWhich x_ActRelationshipEntryRelationshipType codes to use aGap Fix proposalsx_ActRelationshipEntryRelationshipCurrent in CDA at Entry Level GAPS?COMP can be used to indicate non-specific aggregation or composition relationshipSAS could indicate succession at in Lifecycle but would SUCC be better?SUBJ can be used to relate an Entry to a Provenance ActXCRPT can be used to indicate that one Entry is excerpted from another EntryGAPSUCC SucceedUPDT UpdateUSE - Uses

Create ActLEAF CONCEPT:CAUS (is etiology for)Description:Description: An assertion that an act was the cause of another act.This is stronger and more specific than the support link. The source (cause) is typically an observation, but may be any act, while the target may be any act.Examples:a growth of Staphylococcus aureus may be considered the cause of an abscess contamination of the infusion bag was deemed to be the cause of the infection that the patient experienced lack of staff on the shift was deemed to be a supporting factor (proximal factor) causing the patient safety incident where the patient fell out of bed because the bed-sides had not been put up which caused the night patient to fall out of bed

9Other ActRelationshipsSUCCLEAF CONCEPT: SUCC (succeeds)KC Seems like best fit for AR from Last ProvenanceEvent to preceding for LifeCycle would require extension of the x_ActRelationshipEntryRelationship value set in a new one for DPROV EntryRelationship Description:Definition: A new act that carries forward the intention of the original act, but does not completely replace it. The status of the predecessor act must be 'completed'. The original act is the target act and the successor is the source act.

10Other ActRelationships Of InterestUPDTLEAF CONCEPT: UPDT (updates (condition))KC Could be used for LS/LC would require extension of the x_ActRelationshipEntryRelationship value set in a new one for DPROV EntryRelationshipDescription:A condition thread relationship specifically links condition nodes together to form a condition thread. The source is the new condition node and the target links to the most recent node of the existing condition thread.

Other ActRelationships Of InterestUSELEAF CONCEPT: USE (uses)KC Could be the AR from Entry Act to its Provenance OrganizerDescription: Indicates that the source act makes use of (or will make use of) the information content of the target act.UsageNotes: A usage relationship only makes sense if the target act is authored and occurs independently of the source act. Otherwise a simpler relationship such as COMP would be appropriate.

ProvenanceActRelationshipEntryRelationshipHarmonization Proposal Decision 2Does the DPROV TT approve submission of:3 existing ActRelationship Codes to new ProvenanceActRelationshipEntryRelationship value set?SUCCUPDTUSESExternal ReferenceWhich AR codes to use and Gap Fix proposalsx_ActRelationshipExternalReference ActRelationship TypeReasonable Source and Target classes CommentsELNK (episode link)[Observation] ELNK[ExternalObservation] Used to show that the source and the target are part of the same episode (for instance, a diagnosis of "pneumonia" can be linked to an external problem list entry of "pneumonia" to show that the current diagnosis is part of the ongoing episode of pneumonia). REFR (refers to)[Act | Observation | Procedure | SubstanceAdministration | Supply] REFR[ExternalAct | ExternalDocument | ExternalObservation | ExternalProcedure] Used to show a general relationship between the source and the target, when the more specific semantics of the relationship isn't known. RPLC (replace)[Act | Encounter | Observation | ObservationMedia | Organizer | Procedure | SubstanceAdministration | Supply] RPLC[ExternalAct | ExternalDocument | ExternalObservation | ExternalProcedure] Used to indicate that the source entry is a replacement for the target external act.SPRT (has support)[Observation] SPRT[ExternalDocument | ExternalObservation] Used to show that the target provides supporting evidence for the source. SUBJ (has subject) [Observation | RegionOfInterest] SUBJ[ExternalObservation] Used to relate a source region of interest to a target image, or to relate an observation to its subject observation. XCRPT (is excerpt of) [Act | Observation] XCRPT[ExternalAct | ExternalDocument | ExternalObservation | ExternalProcedure] Used to show that the source is excerpted from the target (for instance "the hemoglobin is 10.7" is an excerpt of an externally referenced "complete blood count"). Proposed ActRelationship Type for new v: ProvenanceActRelationshipExternalReference XCRPT (is excerpt of) [Act | Observation] XCRPT[ExternalAct | ExternalDocument | ExternalObservation | ExternalProcedure] Used to show that the source is excerpted from the target (for instance "the hemoglobin is 10.7" is an excerpt of an externally referenced "complete blood count"). FXCRPT (has full excerpt of)

Specializes XCRPT[Act | Observation] XCRPT[ExternalAct | ExternalDocument | ExternalObservation | ExternalProcedure] Used to show that the source is has a full excerpted from the target (complete blood count in a Lab report is excerpted from externally referenced complete blood count.)PXCRPT (has partial excerpt of)

Specializes XCRPT

[Act | Observation] XCRPT[ExternalAct | ExternalDocument | ExternalObservation | ExternalProcedure] Used to show that the source is a partial excerpted from the target (for instance "the hemoglobin is 10.7" is an excerpt of an externally referenced "complete blood count").

v:ProvenanceActRelationshipExternalReferenceHarmonization Proposal Decision 3Does the DPROV TT approve submission of two children specializing XCRPT for addition to new v:ProvenanceActRelationshipExternalReference?

RIM BackgroundReference ActRelationship4.3.8.5CDA entries can reference external objects such as external images and prior reports. These external objects are not part of the authenticated document content. They contain sufficient attributes to enable an explicit reference rather than duplicating the entire referenced object. The CDA entry that wraps the external reference can be used to encode the specific portions of the external reference that are addressed in the narrative block. Each object allows for an identifier and a code, and contains the RIM Act.text attribute, which can be used to store the URL and MIME type of the object. External objects always have a fixed moodCode of "EVN". The reference class contains the attribute reference.seperatableInd, which indicates whether or not the source is intended to be interpreted independently of the target. The indicator cannot prevent an individual or application from separating the source and target, but indicates the author's desire and willingness to attest to the content of the source if separated from the target. Typically, where seperatableInd is "false", the exchanged package should include the target of the reference so that the recipient can render it. A description of allowable reference.typeCode values are shown in the following table. As in the table above (CDA entryRelationship Types), the following table is a guideline for reasonable relationships between CDA entries and external objects, and is not a conformance constraint.

18REVIEWERParticipationFunction for Verifier ParticipantType Code ParticipationFunction Harmonization ProposalREVIEWER Business RequirementesMD requested a new ParticipationType REVIEWERRequest was declined because ParticipationType is fixed in CDA as a structural codeMay be possible to extend CDA ParticipationType value set to include Reviewer as US Realm or for CDA R 2.1Propose Harmonization Request to add as ParticipationFunction as interim alternative despite RIM semantic limitations

RIM Participation.functionCode Participation.functionCode :: CD (0..1) Property conformance: UConcept domain: ParticipationFunctionDefinition: Additional detail about the function that the Participation has in the Act, if such detail is not implied by the Participation.typeCode.Usage Constraint:No HL7 standard specification may be written to depend on the functionCode. When such a constraint is deemed necessary, it is to be defined in the Participation.typeCode. UsageNotes:This code can accommodate a variety of functions greater than that which can be managed in the tightly controlled typeCode. The numbers and kinds of functions applicable depend on the specific kind of act, e.g., each operation may require a different number of assistant surgeons or nurses. Since Participation functions refer to what people do in an Act, they are effectively sub-activities that may all occur in parallel. If more detail needs to be captured about these activities than who does them, component acts should be used instead.

ParticipationFunction Harmonization ProposalREVIEWER - RecommendationMay add fine detail with ParticipationFunctionHowever, no way to test conformance and receiver can ignore while maintaining Recommendation:Add new REVIEWER ParticipationFunctionUsage Note to indicate that REVIEWER is to be used with the ParticipationType = VERIFER22ParticipationTypeVRF (verifier)REVIEWER adds specificity to VRF without connoting attestationSPECIALIZABLE CONCEPT:VRF (verifier)Description:A person who verifies the correctness and appropriateness of the service (plan, order, event, etc.) and hence takes on accountability.ReviewerProposed DefinitionProposed REVIEWER Description:Specifies the exact function an actor is authorized to have as a verifier of an Act. Connotes specialized Verifier per jurisdictional or organizational policyE.g., The Provider Verifier who takes responsibility for authenticity of a Verified record submitted to a payerNeed TT to add more specificity to definitionUsage Note: Used to more fully specify the VERIFER ParticipationTypeREVIEWERPlace in HL7 ParticipationFunction HierarchyABSTRACT CONCEPT: _AuthorizedParticipationFunction [abstract term]

Description:This code is used to specify the exact function an actor is authorized to have in a service in all necessary detail.Concept Properties: internalId: 22338Concept Relationships: Generalizes (derived): _AuthorizedReceiverParticipationFunction Generalizes (derived): _ConsenterParticipationFunction Generalizes (derived): _OverriderParticipationFunctionGeneralizes (derived): _AuthorizedProvenanceParticipationFunctionREVIEWERASSEMBLERREVIEWER ParticipationFunctionHarmonization Proposal DecisionDoes the DPROV TT approve submission of:REVIEWER ParticipationFunctionConstrained to use with VRF [verifier] ParticipationType (not necessary)Defined as: A device that operates on custodians algorithms for data extraction for purpose of generating an artifact. Assembler ParticipationFunction for DEV Participation New ParticipationType/ParticipationFunction?ASSEMBLER [assembly software]Business Need convey Assembling Software that was used to generate Document or Entry Could propose ASSEMBLER as new ParticipationType code but this would be an extension. Similar to Reviewer issue.TT has previously differentiated ASSEMBLER Device from the Authoring Device because:It does not create new informationIt assembles already created informationRecommend proposing as ParticipationFunction to specialize CDA Participation Type SPECIALIZABLE CONCEPT: DEV (device)Description: Participant used in performing the act without being substantially affected by the act (i.e. durable or inert with respect to that particular service)Examples: Monitoring equipment, tools, but also access/drainage lines, prostheses, pace maker, etc.Proposed ASSEMBLER Definition: A device that operates on custodians algorithms for data extraction of existing information for purpose of generating a new artifact.

New ParticipationFunctionASSEMBLER [assembly software]Could make ParticipationFunction to SPECIALIZABLE CONCEPT: DEV (device)Description: Participant used in performing the act without being substantially affected by the act (i.e. durable or inert with respect to that particular service). Examples: monitoring equipment, tools, but also access/drainage lines, prostheses, pace maker, etc.ASSEMBLER [assembly software]Use as Provenance Actor on Entry

30ASSEMBLER [assembly software]Use as Provenance Actor on Header

ASSEMBLER Place in HL7 ParticipationFunction HierarchyABSTRACT CONCEPT: _AuthorizedParticipationFunction [abstract term]Description: This code is used to specify the exact function an actor is authorized to have in a service in all necessary detail.Concept Relationships:Generalizes (derived): _AuthorizedReceiverParticipationFunctionGeneralizes (derived): _ConsenterParticipationFunctionGeneralizes (derived): _OverriderParticipationFunction_AuthorizedProvenanceParticipationFunctionREVIEWERASSEMBLER

Assembler ParticipationFunctionHarmonization Proposal DecisionDoes the DPROV TT approve submission of:Assembler ParticipationFunctionConstrained to use with Device ParticipationType (not necessary)Defined as A device that operates on custodians algorithms for data extraction for purpose of generating an artifact. Provenance Event CodEs ActCodes for ProvenanceEventActsProvenanceEventCodesBusiness NeedA ProvenanceEventAct convey an Entry Lifecycle Event [1*] ProvenanceEvents comprise a ProvenanceOrganizerProvenanceEvent has ProvenanceEvent Act.code, which conveys the type of Lifecycle eventHas effectiveTime [11], which conveys temporal relationship among ProvenanceEventsProvenanceEvents ordered by ActRelationship SAS [starts after start of] with optional Sequence # to explicitly sequence Lifecycle ProvenanceEventsActRelationshipExternalReference convey limited association with Lifespan ProvenanceEvents of Predecessor ExternalActs e.g., an Entry Lifecycle Event update may reference an External Act that this Entry replacesPropose to Harmonization an extended ActRelationshipProvenanceExternalReference value set that includes relevant provenance relationships for future use

ProvenanceEvent value setBusiness Requirements

Need to convey the change that a system event causes to a resource which entails an additional stage in the resources lifespan or lifecycle.36ProvenanceEvent value setUses ActStatus and DataOperations

Only some ActStatus and DataOperations Codes relate to Lifecycle or Lifespan ProvenanceOthers are related only to Workflow

ProvenanceEvent value set DescriptionProvenanceEvent value set described as codes that convey types of Lifecycle or Lifespan eventUsage Note: Conveys the change that a system event causes to a resource which entails an additional stage in the resources lifespan or lifecycle.

Candidate ProvenanceEventsactivateactivateChange the status of an object representing an Act to "active", i.e., so it can be performed or is being performed, for the first timeDataOperationsnewnewAn Act that is in the preparatory stages and may not yet be acted uponActStatuscreatecreateFundamental operation in an Information System (IS) that results only in the act of bringing an object into existence. DataOperationsreadreadFundamental operation in an Information System (IS) that results only in the flow of information about an object to a subject. DataOperationsupdateupdateFundamental operation in an Information System (IS) that results only in the revision or alteration of an object.DataOperationsappendappendFundamental operation in an Information System (IS) that results only in the addition of information to an object already in existence.DataOperationsannotateannotateAdd commentary, explanatory notes, critical notes or similar content to an object.DataOperations deletedeleteFundamental operation in an Information System (IS) that results only in the removal of information.DataOperationscancelledcancelledThe Act has been abandoned before activation.ActStatusabortedabortedThe Act has been terminated prior to the originally intended completion.ActStatusnullifiednullifiedThis Act instance was created in error and has been 'removed' and is treated as though it never existed. A record is retained for audit purposes only.ActStatusobsoleteobsoleteThis Act instance has been replaced by a new instance.ActStatusProvenanceEvent value setHarmonization ProposalDoes the DPROV TT approve submission of the ProvenanceEvent value set listed in preceding Slide?

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