Boston Public Health Commission Data Collection Regulation: Boston Health Equity Measure Set

Transcription

Boston Public Health Commission
Data Collection Regulation:
Boston Health Equity Measure Set
APPROVED:
Barbara Ferrer, PhD, MPH, MEd
Executive Director
Date: September 2, 2013
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BPHC Boston Health Equity Measure Set
Table of Contents
I.
Introduction
5
II.
References
9
III.
Data Submission Guide
37
IV.
Appendices
225
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I.
Introduction
Background
Eliminating prevailing health care disparities related to race, ethnicity, and
socioeconomic factors are key goals of the U.S. Department of Health and Human
Services’ Action Plan to Reduce Racial and Ethnic Health Disparities (Disparities Action
Plan).1 According to the Agency for Healthcare Research and Quality’s (AHRQ) 2012
National Healthcare Disparities Report, however, few measures of disparities in health
care quality related to race or ethnicity have shown improvement over time, and almost
no disparities in access to care have improved. 2 Incomplete data on vulnerable
populations limit the ability to identify problems, target resources, and design
interventions. Increasing the availability and quality of data collected and reported on
racial and ethnic minority populations is a national priority supported by the Affordable
Care Act and numerous federal agency standards and recommendations.
To address this issue, the Boston Public Health Commission (BPHC) promulgated the
Data Collection Regulation on July 1, 2006 (Appendix C). This regulation requires all
hospitals and community health centers in Boston to collect four fields of self-reported
demographic information on all inpatient, outpatient observation, ambulatory, and
emergency department visits. The regulation also required the convening of a
committee of healthcare providers and other stakeholders to develop a measure set to
identify healthcare disparities that may guide quality improvement efforts (see
Appendix D for committee membership).
Boston Health Equity Measure Set
The Health Equity Committee met for a year and recommended nineteen measures
related to health care quality and utilization in two priority areas, primary care and
emergency care. In their process of measure selection, the Committee considered the
validity (i.e., soundness) and practicality (i.e., ease of data collection) of candidate
measures. Whenever possible, measures were drawn from existing nationally accepted
standard measures. Through input from the public review process and with expert
technical assistance from the Disparities Solution Center of Massachusetts General
Hospital the measure set recommended by the Health Equity Committee were revised
and finalized constituting the first Boston Health Equity Measure Set (BHEMS) (Table 1). 3
1
U.S. Department of Health and Human Services, HHS Action Plan to Reduce Racial and Ethnic Disparities: A Nation
Free of Disparities in Health and Health Care. Washington, D.C.: U.S. Department of Health and Human Services, April
2011:12-14.
2
U.S. Department of Health and Human Services, Agency for Health Care Quality and Research, National Healthcare
Quality Report 2012. Washington, D.C.: Agency for Healthcare Research and Quality, May 2013:H7-H8.
3
See Appendix E for a summary of the Health Equity Measure Set development.
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BHEMS aligns with both federal and state health care quality measurement and
improvement initiatives. Six of the nineteen measures in BHEMS are Healthcare Data
Effectiveness and Information Set (HEDIS) measures developed by the National
Committee for Quality Assurance (NCQA), a private not-for-profit health care quality
improvement organization. HEDIS is used by more than ninety percent of American
health plans to measure health care provider performance. Nine of the nineteen
measures in BHEMS are endorsed by the National Quality Forum (NQF), a non-profit,
public-private partnership responsible for developing a portfolio of quality and
efficiency measures for the US Department of Health and Human Services. Eight of the
nineteen measures in BHEMS are recommended by the Massachusetts Statewide
Quality Advisory Committee (SQAC) for the Commonwealth’s first Standard Quality
Measure Set (SQMS).
While there is significant overlap in the BHEMS with other quality reporting and
improvement initiatives there may be differing priorities and data collection methods
used to generate reports. BHEMS will be calculated from individual level demographic
and clinical data for all inpatient, outpatient observation, ambulatory and emergency
department encounters submitted by all hospitals and community health centers in
Boston as required by the BPHC Data Collection Regulation. Measures will be stratified
by demographic in order to identify and address inequities in care utilization and
quality. Future BHEMS may include measures related to health care outcomes and
patient experiences with care.
Providers will be given an opportunity to review and to comment on the BHEMS that is
calculated from their submitted data. Annually, BPHC will issue an analysis of the
BHEMS to reporting hospitals and community health centers to guide quality
improvement initiatives developed to reduce health care inequities.
Table 1. Boston Health Equity Measure Set
Data Source
Measure #
Priority Area
1
Primary care
utilization
Primary care
utilization
Primary care
utilization
Primary care
utilization
Primary care
quality
Primary care
quality
2
3
4
5
6
7
Primary care
NQF#
Measure
Total number of primary care visits
24
(ages
3-17)
36
Total number of patients (include patients with one or
more visits in the reporting period)
Total number of primary care visits by asthma patients (564), as defined by HEDIS
Total number of primary care visits by diabetic patients,
as defined by HEDIS
Total number of primary care visits by hypertension
patients, as defined by HEDIS
(HEDIS) Weight assessment and counseling for nutrition
and physical activity for children and adolescents (Age 217)
(HEDIS) Use of an asthma controller medication for
Hospital
X
CHC
X
X
X
X
X
X
X
X
X
X
X
X
X
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8
quality
Primary care
quality
731
9
Primary care
quality
18
10
1392,
1516
12
13
Primary care
quality
Primary care
quality
ED utilization
ED utilization
14
ED utilization
15
ED utilization
16
ED utilization
17
18
ED utilization
ED quality
11
90
289
163
132
19
ED quality
93
persons with asthma (Age 5-64)
Comprehensive diabetes care (Age 18-75):
(HEDIS) Yearly screening: HbA1c; LDL-C, retinal eye exam,
nephropathy screen, blood pressure
Controlling high blood pressure (Age 18-85):
(HEDIS) Patient with a diagnosis of hypertension whose
most recent blood pressure reading was controlled
(HEDIS) Well-child visits (Ages 0-15 months and 3-6 years)
X
X
X
X
X
X
(HEDIS) Adolescent well-child visits (Age 12-21 years)
X
X
Total number of ED visits
Number of patients with high ED utilization (4 or more
visits in one year)
Number of ED visits by day of week and time of day for
the top ten “non-emergent conditions” as defined by the
MA Division of Healthcare Finance and Policy in
Massachusetts Health Care Cost Trends: Efficiency of
Emergency Department Utilization in Massachusetts;
August, 2012
Number of ED visits by day of week and time of day for
the top ten “emergency but primary care treatable
conditions” as defined by the MA Division of Healthcare
Finance and Policy in Massachusetts Health Care Cost
Trends: Efficiency of Emergency Department Utilization in
Massachusetts; August, 2012
Discharge status (home, observation and inpatient
admissions)
Number of visits to the ED for asthma-related conditions
MI Guidelines (ECG):
a) CMS PQRS: Measure #54: 12-Lead Electrocardiogram
(ECG) Performed for Non-traumatic Chest Pain (in
patients 40 years and older)
b) CMS OPPS: OP-5: ED Median Time to ECG
X
X
MI Guidelines (PCI):
c) AMI-8: Median Time to PCI (Door to Balloon time)
X
d) AMI – 8a: Primary PCI within 90 minutes of hospital
arrival
MI Guidelines (Aspirin):
e) AMI-1: Aspirin at Arrival
X
Syncope Guideline:
CMS PQRS: Measure #55: 12-Lead Electrocardiogram
(ECG) Performed for Syncope (in patients 60 years and
older)
X
X
X
X
X
X
X
X
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II.
References
This section identifies the following for each measure of the Boston Health Equity
Measure Set:
 Brief description of the measure
 Definitions and relevant references used by BPHC to calculate the measure
 Additional Notes which may be used to help to identify data fields BPHC will use
to calculate the measure
Individual level data (i.e., not aggregate level data) is required to be submitted for all
inpatient, outpatient observation, ambulatory, and emergency department encounters
from all Boston hospitals and community health centers. See Section III, Data
Submission Guide, for technical guidance regarding required data submission content,
format, and procedures.
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BPHC Boston Health Equity
Measure Set
Measure #1: Total Number of Primary Care Visits
Measure #1: Total Number of Primary Care Visits
This measure is used to assess the total number of primary care visits within the measurement
year.
It excludes visits where the Visit Type is Emergency Department or Inpatient. In support of the
measure, payment method will also be captured including commercial health plans, public health
plans such as Medicaid and Medicare, and/or out of pocket.
Reference: Definition of Primary Care Visit for Children
HEDIS measure “Children and Adolescents’ Access to Primary Care Practitioners (CAP)” contains
definitions that were used to determine the fields to capture for this measure. The text below
contains excerpts from HEDIS 2013, Volume 2 Access and Availability of Care and Experience with
Care page 244.
Reference: Definition of Well Visits for Adults
HEDIS measure “Adults’ Access to Preventive/Ambulatory Health Services (AAP)” contains
definitions that were used to determine the fields to capture for this measure. See HEDIS 2013,
Volume 2 Access and Availability of Care and Experience with Care page 242.
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Measure Set
Measure #2: Total Number of Patients
Measure #2: Total Number of Patients (One or More Visits during Report
Period)
This measure is used to assess the total number of patients that had one or more primary care
visits during the measurement year.
For this measure, each patient is counted once, even if the patient has more than one visit to one
or more providers at the reporting institution.
Care page 242.
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Measure Set
Measure #3: Total Number of Primary Care Visits by Asthma
Patients (5-64)
Measure #3: Total Number of Primary Care Visits by Asthma Patients (564), as Defined by HEDIS
This measure is used to assess the number of primary care visits by patients 5-64 years of age
during the reporting year who were identified as having persistent asthma.
Care page 244.
Reference: Definition of Persistent Asthma
HEDIS measure “Use of Appropriate Medications for People With Asthma (ASM)” contains
Volume 2 Effectiveness of Care Respiratory Cardiovascular page 123.
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Measure Set
Measure #4: Total Number of Primary Care Visits by Diabetic
Patients
Measure #4: Total Number of Primary Care Visits by Diabetic Patients,
as Defined by HEDIS
This measure is used to assess the number of primary care visits by patients who are identified as
diabetic.
The definition of “diabetic” is based on the HEDIS measure entitled Comprehensive Diabetes Care
cited below.
Care page 244.
Reference: Definition of Diabetic
HEDIS measure “Comprehensive Diabetes Care (CDC)” contains definitions that were used to
determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care
Musculo Skeletal Behavioral page 152.
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Measure Set
Measure #5: Total Number of Primary Care Visits by Hypertension
Patients
Measure #5: Total Number of Primary Care Visits by Hypertension
Patients, as Defined by HEDIS
This measure is used to assess the total number of primary care visits by patients identified as
having hypertension during the measurement year.
The definition of “hypertension” is based on the HEDIS measure entitled Controlling High Blood
Pressure cited below.
Reference: Definition of Hypertension
HEDIS measure “Controlling High Blood Pressure (CBP)” contains definitions that were used to
Respiratory Cardiovascular page 142.
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Measure Set
Measure 6: Weight Assessment and Counseling for Nutrition and
Physical Activity for Children and Adolescents (Age 2-17)
Measure #6: Weight Assessment and Counseling for Nutrition and
Physical Activity for Children and Adolescents (Age 2-17)
This measure is used to assess the percentage of patients 2–17 years of age who had an outpatient
visit with a PCP or OB/GYN and who had evidence of the following during the measurement year.
 BMI percentile documentation (including height and weight).
 Counseling for nutrition.
 Counseling for physical activity.
Note that the age range of this BHEMS measure is age 2-17 years and varies from the HEDIS
measure of age 3-17.
Reference: Applicable HEDIS Measure
HEDIS measure “Weight Assessment and Counseling for Nutrition and Physical Activity for
Children/Adolescents (WCC)” contains definitions that were used to determine the fields to capture
for this measure. See HEDIS 2013, Volume 2 Effectiveness of Care Prevention and Screening page
61.
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Measure Set
Measure 7: Use of an Asthma Controller Medication for Persons
with Asthma (Age 5-56)
Measure #7: Use of an Asthma Controller Medication for Persons with
Asthma (Age 5-64)
This measure is used to assess the percentage of patients 5–64 years of age during the
measurement year who were identified as having persistent asthma and who were appropriately
prescribed medication during the measurement year.
References
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Measure Set
Measure 8: Comprehensive Diabetes Care (Age 18-75)
Measure #8: Comprehensive Diabetes Care (Age 18-75)
This measure is used to assess the percentage of patients 18–75 years of age with diabetes (type 1
and type 2) who had each of the following.
 Hemoglobin A1c (HbA1c) testing.
 HbA1c poor control (>9.0%).
 HbA1c control (<8.0%).
 HbA1c control (<7.0%) for a selected population*.
 LDL-C screening.
 LDL-C control (<100 mg/dL).
 Medical attention for nephropathy.
 BP control (<140/80 mm Hg).
 BP control (<140/90 mm Hg).
 Eye exam (retinal) performed.
Reference: Applicable HEDIS Measure
HEDIS measure “Comprehensive Diabetes Care (CDC)” contains definitions that were used to
Musculo Skeletal Behavioral page 152.
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Measure Set
Measure 9: Controlling High Blood Pressure (Age 18-85)
Measure #9: Controlling High Blood Pressure (Age 18-85)
This measure is used to assess the percentage of patients 18–85 years of age who had a diagnosis
of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the
measurement year.
References
HEDIS measure “Controlling High Blood Pressure (CBP)” contains definitions that were used to
Respiratory Cardiovascular page 142.
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Measure Set
Measure 9: Controlling High Blood Pressure (Age 18-85)
Measure #10: Well Child Visits (Age 0-15 Months and 3-6 Years)
This measure is used to assess:
 the percentage of patients who turned 15 months old during the measurement year and
who had 0, 1, 2, 3, 4, 5, 6 or more well-child visits with a PCP during their first 15 months
of life
 the percentage of patients 3–6 years of age who had one or more well-child visits with a
PCP during the measurement year.
The two different HEDIS references for this measure are described below.
Reference: Well-Child Visits First 15 Months
HEDIS measure “Well-Child Visits in the First 15 Months of Life (W15)” contains definitions that
were used to determine the fields to capture for this measure. The text below contains
excerpts from HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page 285.
Reference: Well-Child Visits 3-6 years
HEDIS measure “Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)”
contains definitions that were used to determine the fields to capture for this measure. See
HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page 288.
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Measure Set
Measure 11: Adolescent Well-Child Visits (age 12-21 years)
Measure #11: Adolescent Well-Child Visits (Age 12-21 years)
This measure is used to assess the percentage of patients age 12-21 years old during the
measurement year who had at least one comprehensive well-child visit with a PCP or an
OB/GYN practitioner during the measurement year.
Reference: Adolescent Well-Child Visits (AWC)
HEDIS measure “Adolescent Well-Care Visits (AWC)” contains definitions that were used to
determine the fields to capture for this measure. See HEDIS 2013, Volume 2 Utilization and
Relative Resource Part A page 291.
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Measure Set
Measure 12: Total Number of ED Visits
Measure #12: Total Number of ED Visits
This measure is used to assess the total number of Emergency Department visits for the
measurement year.
Reference: Definition of ED Visit
See ED Visit excerpt from HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page
304. The HEDIS reference indicates “Count each visit to an ED that does not result in an
inpatient stay once…”. However, the BPHC Boston Health Equity Measure Set does include
these ED visits, so varies from HEDIS for that particular part of the definition.
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Measure Set
Measure 13: Number of Patients with High ED Utilization (four
or more in one year)
Measure #13: Number of Patients with High ED Utilization (four or
more in one year)
This measure is used to assess the number of patients who have had four or more ED visits in
the measurement year.
References
See ED Visit excerpt from HEDIS 2013, Volume 2 Utilization and Relative Resource Part A page
304.
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Measure Set
Measure 14: Number of ED Visits by Day of Week and Time of
Day for the Top Ten “Non-Emergent Conditions” as defined by
the Massachusetts Division of Healthcare Finance and Policy
Measure #14: Number of ED Visits by Day of Week and Time of Day
for the Top Ten “Non-Emergent Conditions” as defined by the
Massachusetts Division of Healthcare Finance and Policy in
Massachusetts Health Care Cost Trends: Efficiency of Emergency
Department Utilization in Massachusetts
This measure is used to assess the number of Emergency Department (ED) visits by day of the
week and time of day for one or more of the top ten clinical conditions categorized as “nonemergent conditions” by the Massachusetts Division of Healthcare Finance and Policy.
Count the number of Encounters where the Visit Type is ED (CPT 99281-99285) and the only
Diagnosis(es) is one or more of the conditions in the table below.
References
The following contains definitions that were used to identify “Preventable/Avoidable ED Visits”.
The text below contains excerpts from “Massachusetts Health Care Cost Trends, Efficiency of
Emergency Department Utilization in Massachusetts”, authored by the Massachusetts Division
of Health Care Finance and Policy 4. The following is from page 21 of this document.
4
http://www.mass.gov/chia/docs/cost-trend-docs/cost-trends-docs-2012/emergency-department-utilization.pdf
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Measure Set
Day for the Top Ten “Non-Emergent Conditions” as defined by
the Massachusetts Division of Healthcare Finance and Policy
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Measure Set
Day for the Top Ten “Emergency But Primary Care Treatable
Conditions” as defined by the Massachusetts Division of
Healthcare Finance and Policy
Measure #15: Number of ED Visits by Day of Week and Time of Day
for the Top Ten “Emergency But Primary Care Treatable Conditions”
as defined by the Massachusetts Division of Healthcare Finance and
Policy in Massachusetts Health Care Cost Trends: Efficiency of
Emergency Department Utilization in Massachusetts
This measure is used to assess the number of Emergency Department (ED) visits by day of the
week and time of day for one or more of the top ten clinical conditions categorized as
“emergency but primary care treatable” by the Massachusetts Division of Healthcare Finance
and Policy.
Count the number of Encounters where the Visit Type is ED (CPT 99281-99285) and the only
Diagnosis(es) is one or more of the conditions in the table below.
References
The following contains definitions that were used to identify “Preventable/Avoidable ED Visits”.
The text below contains excerpts from “Massachusetts Health Care Cost Trends, Efficiency of
Emergency Department Utilization in Massachusetts”, authored by the Massachusetts Division
of Health Care Finance and Policy 5. The following is from page 21 of this document.
5
http://www.mass.gov/chia/docs/cost-trend-docs/cost-trends-docs-2012/emergency-department-utilization.pdf
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Measure Set
Day for the Top Ten “Emergency But Primary Care Treatable
Conditions” as defined by the Massachusetts Division of
Healthcare Finance and Policy
Page 26 of 256
Measure Set
Measure 16: Discharge Status (Home, Observation and Inpatient
Admissions
Measure #16: Discharge Status (Home, Observation and Inpatient
Admissions)
This measure is used to assess the Discharge Status for patients with Home, Observation and
Inpatient Admissions.
Reference: Definition of Discharge Status
The BHEMS did not reference a HEDIS or other nationally recognized standard for this measure.
In lieu of another standard, information published by the Centers for Medicare and Medicaid
Services in “Clarification of Patient Discharge Status Codes and Hospital Transfer Policies” MLN
Matters Number: SE0801 Revised provides the following definition on Page 2.6
The Discharge Status identifies where the patient is at the conclusion of a health care facility
encounter (can be a visit or an actual inpatient stay) or at the end time of a billing cycle.
The Discharge Status is captured in the discharge disposition code (field
sdtc:dischargeDispositionCode) with the exception of hospital discharges, in which case it is
captured in the Hospital Discharge Diagnosis (field statusCode within Hospital Discharge
Diagnosis of an Encounter).
The following describes the discharge disposition codes and their meaning.
HL7 Discharge Disposition Codes
Code System: HL7 Discharge Disposition 2.16.840.1.113883.12.112
Code
Print Name
01
Discharged to home or self-care (routine discharge)
02
Discharged/transferred to another short-term general hospital for inpatient
care
03
Discharged/transferred to skilled nursing facility (SNF)
04
Discharged/transferred to an intermediate-care facility (ICF)
05
Discharged/transferred to another type of institution for inpatient care or
referred for outpatient services to another institution
06
Discharged/transferred to home under care of organized home health service
Organization
07
Left against medical advice or discontinued care
08
Discharged/transferred to home under care of Home IV provider
09
Admitted as an inpatient to this hospital
10…19 Discharge to be defined at state level, if necessary
20
Expired (i.e., dead)
21…29 Expired to be defined at state level, if necessary
30
Still patient or expected to return for outpatient services (i.e., still a patient)
6
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf
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Measure Set
31…39
40
41
42
Measure 16: Discharge Status (Home, Observation and Inpatient
Admissions
Still patient to be defined at state level, if necessary (i.e., still a patient)
Expired (i.e., died) at home
Expired (i.e., died) in a medical facility; e.g., hospital, SNF, ICF, or freestanding
Hospice
Expired (i.e., died) - place unknown
Page 28 of 256
Measure Set
Measure 17: Number of Visits to the ED for Asthma Related
Conditions
Measure #17: Number of Visits to the ED for Asthma Related
Conditions
This measure is used to assess the total number of visits to the ED that displayed asthma
related conditions within the measurement year.
The following highlight some of the key information within the reference above:

Total count of Encounters where the Visit Type is ED (CPT 99281-99285) and the Date is
within the measurement year in which one of the diagnosis entries is asthma.

The Emergency Department visits are defined by CPT codes: 99281-99285. And ICD-9
codes under 493 indicate an asthma diagnosis. So, the count of the combination of CPT
code 99281-99285 and ICD-9 codes under 493 will indicate number of visits to the ED
for asthma-related conditions and symptoms.
Reference: Definition of ED Visit
See the ED Visit excerpt from HEDIS 2013, Volume 2 Utilization and Relative Resource Part A
page 304. The HEDIS reference indicates “Count each visit to an ED that does not result in an
inpatient stay once…”. However, the BPHC Boston Health Equity Measure Set does include
these ED visits, so varies from HEDIS for that particular part of the definition.
Reference: Definition of Asthma Related Condition
Page 29 of 256
Measure Set
Measure 18a: 12-Lead Electrocardiogram (ECG) Performed for
Non-traumatic Chest Pain (patients 40 years and older with ED
Discharge)
Measure #18a: 12-Lead Electrocardiogram (ECG) Performed for Nontraumatic Chest Pain (patients 40 years and older with ED Discharge)
This measure is used to assess the percentage of patients aged 40 years and older with an
emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG
performed.
Reference: Definition from AMA NCQA of Non-traumatic Chest Pain and 12-Lead
Electrocardiogram
See definitions in the American Medical Association National Committee for Quality Assurance
54 -Electrocardiogram Performed for Non-Traumatic Chest Pain.
Reference: Definition from CMS PQRS Measure #54 12-Lead Electrocardiogram
CMS PQRS: Measure #54 contains definitions that were used to determine the fields to capture
for this measure. See excerpts from worksheet “Current” row number 688 in the Excel file
“CMS.Measures.Inventory.web posting.Dec2013.alsb”.
Page 30 of 256
Measure Set
Measure 18b: ED Median Time to ECG
Measure #18b: ED Median Time to ECG
This measure is used to assess the median time from emergency department arrival to ECG
(performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain
patients (with Probable Cardiac Chest Pain).
Reference: CMS Hospital OQR Specifications Manual Chest Measures
See excerpts from CMS Hospital OQR Specifications Manual Chest Measures pages 15 through
17.
Reference: CMS OPPS: OP-5
“‘Median time to ECG’ as defined by Continuous Variable Statement” contains definitions that
were used to determine the fields to capture for this measure. See excerpts from worksheet
“Current” row number 246 in the Excel file
“CMS.Measures.Inventory.webposting.Dec2013.alsb”.
Page 31 of 256
Measure Set
Measure 18c: AMI-8: Median Time to PCI (Door to Balloon time)
Measure #18c: AMI-8: Median Time to PCI (Door to Balloon time)
This measure is used to assess the Median time from arrival to primary percutaneous coronary
intervention (PCI) in patients with ST-segment elevation or left bundle branch block (LBBB) on
the electrocardiogram (ECG) performed closest to hospital arrival time.
References
Specifications Manual for Joint Commission National Quality Core Measures (Measure AMI-8:
Median Time to PCI) was used to determine the fields to capture for this measure. See the full
AMI-8 text at the following link:
https://manual.jointcommission.org/releases/archive/TJC2010B1/MIF0023.html
Page 32 of 256
Measure Set
Measure 18d: AMI-8a: Primary PCI within 90 Minutes of
Hospital Arrival
Measure #18d: AMI – 8a: Primary PCI within 90 Minutes of Hospital
Arrival
This measure is used to assess the number of acute myocardial infarction (AMI) patients
receiving primary percutaneous coronary intervention (PCI) during the hospital stay with a time
from hospital arrival to PCI of 90 minutes or less.
References
Specifications Manual for Joint Commission National Quality Core Measures (Measure: AMI –
8a: Primary PCI within 90 minutes of hospital arrival) was used to determine the fields to
capture for this measure. See the full AMI-8a text at the following link:
Page 33 of 256
Measure Set
Measure 18e: AMI-1: Aspirin at Arrival
Measure #18e: AMI-1: Aspirin at Arrival
This measure is used to assess acute myocardial infarction (AMI) patients without aspirin
contraindications who received aspirin within 24 hours before or after hospital arrival.
References
Specifications Manual for Joint Commission National Quality Core Measures (Measure: AMI-1
Aspirin at Arrival) was used to determine the fields to capture for this measure. See the full
AMI-1 text at the following link:
Page 34 of 256
Measure Set
Measure 19: 12-Lead Electrocardiogram (ECG) Performed for
Syncope (in patients 60 years and older)
Measure #19: 12-Lead Electro cardiogram (ECG) Performed for
This measure is used to assess the percentage of patients aged 60 years and older with an
emergency department discharge diagnosis of syncope who had a 12-lead ECG performed.
References
CMS PQRS: Measure #55: “12-Lead Electro cardiogram (ECG) Performed for Syncope (in
patients 60 years and older)” contains definitions that were used to determine the fields to
capture for this measure. See excerpts from worksheet “Current” row number 688 in the Excel
file “CMS.Measures.Inventory.web posting.Dec2013.alsb”.
Page 35 of 256
Measure Set
Measure 19: 12-Lead Electrocardiogram (ECG) Performed for
Page 36 of 256
III.
Introduction
1.1 Purpose of This Document
This document presents the Data Submission Guide for the Boston Public Health Commission
(BPHC) Data Collection Regulation Boston Equity Measure Set (BHEMS) via the BPHC Health
Information Exchange (HIE) Gateway. This document provides guidance to health care provider
sites designing and implementing information system interfaces to securely exchange clinical
data using messages of a standard format.
This document is a collection of Health Level Seven’s (HL7) Clinical Document Architecture
(CDA) templates that describe the Continuity of Care Document (CCD) supported by BPHC. The
document follows the guidelines within the CDA Release 2 Consolidation Guide so that
messages conform to the nationally recognized HL7 standard.
This document is intended for business and technical staff of health care providers who are
required to report demographic and clinical data to the BPHC. Reporting facilities are
responsible for understanding the operation of the BPHC HIE Gateway.
1.2 Scope
This document describes information regarding the BPHC reporting requirements for BHEMSrelated data. The document includes information about the following:
 High level overview of the HIE infrastructure
 Detailed message definition for CDA compliant BHEMS data
This document does not describe the detailed steps necessary to establish the transport layer
data connection from provider sites to BPHC.
To support the transmission of messages, BPHC has partnered with the Commonwealth of
Massachusetts and utilizes the Mass HIway (www.mass.gov/hhs/masshiway) as a secure
method of sending messages to BPHC. As such, this partnership should reduce the work
required for provider sites to send messages to the Health Equity Data Exchange system at
BPHC. The details about the implementation of this transport layer are not included in this
Guide, but instead are within Mass HIway documents.
1.3 How this Guide is Organized
The following table describes the sections within this guide:
Section
Description
High Level Description of
This section briefly describes the entire
HIE Gateway
HIE system to give readers and
implementers an overall idea of how the
system works and is used.
Possible Events That Trigger This section lists some typical events
Sending Health Equity Data
that may be considered as triggers for
Pages
42-44
45-49
Page 37 of 256
Message Construction and
Document Conventions
BPHC Health Equity
Reporting
Appendix A: OIDS
Appendix B: Vocabulary
sending Health Equity Data messages to
the Boston Public Health Commission
This section signifies the transition of the
document from describing the
background and high level architecture
of the HIE Gateway to the specific
detailed information necessary to
construct a Health Equity Data Message
to be sent to BPHC. This section
describes conventions used throughout
the document.
This section describes the constrained
CCD document type and its associated
CDA templates. This section describes
every component of a BPHC Health
Equity Data Report and should be used
by organizations to create messages for
submission to BPHC.
This section describes any custom object
identifiers (OIDs) defined within the
document.
This section describes all code value sets
used within the BPHC Health Equity Data
Report and is referenced within the
templates defined in Section 7.
46-49
50-224
225
226-247
Page 38 of 256
1.4 References
This Data Submission Guide is derived from and references the following documents.
Document/Reference
Description
HL7 Implementation Guide for
CDA Release 2: IHE Health Story
Consolidation, DSTU Release 1.1
Draft Standard for Trial User
The guide can be found at
http://www.hl7.org
The guide describes the implementation of 8 different
document types within the CDA R2 framework. The guide
was produced and developed through the joint efforts of
Health Level Seven (HL7), Integrating the Healthcare
Environment (IHE), the Health Story Project, and the Office
of the National Coordinator (ONC) within the US
Department of Health and Human Services (HSS). The
BPHC Health Equity Data Report is a constrained version of
the CCD document template described in the guide.
Section 7 re-uses the templates defined in the IHE Health
Story Consolidation Guide, customizing them to fit the
particular requirements for BPHC’s Health Equity Measure
Set.
HL7 Implementation Guide: CDA
Release 2 – Continuity of Care
Document (CCD)
The guide can be found at
http://www.hl7.org
This CCD implementations guide was published by Health
Level Seven (HL7) and was developed to support CCD
implementers. The scope is “just enough” to get started
and is based on the CCR standard – it is not a standalone
or complete guide or reference.
Page 39 of 256
1.5 Glossary of Terms and Acronyms
Term and Acronym
Definition
HL7 Acknowledgment (HL7) (ACK) In the HL7 Standard, acknowledgements (ACK’s) are sent
from applications receiving HL7 messages as a means to
confirm that inbound messages have been received.
When the receiving application accepts and consumes
the data within an HL7 message, the receiving application
is expected to send an ACK back to the sending
application. If the sending application does not receive
the ACK, it may continue to send the same message until
an ACK is received.
Boston Public Health Commission
The oldest health department in the United States, BPHC
(BPHC)
is an independent public agency providing a wide range
of health services and programs. It is governed by a
seven-member board of health appointed by Boston's
mayor. Its mission is to "protect, preserve, and promote
the health and well-being of all Boston residents,
particularly those who are most vulnerable."
Center for Disease Control and
The national public health institute of the United States.
Prevention (CDC)
The CDC is a federal agency under the Department of
Health and Human Services.
Clinical Document Architecture
An XML-based markup standard intended to specify the
(CDA)
encoding, structure and semantics of clinical documents
for exchange. CDA is an ANSI-certified standard from
Health Level Seven (HL7.org)
Electronic Health Record (EHR)
A digital version of a patient’s paper chart.
Health Equity Data
Healthcare equity refers to equal access to or availability
of healthcare facilities and services. Health status equity
refers to the absence of variation in rates of disease
occurrence and disabilities between socioeconomically-,
racially-, and/or geographically-defined population
groups.
Health Information Exchange (HIE) A system that enables the electronic sharing of healthrelated information
Health Level Seven (HL7)
Global authority on standards for interoperability of
health information technology
Mass HIway
The HIway is a secure statewide network that facilitates
the transmission of healthcare data and health
information among providers, hospitals and other
healthcare entities. www.mass.gov/hhs/masshiway
Meaningful Use (MU)
Meaningful use is the set of standards defined by the
Centers for Medicare & Medicaid Services (CMS)
Page 40 of 256
Incentive Programs that governs the use of electronic
health records and allows eligible providers and hospitals
to earn incentive payments by meeting specific criteria
Page 41 of 256
High Level Description of HIE Gateway
For informational purposes, this section describes the high level functionality and conceptual
architecture of the BPHC HIE Gateway.
1.6 High Level Functional Description of BPHC HIE Gateway
The BPHC HIE Gateway provides clinical data exchange services to be used by Health Care
Provider Sites to send Health Equity and other clinical data to BPHC. The primary functions of
the BPHC HIE Gateway include the following:




Security: Handles authentication and authorization of Health Care Provider Sites, and
ensures proper message security including encryption.
Logging: Logs transactions to support troubleshooting and data quality and to meet
auditing and disclosure reporting requirements.
Data Services: Provides persistent storage and management of data, including security
of data at rest and appropriate archiving.
Message Transport: Enables secure, reliable, standards-based communication between
Health Care Provider Sites and BPHC.
Page 42 of 256
1.7 High Level Conceptual Architecture
This section describes the high level architecture of the BPHC HIE Gateway. The HIE Gateway
serves two primary functions:


Message transport services
Message storage
Regarding message transport, the BPHC Gateway utilizes the existing Massachusetts HIway
infrastructure to enable Health care Provider Sites to easily send messages to BPHC. Health
Care Provider Sites can utilize the Mass HIway LAND device to send messages to the BPHC. The
Mass HIway LAND device should be installed locally on the network of the Health Care Provider
Site and serves to send messages to a corresponding Mass HIway LAND device installed within
the BPHC infrastructure.
The interaction between the Health Care Provider Site applications, the Mass HIway and the
Boston Public Health Commission HIE Infrastructure is illustrated in Figure III-1.
Figure III-1: HIE Gateway Infrastructure
BPHC Network
Sending Health Care Provider Site Network
Health Care Provider Site
Application
BPHC
LAND Device
Provider Site
LAND Device
BPHC HIE Warehouse
BPHC HIE
Database
Data Exchange Broker
Mass HiWAY
The HIE Gateway is invoked through the Mass HIway by message interactions between the
Health Care Provider Site LAND Device and the BPHC LAND Device. To achieve interoperability
between Health Care Provider Sites and the BPHC, the LAND devices serve as intermediaries
that mediate communications between the backend systems involved.
Page 43 of 256
1.8 Typical Transaction Sequence Diagram
A typical flow of a message through the infrastructure is that messages are constructed by the
Health Care Provider Site Electronic Health Record systems. Then, the message is transmitted
from the MassHIway LAND device at the Health Care Provider Site to the MassHIway LAND
device at BPHC. From there, the message is forwarded to the BPHC HIE Gateway which
includes a message processing engine and secure data warehouse. After processing, a message
Acknowledgement is sent back through the MassHIway LAND devices from BPHC to the sending
Health Care Provider Site to confirm receipt of the message.
The following diagram illustrates this system interaction:
Figure III-2: Send / Receive Health Equity Message Choreography
Boston Public Health HIE
System
Sending Organization
Capture Data Related to
the Patient Encounter
Perform Coding for the
Encounter and Related
Activities
Create BPHC Health
Disparities Report
Send to BPHC via the Mass
HiWAY
ACK returned to sending
system
Page 44 of 256
Page 45 of 256
Possible Events That Trigger Sending Health Equity Data
As part of establishing this data exchange interface with BPHC, Health Care Provider Sites must
determine when they will send information. That is, they must determine the specific trigger
points for when their Electronic Health Record Systems will construct and send messages to
BPHC. This section lists some typical events that may be considered as triggers for sending
Health Equity messages to the Boston Public Health Commission. BPHC recognizes that the
workflow at provider sites may differ, so these are just meant as options and will be discussed
further as part of the work effort in establishing the interface.
#
1.
2.
3.
4.
5.
Events to Use as Triggers for Sending Messages
Signing of notes from Inpatient Encounter.
Signing of notes from Outpatient Encounter.
Signing of notes from Emergency Department Encounter.
Update to information within Clinical Record.
Receive Error Acknowledgement.
Page 46 of 256
Message Construction
While the sections above provide some background information and describe the high level
architecture of the BPHC HIE Gateway, the following sections include the detailed information
necessary to construct messages to send to the BPHC.
Document Conventions
This section describes some of the document conventions used in describing the message
structure for sending Health Equity data to BPHC.
1.9 Keywords
The optionality constraints in this Data Submission Guide use the HL7 Consolidated CDA
conformance verbs (copyright 2011 Health Level Seven International):
“The keywords SHALL, SHOULD, MAY, NEED NOT, SHOULD NOT, and SHALL NOT in this
document are to be interpreted as described in the HL7 Version 3 Publishing Facilitator's Guide
(http://www.hl7.org).

SHALL: an absolute requirement.

SHALL NOT: an absolute prohibition against inclusion.

SHOULD/SHOULD NOT: best practice or recommendation. There may be valid
reasons to ignore an item, but the full implications must be understood and carefully
weighed before choosing a different course.

MAY/NEED NOT: truly optional. Can be included or omitted as the author decides
with no implications.
The keyword "SHALL" allows the use of Null Flavor unless the requirement is on an attribute or
the use of Null Flavor is explicitly precluded.
The subject of a conformance verb (keyword) in a top-level constraint is the template itself; in
nested constraints, the subject is the element in the containing constraint.
1.10 Use of XPath
Compliance statements that refer to elements of a CDA document are identified using the
notation defined in XML Path Language (XPath), which is available at
http://www.w3.org/TR/xpath.
1.11 Cardinality
Cardinality expresses the number of times an attribute or association may appear in a CDA
document instance that conforms to the specifications described within section 8. Cardinality is
expressed as a minimum and a maximum value separated by ‘..’, and enclosed in ‘* +’, e.g.,
‘*0..1+’.
Minimum cardinality is expressed as an integer that is equal to or greater than zero. If the
minimum cardinality is zero, the element need only appear in message instances when the
sending application has data with which to value the element. Mandatory elements must have
Page 47 of 256
a minimum cardinality greater than zero.
The maximum cardinality is expressed either as a positive integer (greater than zero and
greater than or equal to the minimum cardinality) or as unlimited using an asterisk (“*”).
The cardinality indicators may be interpreted as follows:




0..1 as zero to one present
1..1 as one and only one present
1..* as one or more present
0..* as zero to many present
1.12 Null Flavor
The Null Flavor definitions in this Data Submission Guide use the HL7 Consolidated CDA Null
Flavor (copyright 2011 Health Level Seven International):
“Information technology solutions store and manage data, but sometimes data are not
available: an item may be unknown, not relevant, or not computable or measureable. In HL7, a
flavor of null, or Null Flavor, describes the reason for missing data.”
For example, if a patient arrives at an Emergency Department unconscious and with no
identification, we would use a null flavor to represent the lack of information. The patient’s
birth date would be represented with a null flavor of “NAV”, which is the code for “temporarily
unavailable”. When the patient regains consciousness or a relative arrives, we expect to know
the patient’s birth date.
Use null flavors for unknown, required, or optional attributes:

NI No information. This is the most general and default null flavor.

NA Not applicable. Known to have no proper value (e.g., last menstrual period for a
male).

UNK Unknown. A proper value is applicable, but is not known.

ASKU Asked, but not known. Information was sought, but not found (e.g., the
patient was asked but did not know).

NAV Temporarily unavailable. The information is not available, but is expected to be
available later.

NASK Not asked. The patient was not asked.

MSK There is information on this item available but it has not been provided by the
sender due to security, privacy, or other reasons. There may be an alternate
mechanism for gaining access to this information.
Page 48 of 256
This above list contains those null flavors that are commonly used in clinical documents. For the
full list and descriptions, see the Null Flavor vocabulary domain in the CDA normative edition.
(HL7
Clinical
Document
Architecture
(CDA
Release
2)
http://www.hl7.org/implement/standards/cda.cfm)
1.13 Required Field Notation
The ‘Opt.’ column used in this guide follows HL7 rules for required element codes that are
described in the table below:
Table III-1: Required Column Codes
Reqd. Meaning
Comment
R
Required
R2
Required if known
CR
Conditionally
Required
A conforming sending application shall populate all “R” elements
with a non-empty value.
Conforming receiving application shall process or ignore the
information conveyed by required elements.
A conforming receiving application must not raise an error due
to the presence of a required element, but may raise an error
due to the absence of a required element.
Fields identified as “R2” may be missing from the message, but
must be sent by the sending application if the data is available. If
the sending application does not know the values, then that
element will be omitted.
Receiving applications will be expected to process or ignore data
contained in the element, but must be able to successfully
process the message if the element is omitted (no error message
should be generated because the element is missing).
This usage has an associated condition predicate. This predicate
is an attribute within the message. If the predicate is satisfied:
A conformant sending application must always send the
element.
A conformant receiving application must process or ignore data
in the element. It may raise an error if the element is not
present.
If the predicate is NOT satisfied:
A conformant sending application must NOT send the
element.
O
Optional
A conformant receiving application must NOT raise an
error if the condition predicate is false and the element is
not present, though it may raise an error if the element IS
present.
This usage indicates that the element may or may not be present
in a message.
Conformant receiving applications may not raise an error if it
Page 49 of 256
Reqd.
Meaning
Comment
receives an unexpected optional element.
N
Not used
The usage indicates that the element is not supported. Sending
applications should not send this element. Receiving applications
should ignore this element if present. A receiving application
should not raise an error if it receives an unsupported element.
1.14 Message Examples
Each template described in section 8 provides an XML example for that template. Dynamic
message components are bolded to draw attention to the parts of the message that will
change. Static parts of the message are lightened as these will be the same in all messages.
Figure III-3 Message Example Convention Figure
<observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="2.16.840.1.113883.3.96.1.3" extension=“9d9ee34a-23f4-47eb-8298-f520fc2cc9d1”/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖/>
<effectiveTime>
<low value="20060501"/>
<high value="20120601"/>
</effectiveTime>
<value xsi:type="CD" code="419511003" displayName="Propensity to adverse reactions to drug"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
The free text from which the value code was derived from
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="763049" displayName="Codeine 30mg/ml"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
The free text from which the product code was derived from
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
</observation>
Page 50 of 256
BPHC Health Equity Reporting
1.15 CDA CCD Document Module
The CCD is a core data set of the most relevant administrative, demographic, and clinical
information facts about a patient's healthcare, covering one or more healthcare encounters. It
provides a means for one healthcare practitioner, system, or setting to aggregate all of the
pertinent data about a patient and forward it to another practitioner, system, or setting to
support the continuity of care. The primary use case for the CCD is to provide a snapshot in
time containing the pertinent clinical, demographic, and administrative data for a specific
patient
Template Id
Document Code
Opt
R
[1..1]
R
[1..1]
R
[1..1]
R
[1..1]
R2
[1..1]
R
[1..1]
R
[1..1]
R2
[0..1]
R
[1..1]
R2
[0..1]
R2
[0..1]
Data Element or
Section Name
US Realm Clinical Document = 2.16.840.1.113883.10.20.22.1.1
LOINC = 34133-9 Summarization of Episode Note
Location
Section Template Id
CCD Header Section
2.16.840.1.113883.10.20.22.1.2
CDA Header Content
Allergies Section
2.16.840.1.113883.10.20.22.2.6
Allergies Section
Medications Section
2.16.840.1.113883.10.20.22.2.1.1
Medications Section
Problem List Section
2.16.840.1.113883.10.20.22.2.5.1
Problem List Section
Procedures Section
2.16.840.1.113883.10.20.22.2.7.1
Procedures Section
Results Section
2.16.840.1.113883.10.20.22.2.3.1
Results Section
Encounters Section
2.16.840.1.113883.10.20.22.2.22
Encounters Section
Immunizations Section
2.16.840.1.113883.10.20.22.2.2
Immunizations Section
Payers Section
2.16.840.1.113883.10.20.22.2.18
Payers Section
Social History Section
2.16.840.1.113883.10.20.22.2.17
Social History Section
Vital Signs Section
2.16.840.1.113883.10.20.22.2.4
Vital Signs Section
1.15.1 CDA Header Content
Table III-2 CCD Document Constraints Overview
Name
XPath
Card
Opt
ClinicalDocument
1..1
R
Data
Type
Fixed Value
Page 51 of 256
Name
XPath
Card
Opt
Data
Type
@xmlns:xsi
R
http://www.w3.org/2001/XMLSche
ma-instance
@xmlns
R
urn:hl7-org:v3
@xmlns:cda
R
urn:hl7-org:v3
@xmlns:sdtc
R
urn:hl7-org:sdtc
R
US
realCode
1..1
@code
typeId
R
1..1
R
@root
R
2.16.840.1.113883.1.3
@extension
R
POCD_HD000040
templateId
2..2
R
2.16.840.1.113883.10.20.22.1.1
and
2.16.840.1.113883.10.20.22.1.2 for
the second
@root
id
Message Id
Fixed Value
1..1
R
1..1
R
@root
code
CD
@code
R
34133-9
@displayName
R
Summarization of Episode Note
@codeSystem
R
2.16.840.1.113883.6.1
@codeSystemName
R
LOINC
title
1..1
R
1..1
R
effectiveTime
Start Date
low
@value
End Date
high
R
0..1
@value
confidentialityCode
R2
TS
R
1..1
R
CD
@code
R
N
@displayName
R
Normal
@codeSystem
R
2.16.840.1.113883.5.25
@codeSystemName
R
Confidentiality Code
languageCode
1..1
@code
Service Event
TS
documentationOf
R
R
1..1
CD
en-US
R
Page 52 of 256
Name
XPath
serviceEvent
Card
Opt
1..1
R
Document
Author
author
1..1
R
Patient
recordTarget
1..1
R
patientRole
1..1
R
Document
Owner
custodian
1..1
R
Relatives
participant
1..*
R
@typeCode
Encounter
componentOf
encompassingEncounter
Data
Type
Fixed Value
R
1..1
R
1..1
R
Specification
1. SHALL contain exactly one [1..1] realmCode="US"
2. SHALL contain exactly one [1..1] typeId such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3"
b. SHALL contain exactly one [1..1] @extension="POCD_HD000040"
3. SHALL contain exactly one [1..1] templateId such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1"
4. SHALL contain exactly one [1..1] id such that it
a. SHALL contain exactly one [1..1] @root set to the organization id in which the
message was generated by
b. SHALL contain exactly one [1..1] @extension set to a unique identifier for the
message within the organization. If the same message is sent at a later date, the
id SHOULD contain the same message id.
c. BPHC Captured: The message id is requested for capture to allow BPHC to easily
identify a message. The unique identifier will help to distinguish repeat
message, determine which message resulted in changes and for easy reference
to the same message among systems.
5. SHALL contain exactly one [1..1] code such that it
a. SHALL contain exactly one @code="34133-9"
b. SHALL contain exactly one @displayName = “Summarization of Episode Note”
c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.1”.
d. SHOULD contain exactly one @codeSystemName = “LOINC”
6. SHALL contain exactly one [1..1] title
a. Can either be a locally defined name or the display name corresponding to
clinicalDocument/code
7. SHALL contain exactly one [1..1] effectiveTime
a. BPHC Captured: The effective time signifies that time that encounter took place.
Minimally the start time of the encounter should be specified and the end time is
strongly suggested. The encounter start and end date is used by BPHC to
Page 53 of 256
determine the timeframe in which the encounter belongs as well as to
determine the order and distance between chronological events related to the
encounter. The encounter time is used in utilization measures and for measures
that measure time from the encounter start to a specific event occurring such as
the time to PCI.
8. SHALL contain exactly one [1..1] confidentialityCode such that it
a. SHALL contain exactly one @code="N"
b. SHALL contain exactly one @displayName = “Normal”
d. SHOULD contain exactly one @codeSystemName = “Confidentiality Code”
9. SHALL contain exactly one [1..1] languageCode such that it
a. SHALL contain exactly one @code="en-US"
Figure III-4 CCD Document Example

<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">

<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>

<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!—CCD Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<id extension="TT988" root="2.16.840.1.113883.19.5.99999.1"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9"
displayName="Summarization of Episode Note"/>
<title>Community Health and Hospitals: Health Summary</title>
<effectiveTime >
<low value="201209150000-0400"/>
</effectiveTime>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
…
</patientRole
</recordTarget>
<author>
…
</author>
<custodian>
<assignedCustodian>
…
</assignedCustodian>
</custodian>
<documentationOf>
<serviceEvent classCode="PCPR">
…
</serviceEvent>
</documentationOf>
<component>
<structuredBody>

<component>
<section>
…
</section>
</component>
…
</structuredBody>
Page 54 of 256
</component>
</ClinicalDocument>
1.15.2 CCD Author Content
The author element represents the creator of the clinical document. The author may be a
device, or a person.
Table III-3 CCD Author Constraints Overview
Name
XPath
Card
Opt
author
1..1
R
time
Data
Type
R
@value
assignedAuthor
id
PCPR
R
1..1
R
1..1
R
@root
R
@extension
R
code
Fixed Value
1..1
R
CD
@code
R
@displayName
R
@codeSystem
R
2.16.840.1.113883.6.101
@codeSystemName
R
NUCC Health Care Provider
Taxonomy
addr
1..1
R
Addr
telecom
1..1
R2
Tel
assignedPerson
0..1
R2
Person
0..1
R2
manufacturuerModelName
1..1
R
softwareName
1..1
R
assignedDevice
Specification
1. SHALL contain at least one [1..*] author such that it
a. SHALL contain exactly one [1..1] time
i. SHALL contain exactly one [1..1] @value
b. SHALL contain exactly one [1..1] assignedAuthor such that it
i. SHALL contain exactly one [1..1] id such that it
1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6"
National Provider Identifier
ii. SHOULD contain zero or one [0..1] code such that it
Page 55 of 256
iii.
iv.
v.
vi.
vii.
1. SHOULD contain exactly one [1..1] @code, which SHOULD be
selected from ValueSet Healthcare Provider Taxonomy (NUCC HIPAA) 2.16.840.1.114222.4.11.1066 DYNAMIC
SHALL contain at least one [1..*] addr
SHALL contain at least one [1..*] telecom
SHOULD contain zero or one [0..1] assignedPerson
SHOULD contain zero or one [0..1] assignedAuthoringDevice such that it
1. SHALL contain exactly one [1..1] manufacturerModelName
2. SHALL contain exactly one [1..1] softwareName
There SHALL be exactly one assignedAuthor/assignedPerson or exactly
one assignedAuthor/assignedAuthoringDevice
Figure III-5 CCD Author Example
<author>
<time value="20050329224411+0500"/>
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
Page 56 of 256
1.15.3 CCD Custodian Content
The custodian element represents the organization that is in charge of maintaining the
document. The custodian is the steward that is entrusted with the care of the document. Every
CDA document has exactly one custodian. The custodian participation satisfies the CDA
definition of Stewardship. Since CDA is an exchange standard and may not represent the
original form of the authenticated document (e.g., CDA could include scanned copy of original),
the custodian represents the steward of the original source document. The custodian may be
the document originator, a health information exchange, or other responsible party.
Table III-4 CCD Custodian Constraints Overview
Name
XPath
Card
Opt
custodian
1..1
R
1..1
R
1..1
R
assignedCustodian
representedCustodianOrganiza
tion
Data
Type
Fixed Value
Organiz
ation
Specification
1. SHALL contain exactly one [1..1] custodian such that it
a. SHALL contain exactly one [1..1] assignedCustodian such that it
i. SHALL contain exactly one [1..1] representedCustodianOrganization such
that it
1. SHALL contain at least one [1..*] id such that it
a. SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier
2. SHALL contain exactly one [1..1] name
3. SHALL contain exactly one [1..1] telecom
4. SHALL contain at least one [1..*] addr
Figure III-6 CCD Custodian Example
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom value="tel: 555-555-1002" use="WP"/>
<addr use="WP">
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<state>OR</state>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
Page 57 of 256
1.15.4 CCD Record Target Content
The recordTarget records the patient whose health information is described by the clinical
document; each recordTarget must contain at least one patientRole element.
Table III-5 CCD Record Target Constraints Overview
Name
XPath
Card
Opt
recordTarget/patientRole
1..1
R
1..1
R
id
@root
R
@extension
R
addr
1..*
R
telecom
1..*
R
1..1
R2
Data
Type
Fixed Value
Addr
patient
id
Gender
Marital
Status
Race
Ethnicity
@root
R
@extension
R
name
1..1
R
administrativeGenderCode
1..1
R
Person
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.1
@codeSystemName
R2
AdministrativeGender
maritalStatusCode
0..1
R2
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.2
@codeSystemName
R2
MaritalStautsCode
raceCode
0..1
R2
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.238
@codeSystemName
R2
Race & Ethnicity - CDC
ethnicGroupCode
@code
0..1
R2
R
Page 58 of 256
Name
Guardian
Relative Type
XPath
Card
Opt
Data
Type
Fixed Value
@displayName
R2
@codeSystem
R
2.16.840.1.113883.3.539.1.1
@codeSystemName
R2
BPHC Ethnicity ValueSet
guardian
0..*
R2
code
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.111
@codeSystemName
R2
RoleCode
addr
0..*
R2
Addr
telecom
0..*
R2
Tel
guardianPerson
0..1
R2
Person
birthplace
0..1
R2
place
1..1
R
1..1
R
0..*
R2
1..1
R
addr
languageCommunication
code
Addr
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.1.11.11526
@codeSystemName
R2
Internet Society Language
preferenceInd
0..1
@value
providerOrganization
id
R2
R
0..1
R2
1..1
R
@root
R
@extension
R
name
1..1
R
ED
telecom
1..*
R
Tel
addr
1..*
R
Addr
Specification
1. SHALL contain exactly one [1..1] recordTarget such that it
a. Such recordTargets SHALL contain exactly one [1..1] patientRole
i. This patientRole SHALL contain at least one [1..*] id such that it
1. SHALL contain exactly one @root
Page 59 of 256
a. The root should contain the OID of the sending
application/EMR in which the MRN for the patient is
assigned and maintained for this encounter. If an
organization has a specific OID representing the MRN
number then that OID should be used.
2. SHALL contain exactly one @extension
a. BPHC requires that the extension be populated with the
patient’s MRN number.
3. BPHC Captured: BPHC requires the MRN field for capture to
uniquely identify a patient without complex patient matching
algorithm when multiple messages are received from the same
organization for the same patient.
ii. This patientRole SHALL contain at least one [1..*] addr
1. BPHC Captured: BPHC requires the patient’s address for research
purposes that may include, but are not limited to, research on
health equity and how it pertains to and is potentially impacted
by geographic address of their residence.
iii. This patientRole SHALL contain at least one [1..*] telecom
1.
iv. This patientRole SHALL contain exactly one [1..1] patient such that it
1. SHOULD contain exactly one [1..1] id for the SSN such that it
a. SHALL contain exactly one [1..1] @root =
“2.16.840.1.113883.4.1”
b. SHALL contain exactly one [1..1] @extension
i. The extension should be set to the Patient’s Social
Security Number in the formatted without spaces
or dashes. (999999999)
c. BPHC Captured: BPHC requires the SSN field for capture to
uniquely identify a patient that has been assigned one.
The SSN can be used to match patients across multiple
organizations that with separate medical record numbers.
2. This patient SHALL contain exactly one [1..1] name
3. This patient SHALL contain exactly one [1..1]
administrativeGenderCode, which SHALL be selected from
ValueSet Administrative Gender (HL7 V3)
2.16.840.1.113883.1.11.1 DYNAMIC
a. BPHC Captured: BPHC requires the patient’s gender for
research purposes that may include, but are not limited to,
research on risk factors and how they pertain to each
gender, gender inequality, and gender specific diagnoses.
4. This patient SHALL contain exactly one [1..1] birthTime
a. SHALL be precise to year
b. SHOULD be precise to day
c. BPHC Captured: BPHC requires the patient’s birth time to
determine that patient’s age at the time of an encounter.
Page 60 of 256
Many of the national HEDIS measures require reporting on
specific age ranges and therefore require the patient’s age
to be known.
5. This patient SHOULD contain zero or one [0..1]
maritalStatusCode, which SHALL be selected from ValueSet HL7
MaritalStatus 2.16.840.1.113883.1.11.12212 DYNAMIC
a. BPHC Captured: BPHC requires the patient’s marital status
for research purposes that may include, but are not
limited to, research on health equity and how it pertains to
and is potentially impacted by marital status.
6. This patient MAY contain zero or one [0..1] raceCode, which
SHALL be selected from ValueSet Race
2.16.840.1.113883.1.11.14914 DYNAMIC
a. BPHC Captured: BPHC requires the patient’s race for
research on health equity and how it pertains to and is
potentially impacted by race.
7. This patient MAY contain zero or one [0..1] ethnicGroupCode,
which SHALL be selected from ValueSet Ethnicity Value
2.16.840.1.114222.4.11.837 DYNAMIC
a. BPHC Captured: BPHC requires the patient’s ethnicity for
research on health equity and how it pertains to and is
potentially impacted by ethnicity.
8. This patient MAY contain zero or more [0..*] guardian
a. The guardian, if present, SHOULD contain zero or one
[0..1] code, which SHALL be selected from ValueSet
Personal Relationship Role Type
2.16.840.1.113883.1.11.19563 DYNAMIC
b. The guardian, if present, SHOULD contain zero or more
[0..*] addr
c. The guardian, if present, MAY contain zero or more [0..*]
telecom
d. The guardian, if present, SHALL contain exactly one [1..1]
guardianPerson
9. This patient MAY contain zero or one [0..1] birthplace
a. The birthplace, if present, SHALL contain exactly one [1..1]
place
i. This place SHALL contain exactly one [1..1] addr
10. This patient SHOULD contain zero or more [0..*]
languageCommunication
a. The languageCommunication, if present, SHALL contain
exactly one [1..1] languageCode, which SHALL be selected
from ValueSet Language 2.16.840.1.113883.1.11.11526
DYNAMIC
Page 61 of 256
b. The languageCommunication, if present, MAY contain zero
or one [0..1] preferenceInd
v. This patientRole MAY contain zero or one [0..1] providerOrganization
1. BPHC Captured: BPHC requests the provider organization to
facilitate any follow-up and support research.
Figure III-7 CCD Record Target Example
<recordTarget>
<patientRole>
<id extension="998991" root="2.16.840.1.113883.19.5.99999.2"/>

<id extension="111-00-2330" root="2.16.840.1.113883.4.1"/>

<addr use="HP">

<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>

</addr>
<telecom value="tel:(816)276-6909" use="HP"/>

<patient>
<name use="L">

<given>Isabella</given>
<given>Isa</given>

<family>Jones</family>
</name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"
displayName="Female"/>
<birthTime value="19750501"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2"
codeSystemName="MaritalStatusCode"/>
<raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race & Ethnicity - CDC"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<guardian>
<code code="PRN" displayName="Parent" codeSystem="2.16.840.1.113883.5.111"
codeSystemName="HL7 Role code"/>
<addr use="HP">

<streetAddressLine>1357 Amber Drive</streetAddressLine>
<state>OR</state>

</addr>
<telecom value="tel:(816)276-6909" use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Jones</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<state>OR</state>
Page 62 of 256
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="en"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.4.6"/>
<telecom use="WP" value="tel: 555-555-5000"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<state>OR</state>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
Page 63 of 256
1.15.5 CCD Service Event Content
A serviceEvent represents the main act, such as a colonoscopy or a cardiac stress study, being
documented. In a continuity of care document, CCD, the serviceEvent is a provision of
healthcare over a period of time. In a provision of healthcare serviceEvent, the care providers,
PCP or other longitudinal providers, are recorded within the serviceEvent. The BPHC Health
Equity Report constrains the message to refer only to a single encounter recorded in the
Encounters Section.
Table III-6 CCD Service Event Constraints Overview
Name
XPath
Car
d
Op
t
serviceEvent
1..1
R
@classCode
Data
Type
R
Fixed Value
PCPR
effectiveTime
Start Date
low
1..1
@value
End Date
high
0..1
Provider
Role
performer
functionCode
R2
TS
R
0..*
R2
0..1
R2
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.88
@codeSystemName
R2
ParticipationFunction
assignedEntity
id
Provider
Type
TS
R
@value
Provider(s)
R
1..1
R
1..1
R
@root
R
@extension
R
code
0..1
O
@code
R
@displayName
R2
@codeSystem
R
@codeSystemName
R2
addr
1..1
R
Addr
telecom
1..1
R
Tel
assignedPerson
0..1
R2
Person
Page 64 of 256
Name
XPath
representedOrganization
Car
d
Op
t
Data
Type
0..1
R2
Organiza
tion
Fixed Value
Specification
1. MAY contain zero or more [0..*] documentationOf such that it
a. SHALL contain exactly one [1..1] serviceEvent such that it
i. SHALL contain exactly one [1..1] effectiveTime such that it
1. SHALL contain exactly one [1..1] low
ii. SHOULD contain zero or more [0..*] performer such that it
1. SHALL contain exactly one [1..1] @typeCode="PRF" Participation
physical performer (CodeSystem: HL7ParticipationType
2.16.840.1.113883.5.90)
a. The performer participant represents clinicians who
actually and principally carry out the serviceEvent. In a
transfer of care this represents the healthcare providers
involved in the current or pertinent historical care of the
patient. Preferably, the patient’s key healthcare care team
members would be listed, particularly their primary
physician and any active consulting physicians, therapists,
and counselors
2. SHOULD contain zero or one [0..1] functionCode
a. SHALL contain exactly one [1..1] @code, which SHALL be
selected from CodeSystem ParticipationFunction
2.16.840.1.113883.5.88
b. SHOULD contain exactly one @displayName such that the
value is set accordingly based on the code chosen
c. SHALL contain exactly one @codeSystem =
“2.16.840.1.113883.5.88”
d. SHOULD contain exactly one @codeSystemName =
“ParticipationFunction”
e. BPHC Captured: BPHC requires this field to capture the
provider’s role in the healthcare of a patient. Many of the
HEDIS Measures require a determination if the role of a
provider is a Primary Care Physician or not.
3. SHALL contain exactly one [1..1] assignedEntity such that it
a. SHALL contain exactly one [1..1] id such that it
i. SHALL contain exactly one [1..1] @root =
"2.16.840.1.113883.4.6" National Provider
Identifier
ii. SHALL contain exactly one [1..1] @extension
1. The extension shall be populated with the
provider’s NPI.
Page 65 of 256
b.
c.
d.
e.
f.
iii. BPHC Captured: BPHC requires the id field to
uniquely identify a provider using a national
identifier. The identifier can be used to reference
the provider internally as well as to perform follow
up with outside systems.
SHOULD contain zero or one [0..1] code for the provider
type such that it
i. SHALL contain exactly one [1..1] @code, which
SHOULD be selected from CodeSystem
NUCCProviderTaxonomy (2.16.840.1.113883.6.101)
ii. SHOULD contain exactly one @displayName such
that the value is set accordingly based on the code
chosen
iii. SHALL contain exactly one @codeSystem =
“2.16.840.1.113883.6.101”
iv. SHOULD contain exactly one @codeSystemName =
“NUCCProviderTaxonomy”
v. BPHC Captured: The provider type is required for
capture since it is used in various HEDIS measures
to help determine the visit type. The provider type
should always be specified when known.
SHALL contain exactly one [1..1] addr
SHALL contain exactly one [1..1] telecom
SHOULD contain zero or one [0..1] assignedPerson
i. BPHC Captured: BPHC requests the assigned
person to facilitate any follow-up and support
research.
SHOULD contain zero or one [0..1]
i. BPHC Captured: BPHC requests the provider
organization to facilitate any follow-up and support
research.
Figure III-8 CCD Service Event Example
<documentationOf>
<serviceEvent classCode="PCPR">
<code code="73761001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
displayName="Colonoscopy"/>
<effectiveTime>
<low value="201209080000-0400"/>
<high value="201209150000-0400"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="PP" displayName="Primary Performer"
codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<assignedEntity>

<id extension="PseudoMD-1" root="2.16.840.1.113883.4.6"/>
Page 66 of 256
<code code="207RG0100X" displayName="Gastroenterologist"
codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101"/>
<addr>
<state>OR</state>
</addr>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5.9999.1393"/>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<addr>
<state>OR</state>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
Page 67 of 256
1.16 CDA Section Level Templates
The BPHC Health Equity Report uses the HL7 CCD Templates described in this section with
additional constraints where indicated.
1.16.1 Allergies Section
This section lists and describes any medication allergies, adverse reactions, idiosyncratic
reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or
adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives) used to
assure the safety of health care delivery. At a minimum, it should list currently active and any
relevant historical allergies and adverse reactions.
Table III-1 – Allergies Section 2.16.840.1.113883.10.20.22.2.6
Opt
R2
[0..1]
Template Id
2.16.840.1.113883.10.20.22.2.6
Section Code
LOINC 48765-2 Allergies, adverse reactions, alerts
Entry Name
Allergy Problem
Entry Template Id
2.16.840.1.113883.10.20.22.4.30
Location
Allergy Problem Act
Specification
a. SHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.28".
b. SHALL contain exactly one @displayName = “Allergies, adverse reactions, alerts”
3. SHALL contain exactly one [1..1] title such that it
a. SHALL contain the text “Allergies”
4. SHALL contain exactly one [1..1] text.
a. SHALL contain a text narrative that lists and describes all current and historical
allergies and adverse reactions.
b. BPHC Captured: The section text is a human readable summary of all Allergies
and related information. The text should be a detailed representation of the
coded content within the section including all original text from which the codes
were determined. BPHC requires the text field for auditing purposes.
5. SHALL contain at least one [1..*] entry such that it
a. SHALL contain exactly one [1..1] @typeCode = “DRIV” (Is Derived From)
b. SHALL contain exactly one [1..1] Allergy Problem Act
(2.16.840.1.113883.10.20.22.4.30)
Page 68 of 256
Figure III-9 Allergies Section Example
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.6"/>
<code code="48765-2"
displayName="Allergies, adverse reactions, alerts"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<title>Allergies</title>
<text>
The text narrative as described above
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
!-- Allergy Problem Act template -->
...
</act>
</entry>
</section>
Page 69 of 256
1.16.2 Encounters Section
This section lists and describes healthcare encounters. An Encounter is an interaction,
regardless of the setting, between a patient and a practitioner who is vested with primary
responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include
visits, appointments, as well as non-face-to-face interactions. It is also a contact between a
patient and a practitioner who has primary responsibility for assessing and treating the patient
at a given contact, exercising independent judgment. This section is further constrained for the
BPHC Health Equity Report to include exactly one encounter which is the encounter for which
the CCD document is about.
Table III-2 – Encounters Section 2.16.840.1.113883.10.20.22.2.22.1
Opt
R
[1..1]
Template Id
2.16.840.1.113883.10.20.22.2.22.1
Section Code
LOINC 46240-8 History of encounters
Entry Name
Encounter Activities
Entry Template Id
2.16.840.1.113883.10.20.22.4.49
Location
Encounter
Activities_Allergy_problem_Ent
ry
Specification
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.22.1".
b. SHALL contain exactly one @displayName = “History of encounters”
a. SHALL contain the text “Encounters”
a. SHALL contain a text narrative that lists and describes the encounter in which
the CCD document is describing
b. BPHC Captured: The section text is a human readable summary of the single
encounter and related information. The text should be a detailed representation
of the coded content within the section including all original text from which the
codes were determined. BPHC requires the text field for auditing purposes.
Page 70 of 256
b. SHALL contain exactly one [1..1] Encounter Activities
(2.16.840.1.113883.10.20.22.4.49)
Figure III-10 Encounters Section Example
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.22"/>

<code code="46240-8" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="History of encounters"/>
<title>Encounters</title>
<text>
</text>
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>

...
</encounter>
</entry>
</section>
Page 71 of 256
1.16.3 Immunizations Section
The Immunizations section defines a patient's current immunization status and pertinent
immunization history. The primary use case for the Immunization section is to enable
communication of a patient's immunization status. The section should include current
immunization status, and may contain the entire immunization history that is relevant to the
period of time being summarized.
Table III-3 – Immunizations Section 2.16.840.1.113883.10.20.22.2.2
Template Id
2.16.840.1.113883.10.20.22.2.2
Section Code
LOINC 11369-6 Immunizations
Opt
Entry Name
R
[0..*]
Immunization Activity
Entry Template Id
2.16.840.1.113883.10.20.22.4.52
Location
Immunization
Activity_Coverage_Activity
Specification
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.2".
b. SHALL contain exactly one @displayName = “Immunizations”
a. SHALL contain the text “Immunizations”
a. SHALL contain a text narrative that lists and describes all current and relevant
historical immunizations for the patient.
b. BPHC Captured: The section text is a human readable summary of all
Immunizations and related information. The text should be a detailed
representation of the coded content within the section including all original text
from which the codes were determined. BPHC requires the text field for auditing
purposes.
b. SHALL contain exactly one [1..1] Immunization Activity
(2.16.840.1.113883.10.20.22.4.52)
Page 72 of 256
Figure III-11 Immunizations Section Example
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.2"/>
displayName="Immunizations"
codeSystem="2.16.840.1.113883.6.1"
<title>Immunizations</title>
<text>
</text>
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.52"/>

...
</substanceAdministration>
</entry>
...
</section>
Page 73 of 256
1.16.4 Medications Section
The Medications section defines a patient's current medications and pertinent medication
history. At a minimum, the currently active medications are to be listed, with an entire
medication history as an option. The section may also include a patient's prescription and
dispense history.
This section requires that there be either an entry indicating the subject is not known to be on
any medications, or that there be entries summarizing the subject's medications.
Table III-4 – Medications Section 2.16.840.1.113883.10.20.22.2.1
Opt
R
[0..1]
Template Id
2.16.840.1.113883.10.20.22.2.1
Section Code
LOINC 10160-0 History of medication use
Entry Name
Medication Activity
Entry Template Id
2.16.840.1.113883.10.20.22.4.16
Location
Medication
Activity_Allergy_problem_Entry
Specification
a. SHALL contain exactly one @code="10160-0 "
b. SHALL contain exactly one @displayName = “History of medication use”
a. SHALL contain the text “Medications”
medications for the patient.
b. BPHC Captured: The section text is a human readable summary of all
Medications and related information. The text should be a detailed
purposes.
b. SHALL contain exactly one [1..1] Medication Activity
(2.16.840.1.113883.10.20.22.4.16)
Page 74 of 256
Figure III-12 Medications Section Example
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.6"/>
<code code="10160-0 "
displayName=" History of medication use "
codeSystem="2.16.840.1.113883.6.1"
<title>Medications</title>
<text>
</text>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>

...
</entry>
…
</section>
Page 75 of 256
1.16.5 Payers Section
The Payers section contains data on the patient’s payers, whether a ‘third party’ insurance, selfpay, other payer or guarantor, or some combination of payers, and is used to define which
entity is the responsible fiduciary for the financial aspects of a patient’s care.
Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect
from that payer should be included. Authorization information that can be used to define
pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or
similar authorizations for the patient or provider, or both should be included. At a minimum,
the patient’s pertinent current payment sources should be listed.
The sources of payment are represented as a Coverage Activity, which identifies all of the
insurance policies or government or other programs that cover some or all of the patient's
healthcare expenses. The policies or programs are sequenced by preference. The Coverage
Activity has a sequence number that represents the preference order. Each policy or program
identifies the covered party with respect to the payer, so that the identifiers can be recorded.
Table III-5 – Payers Section 2.16.840.1.113883.10.20.22.2.18
Template Id
2.16.840.1.113883.10.20.22.2.18
Section Code
LOINC 48768-6 Payers
Opt
Entry Name
R
[0..*]
Coverage Activity
Entry Template Id
2.16.840.1.113883.10.20.22.4.60
Location
Coverage Activity
Specification
a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.2.18".
a. SHALL contain exactly one @code=" 48768-6"
b. SHALL contain exactly one @displayName = “Payers”
a. SHALL contain the text “Payers”
historical medications for the patient.
b. BPHC Captured: The section text is a human readable summary of all Payers and
related information. The text should be a detailed representation of the coded
Page 76 of 256
content within the section including all original text from which the codes were
determined. BPHC requires the text field for auditing purposes.
b. SHALL contain exactly one [1..1] Coverage Activity
(2.16.840.1.113883.10.20.22.4.60)
Figure III-13 Payers Section Example
<section>
<templateId root=" 2.16.840.1.113883.10.20.22.2.18"/>
<code code=" 48768-6"
displayName="Payers"
codeSystem="2.16.840.1.113883.6.1"
<title>Insurance Providers</title>
<text>
</text>
<act classCode="ACT" moodCode="DEF">
<templateId root="2.16.840.1.113883.10.20.22.4.60"/>

...
</act>
</entry>
…
</section>
Page 77 of 256
1.16.6 Problem List Section
This section lists and describes all relevant clinical problems at the time the document is
generated. At a minimum, all pertinent current and historical problems should be listed.
Table III-6 – Problem List Section 2.16.840.1.113883.10.20.22.2.5
Opt
R
[0..*]
Template Id
2.16.840.1.113883.10.20.22.2.5
Section Code
LOINC 11450-4 Problem List
Entry Name
Product Concern Act
Entry Template Id
2.16.840.1.113883.10.20.22.4.3
Location
Problem Concern
Act_Allergy_problem_Entry
Specification
b. SHALL contain exactly one @displayName = “Problem List”
a. SHALL contain the text “Problems”
historical medications for the patient.
b. BPHC Captured: The section text is a human readable summary of all Problems
b. SHALL contain exactly one [1..1] Problem Concern Act (Condition)
(2.16.840.1.113883.10.20.22.4.3)
Figure III-14 Problem List Section Example
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.5"/>
displayName="Problem List"
codeSystem="2.16.840.1.113883.6.1"
Page 78 of 256
<title>Problems</title>
<text>
</text>

...
</act>
</entry>
…
</section>
Page 79 of 256
1.16.7 Procedures Section
This section defines all interventional, surgical, diagnostic, or therapeutic procedures or
treatments pertinent to the patient historically at the time the document is generated. The
section is intended to include notable procedures, but can contain all procedures for the period
of time being summarized. The common notion of "procedure" is broader than that specified by
the HL7 Version 3 Reference Information Model (RIM). Therefore this section contains
procedure templates represented with three RIM classes: Act, Observation, and Procedure.
Procedure act is for procedures that alter that physical condition of a patient (Splenectomy).
Observation act is for procedures that result in new information about a patient but do not
cause physical alteration (EEG). Act is for all other types of procedures (dressing change).
Table III-7 – Procedures Section 2.16.840.1.113883.10.20.22.2.5
Opt
R2
[0..*]
R2
[0..*]
R2
[0..*]
Template Id
2.16.840.1.113883.10.20.22.2.7
Section Code
LOINC 47519-4 History of Procedures
Entry Name
Procedure Activity
Procedure
Procedure Activity
Observation
Procedure Activity
Act
Entry Template Id
2.16.840.1.113883.10.20.22.4.14
Location
Procedure Activity
Procedure_Problem_Concern_A
ct_Allergy_problem_Entry
2.16.840.1.113883.10.20.22.4.13
Procedure Activity Observation
2.16.840.1.113883.10.20.22.4.12
Procedure Activity Act
Specification
a. SHALL contain exactly one @code="47519-4 "
b. SHALL contain exactly one @displayName = “History of Procedures”
a. SHALL contain the text “Procedures”
historical procedures for the patient.
b. BPHC Captured: The section text is a human readable summary of all Procedures
Page 80 of 256
5. MAY contain zero or more [0..*] entry such that it
a. SHALL contain exactly one [1..1] Procedure Activity Procedure
(2.16.840.1.113883.10.20.22.4.14)
a. SHALL contain exactly one [1..1] Procedure Activity Observation
(2.16.840.1.113883.10.20.22.4.13)
a. SHALL contain exactly one [1..1] Procedure Activity Act
(2.16.840.1.113883.10.20.22.4.12)
8. There SHALL be at least one procedure, observation or act entry conformant to
Procedure Activity Procedure template, Procedure Activity Observation template or
Procedure Activity Act template in the Procedure Section
Figure III-15 Procedures Section Example
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.7"/>

<code code="47519-4" displayName="PROCEDURES"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<title>Procedures</title>
<text>
</text>
<procedure classCode="PROC" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
...
</procedure>
</entry>
<entry>
<templateId root="2.16.840.1.113883.10.20.22.4.13"/>

...
</observation>
</entry>
<entry>
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.22.4.12"/>

...
</act>
</entry>
</section>
Page 81 of 256
1.16.8 Results Section
The Results section contains the results of observations generated by laboratories, imaging
procedures, and other procedures. The scope includes observations such as hematology,
chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI,
angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The
section often includes notable results such as abnormal values or relevant trends, and could
contain all results for the period of time being documented.
Laboratory results are typically generated by laboratories providing analytic services in areas
such as chemistry, hematology, serology, histology, cytology, anatomic pathology,
microbiology, and/or virology. These observations are based on analysis of specimens obtained
from the patient and submitted to the laboratory.
Imaging results are typically generated by a clinician reviewing the output of an imaging
procedure, such as where a cardiologist reports the left ventricular ejection fraction based on
the review of a cardiac echocardiogram.
Procedure results are typically generated by a clinician to provide more granular information
about component observations made during a procedure, such as where a gastroenterologist
reports the size of a polyp observed during a colonoscopy.
Table III-8 – Results Section 2.16.840.1.113883.10.20.22.2.3.1
Opt
R2
[0..*]
Template Id
2.16.840.1.113883.10.20.22.2.3.1
Section Code
LOINC 30954-2 Relevant diagnostic tests and/or laboratory data
Entry Name
Result Organizer
Entry Template Id
2.16.840.1.113883.10.20.22.4.1
Location
Result
Organizer_Medication_Activity_
Allergy_problem_Entry
Specification
b. SHALL contain exactly one @displayName = “Relevant diagnostic tests and/or
laboratory data”
a. SHALL contain the text “Results”
Page 82 of 256
results for the patient.
b. BPHC Captured: The section text is a human readable summary of all Results and
related information. The text should be a detailed representation of the coded
content within the section including all original text from which the codes were
determined. BPHC requires the text field for auditing purposes.
a. SHALL contain exactly one [1..1] Result Organizer
(2.16.840.1.113883.10.20.22.4.1)
Figure III-16 Results Section Example
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
displayName=" Relevant diagnostic tests and/or laboratory data "
codeSystem="2.16.840.1.113883.6.1"
<title>Results</title>
<text>
</text>
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
...
</organizer>
</entry>
…
</section>
Page 83 of 256
1.16.9 Social History Section
This section contains data defining the patient’s occupational, personal (e.g. lifestyle), social,
and environmental history and health risk factors, as well as administrative data such as marital
status, race, ethnicity and religious affiliation. Social history can have significant influence on a
patient’s physical, psychological and emotional health and wellbeing so should be considered in
the development of a complete record.
Table III-9 – Social History Section 2.16.840.1.113883.10.20.22.2.17
Opt
O
[0..*]
O
[0..*]
R2
[0..*]
Template Id
2.16.840.1.113883.10.20.22.2.17
Section Code
LOINC 29762-2 Social History
Entry Name
Social History
Observation
Pregnancy
Observation
Smoking Status
Observation
Entry Template Id
2.16.840.1.113883.10.20.22.4.38
Location
Social History
Observation_Medication_Activit
y_Allergy_problem_Entry
2.16.840.1.113883.10.20.15.3.8
Pregnancy Observation
2.16.840.1.113883.10.22.4.78
Smoking Status Observation
Specification
a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.2.17".
b. SHALL contain exactly one @displayName = “Social History”
a. SHALL contain the text “Social History”
a. SHALL contain a text narrative that lists and describes the patients social history
b. BPHC Captured: The section text is a human readable summary of the patients
Social History and related information. The text should be a detailed
purposes.
a. SHALL contain at least one [1..*] Social History Observation
(2.16.840.1.113883.10.20.22.4.38)
Page 84 of 256
a. SHALL contain exactly one [1..1] Pregnancy Observation
(2.16.840.1.113883.10.20.15.3.8)
7. 7. SHOULD contain zero or more [0..*] entry such that it
a. SHALL contain exactly one [1..1] Smoking Status Observation
(templateId:2.16.840.1.113883.10.22.4.78)
Figure III-17 Social History Section Example
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
displayName=" Social History"
codeSystem="2.16.840.1.113883.6.1"
<title>Social History</title>
<text>
</text>
<templateId root="2.16.840.1.113883.10.20.22.4.38"/>

...
</observation>
</entry>
<templateId root="2.16.840.1.113883.10.20.22.4.38"/>

...
</observation>
</entry>
…
</section>
Page 85 of 256
1.16.10 Vital Signs Section
The Vital Signs section contains relevant vital signs for the context and use case of the
document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass
index, head circumference, and pulse oximetry. The section should include notable vital signs
such as the most recent, maximum and/or minimum, baseline, or relevant trends.
Vital signs are represented in the same way as other results, but are aggregated into their own
section to follow clinical conventions.
Table III-10 – Vital Signs Section 2.16.840.1.113883.10.20.22.2.4.1
Opt
R2
[0..*]
Template Id
2.16.840.1.113883.10.20.22.2.4.1
Section Code
LOINC 30954-2 Relevant diagnostic tests and/or laboratory data
Entry Name
Vital Signs Organizer
Entry Template Id
2.16.840.1.113883.10.20.22.4.26
Location
Vital Signs
Organizer_Result_Organizer_Me
dication_Activity_Allergy_probl
em_Entry
Specification
b. SHALL contain exactly one @displayName = “Vital Signs”
a. SHALL contain the text “Vital Signs”
a. SHALL contain a text narrative that lists and describes all vital signs taken during
the encounter
b. BPHC Captured: The section text is a human readable summary of all Vital Signs
and related information taken during an encounter. The text should be a
detailed representation of the coded content within the section including all
original text from which the codes were determined. BPHC requires the text
field for auditing purposes.
Page 86 of 256
a. SHALL contain exactly one [1..1] Vital Signs
Organizer(2.16.840.1.113883.10.20.22.4.26)
Figure III-18 Vital Signs Section Example
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<code code="8716-3"
displayName="Vital Signs"
codeSystem="2.16.840.1.113883.6.1"
<title>Vital Signs</title>
<text>
</text>
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.26"/>

...
</organizer>
</entry>
…
</section>
Page 87 of 256
1.17 CDA Entry Level Templates
The BPHC Health Equity Report uses the HL7 CCD templates described below, with additional
constraints where indicated.
1.17.1 Allergy – Intolerance Observation
Used By
Allergy Problem Act
Contains Entries
Allergy Status Observation
Severity Observation
This clinical statement represents that an allergy or adverse reaction exists or does not exist.
The agent that is the cause of the allergy or adverse reaction is represented as a manufactured
material participant playing entity in the allergy - intolerance observation. While the agent is
often implicit in the alert observation (e.g. "allergy to penicillin"), it should also be asserted
explicitly as an entity. The manufactured material participant is used to represent natural and
non-natural occurring substances.
Note: The agent responsible for an allergy or adverse reaction is not always a manufactured
material (for example, food allergies), nor is it necessarily consumed. The following constraints
reflect limitations in the base CDA R2 specification, and should be used to represent any type of
responsible agent.
Table III-7 Allergy - Intolerance Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
Data
Type
Fixed Value
@classCode
R
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = EVN
templateId
1..1
@root
id
R
R
1..1
R2
@root
R
@extension
R
code
1..1
R
2.16.840.1.113883.10.20.22.4.7
SET<II
>
CD
@code
R
ASSERTION
@displayName
R2
Assertion
@codeSystem
R
2.16.840.1.113883.5.4
@codeSystemName
R2
ActCode
Page 88 of 256
Name
XPath
statusCode
Op
t
Data
Type
1..1
R
CS
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
low
1..1
R
IVL<TS
>
1..1
R
TS
@value
End Date
high
R
0..1
@value
Allergy Type
Allergy Type
Free Text
Product
value
1..1
R
CD
R
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
originalText
participant
participantRole
playingEntity
0..1
R2
0..1
R2
R
1..1
1..1
code
2.16.840.1.113883.5.110
(RoleClass) = MANU
2.16.840.1.113883.5.41
(EntityClass) = MMAT
R
@code
R
@displayName
R2
@codeSystem
R
R2
@codeSystemName
originalText
2.16.840.1.113883.5.90
(HL7ParticipationType) = CSM
R
R
1..1
CD
R
R
classCode
Product Free
Text
TS
@xsi:type
@classCode
Product
Code
R2
R
@typeCode
Product
Detail
Fixed Value
@code
effectiveTime
Start Date
Car
d
0..1
R2
Page 89 of 256
Name
Allergy
Status
Observation
Severity
Observation
XPath
entryRelationship
Car
d
Op
t
0..1
O
Data
Type
Fixed Value
@typeCode
R
2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SUBJ
@inversionInd
R
true
entryRelationship
0..1
R2
@typeCode
R
2.16.840.1.113883.5.1002
SUBJ
@inversionInd
R
true
Specification
Note: The specification starts within the observation element
1. Conforms to Substance or Device Allergy – Intolerance Observation template
(2.16.840.1.113883.10.20.24.3.90) See HL7 Consolidation Guide.
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6)
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001)
5. SHOULD exactly one [1..1] id such that it
a. SHALL contain exactly one [1..1] @root
i. The root should be set to the sending organization OID
i. The extension should be set to a unique value to represent the Allergy
Intolerance Observation within the sending organization. This ID should
be used whenever this particular Allergy Intolerance Observation is
referenced.
c. BPHC Captured: BPHC requires this field for capture to provide a unique id for
the observation. The unique id can be used to identify the same observation
used in different messages. The HL7 Consolidation Guide requires an id for this
element.
a. SHALL contain exactly one @code="ASSERTION"
b. SHOULD contain exactly one @displayName = “Assertion”
c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.4”
d. SHOULD contain exactly one @codeSystemName = “ActCode”
7. SHALL contain exactly one [1..1] statusCode such that it
Page 90 of 256
a. SHALL contain exactly one @code="completed"
b. SHOULD contain exactly one @displayName = “completed”
d. SHOULD contain exactly one @codeSystemName = “ActStatus”
8. SHALL contain exactly one [1..1] effectiveTime such that it
a. SHALL contain exactly one [1..1] low such that it
i. SHALL contain exactly one [1..1] @value set to the time that the allergy
began. If it is unknown when the allergy began, this low SHALL contain
@nullFLavor="UNK" instead of @value
b. SHOULD contain zero or one [0..1] high if the allergy is no longer a concern such
that it
i. SHALL contain exactly one [1..1] @value set to the time that the allergy
was determined to no longer be a concern
c. BPHC Captured: The effective time of the allergy marks the point at which the
allergy was first discovered and the high time can mark that it is no longer an
allergy. The allergies effective time is captured to help determine the relevance
of the allergy during the encounter.
9. SHALL contain exactly one [1..1] value such that it
a. SHALL contain exactly one [1..1] @xsi:type = "CD"
b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet
Allergy/Adverse Event Type 2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC
c. SHOULD contain exactly one @displayName such that the value is set
accordingly based on the code chosen
d. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96”
e. SHOULD contain exactly one @codeSystemName = “SNOMED CT”
f. SHOULD contain zero or one [0..1] originalText. The original text is a free text
value that should contain all relevant text from which the code was derived.
g. BPHC Captured: BPHC requires the type of allergy to easily categorize the allergy
into a general category of allergies. Allergy type is supplemental information for
various measures that can be the reason in which certain decisions are made
during an encounter. The original text should contain all free text originally used
to determine the coded value. BPHC requires the originalText for auditing
purposes.
10. SHOULD contain zero or one [0..1] participant such that it
a. SHALL contain exactly one [1..1] @typeCode="CSM" Consumable (CodeSystem:
HL7ParticipationType 2.16.840.1.113883.5.90 STATIC)
b. SHALL contain exactly one [1..1] participantRole such that it
i. SHALL contain exactly one [1..1] @classCode="MANU" Manufactured
Product (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC)
ii. SHALL contain exactly one [1..1] playingEntity such that it
1. SHALL contain exactly one [1..1] @classCode="MMAT"
Manufactured Material (CodeSystem: EntityClass
2.16.840.1.113883.5.41 STATIC)
Page 91 of 256
a. SHALL contain exactly one [1..1] @code, which SHALL be
according to type of allergy
i. In an allergy to a specific medication the code
SHALL be selected from the ValueSet
2.16.840.1.113883.3.88.12.80.16 Medication Brand
Name DYNAMIC or the ValueSet
2.16.840.1.113883.3.88.12.80.17 Medication
Clinical Drug DYNAMIC
ii. In an allergy to a class of medications the code
2.16.840.1.113883.3.88.12.80.18 Medication Drug
Class DYNAMIC
iii. In an allergy to a food or other substance the code
2.16.840.1.113883.3.88.12.80.20 Ingredient Name
DYNAMIC
c. SHALL contain exactly one @codeSystem such that the
d. SHOULD contain exactly one @codeSystemName such
that the value is set accordingly based on the codeSystem
chosen
e. SHOULD contain zero or one [0..1] originalText. The
original text is a free text value that should contain all
relevant text from which the code was derived.
f. BPHC Captured: BPHC requires the product code in which
the patient has an allergy to. The product code marks the
specific substance whether it be food, medication or
something else. The allergy substance is supplemental
information for various measures that can be the reason in
which certain decisions are made during an encounter.
For example, if a patient is allergic to aspirin then it will
not be given upon arrival for chest pain. The original text
should contain all free text originally used to determine
the coded value. BPHC requires the originalText for
auditing purposes.
11. MAY contain zero or one [0..1] entryRelationship such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
b. SHALL contain exactly one [1..1] @inversionInd="true" True
c. SHALL contain exactly one [1..1] Allergy Status Observation
(templateId:2.16.840.1.113883.10.20.22.4.28)
Page 92 of 256
12. SHOULD (Not Used) contain zero or more [0..*] entryRelationship (Reaction
Observation)
13. SHOULD contain zero or one [0..1] entryRelationship such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:
c. SHALL contain exactly one [1..1] Severity Observation
(templateId:2.16.840.1.113883.10.20.22.4.8)
Figure III-19 Allergy - Intolerance Observation Example

<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="2.16.840.1.113883.3.96.1.3" extension=“9d9ee34a-23f4-47eb-8298-f520fc2cc9d1”/>
<effectiveTime>
<low value="20060501"/>
<high value="20120601"/>
</effectiveTime>
<value xsi:type="CD" code="419511003" displayName="Propensity to adverse reactions to drug"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="763049" displayName="Codeine 30mg/ml"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
The free text from which the product code was derived from
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
</observation>
Page 93 of 256
1.17.2 Allergy Problem Act
Used By
Allergies Section_Allergy_problem_Entry
Contains Entries
Allergy – Intolerance Observation
This clinical statement act represents a concern relating to a patient's allergies or adverse
events. A concern is a term used when referring to patient's problems that are related to one
another. Observations of problems or other clinical statements captured at a point in time are
wrapped in an Allergy Problem Act, or "Concern" act, which represents the ongoing process
tracked over time. This outer Allergy Problem Act (representing the "Concern") can contain
nested problem observations or other nested clinical statements relevant to the allergy
concern.
Table III-8 Allergy Problem Act Constraints Overview
Name
XPath
Car
d
Op
t
act
1..1
R
Data
Type
Fixed Value
@classCode
R
2.16.840.1.113883.5.6 (HL7ActClass) =
ACT
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
templateId
1..1
@root
id
R
R
1..1
R2
@root
R
@extension
R
code
1..1
R
2.16.840.1.113883.10.20.22.4.30
SET_II
CD
@code
R
48765-2
@displayName
R2
Allergies, adverse reactions, alerts
@codeSystem
R
2.16.840.1.113883.6.1
@codeSystemName
R2
LOINC
statusCode
1..1
R
CS
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
@value
1..1
R
IVL_TS
1..1
R
TS
R
Page 94 of 256
high
0..1
@value
Allergy
Observation
entryRelationship
@typeCode
R2
TS
R
1..*
R
2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SUBJ
Specification
Note: The specification starts within the act element
1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001)
i. The extension should be set to a unique value to represent the Allergy
Problem Act (Concern) within the sending organization. This ID should be
used whenever this particular Allergy Problem Act is referenced.
the Allergy Problem Act. The unique id can be used to identify the same Allergy
Problem Act used in different messages. The HL7 Consolidation Guide requires
an id for this element.
5. SHALL contain exactly one [1..1] code="48765-2" Allergies, adverse reactions, alerts
(CodeSystem: LOINC 2.16.840.1.113883.6.1)
b. SHOULD contain exactly one @displayName = “Allergies, adverse reactions,
alerts”
a. SHALL contain exactly one @code which SHALL be selected from Value Set:
ProblemAct statusCode 2.16.840.1.113883.11.20.9.19 STATIC 2011-09-09
b. SHOULD contain exactly one @displayName such that the value is set
e. BPHC Captured: BPHC requires the status of an allergy concern. The status helps
to determine the relevance of the allergy concern at the time of an encounter.
7. SHALL contain exactly one [1..1] effectiveTime
Page 95 of 256
a. If statusCode=“active” Active, then effectiveTime SHALL contain [1..1] low
b. If statusCode=“completed” Completed, statusCode=“suspended” Suspended,
statusCode=“aborted” Aborted, then effectiveTime SHALL contain [1..1] high and
SHALL contain [1..1] low marking the effective start time
c. BPHC Captured: BPHC requires the effective time of an allergy concern to
determine if the time at which an allergy concern is valid makes the allergy
relevant to the encounter in question.
8. SHALL contain one or more [1..*] entryRelationship such that it
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
b. SHALL contain exactly one [1..1] Allergy – Intolerance Observation (templateId:
2.16.840.1.113883.10.20.22.4.7)
Figure III-20 Allergy Problem Act Example
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root=“2.16.840.1.113883.3.96.1.3” extension="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts" />
<statusCode code="completed" displayName=“completed”
codeSystem=“2.16.840.1.113883.5.14” codeSystemName=“ActStatus”/>
<effectiveTime">
<low value="20060501"/>
<high value="20100501"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
...
</act>
</entry>
Page 96 of 256
1.17.3 Allergy Status Observation
Used By
Allergy – Intolerance
Observation_Allergy_problem_Entry
Contains Entries
This template represents the status of the allergy indicating whether it is active, no longer
active, or is an historic allergy. There can be only one allergy status observation per alert
observation.
Table III-9 Allergy Status Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
Fixed Value
@classCode
R
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = EVN
templateId
1..1
@root
code
R
R
1..1
R
2.16.840.1.113883.10.20.22.4.28
CD
@code
R
33999-4
@displayName
R2
Status
@codeSystem
R
2.16.840.1.113883.6.1
@codeSystemName
R2
LOINC
statusCode
Allergy
Status
Data
Type
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
value
1..1
R
CE
@xsi:type
R
CE
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
Specification
Page 97 of 256
HL7ActClass 2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
b. SHOULD contain exactly one @displayName = “Status”
a. SHALL contain exactly one [1..1] @xsi:type = "CE"
HITSPProblemStatus 2.16.840.1.113883.3.88.12.80.68 DYNAMIC
a. SHOULD contain exactly one @displayName such that the value is set
b. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96”
c. SHOULD contain exactly one @codeSystemName = “SNOMED CT”
d. SHOULD contain zero or one [0..1] originalText. The original text is a free text
e. BPHC Captured: BPHC requires the problem status for an allergy to determine
the relevance of the allergy to the encounter in question. The original text
should contain all free text originally used to determine the coded value. BPHC
requires the originalText for auditing purposes.
Figure III-21 Allergy Status Observation Example
<templateId root="2.16.840.1.113883.10.20.22.4.28" />

<code code="33999-4" displayName="Status"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed" codeSystem=―2.16.840.1.113883.5.14‖ />
<value xsi:type="CE" code="55561003" displayName="Active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName=“SNOMED CT”/>
</observation>
Page 98 of 256
1.17.4 Coverage Activity
Used By
Payers Section_Allergy_problem_Entry
Contains Entries
Policy Activity
A Coverage Activity groups the policy and authorization acts within a Payers Section to order
the payment sources. A Coverage Activity contains one or more policy activities, each of which
contains zero or more authorization activities. The Coverage Activity id is the Id from the
patient's insurance card. The sequenceNumber/@value shows the policy order of preference.
Table III-10 Coverage Activity Constraints Overview
Name
XPath
Car
d
Op
t
act
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass) =
ACT
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
id
R
@extension
R
1..1
Policy
R
2.16.840.1.113883.10.20.22.4.60
SET_II
CD
@code
R
48768-6
@displayName
R2
Payment Sources
@codeSystem
R
2.16.840.1.113883.6.1
@codeSystemName
R2
LOINC
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
0..1
R2
IVL_TS
1..1
R
TS
@value
Expiration
R2
@root
statusCode
Effective
R
R
1..1
code
Encounter
Time
Fixed Value
@classCode
templateId
Coverage Id
Data
Type
high
@value
entryRelationship
R
0..1
R2
1..*
R
R
TS
Page 99 of 256
@typeCode
sequenceNumber
0..1
R
R2
="COMP" CodeSystem:
HL7ActRelationshipType
2.16.840.1.113883.5.1002
Specification
1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode=“EVN” Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001)
4. SHOULD contain exactly one [1..1] id such that it
i. The extension should be set to a unique value to represent the Coverage
Activity within the sending organization. This ID should be used
whenever this Coverage Activity is referenced.
the Coverage Activity. The unique id can be used to identify the same Coverage
Activity used in different messages. The HL7 Consolidation Guide requires an id
for this element.
5. SHALL contain exactly one [1..1] code for the procedure type such that it
a. SHALL contain exactly one [1..1] @code = “48768-6”
b. SHOULD contain exactly one @ = “Payment Sources”
6. SHALL contain exactly one [1..1] statusCode for the procedure type such that it
a. SHALL contain exactly one [1..1] @code = “completed”
b. SHOULD contain exactly one @ = “completed”
7. SHOULD contain zero or one [0..1] effectiveTime such that it
i. SHALL contain exactly [1..1] @value set to the effective time of coverage
b. SHOULD contain zero or one [1..1] high such that it
i. SHALL contain exactly [1..1] @value set to the expiration of coverage
c. BPHC Captured: The coverage effective time describes the period in which the
coverage is valid. The HEDIS measures requires determining gaps in coverage
and therefor BPHC requires the effectiveTime.
8. SHALL contain one or more [1..*] entryRelationship for a specific policy such that it
Page 100 of 256
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component
(CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002)
b. SHOULD contain zero or one [0..1] sequenceNumber to signify the preference
order of the policy
c. SHALL contain exactly one [1..1] Policy Activity
(templateId:2.16.840.1.113883.10.20.22.4.61)
Figure III-22 Coverage Activity Example
<templateId root="2.16.840.1.113883.10.20.22.4.60"/>

<id root="1fe2cdd0-7aad-11db-9fe1-0800200c9a66"/>
codeSystemName="LOINC" displayName="Payment sources"/>
<effectiveTime">
<low value="20120227"/>
<high value="20140227"/>
</effectiveTime>
<entryRelationship typeCode="COMP">
<templateId root="2.16.840.1.113883.10.20.22.4.61"/>

...
</act>
</entryRelationship>
</act>
Page 101 of 256
1.17.5 Encounter Activities
Used By
Encounters Section_Allergy_problem_Entry
Contains Entries
Encounter Diagnosis
Indication
Service Delivery Location
Addr
Organization
Person
Telecom
This clinical statement describes the interactions between the patient and clinicians.
Interactions include in-person encounters, telephone conversations, and email exchanges.
Table III-11 Encounter Activities Constraints Overview
Name
XPath
Car
d
Op
t
procedure
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass) =
ENC
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
id
Encounter
Type Free
Text
Encounter
Time
Start
1..1
R
@root
R
@extension
R
code
1..1
R
2.16.840.1.113883.10.20.22.4.49
SET_II
CD
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.12
@codeSystemName
R2
CPT-4
originalText
effectiveTime
low
0..1
R2
0..1
R2
IVL_TS
1..1
R
TS
high
R
0..1
@value
Disposition
R
R
@value
End
Fixed Value
@classCode
templateId
Visit Type
Data
Type
sdtc:dischargeDispositionCode
R2
TS
R
0..1
R2
Page 102 of 256
Code
Encounter
Provider
Provider
Role
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.12.112 HL7
@codeSystemName
R2
Discharge Disposition
performer
functionCode
@code
@displayName
@codeSystem
@codeSystemName
assignedEntity
id
@root
@extension
Provider
Type
code
@code
@displayName
@codeSystem
0..*
R2
0..1
R2
R
R2
R
2.16.840.1.113883.5.88
R2
ParticipationFunction
1..1
1..*
R
R
R
R
0..1
O
R
R2
R
addr
telecom
assignedPerson
1..1
1..1
0..1
R2
R
R
R2
Addr
Tel
Person
0..1
R2
Organiza
tion
0..*
O
@codeSystemName
Service
Delivery
Location
participant
Visit Reason
@typeCode
entryRelationship
Diagnosis
@typeCode
entryRelationship
0..1
R
R2
0..*
R
R2
Code System
2.16.840.1.113883.5.90
(HL7ParticipationType) = LOC
2.16.840.1.113883.5.1002
(HL7ActRelationshipType)= RSON
Specification
Note: The specification starts within the encounter element
1. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode=“EVN” Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001)
Page 103 of 256
i. The extension should be set to a unique value to represent the Encounter
within the sending organization. This ID should be used whenever this
particular Encounter is referenced.
the Encounter. The unique id can be used to identify the same Encounter in the
case of messages being resent as an update to a previous encounter. The HL7
Consolidation Guide requires an id for this element.
a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from
ValueSet EncounterTypeCode 2.16.840.1.113883.3.88.12.80.32 DYNAMIC
d. SHOULD contain exactly one @codeSystemName = “CPT”
e. SHOULD contain zero or one [0..1] originalText. The original text is a free text
f. BPHC Captured: BPHC requires the encounter type to categorize the type of visit.
Many of the HEDIS and other national measures are restricted to certain visit
types. The original text should contain all free text originally used to determine
the coded value. BPHC requires the originalText for auditing purposes.
i. SHALL contain exactly [1..1] @value set to the start time for the
encounter
i. SHALL contain exactly [1..1] @value set to the end time for the
encounter
c. BPHC Captured: The effective time of an encounter marks the start and end of
an encounter. The effective time of the encounter is considered the visit time.
The visit time is used by the majority of the national measures to determine if an
encounter is within the time frame covered by the measure. The start time can
be used to determine time between related events.
7. MAY contain zero or one [0..1] sdtc:dischargeDispositionCode, which SHALL be selected
from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status
DYNAMIC or, if access to NUBC is unavailable, from CodeSystem
2.16.840.1.113883.12.112 HL7 Discharge Disposition. The prefix sdtc: SHALL be bound
to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary
extension to CDA R2 for the use of the dischargeDispositionCode element
8. SHOULD contain zero or more [0..*] performer for the Provider such that it
Page 104 of 256
a. SHOULD contain zero or one [0..1] functionCode
i. SHALL contain exactly one [1..1] @code, which SHALL be selected from
CodeSystem ParticipationFunction 2.16.840.1.113883.5.88
ii. SHOULD contain exactly one @displayName such that the value is set
iii. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.5.88”
iv. SHOULD contain exactly one @codeSystemName =
“ParticipationFunction”
v. BPHC Captured: BPHC requires this field to capture the provider’s role in
the healthcare of a patient. Many of the HEDIS Measures require a
determination if the role of a provider is a Primary Care Physician or not.
b. SHALL contain exactly one [1..1] assignedEntity such that it
i. SHALL contain at least one [1..*] id such that it
1. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.4.6"
2. SHALL contain exactly one [1..1] @extension
a. The extension shall be populated with the provider’s NPI.
ii. SHALL contain exactly one [1..1] addr
iii. SHALL contain exactly one [1..1] telecom
iv. SHALL contain exactly one [1..1] assignedPerson_Telecom
v. SHOULD contain zero or one [0..1] representedOrganization
1. BPHC Captured: BPHC requests the represented organization to
9. MAY contain zero or more [0..*] participant for the Service Delivery Location such that
it
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem:
b. SHALL contain exactly one [1..1] Service Delivery Location
(templateId:2.16.840.1.113883.10.20.22.4.32)
10. MAY contain zero or more [0..*] entryRelationship such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
b. SHALL contain exactly one [1..1] Indication
(templateId:2.16.840.1.113883.10.20.22.4.19)
11. MAY contain zero or more [0..*] entryRelationship for the encounter diagnosis such
that it
a. SHALL contain exactly one [1..1] Encounter Diagnosis
(templateId:2.16.840.1.113883.10.20.22.4.80
Figure III-23 Encounter Activities Example
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>


Page 105 of 256
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99241" displayName="Office consultation - 15 minutes"
codeSystemName="CPT" codeSystem="2.16.840.1.113883.6.12" codeSystemVersion="4">
<originalText>
The encounter type free text as described above
</originalText>
</code>
<effectiveTime">
<low value="20090227130000+0500"/>
</effectiveTime>
<performer>
<assignedEntity>
<id root=“2.16.840.1.113883.3.96.1.3” extension ="2a620155-9d11-439e-92a3-5d9815ff4de8"/>
<code code="59058001" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="General Physician"/>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<participantRole classCode="SDLOC">
<templateId root="2.16.840.1.113883.10.20.22.4.32"/>

...
</participantRole>
</participant>
<entryRelationship typeCode="RSON">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
...
</observation>
</encounter>
</entry>
Page 106 of 256
1.17.6 Encounter Diagnosis
Used By
Encounter
Activities_Encounters_Section_Allergy_problem_Entry
Contains Entries
Problem Observation
This template wraps relevant problems or diagnoses at the close of a visit or that need to be
followed after the visit. If the encounter is associated with a Hospital Discharge, the Hospital
Discharge Diagnosis template id and codes should be used below must be used. This entry
requires at least one Problem Observation entry
Table III-12 Encounter Diagnosis Constraints Overview
Name
XPath
Car
d
Op
t
act
1..1
R
R
2.16.840.1.113883.5.6
(HL7ActClass) = ACT
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = EVN
@negationInd
O
1..1
@root
Problem
Observation
Fixed Value
@classCode
templateId
Diagnosis
Type
Data
Type
code
R
2.16.840.1.113883.10.20.22.4.80 or
(2.16.840.1.113883.10.20.22.4.33
for Hospital Discharge)
R
1..1
R
CD
29308-4 or (1535-2 for Hospital
Discharge Diagnosis)
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.1
@codeSystemName
R2
LOINC
entryRelationship
@typeCode
1..*
R
R
2.16.840.1.113883.5.1002
Specification
1. SHALL contain exactly one [1..1] @classCode="Act" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
Page 107 of 256
a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.4.80" or
“2.16.840.1.113883.10.20.22.4.33” for a hospital discharge diagnosis
a. SHALL contain exactly one @code =“29308-4” or “1535-2” for hospital discharge
diagnosis
b. SHOULD contain exactly one @displayName = “Diagnosis” or “Hospital
Discharge Diagnosis”
e. BPHC Captured: The encounter diagnosis or diagnoses are captured by BPHC to
determine the relevance of the encounter to specific measures. E.g. an
encounter with a diagnosis related to asthma would cause the encounter to be
included in the Asthma related HEDIS measures run by BPHC.
5. SHALL contain one or more [1..1] entryRelationship for the problem observation such
that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:
b. SHALL contain exactly one [1..1] Problem Observation
(templateId:2.16.840.1.113883.10.20.22.4.4)
Figure III-24 Encounter Diagnosis Example
<!—Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
<code code="29038-4” codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName=" DIAGNOSIS"/>
<entryRelationship typeCode="SUBJ" >
<observation classCode="OBS" moodCode="EVN" >
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>

...
</observation>
</act>
Page 108 of 256
1.17.7 Health Status Observation
Used By
Problem
Observation_Encounters_Section_Allergy_problem_Entry
Contains Entries
The Health Status Observation records information about the current health status of the
patient.
Table III-13 Health Status Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
R
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = EVN
1..1
@root
code
Problem
Status
Fixed Value
@classCode
templateId
Problem
Status Free
Text
Data
Type
R
R
1..1
R
2.16.840.1.113883.10.20.22.4.5
CE
@code
R
11323-3
@displayName
R2
Health Status
@codeSystem
R
2.16.840.1.113883.6.1
@codeSystemName
R2
LOINC
text
0..1
R2
statusCode
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
value
1..1
R
CD
@xsi:type
R
CD
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
Page 109 of 256
Specification
HL7ActClass 2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
b. SHOULD contain exactly one @displayName = “Health Status”
5. SHOULD contain zero or one [0..1] text such that it contains free text describing the
health status and SHOULD include all relevant text used to derived the health status
value code.
a. BPHC Captured: BPHC is not only interested in research surrounding national
measures, but also in the quality of the data being submitted. BPHC requires the
relevant text from which the health status value code was determined for
auditing purposes.
HealthStatus 2.16.840.1.113883.1.11.20.12 DYNAMIC
f. SHOULD contain exactly one @displayName such that the value is set
g. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.96”
h. SHOULD contain exactly one @codeSystemName = “SNOMED CT”
i. BPHC Captured: The value specifies the general health status of the patient. The
health status provides supporting information about the severity of the
encounter and the diagnosis. It also can provide supporting information to the
resolution of health issues related to the encounter.
Figure III-25 Health Status Observation Example
<templateId root="2.16.840.1.113883.10.20.22.4.5" />

<code code="11323-3" displayName="Health status"
Page 110 of 256
<text>
The problem status free text as described above
</text>
<value xsi:type="CD" code="81323004" displayName="Alive and well"
</observation>
Page 111 of 256
1.17.8 Immunization Activity
Used By
Immunizations
Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
Immunization Medication Information
Immunization Refusal Reason
Instructions
Medication Dispense
Medication Supply Order
An Immunization Activity describes immunization substance administrations that have actually
occurred or are intended to occur. Immunization Activities in "INT" mood are reflections of
immunizations a clinician intends a patient to receive. Immunization Activities in "EVN" mood
reflect immunizations actually received.
An Immunization Activity is very similar to a Medication Activity with some key differentiators.
The drug code system is constrained to CVX codes. Administration timing is less complex.
Patient refusal reasons should be captured. All vaccines administered should be fully
documented in the patient's permanent medical record. Healthcare providers who administer
vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the
permanent medical record of the recipient indicates:
1.
2.
3.
4.
Date of administration
Vaccine manufacturer
Vaccine lot number
Name and title of the person who administered the vaccine and the address of the clinic
or facility where the permanent record will reside
5. Vaccine information statement (VIS)
a. date printed on the VIS
b. date VIS given to patient or parent/guardian.
This information should be included in an Immunization Activity when available.
Table III-14 Immunization Activity Constraints Overview
Name
XPath
Car
d
Op
t
substanceAdministration
1..1
R
@classCode
R
@moodCode
R
@negationInd
R2
templateId
1..1
@root
id
Data
Type
2.16.840.1.113883.5.6
(HL7ActClass) = SBADM
R
R
1..1
Fixed Value
R2
2.16.840.1.113883.10.20.22.4.52
SET_II
Page 112 of 256
Name
Car
d
XPath
@root
R
@extension
R
Delivery
Method
Medication
Free Text
Administere
d Date
Medication
Start
1..1
R
text
0..1
R2
statusCode
1..1
R
CS
R2
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
high
1..1
R
IVL_TS
1..1
R
TS
R
1..1
R
TS
R
O
effectiveTime
PIVL_T
S
@institutionSpecified
O
@operator
@xsi:type
R
A
R
PIVL_TS
O
@value
O
@unit
O
O
repeatNumber
Repeat
Number
low
Repeat
Number
High
high
Medication
Route
CD
@displayName
period
Series
Number
Fixed Value
R
@value
Admin
Timing
Data
Type
@code
@value
Medication
Stop
Op
t
R
R2
routeCode
0..1
O
@code
R
@displayName
R2
CE
Page 113 of 256
Name
Body Site
Dose
Quantity
Car
d
XPath
2.16.840.1.113883.3.26.1.1
@codeSystemName
R2
NCI Thesaurus
approachSiteCode
CD
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
doseQuantity
0..1
O
1..1
R
@value
R
@unit
R2
0..1
R
@unit
R2
rateQuantity
0..1
O
1..1
R
@value
R
@unit
R2
0..1
R
@unit
R2
0..1
O
@value
R
@unit
R2
administrationUnitCode
0..1
IVL_P
Q
R2
@value
maxDoseQuantity
IVL_P
Q
R2
@value
O
PQ
CE
@code
R
@displayName
R2
@codeSystem
R
NCI Thesaurus
R2
R
2.16.840.1.113883.3.26.1.1
1..1
1..1
R
0..1
O
@codeSystemName
consumable
manufacturedProduct
Patient
Instructions
O
R
high
Medication
Information
0..1
@code
low
Product
Form
Fixed Value
R
high
Dose
Restriction
Data
Type
@codeSystem
low
Rate
Quantity
Op
t
entryRelationship
Page 114 of 256
Name
XPath
Car
d
@typeCode
@inversionInd
Medication
Supply
Order
entryRelationship
R
0..1
@typeCode
Medication
Dispense
entryRelationship
0..*
entryRelationship
@typeCode
Fixed Value
2.16.840.1.113883.5.1002
true
2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = REFR
R2
R
0..*
Data
Type
O
R
@typeCode
Refusal
Reason
Op
t
R
2.16.840.1.113883.5.1002
R2
R
2.16.840.1.113883.5.1002
RSON
Specification
Note: The specification starts within the substanceAdmin element
1. SHALL contain exactly one [1..1] @classCode=" SBADM" Substance Administration
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet
MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03
a. BPHC Captured: The mood determines whether the observation is an actual
event in which an immunization is to occur or if this marks the intent to perform
an immunization in the future. BPHC requires the field to support the idea of a
scheduled immunization versus one that has been given.
3. SHOULD contain exactly one [1..1] @negationInd, which SHALL be selected as either
“true” or “false”. A value of “true” should be used to indicate that the medication was
not given. “false” is the default value and the attribute is not required if unless the
value should be “true”.
a. BPHC Captured: The negation indicator is required by BPHC if the immunization
was not given for any reason. The field is used as supporting information to
demonstrate that a particular immunization was not given.
i. The extension should be set to a unique value to represent the
Immunization Activity within the sending organization. This ID should be
used whenever this particular Immunization Activity is referenced.
Page 115 of 256
6.
7.
8.
9.
the Immunization Activity. The unique id can be used to identify the same
Immunization Activity across separate messages. The HL7 Consolidation Guide
requires an id for this element.
SHOULD contain zero or one [0..1] text such that it contains free text describing the
immunization activity and SHOULD include all relevant text used to derived the
immunization activity codes.
relevant text from which the immunization activity codes were determined for
auditing purposes.
SHALL contain exactly one [1..1] statusCode such that it
a. SHALL contain exactly one @code, which SHALL be “completed” or “aborted”
e. BPHC Captured: BPHC captures the immunization status in order to mark that a
particular immunization is either complete or aborted and is supporting
information to the immunization activity for the person in question.
SHALL contain exactly one [1..1] effectiveTime for medication timing such that it
medication
b. SHALL contain exactly one [1..1] high such that it
ii. SHALL contain exactly [1..1] @value set to the stop time for the
medication
c. BPHC Captured: BPHC captures the medication timing for the immunization to
determine when a specific immunization was given. The timing knowledge
allows BPHC to perform research and audit surrounding the validity of
immunizations and their effectiveness over time.
SHOULD contain zero or one [0..1] effectiveTime for Administration Timing such that it
a. MAY contain zero or one [0..1] @institutionSpecified, which should be set to
either “true” or “false”
b. SHALL contain exactly one [1..1] @operator="A"
c. SHALL contain exactly one [1..1] @xsi:type=“PIVL_TS”
d. MAY contain zero or one [0..1] period such that it
ii. SHALL contain exactly one [1..1] @unit
e. BPHC Captured: BPHC captures the administration timing when available to
further investigate how an immunization was given to the patient.
Page 116 of 256
10. MAY contain zero or one [0..1] repeatNumber such that it
a. SHALL contain exactly one [1..1] low
b. SHOULD contain zero or one [0..1] high
c. In "INT" (intent) mood, the repeatNumber defines the number of allowed
administrations. For example, a repeatNumber of "3" means that the substance
can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is
the number of occurrences. For example, a repeatNumber of "3" in a substance
administration event means that the current administration is the 3rd in a series
d. BPHC Captured: BPHC captures the repeat number to determine where the
immunization stands in a series of shots that may be given overtime.
11. MAY contain zero or one [0..1] routeCode such that it
a. SHALL contain exactly one @code, which SHALL be selected from ValueSet
Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC
c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.3.26.1.1”
d. SHOULD contain exactly one @codeSystemName = “NCI Thesaurus”
e. BPHC Captured: The route code is captured by BPHC to indicate the method for
the immunization received by the individual. Knowledge of the route can
provide insight into the effectiveness of the available methods for a particular
immunization.
12. MAY contain zero or one [0..1] approachSiteCode such that it
a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Body
Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC
f. BPHC Captured: The approach site code is captured by BPHC to indicate the
anatomical site in which the immunization was given.
13. SHOULD contain zero or one [0..1] doseQuantity such that it
ii. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from
ValueSet UCUM Units of Measure (case sensitive)
2.16.840.1.113883.1.11.12839 DYNAMIC
Page 117 of 256
2.16.840.1.113883.1.11.12839 DYNAMIC
c. Pre-coordinated consumable: If the consumable code is a pre-coordinated unit
dose (e.g. "metoprolol 25mg tablet") then doseQuantity is a unitless number
that indicates the number of products given per administration (e.g. "2",
meaning 2 x "metoprolol 25mg tablet")
d. Not pre-coordinated consumable: If the consumable code is not pre coordinated (e.g. is simply "metoprolol"), then doseQuantity must represent a
physical quantity with @unit, e.g. "25" and "mg", specifying the amount of
product given per administration
e. BPHC Captured: BPHC captures the dose quantity of the immunization to assign
a measurable value to the immunization given.
14. MAY contain zero or one [0..1] rateQuantity such that it
2.16.840.1.113883.1.11.12839 DYNAMIC
2.16.840.1.113883.1.11.12839 DYNAMIC
c. BPHC Captured: BPHC captures (if applicable) the rate quantity of the
immunization to assign a measurable value to the rate at which the
immunization is given.
15. MAY contain zero or one [0..1] maxDoseQuantity such that it
a. SHALL contain exactly one [1..1] @value
b. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from
ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839
DYNAMIC
c. BPHC Captured: BPHC captures the max dosage (if applicable) for the particular
person and immunization.
16. MAY contain zero or one [0..1] administrationUnitCode such that it
Medication Product Form 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC
Page 118 of 256
e. BPHC Captured: BPHC captures the administration unit code when available to
indicate the physical form of the immunization as presented to the individual.
17. SHALL contain exactly one [1..1] consumable for Medication Information
a. This consumable SHALL contain exactly one [1..1] Immunization Medication
Information (templateId:2.16.840.1.113883.10.20.22.4.54)
18. MAY contain zero or one [0..1] entryRelationship for Patient Instructions such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:
c. SHALL contain exactly one [1..1] Instructions
(templateId:2.16.840.1.113883.10.20.22.4.20)
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
b. SHALL contain exactly one [1..1] Medication Supply Order
(templateId:2.16.840.1.113883.10.20.22.4.17)
b. SHALL contain exactly one [1..1] Medication Dispense
(templateId:2.16.840.1.113883.10.20.22.4.18)
a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:
b. SHALL contain exactly one [1..1] Immunization Refusal Reason
templateId:2.16.840.1.113883.10.20.22.4.53)
Figure III-26 Immunization Activity Example
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.52"/>

<id root=“2.16.840.1.113883.3.96.1.3” extension ="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
<text>
The immunization activity free text as described above
</text>
<effectiveTime xsi:type="IVL_TS">
<low value="20070103"/>
</effectiveTime>
<routeCode code="C28161" codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus" displayName="Intramuscular injection"/>
<doseQuantity value="50" unit="mcg"/>
<consumable>
Page 119 of 256
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.54" />

<manufacturedMaterial>
...
</manufacturedMaterial>
<manufacturerOrganization>
<name>Health LS - Immuno Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<entryRelationship>
<templateId root="2.16.840.1.113883.10.20.22.4.20" />

...
</act>
</entry>
1.17.9 Immunization Medication Information
Used By
Medication Dispense
Medication Supply
Order_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
The Immunization Medication Information represents product information about the
immunization substance. The vaccine manufacturer and vaccine lot number are typically
recorded in the medical record and should be included if known.
Table III-15 Immunization Medication Information Constraints Overview
Name
XPath
Car
d
Op
t
manufacturedProduct
1..1
R
@classCode
R
templateId
R
@root
R
manufacturedMaterial
Product
Name
Product
Name Free
code
1..1
R
1..1
R
@code
R
@displayName
R2
@codeSystem
R
@codeSystemName
R2
originalText
0..1
Data
Type
Fixed Value
2.16.840.1.113883.5.110
(RoleClass) = MANU
2.16.840.1.113883.10.20.22.4.54
R2
Page 120 of 256
Name
XPath
Car
d
Op
t
0..1
O
Data
Type
Fixed Value
Text
Brand Name
translation
@code
O
@displayName
O
@codeSystem
O
@codeSystemName
O
Lot Number
lotNumberText
0..1
O
Drug Manu.
manufacturerOrganization
0..1
O
0..1
O
name
Specification
Note: The specification starts within the manufacturedProduct element
1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6)
a. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.10.20.22.4.54"
3. SHALL contain exactly one [1..1] manufacturedMaterial such that it
a. SHALL contain exactly one [1..1] code such that it
i. SHALL contain exactly one [1..1] @code for the product, which SHALL be
selected from ValueSet Vaccine Administered
2.16.840.1.113883.3.88.12.80.22 DYNAMIC
iv. SHOULD contain exactly one @codeSystemName = “RxNorm”
v. SHOULD contain zero or one [0..1] originalText. The original text is a free
text value that should contain all relevant text from which the code was
derived. such that it which
vi. MAY contain zero or more [0..*] translation such that it
1. SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet 2.16.840.1.113883.3.88.12.80.16 Medication Brand
Name DYNAMIC
2. SHOULD contain exactly one @displayName such that the value is
set accordingly based on the code chosen
3. SHALL contain exactly one @codeSystem =
“2.16.840.1.113883.6.88”
4. SHOULD contain exactly one @codeSystemName = “RxNorm”
5. Translations can be used to represent generic product name,
packaged product code, etc.
Page 121 of 256
vii. BPHC Captured: BPHC requires the vaccine and brand name for an
immunization to identify the specific immunization given during an
encounter. The original text should contain all free text originally used to
determine the coded value. BPHC requires the originalText for auditing
purposes.
b. SHOULD contain zero or one [0..1] lotNumberText
i. BPHC Captured: BPHC requires the lot number of the immunization to
identify the particular lot in which the vaccination is from.
4. MAY contain zero or one [0..1] manufacturerOrganization such that it
a. MAY contain zero or one [0..1] name
b. BPHC Captured: BPHC requires the immunization manufacturer’s name to
identify where the immunization given was produced.
Figure III-27 Immunization Medication Information Example
<templateId root="2.16.840.1.113883.10.20.22.4.54"/>

<code code="88" codeSystem="2.16.840.1.113883.12.292 "
displayName="Influenza virus vaccine" codeSystemName="CVX">
<originalText>
The immunization information free text as described above
</originalText>
<translation code="111" displayName="influenza, live, intranasal"
codeSystemName="CVX" codeSystem=" 2.16.840.1.113883.12.292 " />
</code>
<lotNumberText>1</lotNumberText>
<name>Health LS - Immuno Inc.</name>
Page 122 of 256
1.17.10 Immunization Refusal Reason
Used By
Immunization
Activity_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
The Immunization Refusal Reason Observation documents the rationale for the patient
declining an immunization.
Table III-16 Immunization Refusal Reason Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
Data
Type
Fixed Value
@classCode
R
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = EVN
templateId
1..1
@root
code
R
R
1..1
R
2.16.840.1.113883.10.20.22.4.53
CE
@code
R
11323-3
@displayName
R2
Health Status
@codeSystem
R
2.16.840.1.113883.6.1
@codeSystemName
R2
LOINC
statusCode
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
Specification
HL7ActClass 2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
a. SHALL contain exactly one @code, which SHALL be selected ValueSet No
Immunization Reason Value Set 2.16.840.1.113883.1.11.19717 DYNAMIC
Page 123 of 256
d. SHOULD contain exactly one @codeSystemName = “ActReason”
e. BPHC Captured: BPHC captures the immunization refusal reason such as
allergies or religious beliefs in order to document any justification of refusing an
immunization that is normally given.
health status and SHOULD include all relevant text used to derived the health status
code.
relevant text from which the instruction codes were determined for auditing
purposes.
Figure III-28 Immunization Refusal Reason Example
<templateId root="2.16.840.1.113883.10.20.22.4.53" />
<!—Immunization Refusal template -->
<code displayName="Patient Objection" code="PATOBJ"
codeSystemName="HL7 ActNoImmunizationReason" codeSystem="2.16.840.1.113883.5.8"/>
</observation>
Page 124 of 256
1.17.11 Indication
Used By
Encounter
Activities_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
The Indication Observation documents the rationale for an activity. It can do this with the id
element to reference a problem recorded elsewhere in the document or with a code and value
to record the problem type and problem within the Indication. For example, the indication for a
prescription of a painkiller might be a headache that is documented in the Problems Section.
Table III-17 Indication Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
R
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood)= EVN
1..1
@root
code
CD
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
0..1
R2
IVL_TS
1..1
R
TS
high
R
0..1
@value
Value Code
R
2.16.840.1.113883.10.20.22.4.19
@code
@value
End
R
R
1..1
statusCode
Start
Fixed Value
@classCode
templateId
Time
Data
Type
value
R2
TS
R
1..1
R
@xsi:type
CD
CD
@code
R
@displayName
R2
Page 125 of 256
Name
XPath
Car
d
Op
t
Data
Type
Fixed Value
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
originalText
0..1
R2
ED
Specification
1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.4.19"
4. SHALL contain exactly one [1..1] id
a. Set the observation/id equal to an ID on the problem list to signify that problem
as an indication.
b. BPHC Captured: BPHC requires this field for capture to provide a unique id for
the Indication. The unique id can be used to identify the same indication across
separate messages and also allow reference to problems on the problem list. The
HL7 Consolidation Guide requires an id for this element.
Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01
d. SHOULD contain exactly one @codeSystemName = “SNOMED CT”
e. BPHC Captured: BPHC requires the problem type to categorize the type of
problem in which it refers. Many of the HEDIS and other national measures are
restricted to certain conditions that can be identified based on the problem type
and value. The general category of a problem type can also provide justification
as to why a certain medication was given or prescribed.
indication
Page 126 of 256
i. SHALL contain exactly [1..1] @value set to the end time for the indication
c. BPHC Captured: BPHC captures the start and end time for the indication to
determine the relevance of the indication for the time period being evaluated for
a particular measure.
8. SHALL contain exactly one [1..1] value for the indication value such that it
a. SHALL contain exactly one[1..1] @xsi:type =“CD”
b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet:
Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC
d. SHALL contain exactly one @codeSystem=“2.16.840.1.113883.6.96”
e. SHOULD contain exactly one @codeSystemName=“SNOMED CT”
g. BPHC Captured: BPHC requires the indication value to provide insight as to why
a medication may have been given or subscribed. The original text should
contain all free text originally used to determine the coded value. BPHC requires
the originalText for auditing purposes.
Figure III-29 Indication Example
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<code code="404684003" displayName="Finding"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<effectiveTime>
<low value="20070103"/>
</effectiveTime>
<value xsi:type="CD" code="233604007" displayName="Pneumonia"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
Page 127 of 256
1.17.12 Instructions
Used By
Medication Activity
Medication Dispense
Medication Supply
Order_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
The Instructions template can be used in several ways, such as to record patient instructions
within a Medication Activity or to record fill instructions within a supply order. The act/code
defines the type of instruction. Though not defined in this template, a Vaccine Information
Statement (VIS) document could be referenced through act/reference/externalDocument, and
patient awareness of the instructions can be represented with the generic participant and the
participant/awarenessCode.
Table III-18 Instructions Constraints Overview
Name
XPath
Car
d
Op
t
act
1..1
R
Data
Type
Fixed Value
@classCode
R
2.16.840.1.113883.5.6
(HL7ActClass) = ACT
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = INT
templateId
1..1
@root
code
R
R
1..1
R
2.16.840.1.113883.10.20.22.4.20
CD
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
text
0..1
R2
statusCode
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
Specification
2.16.840.1.113883.5.6)
Page 128 of 256
2. SHALL contain exactly one [1..1] @moodCode="INT" Intent (CodeSystem: ActMood
2.16.840.1.113883.5.1001)
Patient Education 2.16.840.1.113883.11.20.9.34 DYNAMIC
e. BPHC Captured: BPHC captures the type of instruction to provide context for the
particular instruction. The actual instructions are recorded in the text field.
5. SHOULD contain zero or one [0..1] text such that it contains free text instructions and
SHOULD include all relevant text used to derive the instruction code as well as the
actual instructions themselves.
relevant text from which the instruction codes were determined for auditing
purposes.
Figure III-30 Instructions Example
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code code="171044003" displayName="immunization education"
<text>
The instruction free text as described above
</text>
</act>
Page 129 of 256
1.17.13 Medication Activity
Used By
Medications Section
Procedure Activity
Procedure_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
Instructions
Medication Dispense
Medication Information
A medication activity describes substance administrations that have actually occurred (e.g. pills
ingested or injections given) or are intended to occur (e.g. "take 2 tablets twice a day for the
next 10 days"). Medication activities in "INT" mood are reflections of what a clinician intends a
patient to be taking. Medication activities in "EVN" mood reflect actual use. Medication timing
is complex. This template requires that there be a substanceAdministration/effectiveTime
valued with a time interval, representing the start and stop dates. Additional effectiveTime
elements are optional, and can be used to represent frequency and other aspects of more
detailed dosing regimens.
Table III-19 Medication Activity Constraints Overview
Name
XPath
Car
d
Op
t
substanceAdministration
1..1
R
@classCode
R
@moodCode
R
@negationInd
R2
templateId
1..1
@root
id
Medication
Free Text
Fixed Value
2.16.840.1.113883.5.6
(HL7ActClass) = SBADM
R
R
1..1
R2
@root
R
@extension
R
Delivery
Method
Data
Type
1..1
R
text
0..1
R2
statusCode
1..1
R
2.16.840.1.113883.10.20.22.4.16
SET_II
CD
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
Page 130 of 256
Name
Medication
Timing
Medication
Start
XPath
effectiveTime
low
Car
d
Op
t
Data
Type
1..1
R
IVL_TS
1..1
R
TS
@value
Medication
Stop
high
R
1..1
@value
Admin
Timing
O
effectiveTime
PIVL_T
S
O
@operator
@xsi:type
R
A
R
PIVL_TS
O
@value
O
@unit
O
Repeat
Number
low
Repeat
Number
High
high
Dose
Quantity
TS
@institutionSpecified
repeatNumber
Body Site
R
R
period
Medication
Route
Fixed Value
O
R
R2
routeCode
0..1
O
CE
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.3.26.1.1
@codeSystemName
R2
NCI Thesaurus
approachSiteCode
0..1
O
CD
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
doseQuantity
low
0..1
O
1..1
R
@value
R
@unit
R2
IVL_P
Q
Page 131 of 256
Name
XPath
high
Rate
Quantity
Medication
Information
Medication
Supply
Order
R2
@unit
R2
rateQuantity
0..1
O
1..1
R
@value
R
@unit
R2
0..1
R
@unit
R2
maxDoseQuantity
0..1
R
@unit
R2
0..1
Fixed Value
IVL_P
Q
O
PQ
CE
@code
R
@displayName
R2
@codeSystem
R
NCI Thesaurus
R2
R
2.16.840.1.113883.3.26.1.1
1..1
1..1
R
0..1
O
@codeSystemName
consumable
entryRelationship
@typeCode
R
@inversionInd
R
entryRelationship
0..1
@typeCode
Medication
Dispense
O
@value
administrationUnitCode
Data
Type
R2
@value
manufacturedProduct
Patient
Instructions
0..1
R
high
Product
Form
Op
t
@value
low
Dose
Restriction
Car
d
entryRelationship
@typeCode
O
R
0..*
2.16.840.1.113883.5.1002
true
2.16.840.1.113883.5.1002
R2
R
2.16.840.1.113883.5.1002
Specification
Note: The specification starts within the substanceAdmin element
Page 132 of 256
1. SHALL contain exactly one [1..1] @classCode=" SBADM" Substance Administration
a. BPHC Captured: The mood determines whether the observation is an actual
event in which medication is received or if medication activity marks the intent
to prescribe medication for the future. BPHC requires the field to pinpoint when
a particular medication is given or to be used based on the encounter.
3. SHOULD contain exactly one [1..1] @negationInd, which SHALL be selected as either
“true” or “false”. A value of “true” should be used to indicate that the medication was
not given. “false” is the default value and the attribute is not required if unless the
value should be “true”.
a. BPHC Captured: The negation indicator is required by BPHC if the medication
was not given for any reason. The field is used as supporting information to
demonstrate that a particular medication was not given in the event that it
typically would.
i. The extension should be set to a unique value to represent the
Medication Activity within the sending organization. This ID should be
used whenever this particular Medication Activity is referenced.
the Medication Activity. The unique id can be used to identify the same
Medication Activity across separate messages. The HL7 Consolidation Guide
medication activity and SHOULD include all relevant text used to derived the medication
activity codes.
relevant text from which the medication activity codes were determined for
auditing purposes.
8. SHALL contain exactly one [1..1] effectiveTime for medication timing such that it
Page 133 of 256
iii. SHALL contain exactly [1..1] @value set to the start time for the
medication
iv. SHALL contain exactly [1..1] @value set to the stop time for the
medication
c. BPHC Captured: The medication timing is captured by BPHC to provide a
measure of when the medication is in effect. Measures relating to controlling
certain conditions such as high blood pressure require knowledge of the
medication and the time period in which it is effective.
9. SHOULD contain zero or one [0..1] effectiveTime for Administration Timing such that it
a. MAY contain zero or one [0..1] @institutionSpecified, which should be set to
either “true” or “false”
b. SHALL contain exactly one [1..1] @operator="A"
c. SHALL contain exactly one [1..1] @xsi:type=“PIVL_TS”
d. MAY contain zero or one [0..1] period such that it
iii. SHALL contain exactly one [1..1] @value
iv. SHALL contain exactly one [1..1] @unit
e. BPHC Captured: The administration timing is captured by BPHC to provide a
measure of when the medication is to be applied during the given medication
time period. Measures relating to controlling certain conditions such as high
blood pressure require knowledge of the medication and how the medication is
administered.
10. MAY contain zero or one [0..1] repeatNumber such that it
a. SHALL contain exactly one [1..1] low
b. SHOULD contain zero or one [0..1] high
c. In "INT" (intent) mood, the repeatNumber defines the number of allowed
administrations. For example, a repeatNumber of "3" means that the substance
can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is
the number of occurrences. For example, a repeatNumber of "3" in a substance
administration event means that the current administration is the 3rd in a series
d. BPHC Captured: BPHC captures the repetition number for the medication to
determine number of allowed administrations or the current count of the
particular medication administration.
11. MAY contain zero or one [0..1] routeCode such that it
Page 134 of 256
e. BPHC Captured: The route code is captured by BPHC to indicate the method for
the medication received by the individual and is supporting information for
controlling conditions through use of medications.
12. MAY contain zero or one [0..1] approachSiteCode such that it
a. SHALL contain exactly one @code, which SHALL be selected from ValueSet Body
f. BPHC Captured: The approach site code is captured by BPHC to indicate the
anatomical site in which the medication was given.
13. SHOULD contain zero or one [0..1] doseQuantity such that it
2.16.840.1.113883.1.11.12839 DYNAMIC
2.16.840.1.113883.1.11.12839 DYNAMIC
c. Pre-coordinated consumable: If the consumable code is a pre-coordinated unit
dose (e.g. "metoprolol 25mg tablet") then doseQuantity is a unitless number
that indicates the number of products given per administration (e.g. "2",
meaning 2 x "metoprolol 25mg tablet")
d. Not pre-coordinated consumable: If the consumable code is not pre coordinated (e.g. is simply "metoprolol"), then doseQuantity must represent a
physical quantity with @unit, e.g. "25" and "mg", specifying the amount of
product given per administration
e. BPHC Captured: BPHC captures the dose quantity to identify the dose given or
prescribed to the patient. As supporting information to controlling a condition
through medication.
14. MAY contain zero or one [0..1] rateQuantity such that it
Page 135 of 256
2.16.840.1.113883.1.11.12839 DYNAMIC
2.16.840.1.113883.1.11.12839 DYNAMIC
c. BPHC Captured: BPHC captures the rate that the medication is given or should
be taken as supporting information to controlling a condition through
medication.
15. MAY contain zero or one [0..1] maxDoseQuantity such that it
b. SHOULD contain zero or one [0..1] @unit, which SHALL be selected from
DYNAMIC
c. BPHC Captured: BPHC captures the max dose quantity when available to identify
the maximum dosage allowed by the patient when taking the medication and is
used as supporting information to controlling a condition through medication.
16. MAY contain zero or one [0..1] administrationUnitCode such that it
e. BPHC Captured: BPHC captures the administration unit code when available to
indicate the physical form of the medication as presented to the individual.
17. SHALL contain exactly one [1..1] consumable for Medication Information
a. This consumable SHALL contain exactly one [1..1] Medication Information
(templateId:2.16.840.1.113883.10.20.22.4.23)
(templateId:2.16.840.1.113883.10.20.22.4.20)
Page 136 of 256
(templateId:2.16.840.1.113883.10.20.22.4.17)
b. SHALL contain exactly one [1..1] Medication Dispense
(templateId:2.16.840.1.113883.10.20.22.4.18)
Figure III-31 Medication Activity Example
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root=“2.16.840.1.113883.3.96.1.3” extension="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<text>
The medication activity free text as described above
</text>
<effectiveTime xsi:type="IVL_TS">
<low value="20070103"/>
<high value="20120515"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<routeCode code="C38216" displayName="RESPIRATORY (INHALATI ON)"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" />
<doseQuantity>
<low value="1" unit="mg/actuat" />
</doseQuantity>
<rateQuantity>
<low value="90" unit="ml/min"/>
</rateQuantity>
<maxDoseQuantity value="1" unit="mg/actuat" />
<administrationUnitCode code="C42944" displayName="INHALANT"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" />
<consumable>
<templateId root="2.16.840.1.113883.10.20.22.4.23" />
...
</consumable>
<templateId root="2.16.840.1.113883.10.20.22.4.20" />
...
</act>
<entryRelationship typeCode="REFR">
<supply classCode="SPLY" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.22.4.17" />

...
</supply>
<supply classCode="SPLY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.18" />

...
</supply>
Page 137 of 256
</entry>
1.17.14 Medication Dispense
Used By
Medication Activity
Immunization
Contains Entries
Immunization Medication
Information
This template records the intent to supply a patient with medications.
Table III-20 Medication Dispense Constraints Overview
Name
XPath
Car
d
Op
t
supply
1..1
R
R
2.16.840.1.113883.5.6
(HL7ActClass) = SPLY
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = EVN
1..1
@root
Fill Status
Dispense
Date
id
R
R
@root
R
@extension
R
statusCode
2.16.840.1.113883.10.20.22.4.18
R
1..1
1..1
R
SET_II
CS
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
0..1
R2
IVL_TS
0..1
R2
TS
@value
high
R
0..1
@value
Current
Dispension
Number
Fixed Value
@classCode
templateId
Prescription
Number
Data
Type
repeatNumber
O
TS
R
0..1
R2
Page 138 of 256
Name
XPath
Car
d
@value
Quantity
Dispensed
Medication
Information
quantity
R2
product
entryRelationship
@typeCode
Fixed Value
R2
@unit
manufacturedProduct
Medication
Supply
Order
0..1
R2
product
Data
Type
R2
@value
manufacturedProduct
Immunization
Information
Op
t
0..1
CR
1..1
R
0..1
CR
1..1
R
0..1
O
R
2.16.840.1.113883.5.1002
Specification
Note: The specification starts within the supply element
1. SHALL contain exactly one [1..1] @classCode=" SPLY " Supply (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode=" EVN " Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001)
i. The extension should be set to a unique value that represents the
prescription number.
the Dispense Activity. The unique id can be used to identify the same
Medication Dispense across separate messages. The HL7 Consolidation Guide
Medication Fill Status 2.16.840.1.113883.3.88.12.80.64 DYNAMIC
Page 139 of 256
e. BPHC Captured: BPHC captures the fill status of the medication dispense to
determine if a medication has been filled at the time of the encounter or when it
should be expected to become relevant for the particular patient. The fill status
provides supporting information for measures for controlling conditions through
the use of appropriate medication.
6. SHALL contain exactly one [1..1] effectiveTime for the dispense date such that it
a. SHOULD contain zero or one [0..1] low such that it
i. SHALL contain exactly [1..1] @value set to the date that the medication
was dispensed
b. MAY contain zero or one [0..1] high such that it
i. SHALL contain exactly [1..1] @value
c. BPHC Captured: BPHC requires the date in which the medication was dispensed
to determine the relevance of the medication to the time period in which a
measure covers.
7. SHOULD contain zero or one [0..1] repeatNumber such that it
a. SHALL contain exactly one [1..1] @value set to the dispense number out of a
number of refills
i. In "EVN" (event) mood, the repeatNumber is the number of occurrences.
For example, a repeatNumber of "3" in a dispense act means that the
current dispensation is the 3rd
b. BPHC Captured: The repeat number is captured by BPHC to specify the current
refill number for the particular dispense event. Some measures allow the use
medication dispenses to determine presence of certain condition within a
patient such as the presence to asthma and is therefore requested for capture
by BPHC.
8. SHOULD contain zero or one [0..1] quantity such that it
b. SHOULD contain zero or one [0..1] @unit, which SHOULD be selected from
DYNAMIC
c. BPHC Captured: The quantity of medication dispensed is captured by BPHC as
supporting information in determining the total amount of medication given to a
patient. In conjunction with the time period and the type of product, the
medication dispense can be used as evidence of a certain conditions within a
patient.
9. SHOULD contain zero or one [0..1] product (Medication Information) such that it
a. SHALL contain exactly one [1..1] Medication Information
(templateId:2.16.840.1.113883.10.20.22.4.23)
10. SHOULD contain zero or one [0..1] product (Immunization Information) such that it
a. SHALL contain exactly one [1..1] Immunization Medication Information
(templateId:2.16.840.1.113883.10.20.22.4.54)
i. A supply act SHALL contain one product/Medication Information or one
product/Immunization Medication Information template
Page 140 of 256
(templateId:2.16.840.1.113883.10.20.22.4.17)
Figure III-32 Medication Dispense Example
<supply classCode="SPLY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.18"/>
<id root=“2.16.840.1.113883.3.96.1.3” extension="cb734647-fc99-424c-a864-7e3cda82e704"/>
<statusCode code="completed" codeSystem=“2.16.840.1.113883.5.14”/>
<effectiveTime>
<low value="20070103" />
<high value="20070104" />
</effectiveTime>
<repeatNumber value="1" />
<quantity value="50" />
<product>
<templateId root="2.16.840.1.113883.10.20.22.4.23" />
...
</product>
<templateId root="2.16.840.1.113883.10.20.22.4.17" />

...
</supply>
</supply>
1.17.15 Medication Information
Used By
Medication Dispense
Medication
Contains Entries
The medication can be recorded as a pre-coordinated product strength, product form, or
product concentration (e.g., "metoprolol 25mg tablet", "amoxicillin 400mg/5mL suspension");
or not pre-coordinated (e.g., "metoprolol product").
Table III-21 Medication Information Constraints Overview
Name
XPath
Car
d
Op
t
manufacturedProduct
1..1
R
@classCode
R
Data
Type
Fixed Value
2.16.840.1.113883.5.110
(RoleClass) = MANU
Page 141 of 256
Name
Car
d
XPath
templateId
R
@root
R
manufacturedMaterial
Product
Name
Op
t
code
1..1
R
1..1
R
@code
R
@displayName
R2
@codeSystem
R
@codeSystemName
R2
Product
Name Free
Text
originalText
0..1
R2
Brand Name
translation
0..1
O
Drug Manu.
@code
O
@displayName
O
@codeSystem
O
@codeSystemName
O
manufacturerOrganization
name
0..1
O
0..1
O
Data
Type
Fixed Value
2.16.840.1.113883.10.20.22.4.23
Specification
Note: The specification starts within the manufacturedProduct element
1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6)
a. SHALL contain exactly one [1..1] @root = "2.16.840.1.113883.10.20.22.4.23"
3. SHALL contain exactly one [1..1] manufacturedMaterial such that it
a. SHALL contain exactly one [1..1] code such that it
i. SHALL contain exactly one [1..1] @code for the product, which SHALL be
selected from ValueSet Medication Clinical Drug
2.16.840.1.113883.3.88.12.80.17 DYNAMIC
iv. SHOULD contain exactly one @codeSystemName = “RxNorm”
v. SHOULD contain zero or one [0..1] originalText. The original text is a free
text value that should contain all relevant text from which the code was
derived. such that it which
vi. MAY contain zero or more [0..*] translation such that it
Page 142 of 256
1. SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet 2.16.840.1.113883.3.88.12.80.16 Medication Brand
Name DYNAMIC
“2.16.840.1.113883.6.88”
4. SHOULD contain exactly one @codeSystemName = “RxNorm”
5. Translations can be used to represent generic product name,
packaged product code, etc.
vii. BPHC Captured: BPHC requires the medication and the medication brand
name for a medication event to identify the specific medication given
during an encounter. The medication code and brand can be used in
conjunction with other medication usage information as evidence of
conditions within a patient. The original text should contain all free text
originally used to determine the coded value. BPHC requires the
originalText for auditing purposes.
4. MAY contain zero or one [0..1] manufacturerOrganization such that it
a. MAY contain zero or one [0..1] name
b. BPHC Captured: The name of the manufacturing organization for the particular
medication is captured by BPHC if available as supporting information about a
particular medication and for auditing purposes.
Figure III-33 Medication Information Example
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<code code="219483" displayName="ProventilHFA"
codeSystem="2.16.840.1.113883.6.88" codeSystemName=“RxNorm”>
<originalText>
The medication information free text as described above
</originalText>
<translation code="219483" displayName="Proventil HFA"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" />
</code>
<name>Medication Factory Inc.</name>
1.17.16 Medication Supply Order
Used By
Medication Dispense
Medication Activity
Immunization
Contains Entries
Immunization Medication
Information
Instructions
This template records the intent to supply a patient with medications.
Page 143 of 256
Table III-22 Medication Supply Order Constraints Overview
Name
XPath
Car
d
Op
t
supply
1..1
R
R
2.16.840.1.113883.5.6
(HL7ActClass) = SPLY
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = INT
1..1
@root
Fill Status
Fill Date
id
R
@extension
R
statusCode
1..1
CS
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
0..1
R2
IVL<TS
>
0..1
R2
TS
R
1..1
repeatNumber
quantity
R
0..1
R2
R2
0..1
R2
@value
R2
@unit
R2
product
manufacturedProduct
product
manufacturedProduct
entryRelationship
TS
R
@value
Patient
Instructions
R
SET<II
>
R
@value
Immunization
Information
2.16.840.1.113883.10.20.22.4.17
@code
high
Medication
Information
R
@root
@value
Quantity
Dispensed
R
R
1..1
low
Allowed Fills
Fixed Value
@classCode
templateId
Order
Number
Data
Type
0..1
CR
1..1
R
0..1
CR
1..1
R
0..1
O
Page 144 of 256
Name
XPath
Car
d
Op
t
Data
Type
Fixed Value
@typeCode
R
2.16.840.1.113883.5.1002
@inversionInd
R
true
act
R
Specification
Note: The specification starts within the supply element
1. SHALL contain exactly one [1..1] @classCode=" SPLY " Supply (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode=" INT " Intent (CodeSystem: ActMood
2.16.840.1.113883.5.1001)
i. The extension should be set to a unique value to for the medication
supply order number within the organization requesting the supply.
the Medication Supply Order. The unique id can be used to identify the same
Medication Supply Order across separate messages. The HL7 Consolidation
Guide requires an id for this element.
e. BPHC Captured: The medication supply order fill status is captured by BPHC to
provide supporting information to the medication in use or to be used by the
patient. Medication usage can be used as evidence of certain conditions in
measures as well as in controlling a condition through the appropriate
medications.
6. SHALL contain exactly one [1..1] effectiveTime for the fill date such that it
i. SHALL contain exactly [1..1] @value set to the date that the medication
start time
ii. SHALL contain exactly [1..1] @value set to the expiration date
Page 145 of 256
c. BPHC Captured: BPHC captures the fill date to determine the relevance of the
medication supply to the time period considered by the particular measure.
7. SHALL contain exactly one [1..1] repeatNumber such that it
a. SHALL contain exactly one [1..1] @value set to the number of times the
substance can be supplied.
i. In "INT" (intent) mood, the repeatNumber defines the number of allowed
fills. For example, a repeatNumber of "3" means that the substance can
be supplied up to 3 times (or, can be dispensed, with 2 refills)
b. BPHC Captured: The repeat number specifies the number of refills allowed for
the prescribed medication. The refill number is captured by BPHC to provide
supporting information about the amount of medication prescribed to the
patient for a condition.
8. SHOULD contain zero or one [0..1] quantity such that it
b. SHOULD contain zero or one [0..1] @unit, which SHOULD be selected from
DYNAMIC
c. BPHC Captured: The quantity is captured by medication as supporting
information for the amount of medication prescribed. In measures that allow
the use of medication as a valid identifier of a condition within a patient, there is
a minimum amount of medication needed to meet the requirements.
9. SHOULD contain zero or one [0..1] product (Medication Information) such that it
a. SHALL contain exactly one [1..1] Medication Information
(templateId:2.16.840.1.113883.10.20.22.4.23)
10. SHOULD contain zero or one [0..1] product (Immunization Information) such that it
a. SHALL contain exactly one [1..1] Immunization Medication Information
(templateId:2.16.840.1.113883.10.20.22.4.54)
i. A supply act SHALL contain one product/Medication Information or one
product/Immunization Medication Information template
(templateId:2.16.840.1.113883.10.20.22.4.20)
Figure III-34 Medication Supply Order Example
<templateId root="2.16.840.1.113883.10.20.22.4.17" />
<id root=“2.16.840.1.113883.3.96.1.3” extension="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<statusCode code="completed" codeSystem=“2.16.840.1.113883.5.14”/>
<effectiveTime>
<low value="20070103" />
<high value="20070104" />
</effectiveTime>
<repeatNumber value="1" />
Page 146 of 256
<quantity value="75" />
<product>
<templateId root="2.16.840.1.113883.10.20.22.4.23" />
...
</product>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<templateId root="2.16.840.1.113883.10.20.22.4.20" />
...
</act>
</supply>
Page 147 of 256
1.17.17 Policy Activity
Used By
Coverage
Contains Entries
Organization
Person
A policy activity represents the policy or program providing the coverage. The person for whom
payment is being provided (e .g. the patient) is the covered party. The subscriber of the policy
or program is represented as a participant that is the holder the coverage. The payer is
represented as the performer of the policy activity.
Table III-23 Policy Activity Constraints Overview
Name
XPath
Car
d
Op
t
act
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass) =
ACT
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
Health
Insurance
Type
Policy Status
Payer
Fixed Value
@classCode
templateId
Policy Id
Data
Type
id
R
R
1..1
R2
@root
R
@extension
R
code
0..1
R2
2.16.840.1.113883.10.20.22.4.12
SET<II
>
CE
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.255.1336
@codeSystemName
R2
ASC X12
statusCode
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
R2
R
ActStatus
@codeSystemName
performer
@typeCode
templateId
@root
1..1
1..1
R
R
R
2.16.840.1.113883.5.90
(HL7ParticipationType) = PRF
2.16.840.1.113883.10.20.22.4.87
Page 148 of 256
assignedEntity
PBM routing
numbers, or
payer ids
Provider
Type
1..1
R
id
1..*
R
code
@code
@displayName
@codeSystem
0..1
O
R
R2
R
End
Financial
Responsible
Id
Provider
Type
Organizati
on
0..1
1..1
R2
R
@typeCode
templateId
@root
1..1
R
R
R
effectiveTime
0..1
R2
1..1
1..1
R
R
R2
R
R
id
0..1
R2
code
@code
@displayName
@codeSystem
1..1
R
R
R2
R
GUAR
Guarantor
2.16.840.1.113883.5.111
R2
RoleCode
Financial
Responsibilit
y Time
Start
RoleCode
R2
@codeSystemName
Guarantor
2.16.840.1.113883.5.110
performer
low
@value
high
@value
assignedEntity
0..1
@codeSystemName
2.16.840.1.113883.5.90
(HL7ParticipationType) = PRF
2.16.840.1.113883.10.20.22.4.88
IVL<TS
>
TS
TS
0..1
1..1
R2
R
@typeCode
templateId
@root
1..1
R
R
R
time
low
high
participantRole
0..1
0..1
0..1
1..1
R2
R2
R2
R
id
1..*
@root
code
1..1
R
R
R
or assigned person
Patient
Health Plan
Coverage
Dates
Cover Party
Member Id
participant
Patient
2.16.840.1.113883.5.90
(HL7ParticipationType) = COV
2.16.840.1.113883.10.20.22.4.89
IVL_TS
TS
TS
Page 149 of 256
@code
@displayName
@codeSystem
R
R2
R
0..1
R2
R2
1..1
1..1
R
R2
@codeSystemName
playingEntity
Patient
Name
Subscriber
name
participant
Health Plan
@typeCode
templateId
@root
time
low
high
participantRole
id
@root
entryRelationship
1..1
0..1
0..1
0..1
1..1
1..*
1..*
@typeCode
Coverage
Description
act
R
1..1
@classCode
@moodCode
templateId
@root
id
Health Plan
Id
Health Plan
Name
R
R
R
O
O
O
R
R
R
R
1..1
RoleCode
PN
2.16.840.1.113883.5.90
(HL7ParticipationType) = HLD
IVL_TS
TS
TS
2.16.840.1.113883.10.20.22.4.90
Health Plan Coverage Dates
Subscriber Information
Subscriber Member Id
@typeCode="REFR" CodeSystem:
HL7ActRelationshipType
2.16.840.1.113883.5.1002
R
R
1..1
2.16.840.1.113883.5.111
R
R
R
R
2.16.840.1.113883.5.6
(HL7ActClass) = ACT
2.16.840.1.113883.5.6
(HL7ActClass) = DEF
2.16.840.1.113883.10.20.1.19
@root
text
Specification
2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode= “EVN” Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001)
a. SHALL contain exactly one [1..1] @root=" 2.16.840.1.113883.10.20.22.4.61 "
i. The root should be set to the health insurance NAIC identification
number or another unique identification number for the health insurance
Page 150 of 256
company providing the policy. If the policy is a self then set to the
sending organization OID.
i. The extension should be set to a unique value that represents the policy
number. In the case of self pay, set to a unique identifier within the
sending organization that represents the self-pay policy.
the Policy Activity. The unique id can be used to identify the same Policy Activity
across separate messages. The HL7 Consolidation Guide requires an id for this
element.
5. SHALL contain exactly one [1..1] code for the health insurance type such that it
a. SHALL contain exactly one [1..1] @code ValueSet: Health Insurance Type Value
Set 2.16.840.1.113883.3.88.12.3221.5.2 DYNAMIC
c. SHALL contain exactly one @codeSystem = “2.16.840.1.113883.6.255.1336”
d. SHOULD contain exactly one @codeSystemName = “ASC X12”
e. BPHC Captured: The Health Insurance type is captured by BPHC as supporting
information to measures restricted to certain health insurance types.
6. SHALL contain exactly one [1..1] statusCode, such that it
a. SHALL contain exactly one @code = “completed”
7. SHALL contain exactly one [1..1] performer that represents the payer such that it
a. SHALL contain exactly one [1..1] @typeCode="PRF" Performer (CodeSystem:
HL7ParticipationType 2.16.840.1.113883.5.90)
b. SHALL contain exactly one [1..1] templateId such that it
i. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.87" Payer Performer
c. SHALL contain exactly one [1..1] assignedEntity such that it
i. SHALL contain at least one [1..*] id
ii. SHOULD contain zero or one [0..1] code
1. The code, if present, SHALL contain zero or one [0..1] @code
(ValueSet: HL7FinanciallyResponsiblePartyType
2.16.840.1.113883.1.11.10416 DYNAMIC)
3. SHALL contain exactly one @codeSystem
=“2.16.840.1.113883.5.110”
4. SHOULD contain exactly one @codeSystemName =“RoleCode”
5. BPHC Captured: The role code is captured by BPHC in order to
identify the responsible party even if it is the patient themselves.
Page 151 of 256
The role code is supporting information for the health insurance
policy.
iii. SHOULD contain zero or one [0..1] representedOrganization
1. BPHC Captured: The organization responsible financially if
applicable is capture by BPHC as supporting information for
health insurance as it pertains to the measures.
8. SHOULD contain zero or one [0..1] performer="PRF" Performer that represents the
guarantor (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) such that it
a. SHALL contain exactly one [1..1] templateId such that it
@root="2.16.840.1.113883.10.20.22.4.88" Guarantor Performer
b. SHOULD contain zero or one [0..1] time such that it
i. SHALL contain exactly one [1..1] low such that it
1. SHALL contain exactly [1..1] @value set to the date that financial
responsibility begins
ii. SHOULD contain zero or one [1..1] high such that it
1. SHALL contain exactly [1..1] @value set to the date that financial
responsibility ends
iii. BPHC Captured: BPHC captures the date from and to which financial
responsibility is valid. Measures have requirements that health insurance
cannot have major gaps and therefore the guarantor time is important.
c. SHALL contain exactly one [1..1] assignedEntity such that it
i. This assignedEntity SHALL contain exactly one [1..1] code
1. This code SHALL contain exactly one [1..1] @code="GUAR"
2. SHOULD contain exactly one @displayName =“ Guarantor”
=“2.16.840.1.113883.5.111”
ii. SHOULD include assignedEntity/assignedPerson AND/OR
assignedEntity/representedOrganization
1. BPHC Captured: BPHC requires either the person or organization
that is the guarantor for the policy to identify the particular entity
responsible.
9. SHALL contain exactly one [1..1] participant that represents the patient such that it
a. SHALL contain exactly one [1..1] @typeCode="COV" Coverage target
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90)
@root="2.16.840.1.113883.10.20.22.4.89" Covered Party Participant
c. SHOULD contain zero or one [0..1] time such that it
i. SHOULD contain zero or one [0..1] low such that it
1. SHALL contain exactly one [1..1] @value set to health plan
coverage start
Page 152 of 256
1. SHALL contain exactly one [1..1] @value set to the health plan
coverage expiration
iii. BPHC Captured: BPHC requires the health plan coverage start and
expiration dates to help identify any gaps in coverage that may remove
the patient’s encounters from a particular measure.
d. SHALL contain exactly one [1..1] participantRole
i. This participantRole SHALL contain at least one [1..*] id
1. This id is a unique identifier for the covered party member.
Implementers SHOULD use the same GUID for each instance of a
member identifier from the same health plan
ii. This participantRole SHALL contain exactly one [1..1] code such that it
1. This code SHOULD contain zero or one [0..1] @code (ValueSet:
Coverage Role Type Value Set 2.16.840.1.113883.1.11.18877
DYNAMIC)
=“2.16.840.1.113883.5.111”
5. BPHC Captured: BPHC requires the coverage role of the covered
party member to further identify the patient’s responsibility. Selfcoverage would be specified by a code of SELF which is used as
one of the health care type restrictions within the set of measures
that BPHC will consider.
iii. This participantRole SHOULD contain zero or one [0..1] playingEntity
such that it
a. If the member name as recorded by the health plan differs
from the patient name as recorded in the
registration/medication summary (e.g., due to marriage or
for other reasons), then the member name SHALL be
recorded in the name element
10. SHOULD contain zero or one [0..1] participant for the policy subscriber such that it
a. SHALL contain exactly one [1..1] @typeCode="HLD" Holder (CodeSystem:
HL7ParticipationType 2.16.840.1.113883.5.90)
@root="2.16.840.1.113883.10.20.22.4.90" Policy Holder Participant
c. MAY contain zero or one [0..1] time such that it
i. SHOULD contain zero or one [0..1] low such that it
1. SHALL contain exactly one [1..1] @value set to health plan
coverage start
Page 153 of 256
1. SHALL contain exactly one [1..1] @value set to the health plan
coverage expiration
iii. BPHC Captured: BPHC requires the health plan coverage start and
expiration dates to help identify any gaps in coverage that may remove
the patient’s encounters from a particular measure.
d. SHALL contain exactly one [1..1] participantRole such that it
i. SHALL contain at least one [1..*] id
1. This id is a unique identifier for the subscriber of the coverage
11. SHALL contain at least one [1..*] entryRelationship such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
b. SHALL contain exactly one [1..1] @typeCode="DEF", representing a description
of the coverage plan
c. SHALL contain exactly one [1..1] id, to represent the plan identifier such that it
d. SHALL contain exactly one [1..1] text with the name of the plan
e. BPHC Captured: BPHC requires the health plan name as supporting information
about the type coverage that a patient has at the time of the encounter.
Figure III-35 Policy Activity Example
<templateId root="2.16.840.1.113883.10.20.22.4.61" />

<id root="3e676a50-7aac-11db-9fe1-0800200c9a66" />
<code code="SELF" codeSystemName="HL7 RoleClassRelationship"
codeSystem="2.16.840.1.113883.5.110" />
<statusCode code="completed" />

<templateId root="2.16.840.1.113883.10.20.22.4.87"/>

<assignedEntity>
<id root="2.16.840.1.113883.19"/>
<code code="PAYOR" codeSystem="2.16.840.1.113883.5.110"
codeSystemName="HL7 RoleCode" />
<name>Good Health Insurance</name>
</assignedEntity>
</performer>

<templateId root="2.16.840.1.113883.10.20.22.4.88" />
<time>
<low nullFlavor="UNK" />
<high nullFlavor="UNK" />
</time>
<assignedEntity>
<id root="329fcdf0-7ab3-11db-9fe1-0800200c9a66" />
<code code="GUAR" codeSystem="2.16.840.1.113883.5.111"
codeSystemName="HL7 RoleCode" />
<assignedPerson>
<name>
<prefix>Mr.</prefix>
<given>Adam</given>
<given>Frankie</given>
<family>Everyman</family>
Page 154 of 256
</name>
</assignedPerson>
</assignedEntity>
</performer>
<participant typeCode="COV">

<templateId root="2.16.840.1.113883.10.20.22.4.89" />
<time>
</time>
<participantRole classCode="PAT">
<id root="14d4a520-7aae-11db-9fe1-0800200c9a66" extension="1138345"/>

<code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="Self" />
<playingEntity>
<name>

<prefix>Mr.</prefix>
<given>Frank</given>
<given>A.</given>
<family>Everyman</family>
</name>
</playingEntity>
</participantRole>
</participant>

<participant typeCode="HLD">
<templateId root="2.16.840.1.113883.10.20.22.4.90" />
<time>
</time>
<participantRole>
<id extension="1138345" root="2.16.840.1.113883.19" />
</participantRole>
</participant>
<act classCode="ACT" moodCode="DEF">
<id root="329fcdf0-7ab3-11db-9fe1-0800200c9a66" />
<text>Health Plan Name</text>
</act>
</act>
Page 155 of 256
1.17.18 Pregnancy Observation
Used By
Social History
Section_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
This clinical statement represents current and/or prior pregnancy dates enabling investigators
to determine if the subject of the case report was pregnant during the course of a condition.
Table III-24 Pregnancy Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass) =
OBS
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
Observation
Status
Observation
Time
Start
code
Value Code
R
R
0..1
R2
2.16.840.1.113883.10.20.15.3.8
CD
@code
R
ASSERTION
@displayName
R2
Assertion
@codeSystem
R
2.16.840.1.113883.5.4
@codeSystemName
R2
ActCode
statusCode
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
0..1
R2
IVL_TS
1..1
R
TS
@value
End
Fixed Value
@classCode
templateId
Social
History Type
Data
Type
high
@value
value
@xsi:type
@code
@displayName
R
0..1
R2
TS
1..1
R
R
CD
R
R2
CD
77386006
Pregnant with
Page 156 of 256
@codeSystem
@codeSystemName
Value Free
Text
Est. Date of
Delivery
originalText
0..1
R2
entryRelationship
0..1
O
@typeCode
observation
2.16.840.1.113883.5.1002
1..1
R
@moodCode
templateId
@root
code
@code
@displayName
@codeSystem
R
R
R
R
R
1..1
1..1
@codeSystemName
1..1
@codeSystemName
Estimated
Date of
Delivery
R
@classCode
statusCode
@code
@displayName
@codeSystem
value
@value
2.16.840.1.113883.6.96
SNOMED CT
R
R2
1..1
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
2.16.840.1.113883.5.1001
(ActMood) = EVN
2.16.840.1.113883.10.20.15.3.1
CE
R
11778-8
Estimated date of delivery
2.16.840.1.113883.6.1
R2
R
R
R2
R
LOINC
completed
completed
completed
2.16.840.1.113883.5.14
R2
ActStatus
R
R
TS
Specification
HL7ActClass 2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
a. SHALL contain exactly one [1..1] @code =“ASSERTION”
b. SHOULD contain exactly one @displayName = completed
Page 157 of 256
c. BPHC Captured: The pregnancy observation effective time is captured by BPHC
to determine if pregnancy is a factor to be considered for a particular patient
within the time frame covered by the measure.
a. SHALL contain exactly one @code = “ 77386006”
b. SHOULD contain exactly one @displayName = “Pregnant with”
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
b. SHALL contain exactly one [1..1] observation such that it
i. SHALL contain exactly one [1..1] @classCode="OBS" Observation
ii. SHALL contain exactly one [1..1] @moodCode="EVN" Event
(CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC)
iii. SHALL contain exactly one [1..1] templateId such that it
1. a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.15.3.1"
iv. SHALL contain exactly one [1..1] code such that it
1. SHALL contain exactly one @code = “11778-8”
2. SHOULD contain exactly one @displayName = “Estimated date of
delivery”
“2.16.840.1.113883.6.1”
4. SHOULD contain exactly one @codeSystemName = “LOINC”
v. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14)
1. SHALL contain exactly one @code = “completed”
2. SHOULD contain exactly one @displayName = completed
“2.16.840.1.113883.5.14”
4. SHOULD contain exactly one @codeSystemName = “ActStatus”
vi. SHALL contain exactly one [1..1] value with @xsi:type="TS" such that it
1. SHALL contain exactly one @value
Page 158 of 256
2. BPHC Captured: BPHC requires the estimated date of delivery if
known to determine relevance of the pregnancy to other
encounters by the patient as well as during the measured
timeframe.
Figure III-36 Pregnancy Observation Example

<templateId root="2.16.840.1.113883.10.20.15.3.8"/>
<effectiveTime>
<low value="20110410"/>
</effectiveTime>
<value xsi:type="CD" code="77386006"
displayName="pregnant" codeSystem="2.16.840.1.113883.6.96"/>

<templateId root="2.16.840.1.113883.10.20.15.3.1"/>
displayName="Estimated date of delivery"/>
<value xsi:type="TS">20110919</value>
</observation>
</observation>
Page 159 of 256
1.17.19 Problem Concern Act
Used By
Problem
Contains Entries
Problem Observation
Observations of problems or other clinical statements captured at a point in time are wrapped
in a "Concern" act, which represents the ongoing process tracked over time. This allows for
binding related observations of problems. For example, the observation of "Acute MI" in 2004
can be related to the observation of "History of MI" in 2006 because they are the same
concern. The conformance statements in this section define an outer "problem act"
(representing the "Concern") that can contain a nested "problem observation" or other nested
clinical statements.
Table III-25 Problem Concern Act Constraints Overview
Name
XPath
Car
d
Op
t
act
1..1
R
Fixed Value
@classCode
R
2.16.840.1.113883.5.6 (HL7ActClass) =
ACT
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
templateId
1..1
@root
id
R
R
1..1
R2
@root
R
@extension
R
code
1..1
R
2.16.840.1.113883.10.20.22.4.3
SET_II
CD
@code
R
CONC
@displayName
R2
Concern
@codeSystem
R
2.16.840.1.113883.5.6
@codeSystemName
R2
ActClass
statusCode
Concern
Active Date
Data
Type
1..1
R
CS
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
1..1
R
IVL_TS
1..1
R
TS
Page 160 of 256
@value
high
R
0..1
@value
Problem
Observation
entryRelationship
@typeCode
R2
TS
R
1..*
R
2.16.840.1.113883.5.1002
Specification
2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001)
i. The extension should be set to a unique value to represent the Problem
Concern Act within the sending organization. This ID should be used
whenever this Problem Concern Act is referenced.
c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the
Problem Concern Act. The unique id can be used to identify the same Problem
Concern Act used in different messages. The HL7 Consolidation Guide requires an id
for this element.
a. SHALL contain exactly one @code="CONC"
b. SHOULD contain exactly one @displayName = “Concern”
d. SHOULD contain exactly one @codeSystemName = “ActClass”
a. SHALL contain exactly one @code which SHALL be selected from Value Set:
e. BPHC Captured: BPHC captures the status of the problem concern to determine
the problem’s relevance for the measure in question.
Page 161 of 256
i. SHALL contain exactly [1..1] @value set to the date that the concern
became active
i. SHALL contain exactly [1..1] @value set to the date that the concern is no
longer active
c. BPHC Captured: BPHC captures the status of the problem concern to determine
the problem’s relevance based on the time period covered by the particular
measure taken.
8. SHALL contain one or more [1..*] entryRelationship such that it
b. SHALL contain exactly one [1..1] Problem Observation
(2.16.840.1.113883.10.20.22.4.4)
Figure III-37 Problem Concern Act Example
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root=“2.16.840.1.113883.3.96.1.3” extension="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"
codeSystemName="ActClass" displayName="Concern" />
<effectiveTime">
<low value="20060501"/>
<high value="20100501"/>
</effectiveTime>

<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
..
</observation>
</act>
</entry>
Page 162 of 256
1.17.20 Problem Observation
Used By
Encounter Diagnosis
Problem Concern
Act_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
Health Status Observation
Problem Status
A problem is a clinical statement that a clinician has noted. In health care it is a condition that
requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any
unmet or partially met basic human need.
A Problem Observation is required to be wrapped in an act wrapper in locations such as the
Problem Section, Allergies Section, and Hospital Discharge Diagnosis Section, where the type of
problem needs to be identified or the condition tracked.
A Problem Observation can be a valid "standalone" template instance in cases where a simple
problem observation is to be sent.
The negationInd attribute, if true, specifies that the problem indicated was observed to not
have occurred (which is subtly but importantly different from having not been observed).
NegationInd='true' is an acceptable way to make a clinical assertion that something did not
occur, for example, "no diabetes".
Table III-26 Problem Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
Fixed Value
@classCode
R
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = EVN
@negationInd
O
templateId
1..1
@root
id
Problem
Type
Data
Type
R
R
1..1
R2
@root
R
@extension
R
code
1..1
R
@code
R
@displayName
R2
2.16.840.1.113883.10.20.22.4.4
SET_II
CD
Page 163 of 256
Name
Problem
Observation
Free Text
Car
d
XPath
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
text
0..1
R2
statusCode
1..1
R
Problem
Code Free
Text
Problem
Status
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
low
1..1
R
IVL_TS
1..1
R
TS
high
R
0..1
value
R2
TS
R
1..1
R
CD
@xsi:type
R
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
originalText
0..1
R2
entryRelationship
0..1
O
@typeCode
Health
Observation
Status
CS
@code
@value
Problem
Code
Fixed Value
R
@value
Resolution
Date
Data
Type
@codeSystem
effectiveTime
Onset Date
Op
t
entryRelationship
@typeCode
0..1
CD
R
2.16.840.1.113883.5.1002
O
2.16.840.1.113883.5.1002
REFR
R
Specification
HL7ActClass 2.16.840.1.113883.5.6)
Page 164 of 256
2.16.840.1.113883.5.1001)
3. MAY contain zero or one [0..1] @negationInd
a. Use negationInd="true" to indicate that the problem was not observed
i. The extension should be set to a unique value to represent the Problem
Observation within the sending organization. This ID should be used
whenever this particular Problem Observation is referenced.
element.
a. SHALL contain exactly one @code which SHOULD be selected from ValueSet
e. BPHC Captured: BPHC captures the problem type to categorize the problem.
The problem type aids in the identification of conditions explored by national
measures.
problem observation and SHOULD include all relevant text used to derived the problem
observation codes.
relevant text from which the problem observation codes were determined for
auditing purposes.
i. SHALL contain exactly one [1..1] @value set to the problem onset date
Page 165 of 256
b. SHOULD contain zero or one [0..1] high if the problem is no longer a concern
such that it
ii. SHALL contain exactly one [1..1] @value set to the time that the problem
was determined to no longer be a concern
c. If the problem is known to be resolved, but the date of resolution is not known,
then the high element SHALL be present, and the nullFlavor attribute SHALL be
set to 'UNK'. Therefore, the existence of an high element within a problem does
indicate that the problem has been resolved
d. BPHC Captured: The problem’s effective time is required for capture by BPHC to
determine the relevance of the problem during the time period of the measure
being explored.
Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC
i. If the diagnosis is unknown, @nullFlavor may be used and SHOULD be
set to “UNK”
g. BPHC Captured: Many of the national measures are specific to a certain
condition such as Diabetes or Asthma. The problem code can be used to identify
the presence of one of these conditions and therefore is required for capture by
BPHC. The original text should contain all free text originally used to determine
11. MAY contain zero or one [0..1] entryRelationship for the Problem Status such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Has subject (CodeSystem:
b. SHALL contain exactly one [1..1] Problem Status
(templateId:2.16.840.1.113883.10.20.22.4.6)
12. MAY contain zero or one [0..1] entryRelationship for the Health Observation Status
such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Has Subject (CodeSystem:
b. SHALL contain exactly one [1..1] Health Status Observation
(templateId:2.16.840.1.113883.10.20.22.4.5)
Figure III-38 Problem Observation Example

<templateId root="2.16.840.1.113883.10.20.22.4.4" />
<id root="2.16.840.1.113883.3.96.1.3" extension="ab1791b0-5c71-11db-b0de-0800200c9a66" />
<code code="409586006" displayName="Complaint"
Page 166 of 256
codeSystem="2.16.840.1.113883.6.96 codeSystemName="SNOMED CT"/>
<text>
The problem observation free text as described above
</text>
<effectiveTime>
<low value="20070103" />
</effectiveTime>
<value xsi:type="CD" code="195967001" displayName="Asthma"
codeSystem="2.16.840.1.113883.6.96"
<originalText>
</originalText
</value>
<templateId root="2.16.840.1.113883.10.20.22.4.6" />
<!—Problem Status template -->
...
</observation>
<templateId root="2.16.840.1.113883.10.20.22.4.5" />

...
</observation>
</observation>
Figure III-39 Problem Observation for No Known Problems
<observation classCode="OBS" moodCode="EVN" negationInd="true">

<templateId root="2.16.840.1.113883.10.20.22.4.4" />
<code code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7ActCode" />
<value xsi:type="CD" code="55607006" displayName="Problem"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
</observation>
Page 167 of 256
1.17.21 Problem Status
Used By
Problem
Observation_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
The Problem Status records whether the indicated problem is active, inactive, or resolved.
Table III-27 Problem Status Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
R
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = EVN
1..1
@root
code
Problem
Status
Fixed Value
@classCode
templateId
Problem
Status Free
Text
Data
Type
R
R
1..1
R
2.16.840.1.113883.10.20.22.4.6
CD
@code
R
33999-4
@displayName
R2
Status
@codeSystem
R
2.16.840.1.113883.6.1
@codeSystemName
R2
LOINC
text
0..1
R2
statusCode
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
value
1..1
R
CD
@xsi:type
R
CD
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
Specification
Page 168 of 256
HL7ActClass 2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
b. SHOULD contain exactly one @displayName = “Status”
problem status and SHOULD include all relevant text used to derived the problem status
code.
relevant text from which the problem status codes were determined for auditing
purposes.
f. BPHC Captured: BPHC captures the problem status to determine the relevance
of a problem to the measure being explored.
Figure III-40 Problem Status Example
<templateId root="2.16.840.1.113883.10.20.22.4.6" />

<code code="33999-4" displayName="Status"
<text>
The problem status free text as described above
</text>
Page 169 of 256
<value xsi:type="CD" code="55561003" displayName="Active"
</observation>
Page 170 of 256
1.17.22 Procedure Activity Act
Used By
Procedures
Contains Entries
Medication Activity
Addr
Organization
Telecom
The common notion of "procedure" is broader than that specified by the HL7 Version 3
Reference Information Model (RIM). Therefore procedure templates can be represented with
various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g.
splenectomy). This clinical statement represents any procedure that cannot be classified as an
observation or a procedure according to the HL7 RIM. Examples of these procedures are a
dressing change, teaching or feeding a patient or providing comfort measures.
Table III-28 Procedure Activity Act Constraints Overview
Name
XPath
Car
d
Op
t
act
1..1
R
@classCode
R
@moodCode
R
templateId
1..1
@root
id
Procedure
Type
Procedure
Type Free
Text
Procedure
Status
R
R2
@root
R
@extension
R
1..1
Fixed Value
2.16.840.1.113883.5.6 (HL7ActClass) =
ACT
R
1..1
code
Data
Type
R
2.16.840.1.113883.10.20.22.4.12
SET_II
CE
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.1 or
2.16.840.1.113883.6.96
@codeSystemName
R2
LOINC or SNOMED
originalText
statusCode
0..1
R2
1..1
R
@code
R
@displayName
R2
CS
Page 171 of 256
Procedure
Time
Start
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
0..1
R2
IVL_TS
1..1
R
TS
@value
End
high
R
0..1
@value
Priority
Code
priorityCode
Provider
Type
performer
assignedEntity
id
code
@code
@displayName
@codeSystem
TS
R
0..1
@code
@displayName
@codeSystem
@codeSystemName
Procedure
Provider
R2
R2
CE
R
R2
R
R2
0..*
1..1
1..*
R2
R
R
0..1
O
R
R2
R
addr
telecom
1..1
1..1
R2
R
R
0..1
R2
0..*
O
@codeSystemName
2.16.840.1.113883.5.7
ActPriority
Procedure Provider
Addr
Tel
Organizati
Service
Delivery
Location
Encounter
participant
@typeCode
entryRelationship
0..1
@typeCode
Medication
Activity
entryRelationship
@typeCode
R
O
R
0..1
on
Code System
2.16.840.1.113883.5.90
2.16.840.1.113883.5.1002
(HL7ActRelationshipType)= COMP
(Has Component)
O
R
2.16.840.1.113883.5.1002
COMP
Specification
2.16.840.1.113883.5.6)
Page 172 of 256
i. The extension should be set to a unique value to represent the Procedure
Activity Act within the sending organization. This ID should be used
whenever this particular Procedure Activity Act is referenced.
c. BPHC Captured: BPHC requires this field for capture to provide a unique id for the
act. The unique id can be used to identify the same act used in different messages.
The HL7 Consolidation Guide requires an id for this element.
a. SHALL contain exactly one [1..1] @code, which SHOULD be selected from LOINC
(codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem:
2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem:
2.16.840.1.113883.6.12), ICD9 Procedures (CodeSystem: 2.16.840.1.113883.6.104),
ICD10 Procedure Coding System (CodeSystem: 2.16.840.1.113883.6.4) If the
diagnosis is unknown, @nullFlavor may be used and SHOULD be set to “UNK”
b. SHOULD contain exactly one @displayName such that the value is set accordingly
based on the code chosen
c. SHALL contain exactly one @codeSystem
d. SHOULD contain exactly one @codeSystemName such that the value is set
accordingly based on the codeSystem chosen
e. SHOULD contain zero or one [0..1] originalText. The original text is a free text value
that should contain all relevant text from which the code was derived.
f. BPHC Captured: BPHC requires the procedure type to perform research on
particular measures that require knowledge of certain procedures. e.g. Measuring
Median Time to PCI where the PCI would be represented as a procedure in the CDC
message. The original text should contain all free text originally used to determine
a. SHALL contain exactly one @code which SHALL be selected from ValueSet
ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC
e. BPHC Captured: The status of a procedure is captured by BPHC to determine the
relevance of the procedure to the measure being taken.
i. SHALL contain exactly [1..1] @value set to the start time for the procedure
Page 173 of 256
i. SHALL contain exactly [1..1] @value set to the end time for the procedure
c. BPHC Captured: The procedures start and end time are captured to determine the
procedures relevance to the measure being taken. The start and end time of the
procedure is important in determining the timeline in which the procedure occurred.
E.g. Median Time to PCI looks at the time of the PCI (procedure) compared to the
start time of the encounter itself.
8. MAY contain zero or one [0..1] priorityCode such that it
ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC
d. SHOULD contain exactly one @codeSystemName = “ActPriority”
e. BPHC Captured: The priority code is captured by BPHC as supporting information to
the procedure activity.
9. SHOULD contain zero or more [0..*] performer for the Procedure Provider such that it
a. SHALL contain exactly one [1..1] assignedEntity such that it
iv. SHOULD contain zero or one [0..1] representedOrganization
10. MAY contain zero or more [0..*] participant for the Service Delivery Location such that it
(templateId:2.16.840.1.113883.10.20.22.4.32)
11. MAY contain zero or more [0..*] entryRelationship for a reference encounter such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component
(CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
b. SHALL contain exactly one [1..1] @inversionInd="true" true
c. SHALL contain exactly one [1..1] encounter such that it
i. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6 STATIC)
ii. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC)
iii. SHALL contain exactly one [1..1] id
1. Set the encounter ID to the ID of an encounter in another section to
signify they are the same encounter
12. MAY contain zero or one [0..1] entryRelationship for Medication Activity such that it
Page 174 of 256
(templateId:2.16.840.1.113883.10.20.22.4.16)
Figure III-41 Procedure Activity Act Example
<templateId root="2.16.840.1.113883.10.20.22.4.12" />

<id root=“2.16.840.1.113883.3.96.1.3” extension="d68b7e32-7810-4f5b-9cc2-acd54b0fd8zz" />
codeSystemName="SNOMED CT" displayName="Colonic polypectomy">
<originalText>
The procedure type free text as described above
</originalText>
</code>
<effectiveTime">
<low value="20060501"/>
<high value="20100501"/>
</effectiveTime>
<priorityCode code="CR" codeSystem="2.16.840.1.113883.5.7"
codeSystemName="ActPriority" displayName="Callback results" />
<performer>
<assignedEntity>
<id root=“2.16.840.1.113883.3.96.1.3” extension="2.16.840.1.113883.19.5.9999.456" extension="2981823" />
<addr>
<state>OR</state>
</addr>
<telecom use="WP" value="555-555-5000" />
<id root=“2.16.840.1.113883.3.96.1.3” extension="2.16.840.1.113883.19.5.9999.1393" />
<addr>
<state>OR</state>
</addr>
</assignedEntity>
</performer>
<templateId root="2.16.840.1.113883.10.20.22.4.32" />
...
</participantRole>
</participant>
</act>
Page 175 of 256
1.17.23 Procedure Activity Observation
Used By
Procedures
Contains Entries
Medication Activity
Addr
Organization
Telecom
splenectomy). This clinical statement represents procedures that result in new information
about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples
of these procedures are diagnostic imaging procedures, EEGs and EKGs.
Table III-29 Procedure Activity Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
@classCode
R
@moodCode
R
templateId
1..1
@root
id
Procedure
Type
Procedure
Type Free
Text
Procedure
Status
R
R2
@root
R
@extension
R
1..1
Fixed Value
2.16.840.1.113883.5.6 (HL7ActClass) =
OBS
R
1..1
code
Data
Type
R
2.16.840.1.113883.10.20.22.4.13
SET_II
CE
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.1 or
2.16.840.1.113883.6.96
@codeSystemName
R2
LOINC or SNOMED
originalText
statusCode
0..1
R2
1..1
R
@code
R
@displayName
R2
CS
Page 176 of 256
Procedure
Time
Start
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
0..1
R2
IVL_TS
1..1
R
TS
@value
End
high
R
0..1
@value
Priority
Code
Value Code
Value Free
Text
Method
Code
priorityCode
@code
@displayName
@codeSystem
@codeSystemName
value
@xsi:type
@code
@displayName
0..1
R2
1..1
R
R2
R
R2
R
@codeSystemName
R2
targetSiteCode
0..1
R2
0..1
R2
Provider
Type
performer
assignedEntity
id
code
@code
@displayName
@codeSystem
0..1
2.16.840.1.113883.6.1 or
2.16.840.1.113883.6.96
LOINC or SNOMED CT
CE
R2
CE
R
R2
R
R2
0..*
1..1
1..*
R2
R
R
0..1
O
R
R2
R
@codeSystemName
addr
telecom
CD
R
R2
R
R2
@code
@displayName
@codeSystem
@codeSystemName
Procedure
Provider
2.16.840.1.113883.5.7
ActPriority
CD
R
methodCode
CE
R
R2
@codeSystem
originalText
TS
R
@code
@displayName
@codeSystem
@codeSystemName
Target Site
Code
R2
1..1
1..1
0..1
R2
R
R
R2
2.16.840.1.113883.6.96
SNOMED CT
Procedure Provider
Addr
Tel
Organizati
Page 177 of 256
on
Service
Delivery
Location
Encounter
participant
@typeCode
entryRelationship
0..*
0..1
@typeCode
Medication
Activity
entryRelationship
@typeCode
O
R
O
R
0..1
Code System
2.16.840.1.113883.5.90
2.16.840.1.113883.5.1002
(Has Component)
O
R
2.16.840.1.113883.5.1002
COMP
Specification
HL7ActClass 2.16.840.1.113883.5.6)
Activity Observation within the sending organization. This ID should be
used whenever this particular Procedure Activity Observation is
referenced.
element.
2.16.840.1.113883.6.12), ICD9 Procedures (CodeSystem:
2.16.840.1.113883.6.104), ICD10 Procedure Coding System (CodeSystem:
2.16.840.1.113883.6.4) If the diagnosis is unknown, @nullFlavor may be used
and SHOULD be set to “UNK”
Page 178 of 256
6.
7.
8.
9.
particular measures that require knowledge of certain procedures. e.g.
Measuring Median Time to PCI where the PCI would be represented as a
procedure in the CDC message. The original text should contain all free text
originally used to determine the coded value. BPHC requires the originalText for
auditing purposes.
SHALL contain exactly one [1..1] statusCode, such that it
SHOULD contain zero or one [0..1] effectiveTime such that it
procedure
procedure
c. BPHC Captured: The procedures start and end time are captured to determine
the procedures relevance to the measure being taken. The start and end time of
the procedure is important in determining the timeline in which the procedure
occurred. E.g. Median Time to PCI looks at the time of the PCI (procedure)
compared to the start time of the encounter itself.
MAY contain zero or one [0..1] priorityCode such that it
e. BPHC Captured: The priority code is captured by BPHC as supporting information
to the procedure activity.
SHALL contain exactly one [1..1] value for the procedure type such that it
Page 179 of 256
a. SHALL contain exactly one[1..1] @xsi:type =“CD”
b. SHALL contain exactly one [1..1] @code
d. SHALL contain exactly one @codeSystem
e. SHOULD contain exactly one @codeSystemName such that the value is set
g. BPHC Captured: BPHC requires the procedure type to perform research on
auditing purposes.
10. MAY contain zero or one [0..1] methodCode such that it
a. SHALL contain exactly one @code
e. MethodCode SHALL NOT conflict with the method inherent in observation /
value and should be omitted if the value adequately describes the method.
f. BPHC Captured: The method code is captured by BPHC as supporting
information to the procedure activity.
11. SHOULD contain zero or more [0..*] targetSiteCode such that it
a. SHALL contain exactly one @code which SHALL be selected from ValueSet Body
e. BPHC Captured: The target site code is captured by BPHC as supporting
Page 180 of 256
13. MAY contain zero or more [0..*] participant for the Service Delivery Location such that
it
(templateId:2.16.840.1.113883.10.20.22.4.32)
14. MAY contain zero or more [0..*] entryRelationship for a reference encounter such that
it
i. SHALL contain exactly one [1..1] @classCode="ENC" Encounter
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC)
1. Set the encounter ID to the ID of an encounter in another section
to signify they are the same encounter
(templateId:2.16.840.1.113883.10.20.22.4.16)
Figure III-42 Procedure Activity Observation Example
<templateId root="2.16.840.1.113883.10.20.22.4.13" />

<id extension="123456789" root="2.16.840.1.113883.19" />
displayName="Colonic polypectomy" codeSystemName="SNOMED-CT">
<originalText>
</originalText>
</code>
<statusCode code="aborted" 2.16.840.1.113883.5.14 />
<effectiveTime">
<low value="20060501"/>
</effectiveTime>
<priorityCode code="CR" codeSystem="2.16.840.1.113883.5.7"
codeSystemName="ActPriority" displayName="Callback results" />
<value xsi:type="CD" />
<methodCode nullFlavor="UNK" />
<targetSiteCode code="416949008" codeSystem="2.16.840.1.113883.6.96 "
Page 181 of 256
codeSystemName="SNOMED CT" displayName="Abdomen and pelvis" />
<performer>
<assignedEntity>
<addr>
<state>OR</state>
</addr>
<addr>
<state>OR</state>
</addr>
</assignedEntity>
</performer>
<templateId root="2.16.840.1.113883.10.20.22.4.32" />
...
</participantRole>
</participant>
</observation>
Page 182 of 256
1.17.24 Procedure Activity Procedure
Used By
Procedures
Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
Medication Activity
Addr
Organization
Telecom
splenectomy).
This clinical statement represents procedures whose immediate and primary outcome (postcondition) is the alteration of the physical condition of the patient. Examples of these
procedures are an appendectomy, hip replacement and a creation of a gastrostomy.
Table III-30 Procedure Activity Procedure Constraints Overview
Name
XPath
Car
d
Op
t
procedure
1..1
R
@classCode
R
@moodCode
R
templateId
1..1
@root
id
Procedure
Type
Procedure
Type Free
Text
Procedure
Status
R
R2
@root
R
@extension
R
1..1
Fixed Value
2.16.840.1.113883.5.6 (HL7ActClass) =
PROC
R
1..1
code
Data
Type
R
2.16.840.1.113883.10.20.22.4.14
SET_II
CE
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.1 or
2.16.840.1.113883.6.96
@codeSystemName
R2
LOINC or SNOMED
originalText
statusCode
0..1
R2
1..1
R
CS
Page 183 of 256
Procedure
Time
Start
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
0..1
R2
IVL_TS
1..1
R
TS
@value
End
high
R
0..1
@value
Priority
Code
priorityCode
methodCode
0..1
Specimen
targetSiteCode
@code
@displayName
@codeSystem
@codeSystemName
specimen
specimenRole
id
specimenPlayingEntity
code
@code
@displayName
@codeSystem
0..1
Provider
R2
0..1
R2
0..*
1..1
0..*
R
R2
R
R2
O
R
R2
0..1
0..1
quantity
@value
name
desc
performer
assignedEntity
id
code
CE
2.16.840.1.113883.5.7
ActPriority
CE
R
R2
R
R2
@codeSystemName
Procedure
Provider
R2
R
R2
R
R2
@code
@displayName
@codeSystem
@codeSystemName
Target Site
Code
TS
R
@code
@displayName
@codeSystem
@codeSystemName
Method
Code
R2
0..*
1..1
1..*
0..1
CE
2.16.840.1.113883.6.96
SNOMED CT
O
O
R
R2
R
R2
O
PQ
O
O
PN
ED
R2
R
R
O
Procedure Provider
Page 184 of 256
Type
@code
@displayName
@codeSystem
R
R2
R
addr
telecom
1..1
1..1
R2
R
R
0..1
R2
0..*
O
@codeSystemName
Addr
Tel
Organizati
Service
Delivery
Location
Encounter
participant
@typeCode
entryRelationship
0..1
@typeCode
Medication
Activity
entryRelationship
@typeCode
R
O
R
0..1
on
Code System
2.16.840.1.113883.5.90
2.16.840.1.113883.5.1002
(Has Component)
O
R
2.16.840.1.113883.5.1002
COMP
Specification
Note: The specification starts within the procedure element
1. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6)
Activity Procedure within the sending organization. This ID should be
used whenever this particular Procedure Activity Procedure is
referenced.
the procedure. The unique id can be used to identify the same procedure used
in different messages. The HL7 Consolidation Guide requires an id for this
element.
Page 185 of 256
2.16.840.1.113883.6.12), ICD9 Procedures (CodeSystem:
2.16.840.1.113883.6.104), ICD10 Procedure Coding System (CodeSystem:
2.16.840.1.113883.6.4) If the diagnosis is unknown, @nullFlavor may be used
and SHOULD be set to “UNK”
auditing purposes.
procedure
procedure
c. BPHC Captured: The procedures start and end time are captured to determine
the procedures relevance to the measure being taken. The start and end time of
the procedure is important in determining the timeline in which the procedure
occurred. E.g. Median Time to PCI looks at the time of the PCI (procedure)
compared to the start time of the encounter itself.
8. MAY contain zero or one [0..1] priorityCode such that it
Page 186 of 256
e. BPHC Captured: The priority code is captured by BPHC as supporting information
to the procedure activity.
d. SHOULD contain exactly one @codeSystemName
11. MAY contain zero or more [0..*] specimen such that it
a. SHALL contain exactly one [1..1] specimenRole such that it
i. SHOULD contain zero or more [0..*] id such that it
1. SHALL contain exactly one [1..1] @root, which is set to the
organization’s OID
2. SHALL contain exactly one [1..1] @extension, which should be set
to a unique value to represent the specimen within the
organization. This ID should be used whenever this particular
specimen is referenced.
3. If you want to indicate that the Procedure and the Results are
referring to the same specimen, the
Procedure/specimen/specimenRole/id SHOULD be set to equal an
Organizer/specimen/ specimenRole/id
4. BPHC Captured: BPHC captures this field to provide a unique id
for the specimen. The unique id can be used to identify the same
specimen used in different messages.
ii. MAY contain zero or one [0..1] specimenPlayingEntity such that it
Page 187 of 256
1. MAY contain zero or one [0..1] code such that it
a. SHALL contain exactly one @code which SHOULD be
selected from ValueSet
“2.16.840.1.113883.6.96”
“SNOMED CT”
2. MAY contain zero or one [0..1] quantity such that it
a. SHOULD contain zero or one [0..1] @value
3. MAY contain zero or one [0..1] name
4. MAY contain zero or one [0..1] description
b. This specimen is for representing specimens obtained from a procedure
facilitate any follow-up and support research.MAY contain zero or
more [0..*] participant for the Service Delivery Location such that
it
(templateId:2.16.840.1.113883.10.20.22.4.32)
13. MAY contain zero or more [0..*] entryRelationship for a reference encounter such that
it
i. SHALL contain exactly one [1..1] @classCode="ENC" Encounter
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC)
Page 188 of 256
1. Set the encounter ID to the ID of an encounter in another section
to signify they are the same encounter
(templateId:2.16.840.1.113883.10.20.22.4.16)
Figure III-43 Procedure Activity Procedure Example
<procedure classCode="PROC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.14" />

<id root=“2.16.840.1.113883.3.96.1.3” extension="d68b7e32-7810-4f5b-9cc2-acd54b0fd85d" />
codeSystemName="SNOMED CT" displayName="Colonoscopy">
<originalText>
</originalText>
</code>
<effectiveTime">
<low value="20060501"/>
<high value="20100501"/>
</effectiveTime>
<methodCode nullFlavor="UNK" />
<targetSiteCode code="appropriate_code" displayName="colon"
codeSystem="2.16.840.1.113883.3.88.12.3221.8.9" codeSystemName="Body Site Value Set"/>
<specimen typeCode="SPC">
<specimenRole classCode="SPEC">
<id root=“2.16.840.1.113883.3.96.1.3” extension="c2ee9ee9-ae31-4628-a919-fec1cbb58683" />
<specimenPlayingEntity>
displayName="colonic polyp sample" codeSystemName=“SNOMED CT” />
</specimenPlayingEntity>
</specimenRole>
</specimen>
<performer>
<assignedEntity>
<addr>
<state>OR</state>
</addr>
<addr>
<state>OR</state>
</addr>
</assignedEntity>
</performer>
Page 189 of 256
<templateId root="2.16.840.1.113883.10.20.22.4.32" />
...
</participantRole>
</participant>
</procedure>
Page 190 of 256
1.17.25 Result Observation
Used By
Result
Organizer_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
This clinical statement represents details of a lab, radiology, or other study performed on a
patient. The result observation includes a statusCode to allow recording the status of an
observation. If a Results Observation is not completed, the Result Organizer must include
corresponding statusCode. “Pending” results (e.g., a test has been run but results have not
been reported yet) should be represented as “active” ActStatus.
Table III-31 Result Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass) =
OBS
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
id
R
R
1..1
R2
@root
R
@extension
R
code
1..1
R
2.16.840.1.113883.10.20.22.4.2
SET_II
CD
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.1 or
2.16.840.1.113883.6.96
@codeSystemName
R2
LOINC or SNOMED
Result Free
Text
text
0..1
R2
ED
Result Status
statusCode
1..1
R
CS
Result Time
Fixed Value
@classCode
templateId
Result Type
Data
Type
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
0..1
R2
IVL_TS
Page 191 of 256
Start
low
1..1
@value
End
Value Code
Interpretation
Code
high
@value
value
@xsi:type
@value
@unit
interpretationCode
methodCode
0..1
1..1
0..1
Range Text
targetSiteCode
@code
@displayName
@codeSystem
@codeSystemName
referenceRange
observationRange
text
R2
R
R
R
R
R2
R2
TS
PQ
PQ
CE
R
R2
R
R2
0..1
@code
@displayName
@codeSystem
@codeSystemName
Target Site
Code
TS
R
@code
@displayName
@codeSystem
@codeSystemName
Method
Code
R
R2
2.16.840.1.113883.5.83
ObservationInterpretation
CE
R
R2
R
R2
0..1
R2
0..1
1..1
0..1
R
R2
R
R2
R2
R2
R2
CE
2.16.840.1.113883.6.96
SNOMED CT
Specification
HL7ActClass 2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode=“EVN” Event 2.16.840.1.113883.5.1001
(ActMood)
i. The extension should be set to a unique value to represent the Result
whenever this particular Result Observation is referenced.
Page 192 of 256
5.
6.
7.
8.
element.
SHALL contain exactly one [1..1] code for the result type such that it
2.16.840.1.113883.6.96)
i. Laboratory results SHOULD be from LOINC (CodeSystem:
2.16.840.1.113883.6.1) or other constrained terminology named by the
US Department of Health and Human Services Office of National
Coordinator or other federal agency. Local and/or regional codes for
laboratory results are allowed. The Local and/or regional codes SHOULD
be sent in the translation element. See the Local code example figure
e. BPHC Captured: BPHC captures the result type to categorize the result. Some
measures are dependent on results of certain procedures to identify if the
patient and/or encounter is included in the measure. E.g. The result of certain
lab requests can identify conditions such as diabetes.
SHOULD contain zero or one [0..1] text such that it contains free text describing the
result and SHOULD include all relevant text used to derive any result codes.
relevant text from which the result codes were determined for auditing
purposes.
SHALL contain exactly one [1..1] statusCode, such that it
a. SHALL contain exactly one @code which SHALL be selected from ValueSet Result
Status 2.16.840.1.113883.11.20.9.39 STATIC
e. BPHC Captured: The result status code is captured by BPHC to determine the
relevance of the result to any measure considering result observations.
SHOULD contain zero or one [0..1] effectiveTime such that it
Page 193 of 256
c. Represents clinically effective time of the measurement, which may be when the
measurement was performed (e.g., a BP measurement), or may be when sample
was taken (and measured some time afterwards)
d. BPHC Captured: The result effective time is captured by BPHC to determine the
relevance of the result given the time frame in which the measure is being taken.
9. SHALL contain exactly one [1..1] value for the result such that it
a. SHALL contain exactly one[1..1] @xsi:type =“PQ”
b. SHALL contain exactly one [1..1] @value
c. SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet
UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839
DYNAMIC
d. BPHC Captured: The value is captured to provide a measurable value for the
result. The value is then used within a measure to identify conditions such as
diabetes.
10. SHOULD contain zero or one [0..1] interpretationCode such that it
Observation Interpretation (HL7)2.16.840.1.113883.1.11.78 DYNAMIC
c. SHALL contain exactly one @codeSystem = 2.16.840.1.113883.5.83
d. SHOULD contain exactly one @codeSystemName = ObservationInterpretation
e. MethodCode SHALL NOT conflict with the method inherent in Procedure / code
f. BPHC Captured: The interpretation code describes how the value should be
interpreted (e.g. Abnormal, Normal, etc…). The interpretation code is to
supporting information to examining the result and should be sent if available.
f. BPHC Captured: BPHC captures the method code as supporting information for
the result observation.
Page 194 of 256
e. BPHC Captured: BPHC captures the target site code as supporting information
for the result observation.
13. SHOULD contain zero or one [0..1] referenceRange for the result such that it
a. SHALL contain exactly one [1..1] observationRange such that it
i. SHOULD contain zero or one [0..1] text containing the free text reference
range for the result observation
Figure III-44 Result Observation Example

<templateId root="2.16.840.1.113883.10.20.22.4.2" />
<id extension="123456789" root ="107c2dc0-67a5-11db-bd13-0800200c9a66" />
<code code="30313-1" displayName="Hgb BldA-mCnc"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<text>
The result free text as described above
</text>
<effectiveTime">
<low value="200003231430"/>
</effectiveTime>
<value xsi:type="PQ" value="13.2" unit="g/dl" />
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" />
<referenceRange>
<observationRange>
<text>M 13-18 g/dl; F 12-16 g/dl</text>
</observationRange>
</referenceRange>
</observation>
Page 195 of 256
1.17.26 Result Organizer
Used By
Results
Contains Entries
Result Observation
This clinical statement identifies set of result observations. It contains information applicable to
all of the contained result observations. Result type codes categorize a result into one of several
commonly accepted values (e.g., “Hematology”, “Chemistry”, and “Nuclear Medicine”). These
values are often implicit in the Organizer/code (e.g., an Organizer/code of “complete blood
count” implies a ResultTypeCode of “Hematology”). This template requires Organizer/code to
include a ResultTypeCode either directly or as a translation of a code from some other code
system.
An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown.
If any Results Observation within the organizer has a statusCode of ‘active’, the Result
Organizer must also have as statusCode of ‘active.
Table III-32 Result Organizer Constraints Overview
Name
XPath
Car
d
Op
t
organizer
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass)
(CLUSTER or BATTERY)
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
id
Result Status
Fixed Value
@classCode
templateId
Result Type
Data
Type
R
R
1..1
R2
@root
R
@extension
R
code
1..1
R
2.16.840.1.113883.10.20.22.4.1
SET_II
CE
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.1 or
2.16.840.1.113883.6.96
@codeSystemName
R2
LOINC or SNOMED
statusCode
1..1
R
@code
R
@displayName
R2
CS
Page 196 of 256
@codeSystem
Specimen
@codeSystemName
specimen
specimenRole
id
specimenPlayingEntity
code
@code
@displayName
@codeSystem
0..*
1..1
0..*
0..1
0..1
@codeSystemName
quantity
@value
name
desc
Result
Observation
Procedure
Reference
2.16.840.1.113883.5.14
R2
O
R
R2
ActStatus
O
O
R
R2
R
R2
O
PQ
O
O
PN
ED
component
1..*
R
component
procedure
0..1
1..1
R2
R
@classCode
@moodCode
templateId
@root
Procedure
Identifier
R
id
1..1
1..1
@root
@extension
R
R
R
R
2.16.840.1.113883.5.6
(HL7ActClass) = PROC
2.16.840.1.113883.10.20.22.4.14
R
R
R
Specification
Note: The specification starts within the organizer element
1. SHALL contain exactly one [1..1] @classCode such that it
2. SHOULD contain zero or one [0..1] @classCode="CLUSTER" Cluster (CodeSystem:
2.16.840.1.113883.5.6 HL7ActClass) OR SHOULD contain zero or one [0..1]
@classCode="BATTERY" Battery (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass)
2.16.840.1.113883.5.1001)
i. The extension should be set to a unique value to represent the Result
Organizer within the sending organization. This ID should be used
whenever this particular Result Organizer is referenced.
Page 197 of 256
the organizer. The unique id can be used to identify the same organizer used in
different messages. The HL7 Consolidation Guide requires an id for this element.
6. SHALL contain exactly one [1..1] code for the result type such that it
2.16.840.1.113883.6.12)
i. Laboratory results SHOULD be from LOINC (CodeSystem:
2.16.840.1.113883.6.1) or other constrained terminology named by the
US Department of Health and Human Services Office of National
Coordinator or other federal agency. Local and/or regional codes for
laboratory results SHOULD also be allowed
f. BPHC Captured: BPHC requires the result type to perform research on diabetic
related measures to determine if a result is pertinent to a person having
diabetes. The original text should contain all free text originally used to
determine the coded value. BPHC requires the originalText for auditing
purposes.
a. SHALL contain exactly one @code which SHALL be selected ValueSet Result
Status 2.16.840.1.113883.11.20.9.39 STATIC 2012-04-27
e. BPHC Captured: The result organizer status code is captured to determine the
relevance of the set of results described by the organizer.
8. MAY contain zero or more [0..*] specimen such that it
a. SHALL contain exactly one [1..1] specimenRole such that it
i. SHOULD contain zero or more [0..*] id such that it
1. SHALL contain exactly one [1..1] @root, which is set to the
organization’s OID
2. SHALL contain exactly one [1..1] @extension, which should be set
to a unique value to represent the specimen within the
organization. This ID should be used whenever this particular
specimen is referenced.
Page 198 of 256
3. If you want to indicate that the Procedure and the Results are
referring to the same specimen, the
Procedure/specimen/specimenRole/id SHOULD be set to equal an
Organizer/specimen/ specimenRole/id
ii. MAY contain zero or one [0..1] specimenPlayingEntity such that it
1. MAY contain zero or one [0..1] code such that it
a. SHALL contain exactly one @code which SHOULD be
selected from ValueSet
“2.16.840.1.113883.6.96”
“SNOMED CT”
2. MAY contain zero or one [0..1] quantity such that it
a. SHOULD contain zero or one [0..1] @value
3. MAY contain zero or one [0..1] name
4. MAY contain zero or one [0..1] description
b. This specimen is for representing specimens used in determining the results
9. SHALL contain one or more [1..*] component for Result Observations such that it
a. SHALL contain exactly one [1..1] Result Observation
(templateId:2.16.840.1.113883.10.20.22.4.2)
10. SHOULD contain zero or one [0..1] component for the associate procedure if there is
one such that it
a. SHALL contain exactly one [1..1] procedure such that it
i. SHALL contain exactly one [1..1] @classCode = “PROC”
2.16.840.1.113883.5.6 (HL7ActClass)
ii. SHALL contain exactly one [1..1] @moodCode = “EVN”
@root=“2.16.840.1.113883.10.20.22.4.14”
b. SHALL contain exactly one [1..1] id such that it
i. SHALL contain exactly one [1..1] @root, which is set to the organization’s
OID
ii. SHALL contain exactly one [1..1] @extension, which should be set to a
unique value to represent the procedure within the organization. This ID
should be used whenever this particular procedure is referenced.
iii. BPHC Captured: If the procedure in which this result or set of results
belongs is known, the id field should be included and set to the id of that
procedure. The id is captured by BPHC to provide a clear connection
between procedures and their associated results.
Page 199 of 256
Figure III-45 Results Organizer Example
<organizer classCode="BATTERY" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.1" />
<id root=“2.16.840.1.113883.3.96.1.3” extension ="7d5a02b0-67a4-11db-bd13-0800200c9a66" />
<code code="43789009" displayName="CBC WO DIFFERENTIAL"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" >
</code>
<component>
<templateId root="2.16.840.1.113883.10.20.22.4.2" />
...
</observation>
</component>
<component>
<templateId root="2.16.840.1.113883.10.20.22.4.2" />
...
</observation>
</component>
<component>
<templateId root="2.16.840.1.113883.10.20.22.4.2" />
...
</observation>
</component>
</organizer>
Page 200 of 256
1.17.27 Service Delivery Location
Used By
Procedure Activity
Contains Entries
Addr
Telecom
This clinical statement represents the location of a service event where an act, observation or
procedure took place.
Table III-33 Service Delivery Location Constraints Overview
Name
XPath
Car
d
Op
t
participantRole
1..1
R
@classCode
templateId
1..1
code
R
R
1..1
R
2.16.840.1.113883.10.20.22.4.32
CE
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.259
@codeSystemName
R2
HealthcareServiceLocation
Place
Address
addr
0..*
R2
Addr
Place
Telecom
Address
telecom
0..*
R2
Tel
playingEntity
0..1
O
2.16.840.1.113883.5.41
(EntityClass) = PLC
@classCode
Place Name
Fixed Value
2.16.840.1.113883.5.111
(RoleCode) = SDLOC
R
@root
Service
Location
Data
Type
name
PN
Specification
Note: The specification starts within the participantRole element
1. SHALL contain exactly one [1..1] @classCode="SDLOC" Service Delivery Location
(CodeSystem: RoleCode 2.16.840.1.113883.5.111 STATIC)
Page 201 of 256
SHALL contain exactly one [1..1] code such that it
HealthcareServiceLocation 2.16.840.1.113883.1.11.20275
d. SHOULD contain exactly one @codeSystemName = “HealthcareServiceLocation”
4. SHOULD contain zero or more [0..*] addr
5. SHOULD contain zero or more [0..*] telecom
6. MAY contain zero or one [0..1] playingEntity for the Place such that it
a. SHALL contain exactly one [1..1] @classCode="PLC" (CodeSystem: EntityClass
2.16.840.1.113883.5.41 STATIC)
b. MAY contain zero or one [0..1] name
3.
Figure III-46 Service Delivery Location Example
<templateId root="2.16.840.1.113883.10.20.22.4.32" />
codeSystemName="HealthcareServiceLocation" displayName="Urgent Care Center" />
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
</addr>
<telecom nullFlavor="UNK" />
<playingEntity classCode="PLC">
</playingEntity>
</participantRole>
Page 202 of 256
1.17.28 Severity Observation
Used By
Allergy – Intolerance
Observation_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
This clinical statement represents the gravity of the problem, such as allergy or reaction, in
terms of its actual or potential impact on the patient. The Severity Observation can be
associated with an Allergy Observation, Reaction
Observation or both. When the Severity Observation is associated directly with an Allergy it
characterizes the Allergy. When the Severity Observation is associated with a Reaction
Observation it characterizes a Reaction. A person may manifest many symptoms in a reaction to
a single substance, and each reaction to the substance can be represented. However, each
reaction observation can have only one severity observation associated with it. For example,
someone may have a rash reaction observation as well as an itching reaction observation, but
each can have only one level of severity.
Table III-34 Severity Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
Fixed Value
@classCode
R
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
R
2.16.840.1.113883.5.1001
(ActMood) = EVN
templateId
1..1
@root
code
Severity
Free Text
Data
Type
R
R
1..1
R
2.16.840.1.113883.10.20.22.4.8
CE
@code
R
SEV
@displayName
R2
Severity Observation
@codeSystem
R
2.16.840.1.113883.5.4
@codeSystemName
R2
Act Code
text
0..1
R2
statusCode
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
1..1
R
IVL_TS
Page 203 of 256
Name
Severity
Coded
XPath
value
Car
d
Op
t
Data
Type
1..1
R
CD
Fixed Value
@xsi:type
R
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED CT
interpretationCode
0..1
CD
R2
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.5.83
@codeSystemName
R2
Observation Interpretation
Specification
HL7ActClass 2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
a. SHALL contain exactly one @code="SEV"
b. SHOULD contain exactly one @displayName = “Severity Observation”
severity and SHOULD include all relevant text used to derived the severity code
relevant text from which the severity codes were determined for auditing
purposes.
Page 204 of 256
Problem Severity 2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC
f. BPHC Captured: The severity of the problem is captured by BPHC to help
determine the relevance of a problem to the measures being executed.
g. SHALL contain exactly one [0..1] interpretationCode such that it
i. SHALL contain exactly one [1..1] @code, which SHALL be selected from
ValueSet Observation Interpretation (HL7) 2.16.840.1.113883.1.11.78
DYNAMIC
iv. SHOULD contain exactly one @codeSystemName = “Observation
Interpretation”
v. BPHC Captured: The interpretation is captured to provide additional
information to the severity of the problem.
Figure III-47 Problem severity Observation Example
<templateId root="2.16.840.1.113883.10.20.22.4.8" />

<code code="SEV" displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" />
<text>
The severity free text as described above
</text>
<statusCode code="completed" />
<value xsi:type="CD" code="371924009" displayName="Moderate to severe"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
<interpretationCode code="S" displayName="Susceptible"
codeSystem="2.16.840.1.113883.1.11.78" codeSystemName="Observation Interpretation"/>
</observation>
Page 205 of 256
1.17.29 Smoking Status Observation
Used By
Social History
Contains Entries
This clinical statement represents a patient’s current smoking status. The vocabulary selected
for this clinical statement is the best approximation of the statuses in Meaningful Use (MU)
Stage 1.
If the patient is a smoker (77176002), the effectiveTime/low element must be present. If the
patient is an ex-smoker (8517006), both the effectiveTime/low and effectiveTime/high element
must be present.
The smoking status value set includes a special code to communicate if the smoking status is
unknown which is different from how Consolidated CDA generally communicates unknown
information.
Table III-35 Smoking Status Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass) =
OBS
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
Observation
Status
Observation
Time
Fixed Value
@classCode
templateId
Social
History Type
Data
Type
code
R
R
0..1
R2
2.16.840.1.113883.10.22.4.78
CD
@code
R
ASSERTION
@displayName
R2
Assertion
@codeSystem
R
2.16.840.1.113883.5.4
@codeSystemName
R2
ActCode
statusCode
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
0..1
R2
IVL_TS
Page 206 of 256
Start
low
1..1
@value
End
Value Code
Value Free
Text
high
@value
value
@xsi:type
@code
@displayName
@codeSystem
@codeSystemName
originalText
R
TS
R
0..1
R2
TS
1..1
R
R
CD
R
R2
R
R2
0..1
Shows CD as example
CD
2.16.840.1.113883.6.96
SNOMED CT
R2
Specification
HL7ActClass 2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.22.4.78"
3. SHALL contain exactly one [1..1] code for the observation type such that it
a. SHALL contain exactly one [1..1] @code = “ASSERTION”
c. BPHC Captured: BPHC captures the smoking status effective time to determine
the relevance of the smoking status to the timeframe of measure in question.
a. SHALL contain exactly one[1..1] @xsi:type = “CD”
b. SHALL contain exactly one [1..1] @code, which SHOULD be selected from
ValueSet Smoking Status 2.16.840.1.113883.10.22.4.78 DYNAMIC
Page 207 of 256
g. BPHC Captured: BPHC requires the smoking status value code to identify if
smoking is a risk factor for the particular person. The original text should contain
all free text originally used to determine the coded value. BPHC requires the
originalText for auditing purposes.
Figure III-48 Smoking Status Observation Example

<templateId root="2.16.840.1.113883.10.20.22.4.78" />
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" />
<effectiveTime>
<low value="20050501" />
<high value="20090227130000+0500" />
</effectiveTime>
<value xsi:type="CD" code="8517006" displayName="Former smoker"
codeSystem="2.16.840.1.113883.6.96" />
</observation>
Page 208 of 256
1.17.30 Social History Observation
Used By
Social History
Contains Entries
This Social History Observation defines the patient’s occupational, personal (e.g., lifestyle),
social, and environmental history and health risk factors, as well as administrative data such as
marital status, race, ethnicity, and religious affiliation.
Table III-36 Social History Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass) =
OBS
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
id
Observation
Type Free
Text
Observation
Status
Observation
Time
Start
Fixed Value
@classCode
templateId
Social
History Type
Data
Type
R
R
1..1
R2
@root
R
@extension
R
code
0..1
R2
2.16.840.1.113883.10.20.22.4.38
SET_II
CD
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED
originalText
statusCode
0..1
R2
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
0..1
R2
IVL_TS
1..1
R
TS
Page 209 of 256
@value
End
Value Code
Value Free
Text
high
@value
value
@xsi:type
@code
@displayName
@codeSystem
@codeSystemName
originalText
R
0..1
R2
TS
1..1
R
R
CD
Shows CD as example
CD or PQ or ST or ED
R
R2
R
R2
0..1
R2
Specification
HL7ActClass 2.16.840.1.113883.5.6)
2.16.840.1.113883.5.1001)
i. The extension should be set to a unique value to represent the Social
History Observation within the sending organization. This ID should be
used whenever this particular Social History Observation is referenced.
element.
5. SHALL contain exactly one [1..1] code for the observation type such that it
ValueSet Social History Type Set Definition 2.16.840.1.113883.3.88.12.80.60
STATIC 2008-12-18
f. BPHC Captured: BPHC requires the social history observation type code to
identify the type of observation. A person’s social history can identify lifestyle
risk factors that are commonly studied such as the effects of drinking and
smoking on one’s health. The original text should contain all free text originally
Page 210 of 256
used to determine the coded value. BPHC requires the originalText for auditing
purposes.
c. BPHC Captured: BPHC captures the social history observation effective time to
determine the relevance of the observation given the timeframe of measure in
question.
a. SHALL contain exactly one[1..1] @xsi:type
i. The HL7 CDA R2 Consolidation guides states that the type can be ANY.
The BPHC Health Equity limits the @xsi:type to CD, PQ , ST, ED. When
value is a physical quantity, the unit of measure SHALL be expressed
using a valid Unified Code for Units of Measure (UCUM) expression.
b. SHOULD contain zero or one [0..1] originalText. The original text is a free text
c. BPHC Captured: BPHC requires the social history observation value code to
assign a measureable value to the social history observation. The original text
should contain all free text originally used to determine the coded value. BPHC
requires the originalText for auditing purposes.
Figure III-49 Social History Observation Example
<templateId root="2.16.840.1.113883.10.20.22.4.38" />

<id root=“2.16.840.1.113883.3.96.1.3” extension ="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1" />
displayName="Tobacco use and exposure">
<originalText>
The social observation type free text as described above
</originalText>
</code>
<value xsi:type="ST">1 pack per day</value>
</observation>
Page 211 of 256
1.17.31 Vital Signs Observation
Used By
Vital Signs
Organizer_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
Vital signs are represented as are other results, with additional vocabulary constraints.
Table III-37 Vital Signs Observation Constraints Overview
Name
XPath
Car
d
Op
t
observation
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass) =
OBS
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
id
R
R
1..1
R2
@root
R
@extension
R
code
1..1
R
2.16.840.1.113883.10.20.22.4.27
SET_II
CD
@code
R
@displayName
R2
@codeSystem
R
2.16.840.1.113883.6.1
@codeSystemName
R2
LOINC
Result Free
Text
text
0..1
R2
ED
Result Status
statusCode
1..1
R
CS
Result Time
Start
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
1..1
R
IVL_TS
1..1
R
TS
@value
End
Value Code
Fixed Value
@classCode
templateId
Result Type
Data
Type
high
@value
value
@xsi:type
R
0..1
R2
TS
1..1
R
R
R
PQ
PQ
Page 212 of 256
@value
@unit
Interpretation
Code
interpretationCode
R
R2
0..1
@code
@displayName
@codeSystem
@codeSystemName
Method
Code
methodCode
Range Text
targetSiteCode
@code
@displayName
@codeSystem
@codeSystemName
referenceRange
observationRange
text
CE
R
R2
R
R2
0..1
@code
@displayName
@codeSystem
@codeSystemName
Target Site
Code
R2
R2
2.16.840.1.113883.5.83
ObservationInterpretation
CE
R
R2
R
R2
0..1
R2
0..1
1..1
0..1
R
R2
R
R2
R2
R2
R2
CE
2.16.840.1.113883.6.96
SNOMED CT
Specification
HL7ActClass 2.16.840.1.113883.5.6)
2. SHALL contain exactly one [1..1] @moodCode=“EVN” Event 2.16.840.1.113883.5.1001
(ActMood)
i. The extension should be set to a unique value to represent the Vital Signs
whenever this particular Vital Signs Observation is referenced.
element.
5. SHALL contain exactly one [1..1] code for the result type such that it
ValueSet HITSP Vital Sign Result Type 2.16.840.1.113883.3.88.12.80.62
DYNAMIC
Page 213 of 256
e. BPHC Captured: BPHC captures the vital sign result type to categorize the vital
sign reading. The result type can be used to identify those vital sign readings
applicable to the measure being run.
result and SHOULD include all relevant text used to derive any result codes.
relevant text from which the result codes were determined for auditing
purposes.
c. Represents clinically effective time of the measurement, which may be when the
measurement was performed (e.g., a BP measurement), or may be when sample
was taken (and measured some time afterwards)
d. BPHC Captured: BPHC captures the effective time of the vital sign observation to
determine its relevance given the time period covered by the measure in
question.
9. SHALL contain exactly one [1..1] value for the result such that it
a. SHALL contain exactly one[1..1] @xsi:type =“PQ”
b. SHALL contain exactly one [1..1] @value
c. SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet
UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839
DYNAMIC
d. BPHC Captured: The vital sign result is captured by BPHC since the available
measurements can be used to determine conditions such as high blood pressure
and to see how the condition is managed overtime.
10. SHOULD contain zero or one [0..1] interpretationCode such that it
Observation Interpretation (HL7)2.16.840.1.113883.1.11.78 DYNAMIC
Page 214 of 256
c. SHALL contain exactly one @codeSystem = 2.16.840.1.113883.5.83
d. SHOULD contain exactly one @codeSystemName = ObservationInterpretation
e. BPHC Captured: The interpretation code is captured by BPHC as supporting
information to the vital sign observation.
12. SHOULD contain zero or more [0..1] targetSiteCode such that it
Figure III-50 Vital Signs Observation Example
<templateId root="2.16.840.1.113883.10.20.22.4.27" />

<id root=“2.16.840.1.113883.3.96.1.3” extension ="c6f88321-67ad-11db-bd13-0800200c9a66" />
codeSystemName="LOINC" displayName="Height" />
<text>
The result free text as described above
</text>
<statusCode code="completed" displayName=―completed‖
codeSystem=―2.16.840.1.113883.5.14‖ codeSystemName=―ActStatus‖/>
<effectiveTime">
<low value="19991114"/>
</effectiveTime>
<value xsi:type="PQ" value="177" unit="cm" />
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" />
</observation>
Page 215 of 256
1.17.32 Vital Signs Organizer
Used By
Vital Signs
Contains Entries
Vital Sign Observation
The Vital Signs Organizer groups vital signs, which is similar to the Result Organizer, but with
further constraints. An appropriate nullFlavor can be used when the organizer/code or
organizer/id is unknown.
Table III-38 Vital Signs Organizer Constraints Overview
Name
XPath
Car
d
Op
t
organizer
1..1
R
R
2.16.840.1.113883.5.6 (HL7ActClass) =
CLUSTER
@moodCode
R
2.16.840.1.113883.5.1001 (ActMood) =
EVN
1..1
@root
id
Status
R
R
1..1
R2
@root
R
@extension
R
code
1..1
R
2.16.840.1.113883.10.20.22.4.26
SET_II
CE
@code
R
46680005
@displayName
R2
"Vital signs"
@codeSystem
R
2.16.840.1.113883.6.96
@codeSystemName
R2
SNOMED
statusCode
1..1
R
CS
@code
R
completed
@displayName
R2
completed
@codeSystem
R
2.16.840.1.113883.5.14
@codeSystemName
R2
ActStatus
effectiveTime
low
1..1
R
IVL_TS
1..1
R
TS
@value
high
Vital Signs
Fixed Value
@classCode
templateId
Type
Data
Type
@value
component
R
0..1
R2
1..*
R
R
TS
Page 216 of 256
Observation
Specification
Note: The specification starts within the organizer element
1. SHALL contain exactly one [1..1] @classCode such that it
2. SHOULD contain zero or one [0..1] @classCode="CLUSTER" Cluster (CodeSystem:
2.16.840.1.113883.5.6 HL7ActClass)
2.16.840.1.113883.5.1001)
i. The extension should be set to a unique value to represent the Vital Signs
Organizer within the sending organization. This ID should be used
whenever this particular Vital Signs Organizer is referenced.
the organizer. The unique id can be used to identify the same organizer used in
different messages. The HL7 Consolidation Guide requires an id for this element.
6. SHALL contain exactly one [1..1] code for the organizer type such that it
a. SHALL contain exactly one [1..1] @code = “46680005”
b. SHOULD contain exactly one @displayName = "Vital signs"
d. SHOULD contain exactly one @codeSystemName =“SNOMED CT”
b. SHOULD = “completed”
ii. SHALL contain exactly [1..1] @value set to the start time for the organizer
ii. SHALL contain exactly [1..1] @value set to the end time for the organizer
c. BPHC Captured: The vital sign organizer effective time is captured by BPHC to
determine the relevance of the vital sign result(s) within the organizer based on
the time period considered by the measure.
9. SHALL contain one or more [1..*] component for Result Observations such that it
a. SHALL contain exactly one [1..1] Vital Sign Observation
(2.16.840.1.113883.10.20.22.4.27)
Page 217 of 256
Figure III-51 Vital Signs Organizer Example
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.26" />

<id root=“2.16.840.1.113883.3.96.1.3” extension ="c6f88320-67ad-11db-bd13-0800200c9a66" />
codeSystemName="SNOMED-CT" displayName="Vital signs" />
<effectiveTime>
<low value="19991114"/>
</effectiveTime>
<component>
<templateId root="2.16.840.1.113883.10.20.22.4.27" />
...
</observation>
</component>
<component>
<templateId root="2.16.840.1.113883.10.20.22.4.27" />
...
</observation>
</component>
<component>
<templateId root="2.16.840.1.113883.10.20.22.4.27" />
...
</observation>
</component>
</organizer>
Page 218 of 256
1.18 CDA Common Data Types
1.18.1 Addr
[addr: 2.16.840.1.113883.10.20.22.5.2(open)]
Used By
Author Content
Custodian Content
Record Target Content
Service Event Content
Procedure Activity Procedure
Organization
_Immunizations_Section_Encounters_Section_Allergy_problem_Entry
Contains Entries
Reusable "address" template, designed for use in US Realm CDA Header.
Table III-39 Addr Constraints Overview
Name
XPath
Car
d
Op
t
addr
1..1
R
@use
Data
Type
Fixed Value
R
country
0..1
R2
state
0..1
CR
city
1..1
R
postalCode
0..1
CR
streetAddressLine
1..4
R
Specification
Note: The specification starts within the addr element
1. SHOULD contain exactly one [1..1] @use, which SHALL be selected from ValueSet
PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01
2. SHOULD contain zero or one [0..1] country, where the @code SHALL be selected from
ValueSet CountryValueSet 2.16.840.1.113883.3.88.12.80.63 DYNAMIC
3. SHOULD contain zero or one [0..1] state (ValueSet: StateValueSet
2.16.840.1.113883.3.88.12.80.1 DYNAMIC)
a. State is required if the country is US. If country is not specified, it is assumed to
be US. If country is something other than US, the state MAY be present but MAY
be bound to different vocabularies
4. SHALL contain exactly one [1..1] city
Page 219 of 256
5. SHOULD contain zero or one [0..1] postalCode (ValueSet: PostalCodeValueSet
2.16.840.1.113883.3.88.12.80.2 DYNAMIC)
a. PostalCode is required if the country is US. If country is not specified, it is
assumed to be US. If country is something other than US, the postalCode MAY
be present but MAY be bound to different vocabularies
6. SHALL contain at least one and not more than 4 streetAddressLine
7. SHALL NOT have mixed content except for white space
Figure III-52 Addr Example
<addr use="H">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
</addr>
Page 220 of 256
1.18.2 Organization
Used By
Custodian Content
Policy Activity
Procedure Activity
Contains Entries
Addr
Telecom
Reusable "organization" template for the Organization data type.
Table III-40 Organization Constraints Overview
Name
XPath
Car
d
Op
t
id
1..1
R
@root
R
@extension
R
Data
Type
name
1..1
R
addr
1..*
R
Addr
telecom
0..*
R2
Tel
Fixed Value
Specification
Note: The specification starts within the associated organization element
i. The root should be set to the sending to the organization OID
i. The extension should be set to a unique identifier of a specific
office/department within the organization.
c. BPHC Captured: BPHC requires the organization identifier to be supplied with
every organization element. The organization identifier root uniquely identifies
the organization providing the associated services. The extension is required to
uniquely identify the actual office/department in which the services are provided
to allow BPHC to run reports at a more granular level.
3. SHALL contain one or more [1..*] addr
4. SHOULD contain zero or more [0..*] telecom
Page 221 of 256
Figure III-53 Organization Example (providerOrganization case)
<providerOrganization>
<id root="2.16.840.1.113883.4.6"/>
<telecom use="WP" value="tel: 555-555-5000"/>
<addr>
<state>OR</state>
</addr>
</providerOrganization>
Page 222 of 256
1.18.3 Person
Used By
Author Content
Policy
Contains Entries
Reusable "person" template for the Person data type.
Table III-41 Person Constraints Overview
Name
XPath
Car
d
Op
t
Data
Type
id
1..1
R
SET_II
@root
R
@extension
R
name
1..1
@use
Fixed Value
R
R2
given
1..*
R
family
1..1
R
Specification
Note: The specification starts within the associated person element
a. SHALL contain exactly one [1..1] @root which SHOULD be set to the assigning
authority for the person
b. SHALL contain exactly one [1..1] @extension which SHOULD be set to the
unique id of the person with the assigning authority
2. SHALL contain exactly one [1..1] name such that it
a. SHOULD contain zero or one @use, which SHALL be selected from Value Set:
EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01
b. SHALL contain one or more [1..*] given
i. The first given will be the person’s first name
ii. A second given if present will be the person’s middle name
c. SHALL contain exactly one [1..1] family which is the person’s last name
Figure III-54 Person Example (assignedPerson case)
<assignedPerson>
<id root="2.16.840.1.113883.4.6" extension=“1234”/>
<name user=―L‖>
<given>Christine</given>
<family>Cure</family>
</name>
</assignedPerson>
Page 223 of 256
1.18.4 Telecom
Used By
Author Content
Custodian Content
Procedure Activity Procedure
Organization
_Encounters_Section_Allergy_problem_Entry
Contains Entries
Telecom
Reusable "telecom" template
Table III-42 Telecom Constraints Overview
Name
XPath
Car
d
Op
t
telecom
1..1
R
@use
R
@value
R
Data
Type
Fixed Value
Specification
Note: The specification starts within the telecom element
1. SHALL contain exactly one [1..1] @use, which SHALL be selected from ValueSet:
Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC
2. SHALL contain exactly one [1..1] @value
Figure III-55 Telecom Example
<telecom use="WP" value="tel:555-555-1212"/>
Page 224 of 256
IV.
Appendices
Appendix A: OIDS
This section lists the OIDs used throughout this document.
BPHC Defined OIDs
Name
BPHC Location ID
BPHC Organization ID
BPHC DEA
OID
2.16.840.1.113883.3.96.1.1
2.16.840.1.113883.3.96.1.3
2.16.840.1.113883.3.96.1.4
Page 225 of 256
Appendix B: Vocabulary
The following sub-sections contain code set values that must be used for particular fields within
the Health Equity message.
1.19 Act Priority Value Set
Value Set
Code System
Description
Code
A
CR
CS
CSP
CSR
EL
EM
P
PRN
R
RR
S
T
UD
UR
ActPriority 2.16.840.1.113883.5.7
A code or set of codes (e.g., for routine, emergency,) specifying the urgency under which
the Act happened, can happen, is happening, is intended to happen, or is
requested/demanded to happen.
Print Name
ASAP
Callback results
Callback for scheduling
Callback placer for scheduling
Contact recipient for scheduling
Elective
Emergency
Preoperative
As needed
Routine
Rush reporting
Stat
Timing critical
Use as directed
Urgent
1.20 Administrative Gender Value Set
Value Set
Code System
Description
Code
F
M
UN
Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 DYNAMIC
AdministrativeGender 2.16.840.1.113883.5.1
Gender Codes
Print Name
Female
Male
Undifferentiated
1.21 Allergy/Adverse Event Type Value Set
Value Set
Code System
Description
Code
Allergy/Adverse Event Type 2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC
SNOMED CT 2.16.840.1.113883.6.96
This Value Set describes the type of product and intolerance suffered by the patient
http://phinvads.cdc.gov/vads/ViewValueSet.action?id=7AFDBFB5-A277DE11-9B52-0015173D1785
Print Name
Page 226 of 256
420134006
418038007
419511003
418471000
419199007
416098002
414285001
59037007
235719002
Propensity to adverse reactions (disorder)
Propensity to adverse reactions to substance (disorder)
Propensity to adverse reactions to drug (disorder)
Propensity to adverse reactions to food (disorder)
Allergy to substance (disorder)
Drug allergy (disorder)
Food allergy (disorder)
Drug intolerance (disorder)
Food intolerance (disorder)
1.22 Body Site Value Set
Value Set
Code System
Description
Code
Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC
SNOMED CT 2.16.840.1.113883.6.96
Contains values descending from the SNOMED CT® Anatomical Structure (91723000)
hierarchy or Acquired body structure (body structure) (280115004) or Anatomical site
notations for tumor staging (body structure) (258331007) or Body structure, altered
from its original anatomical structure (morphologic abnormality) (118956008) or Physical
anatomical entity (body structure) (91722005) This indicates the anatomical site.
http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html
Print Name
Page 227 of 256
1.23 Country Value Set
Value Set
Code System
Description
Code
CountryValueSet 2.16.840.1.113883.3.88.12.80.63 DYNAMIC
ISO 3166-1 Country Codes: 1.0.3166.1
A value set of codes for the representation of names of countries, territories and areas of
geographical interest. Note: This table provides the ISO 3166-1 code elements available
in the alpha-2 code of ISO's country code standard
http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm
Print Name
1.24 Coverage Role Value Set
Value Set
Code System
Description
Code
FAMDEP
FSTUD
HANDIC
INJ
PSTUD
SELF
SPON
STUD
Coverage Role Type Value Set 2.16.840.1.113883.1.11.18877 DYNAMIC
RoleCode 2.16.840.1.113883.5.111
The type of coverage
Print Name
Family dependent
Full-time student
Handicapped dependent
Injured plaintiff
Part-time student
Self
Sponsored dependent
Student
1.25 Discharge Disposition Value Set
Value Set
Code System
Description
Code
01
02
03
04
05
06
07
08
09
10 …19
20
21 ... 29
30
31 … 39
HL7 Discharge Disposition 2.16.840.1.113883.12.112
Alternative Discharge Disposition Codes
Print Name
Discharged to home or self-care (routine discharge)
Discharged/transferred to another short-term general hospital for inpatient
Care
Discharged/transferred to skilled nursing facility (SNF)
Discharged/transferred to an intermediate-care facility (ICF)
Discharged/transferred to another type of institution for inpatient care or
referred for outpatient services to another institution
Discharged/transferred to home under care of organized home health service
Organization
Left against medical advice or discontinued care
Discharged/transferred to home under care of Home IV provider
Admitted as an inpatient to this hospital
Discharge to be defined at state level, if necessary
Expired (e.g., dead)
Expired to be defined at state level, if necessary
Still patient or expected to return for outpatient services (e.g., still a patient)
Still patient to be defined at state level, if necessary (e.g., still a patient)
Page 228 of 256
40
41
Expired (e.g., died) at home
Expired (e.g., died) in a medical facility; e.g., hospital, SNF, ICF, or freestanding
hospice
1.26 Encounter Type Value Set
Value Set
Code System
Description
Code
EncounterTypeCode 2.16.840.1.113883.3.88.12.80.32 DYNAMIC
CPT-4 2.16.840.1.113883.6.12
This value set includes only the codes of the Current Procedure and Terminology
designated for Evaluation and Management (99200 – 99607) (subscription to AMA
Required
http://www.amacodingonline.com/)
Print Name
1.27 Entity Name Use Value Set
Value Set
Code System
Description
Code
A
ABC
ASGN
C
I
IDE
L
P
PHON
R
SNDX
SRCH
SYL
EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01
EntityNameUse 2.16.840.1.113883.5.45
The name usage
Print Name
Artist/Stage
Alphabetic
Assigned
License
Indigenous/Tribal
Ideographic
Legal
Pseudonym
Phonetic
Religious
Soundex
Search
Syllabic
1.28 Ethnicity (BPHC Vocabulary)
Value Set
OID
Description
Code
2135-2
2186-5
2058-6
US
2148-5
2151-9
BPHC Ethnicity Codes
2.16.840.1.113883.3.539.1.1
BPHC specified ethnicity codes. This code set is a combination of the HITSP
recommended CDC Ethnicity Codes, ISO country codes, and custom BPHC codes.
Print Name
Hispanic or Latino
Not Hispanic or Latino
African American
American
Mexican, Mexican
American, Chicano
Page 229 of 256
2155-0
2157-6
2158-4
2161-8
2135-2
2186-5
2058-6
2156-8
2159-2
2160-0
2162-6
BZ
2165-9
2166-7
2167-5
BR
2168-3
2169-1
2170-9
2171-7
2172-5
2173-3
2I74-1
2175-8
2176-6
GY
2060-2
2062-8
2061-0
RW
KE
MA
DZ
2120-4
SN
CD
CD
CM
NA
2065-1
ZW
ZM
TZ
2052-9
ER
MU
LY
TD
CV
BIRUANDI
AO
MZ
Central American
Guatemalan
Honduran
Salvadoran
Hispanic or Latino
Not Hispanic or Latino
African American
Costa Rican
Nicaraguan
Panamanian
Central American Indian
Belizean
South American
Argentinean
Bolivian
Brazilian
Chilean
Columbian
Ecuadorian
Paraguayan
Peruvian
Uruguayan
Venezuelan
South American Indian
Criollo
Guyanan
African
Ethiopian
Botswanan
Rwanda
Kenyan
Moroccan
Algerian
Egyptian
Senegalese
Democratic Republic of the Congo
Central African Republic
Cameroon
Nambia
Niger
Zimbabwian
Zambia
Tanzinia
Madagascar
Eriteria
Mauritia
Libia
Chad
Cape Verdean
Biruandi
Angola
Mozambique
Page 230 of 256
GH
2063-6
2065-1
SL
SO
2028-9
2029-7
2030-5
2031-3
2032-1
2033-9
2034-7
2035-4
2036-2
2037-0
2038-8
2039-6
2040-4
2041-2
2042-0
2043-8
2044-6
2045-3
2046-1
2047-9
2048-7
2049-5
2050-3
2051-1
MN
TIBET
KARON
CARIBI
2182-4
2184-0
2071-9
2068-5
2180-8
2070-1
2072-7
2074-3
2073-5
2075-0
2108-9
2110-5
2111-3
2112-1
GR
2113-9
2114-7
2116-2
2137-8
Ghanian
Liberian
Nigerian
Sierra Leonian
Somalian
Asian
Asian Indian
Bangladeshi
Bhutanese
Burmese
Cambodian
Chinese
Taiwanese
Filipino
Hmong
Indonesian
Japanese
Korean
Laotian
Malaysian
Okinawan
Pakistani
Sri Lankan
Thai
Vietnamese
Iwo Jiman
Maldivian
Nepalese
Singaporean
Mongolian
Tibetan
Karon
Caribbean Island
Cuban
Dominican
Haitian
Barbadian
Puerto Rican
Dominica Islander
Jamaican
Trinidadian
Tobagoan
West Indian
European
English
French
German
Greek
Irish
Italian
Scottish
Spanish
Page 231 of 256
PT
AT
CH
LT
EE
LV
FI
SE
DK
NO
WELSH
2118-8
2119-6
2121-2
2122-0
2123-8
KW
KURDISH
TR
YE
SA
2124-6
2129-5
2125-3
2126-1
2127-9
EASTEU
AL
RU
2109-7
BA
1207-0
2115-4
UA
MD
CZ
HU
RO
BG
SK
SI
OTH
UNKNOW
Portuguese
Austrian
Swiss
Lithuania
Estonia
Latvia
Finish
Swedish
Danes
Norwegian
Welsh
Middle Eastern
Assyrian
Iranian
Iraqi
Lebanese
Kuwati
Kurdish
Turkish
Yemen
Saudi Arabian
Palestinian
Arab
Syrian
Afghanistani
Israeli
Eastern European
Albanian
Russian
Armenian
Bosnian
Croatian
Polish
Ukranian
Moldovian
Czech
Hungarian
Romanian
Bulgarian
Slovakian
Slovenian
Other Ethnicity (please specify)
Unknown/not specified
1.29 Financially Responsible Party Value Set
Value Set
Code System
Description
Code
FinanciallyResponsiblePartyType 2.16.840.1.113883.1.11.10416 DYNAMIC
RoleCode 2.16.840.1.113883.5.110
The entity responsible financially
http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008
Print Name
Page 232 of 256
1.30 Health Insurance Type Value Set
Value Set
Code System
Description
Code
Health Insurance Type Value Set 2.16.840.1.113883.3.88.12.3221.5.2 DYNAMIC
ASC X12 2.16.840.1.113883.6.255.1336
The health insurance type. The full value set is available in HITSP C80
Print Name
1.31 Health Status Value Set
Value Set
Code System
Description
Code
81323004
313386006
162467007
161901003
271593001
21134002
161045001
HealthStatus 2.16.840.1.113883.1.11.20.12 DYNAMIC
SNOMED CT 2.16.840.1.113883.6.96
Represents the general health status of the patient.
Print Name
Alive and well
In remission
Symptom free
Chronically ill
Severely ill
Disabled
Severely disabled
1.32 Healthcare Provider Taxonomy Value Set
Value Set
Code
System
Description
Code
Healthcare Provider Taxonomy (NUCC - HIPAA) 2.16.840.1.114222.4.11.1066
DYNAMIC
NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101
Print Name
1.33 Healthcare Service Location Value Set
Value
Set
Code
System
Descripti
on
Code
HealthcareServiceLocation 2.16.840.1.113883.1.11.20275 DYNAMIC
HealthcareServiceLocation 2.16.840.1.113883.6.259
A comprehensive classification of locations and settings where healthcare services are provided. This
value set is based on the National Healthcare Safety Network (NHSN) location code system that has
been developed over a number of years through CDC's interaction with a variety of healthcare facilities
and is intended to serve a variety of reporting needs where coding of healthcare service locations is
required. Full value set may be found at:
http://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=Healthcare+Se
rvice+Location+%28NHSN%29
Print Name
Page 233 of 256
1.34 HITSP Problem Status Value Set
Value Set
Code System
SNOMED CT 2.16.840.1.113883.6.96
Description
The status of the problem.
Code
Print Name
55561003
Active
73425007
Inactive*
413322009
Resolved**
* An inactive problem refers to one that is quiescent, and may appear again in the future
** A resolved problem refers to one that use to affect a patient, but does not anymore
1.35 HITSP Vital Sign Result Type Value Set
Value Set
Code System
Description
Code
9279-1
8867-4
2710-2
8480-6
8462-4
8310-5
8302-2
8306-3
8287-5
3141-9
39156-5
3140-1
HITSP Vital Sign Result Type 2.16.840.1.113883.3.88.12.80.62 DYNAMIC
LOINC 2.16.840.1.113883.6.1
This identifies the vital sign result type
Print Name
Respiratory Rate
Heart Rate
O2 % BldC Oximetry
BP Systolic
BP Diastolic
Body Temperature
Height
Height (Lying)
Head Circumference
Weight Measured
BMI (Body Mass Index)
BSA (Body Surface Area)
1.36 Ingredient Name Value Set
Value Set
Code System
Description
Code
Ingredient Name 2.16.840.1.113883.3.88.12.80.20 DYNAMIC
Unique Ingredient Identifier (UNII) 2.16.840.1.113883.4.9
Unique ingredient identifiers (UNIIs) for substances in drugs, biologics, foods, and devices.
http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabeling/ucm162523.htm
Print Name
1.37 Insurance Type Code
Value Set Name:
CoverageType
Value Set OID:
2.16.840.1.113883.3.88.12.3221.5.2
Code Set OID:
2.16.840.1.113883.6.255.1336
Value Set Author:
HITSP
Value Set Version:
20071213
Page 234 of 256
Base Code Set(s):
X12N Data Element 1336
Code
12
Description
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13
Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination
period with an employer’s group health plan
14
Medicare Secondary, No-fault Insurance including Auto is Primary
15
Medicare Secondary Worker’s Compensation
16
Medicare Secondary Public Health Service (PHS)or Other Federal Agency
41
Medicare Secondary Black Lung
42
Medicare Secondary Veteran’s Administration
43
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
47
Medicare Secondary, Other Liability Insurance is Primary
AP
Auto Insurance Policy
C1
Commercial
CO
Consolidated Omnibus Budget Reconciliation Act (COBRA)
CP
Medicare Conditionally Primary
D
Disability
DB
Disability Benefits
EP
Exclusive Provider Organization
FF
Family or Friends
GP
Group Policy
HM
Health Maintenance Organization (HMO)
HN
Health Maintenance Organization (HMO) - Medicare Risk
HS
Special Low Income Medicare Beneficiary
IN
Indemnity
IP
Individual Policy
LC
Long Term Care
LD
Long Term Policy
LI
Life Insurance
LT
Litigation
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
MH
Medigap Part A
MI
Medigap Part B
MP
Medicare Primary
OT
Other
PE
Property Insurance - Personal
Page 235 of 256
PL
Personal
PP
Personal Payment (Cash - No Insurance)
PR
Preferred Provider Organization (PPO)
PS
Point of Service (POS)
QM
Qualified Medicare Beneficiary
RP
Property Insurance - Real
SP
Supplemental Policy
TF
Tax Equity Fiscal Responsibility Act (TEFRA)
WC
Workers Compensation
WU
Wrap Up Policy
Page 236 of 256
1.38 Language Value Set
Value Set
Code System
Description
Code
Language 2.16.840.1.113883.1.11.11526 DYNAMIC
Internet Society Language 2.16.840.1.113883.1.11.11526
A value set of codes defined by Internet RFC 4646 (replacing RFC 3066). Please see ISO
639 language code set maintained by Library of Congress for enumeration of language
codes
http://www.ietf.org/rfc/rfc4646.txt
Print Name
1.39 Marital Status
Value Set
Code System
Description
Code
A
D
I
L
M
P
S
T
W
HL7 Marital Status 2.16.840.1.113883.1.11.12212 DYNAMIC
MaritalStatus 2.16.840.1.113883.5.2
Martial Statuses
Print Name
Annulled
Divorced
Interlocutory
Legally Separated
Married
Polygamous
Never Married
Domestic partner
Widowed
1.40 Medication Brand Name Value Set
Value Set
Code System
Description
Code
Medication Brand Name 2.16.840.1.113883.3.88.12.80.16 DYNAMIC
RxNorm 2.16.840.1.113883.6.88
Medication Brand Names
http://phinvads.cdc.gov/vads/ViewValueSet.action?id=229BEF3E-971C-DF11-B3340015173D1785
Print Name
1.41 Medication Clinical Drug Value Set
Value Set
Code System
Description
Code
Medication Clinical Drug 2.16.840.1.113883.3.88.12.80.17 DYNAMIC
RxNorm 2.16.840.1.113883.6.88
Clinical Drug Names
http://phinvads.cdc.gov/vads/ViewValueSet.action?id=239BEF3E-971C-DF11-B3340015173D1785
Print Name
Page 237 of 256
1.42 Medication Drug Class Value Set
Value Set
Code System
Description
Code
Medication Drug Class 2.16.840.1.113883.3.88.12.80.18 DYNAMIC
NDF-RT 2.16.840.1.113883.3.26.1.5
This identifies the pharmacological drug class, such as Cephalosporins. Shall contain a
value descending from the NDF-RT concept types of “Mechanism of Action N0000000223”, “Physiologic Effect - N0000009802” or “Chemical Structure N0000000002”. NUI will be used as the concept code.
http://phinvads.cdc.gov/vads/ViewValueSet.action?id=77FDBFB5-A277-DE11-9B520015173D1785
Print Name
1.43 Medication Fill Status Value Set
Value Set
Code System
Description
Code
aborted
completed
ActStatus 2.16.840.1.113883.5.14
Subset of ActStatus to be used as a medication fill status
Print Name
Aborted
Completed
Page 238 of 256
1.44 Medication Product Form Value Set
Value Set
Code System
Description
Code
National Cancer Institute (NCI) Thesaurus 2.16.840.1.113883.3.26.1.1
This is the physical form of the product as presented to the individual. For example:
tablet, capsule, liquid or ointment.
http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabeling/ucm162038
.htm
Print Name
1.45 Medication Route FDA Value Set
Value Set
Code
System
Description
Code
C38192
C38193
C38194
C38675
C38197
C38633
C38205
C38206
C38208
C38209
C38210
C38211
C38212
C38200
C38215
C38219
C38220
C38221
C38222
C38223
C38224
C38225
C38226
C38227
C38228
C38229
C38230
C38231
C38232
C38233
C38234
National Cancer Institute (NCI) Thesaurus 2.16.840.1.113883.3.26.1.1
This indicates the method for the medication received by the individual (e.g., by mouth,
intravenously, topically, etc.). NCI concept code for route of administration: C38114
http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabeling/ucm162034.htm
Print Name
BUCCAL
CONJUNCTIVAL
CUTANEOUS
DENTAL
ELECTRO-OSMOSIS
ENDOCERVICAL
ENDOSINUSIAL
ENDOTRACHEAL
ENTERAL
EPIDURAL
EXTRA-AMNIOTIC
EXTRACORPOREAL
HEMODIALYSIS
INFILTRATION
INTERSTITIAL
INTRA-ABDOMINAL
INTRA-AMNIOTIC
INTRA-ARTERIAL
INTRA-ARTICULAR
INTRABILIARY
INTRABRONCHIAL
INTRABURSAL
INTRACARDIAC
INTRACARTILAGINOUS
INTRACAUDAL
INTRACAVERNOUS
INTRACAVITARY
INTRACEREBRAL
INTRACISTERNAL
INTRACORNEAL
INTRACORONAL, DENTAL
Page 239 of 256
C38217
C38218
C38235
C38236
C38238
C38239
C38240
C38241
C38242
C79144
C38243
C38245
C38246
C38247
C38248
C38249
C38250
C79138
C38251
C38252
C79137
C38253
C38254
C28161
C79141
C38255
C79142
C38256
C38257
C38258
C38259
C38260
C38261
C79139
C38262
C38263
C38264
C38265
C38266
C38267
C38207
C38268
C38269
C38270
C38272
C38273
C38276
C38277
C38278
C38280
C38203
C38281
INTRACORONARY
INTRACORPORUS CAVERNOSUM
INTRACRANIAL
INTRADERMAL
INTRADISCAL
INTRADUCTAL
INTRADUODENAL
INTRADURAL
INTRAEPICARDIAL
INTRAEPIDERMAL
INTRAESOPHAGEAL
INTRAGASTRIC
INTRAGINGIVAL
INTRAHEPATIC
INTRAILEAL
INTRALESIONAL
INTRALINGUAL
INTRALUMINAL
INTRALYMPHATIC
INTRAMAMMARY
INTRAMEDULLARY
INTRAMENINGEAL
INTRAMUSCULAR
INTRANODAL
INTRAOCULAR
INTRAOMENTUM
INTRAOVARIAN
INTRAPERICARDIAL
INTRAPERITONEAL
INTRAPLEURAL
INTRAPROSTATIC
INTRAPULMONARY
INTRARUMINAL
INTRASINAL
INTRASPINAL
INTRASYNOVIAL
INTRATENDINOUS
INTRATESTICULAR
INTRATHECAL
INTRATHORACIC
INTRATUBULAR
INTRATUMOR
INTRATYMPANIC
INTRAUTERINE
INTRAVASCULAR
INTRAVENOUS
INTRAVENTRICULAR
INTRAVESICAL
INTRAVITREAL
IONTOPHORESIS
IRRIGATION
LARYNGEAL
Page 240 of 256
C38282
C38284
C38285
C48623
C38286
C38287
C38288
C38289
C38291
C38676
C38292
C38677
C38293
C38294
C38295
C38216
C38296
C38198
C38297
C38298
C38299
C65103
C38300
C38301
C79143
C38304
C38305
C79145
C38283
C38307
C38308
C38309
C38312
C38271
C38313
NASAL
NASOGASTRIC
NOT APPLICABLE
OCCLUSIVE DRESSING TECHNIQUE
OPHTHALMIC
ORAL
OROPHARYNGEAL
PARENTERAL
PERCUTANEOUS
PERIARTICULAR
PERIDURAL
PERINEURAL
PERIODONTAL
RECTAL
RESPIRATORY (INHALATION)
RETROBULBAR
SOFT TISSUE
SUBARACHNOID
SUBCONJUNCTIVAL
SUBCUTANEOUS
SUBGINGIVAL
SUBLINGUAL
SUBMUCOSAL
SUBRETINAL
TOPICAL
TRANSDERMAL
TRANSENDOCARDIAL
TRANSMUCOSAL
TRANSPLACENTAL
TRANSTRACHEAL
TRANSTYMPANIC
URETERAL
URETHRAL
VAGINAL
Page 241 of 256
1.46 Mood Code Evn/Int Value Set
Value Set
Code System
Description
Code
EVN
INT
ActMood 2.16.840.1.113883.5.1001
Subset of HL7 ActMood codes, constrained to represent event (EVN) and
intent (INT) moods
Print Name
Event
Intent
1.47 No Immunization Reason Value Set
Value Set
Code System
Description
Code
IMMUNE
MEDPREC
OSTOCK
PATOBJ
PHILISOP
RELIG
VACEFF
VACSAF
No Immunization Reason Value Set 2.16.840.1.113883.1.11.19717 DYNAMIC
ActReason 2.16.840.1.113883.5.8
Reason for not getting an immunization
Print Name
Immunity
Medical precaution
Out of stock
Patient objection
Philosophical objection
Religious objection
Vaccine efficacy concerns
Vaccine safety concerns
1.48 Observation Interpretation Value Set
Value Set
Code System
Description
Code
A
HX
LX
B
Carrier
D
U
IND
I
MS
NEG
N
POS
R
S
VS
Observation Interpretation (HL7) 2.16.840.1.113883.1.11.78 DYNAMIC
ObservationInterpretation 2.16.840.1.113883.5.83
Describes how to interpret the associated observation
Print Name
Abnormal
above high threshold
below low threshold
better
Carrier
decreased
increased
Indeterminate
intermediate
moderately susceptible
Negative
Normal
Positive
resistent
susceptible
Very susceptible
Page 242 of 256
W
worse
1.49 Participation Function Value Set
Value Set
Code System
Description
Code
ParticipationFunction 2.16.840.1.113883.5.88
ParticipationFunction 2.16.840.1.113883.5.88
http://wiki.hl7.de/index.php/2.16.840.1.113883.5.88
Print Name
1.50 Patient Education Value Set
Value Set
Code System
Description
Code
Patient Education 2.16.840.1.113883.11.20.9.34 DYNAMIC
SNOMED CT 2.16.840.1.113883.6.96
Limited to terms descending from the Education (409073007) hierarchy. Code system
browser: https://uts.nlm.nih.gov/snomedctBrowser.html
Print Name
1.51 Personal Relationship Role Type Value Set
Value Set
Code System
Description
Code
Personal Relationship Role Type 2.16.840.1.113883.1.11.19563 DYNAMIC
RoleCode 2.16.840.1.113883.5.111
A Personal Relationship records the role of a person in relation to another person. This
value set is to be used when recording the relationships between different people who
are not necessarily related by family ties, but also includes family relationships.
http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008
Print Name
1.52 Postal Address Use Value Set
Value Set
Code System
Description
Code
BAD
DIR
H
HP
HV
PHYS
PST
PUB
TMP
WP
PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01
AddressUse 2.16.840.1.113883.5.1119
How the address is used
Print Name
bad address
direct
home address
primary home
vacation home
physical visit address
postal address
public
temporary
work place
Page 243 of 256
1.53 Postal Code Value Set
Value Set
Code System
Description
PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMIC
Code
Print Name
US Postal Codes 2.16.840.1.113883.6.231
A value set of codes postal (ZIP) Code of an address in the United States.
http://zip4.usps.com/zip4/welcome.jsp
1.54 Problem Value Set
Value Set
Code System
Description
Code
Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC
SNOMED CT 2.16.840.1.113883.6.96
Problems and diagnoses. Limited to terms descending from the Clinical Findings
(404684003) or Situation with Explicit Context (243796009) hierarchies.
http://phinvads.cdc.gov/vads/ViewValueSet.action?id=70FDBFB5-A277-DE11-9B520015173D1785
Print Name
1.55 Problem Act statusCode Value Set
Value Set
Code System
Description
Code
active
suspended
aborted
completed
ActStatus 2.16.840.1.113883.5.14
This Value Set indicates the status of the problem concern act.
Print Name
active
suspended
aborted
completed
1.56 Problem Severity Value Set
Value Set
Code System
Description
Code
255604002
371923003
6736007
371924009
24484000
399166001
Problem Severity 2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC
SNOMED CT 2.16.840.1.113883.6.96
This is a description of the level of the severity of the problem.
Print Name
Mild (qualifier value)
Mild to moderate (qualifier value)
Moderate (severity modifier) (qualifier value)
Moderate to severe (qualifier value)
Severe (severity modifier) (qualifier value)
Fatal (qualifier value)
1.57 Problem Type Value Set
Value Set
Page 244 of 256
Code System
Description
Code
404684003
409586006
282291009
64572001
248536006
418799008
55607006
373930000
SNOMED CT 2.16.840.1.113883.6.96
This value set indicates the level of medical judgment used to determine the existence of
a problem.
Print Name
Finding
Complaint
Diagnosis
Condition
Finding of functional performance and activity
Symptom
Problem
Cognitive function finding
1.58 Procedure Act Status Value Set
Value Set
Code System
Description
Code
completed
active
aborted
cancelled
ActStatus 2.16.840.1.113883.5.14
A ValueSet of HL7 actStatus codes for use with a procedure activity
Print Name
Completed
Active
Aborted
Cancelled
1.59 Provider Code Value Set
Value Set
Code System
Description
Code
Provider Code (All)
NUCC Provider Codes
The provider codes to determine the type of the provider
http://phinvads.cdc.gov/vads/http:/phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.84
0.1.113883.6.101
Print Name
1.60 Race Value Set
Value Set
Code
System
Descriptio
n
Code
Race 2.16.840.1.113883.1.11.14914 DYNAMIC
Race and Ethnicity - CDC 2.16.840.1.113883.6.238
A Value Set of codes for Classifying data based upon race. Race is always reported at the discretion of
the person for whom this attribute is reported, and reporting must be completed according to
Federal guidelines for race reporting. Any code descending from the Race concept (1000-9) in that
terminology may be used in the exchange
http://phinvads.cdc.gov/vads/ViewCodeSystemConcept.action?oid=2.16.840.1.113883.6.238&code=
1000-9
Print Name
Page 245 of 256
1.61 Result Status Value Set
Value Set
Code System
Description
Code
aborted
active
cancelled
completed
held
suspended
Result Status 2.16.840.1.113883.11.20.9.39 STATIC 2012-07-01
ActStatus 2.16.840.1.113883.5.14
This value set indicates the status of the results observation or
organizer
Print Name
aborted
active
cancelled
completed
held
suspended
1.62 Smoking Status Value Set
Value Set
Code System
Description
Code
449868002
428041000124106
8517006
266919005
77176002
266927001
Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2012-07-01
SNOMED CT 2.16.840.1.113883.6.96
This value set indicates the current smoking status of a patient
Print Name
Current every day smoker
Current some day smoker
Former smoker
Never smoker (Never Smoked)
Smoker, current status unknown
Unknown if ever smoked
1.63 Social History Type Value Set
Value Set
Code System
Description
Code
229819007
256235009
160573003
364393001
364703007
425400000
363908000
228272008
105421008
Social History Type Set Definition 2.16.840.1.113883.3.88.12.80.60 STATIC 2008-12-18
SNOMED CT 2.16.840.1.113883.6.96
The social history type value set
Print Name
Tobacco use and exposure
Exercise
Alcohol intake
Nutritional observable
Employment detail
Toxic exposure status
Details of drug misuse behavior
Health-related behavior
Educational Achievement
1.64 State Value Set
Value Set
Code System
Description
StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMIC
FIPS 5-2 (State) 2.16.840.1.113883.6.92
Codes for the Identification of the States, the District of Columbia and the Outlying Areas
Page 246 of 256
Code
of the United States, and Associated Areas Publication # 5-2, May, 1987
http://www.itl.nist.gov/fipspubs/fip5-2.htm
Print Name
1.65 Telecom Use Value Set
Value Set
Code System
Description
Code
HP
WP
MC
HV
Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC
AddressUse 2.16.840.1.113883.5.1119
Codes for the Identification of the States, the District of Columbia and the Outlying Areas
of the United States, and Associated Areas Publication # 5-2, May, 1987
http://www.itl.nist.gov/fipspubs/fip5-2.htm
Print Name
primary home
work place
mobile contact
vacation home
1.66 Unit of Measure Value Set
Value Set
Code System
Description
Code
UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC
Unified Code for Units of Measure (UCUM) 2.16.840.1.113883.6.8
UCUM codes include all units of measures being contemporarily used in international
science, engineering, and business. The purpose is to facilitate unambiguous electronic
communication of quantities together with their units. The focus is on electronic
communication, as opposed to communication between humans.
http://www.regenstrief.org/medinformatics/ucum
Print Name
1.67 Vaccine Administered Value Set
Value Set
Code System
Description
Code
Vaccine Administered Value Set 2.16.840.1. 113883.3.88.12.80.22 DYNAMIC
Vaccines administered (CVX) 2.16.840.1.113883.12.292
A value set of available vaccines.
http://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.12.292
Print Name
Page 247 of 256
Appendix C: Boston Public Health Commission Data Collection
Regulation, promulgated July 1, 2006
Whereas; The Boston Public Health Commission is charged with protecting, preserving and
promoting the health and well-being of all Boston residents, particularly those who are most
vulnerable.
Whereas; Health disparities, the differences between populations in presence of disease, access
to health care, use of health care services, and health outcomes, have been recognized within
the city of Boston, and nationally, over the last several years. Racial and ethnic minorities,
which account for more than half of Boston’s population, are more likely to have high blood
pressure, diabetes, HIV, prostate cancer, asthma, lead poisoning, and other serious health
conditions.
Whereas; The Boston Public Health Commission’s Disparities Project is charged with developing
methods of reducing health disparities.
Whereas; Patient demographic information (race, ethnicity, primary language, and education
level) can be used to identify differences in health care use and health outcomes, and to
develop interventions to address identified disparities. Such information should be collected by
all Boston hospitals through a standardized method provided by the Commission, to ensure
that data is recorded and analyzed accurately.
Whereas; Collection of this information is a necessary pre-condition to strengthening internal
quality improvement measures to address the needs of populations who face disparities. As
such use increases and optimal internal action steps become clearer, future regulatory
measures may be beneficial.
Whereas; The standardized collection of demographic data will enable hospitals and the City to
learn more about health disparities, and to develop practical, effective activities that Boston’s
health care institutions can undertake to reduce disparities.
Therefore, The Boston Public Health Commission enacts the following regulation, to be adopted
for the purpose of monitoring the health status of Boston’s residents and developing initiatives
that will eliminate the health disparities that exist in the city of Boston.
Section 1.00 Definitions
For the purposes of this regulation and its guidelines, the following terms shall be defined as
follows:
Acute Care Hospitals - any hospital licensed under M.G.L. c.111 §51 which contains a majority
of medical-surgical, pediatric, obstetric, and maternity beds, as defined by 105 CMR 130.026
and 130.601.
Page 248 of 256
Commission – The Boston Public Health Commission.
Community Health Centers - defined as free-standing or hospital licensed community health
centers licensed by the Massachusetts Department of Public Health pursuant to M.G.L. c.111
§51.
Disparities Project – A Boston Public Health Commission initiative comprised of short and longterm strategies aimed at reducing health disparities in Boston.
Education Level – Refers to the highest grade completed by the patient to-date. For children,
this refers to the highest grade completed by the parent or guardian to-date.
Health Disparities - Differences between populations in presence of disease, access to health
care, use and delivery of health care services, and health outcomes.
Hospital - Any institution within the City of Boston, however named, whether conducted for
charity or for profit, which is licensed pursuant to M.G.L. c.111 §51 and advertised, announced,
established or maintained for the purpose of caring for persons admitted thereto for diagnosis
and/or medical, surgical or restorative treatment which is rendered within said institution.
Patient Registrar– The staff person(s) responsible for registering patients prior to a hospital or
office visit.
Preferred Language – The language the patient prefers to speak.
Registration – The process through which patient information such as name, address, health
insurance information, is documented prior to a hospital or provider appointment. It is also
during this time that demographic data is collected. Registration may be conducted over the
telephone or in person, depending on the health care institution.
Section 2.00 Institutional Commitment to Eliminating Health Disparities
All hospitals, community health centers, and healthcare providers shall be committed to
identifying and eliminating inequalities in health care.
Section 3.00 Acute Care Hospital Data Collection Requirements
1. Using a template provided by the Commission, all acute care hospitals in the City of Boston
shall collect information on each patient that includes at a minimum the following fields:
a. Race
b. Ethnicity
c. Preferred Language
d. Level of Education
Page 249 of 256
2. Information shall be collected in a manner that ensures patient privacy, whether over the
telephone or in person.
3. Using a template approved by the Commission, all acute care hospitals in the City of Boston
shall submit to the Commission on a quarterly basis a report that aggregates data and
eliminates individual patient identifiers showing the distribution of data on patients using at a
minimum the following fields:
a. Race
b. Ethnicity
c. Preferred Language
d. Level of Education
4. Quarterly reports shall be made in an electronic format.
5. The Commission will endeavor to coordinate the data collection process with other
Commission and State data collection requirements in order to minimize the administrative
efforts of covered hospitals.
Section 4.00 Quality Improvement
1. All acute care hospitals shall develop and implement quality improvement efforts, designed
to identify and address disparities in treatment. These improvement efforts shall include, but
are not limited to, efforts to assess and compare by patient population:
a. Utilization;
b. Quality of care;
c. Outcomes; and,
d. Satisfaction/Patient Experiences with Care.
2. All acute care hospitals shall provide to the Commission, evidence that processes and policies
have been implemented to address issues of disparities.
3. The Commission will schedule a periodic, public symposium which will serve as a forum for
hospitals to share information and ideas related to quality improvement efforts aimed at
eliminating health disparities.
4. The Commission shall convene a committee made up of interested parties to encourage
ongoing coordination among healthcare providers, the Commission and State Agencies
regarding healthcare disparities.
5. The provisions of this section do not amend, modify or otherwise relieve any hospital or
community health center of any other regulatory, administrative or statutory reporting
requirements.
Section 5.00 Non-Acute Care Hospital and Community Health Center Data Collection
Page 250 of 256
Requirements
1. Upon certification by the Executive Director of substantial compliance of all acute care
hospitals with the requirements of Sections 3.00 and 4.00 of this regulation, the Executive
Director shall issue guidelines for the implementation of the provisions of Sections 3.00 and
4.00 of this regulation to all non-acute care hospitals and community health centers.
2. Such guidelines shall provide for an implementation period of at least six months.
3. The guidelines shall be publicly posted and subject to a 60 day comment period, during which
time comments shall be received regarding the implementation of Sections 3.00 and 4.00 for
non-acute care hospitals and community health centers.
Section 6.00 Guidelines
1. The Executive Director of the Commission shall issue guidelines, setting forth the format for
collecting and reporting procedures.
Section 7.00 Enforcement
1. Authority to enforce this regulation shall be held by the Commission.
2. Any violation of this regulation may be enforced in the manner provided in M.G.L. c.111 §§
31 and 187 by the Boston Public Health Commission, its subsidiary programs or designees.
Section 8.00 Severability
If any provision, clause, sentence, paragraph or word of this regulation or the application
thereof to any person, entity or circumstances shall be held invalid, such invalidity shall not
affect the other provisions of this article which can be given effect without the invalid
provisions or application and this end the provisions of this regulation are declared severable.
Section 9.00 Effective Date
This regulation, except as provided for below, shall take effect July 1, 2006.
Within 120 days of the effective date, all acute care hospitals shall file with the Commission a
plan for compliance with Sections 3.00 and 4.00.
Within 360 days of the effective date, all acute care hospitals shall comply with sections 3.00
and 4.00. If an acute care hospital can demonstrate a good faith effort to comply with the
requirements of the regulation, the Executive Director may extend the period for compliance
by up to 200 days.
All hospitals, acute care hospitals and community health centers licensed by the
Page 251 of 256
Commonwealth of Massachusetts after July 1, 2006, shall comply with all provisions within 360
days of licensing.
Section 10.00 Authority
This regulation is promulgated pursuant to: M.G.L. c. 111, §§ 31 and 2-7(a)(15).
Page 252 of 256
Appendix D: Boston Health Equity Committee
Co-Chairs
Barbara Ferrer, PhD, MPH, ME.D, Executive Director, Boston Public Health Commission
Joseph Betancourt, MD, MPH, Senior Scientist, Institute for Health Policy; Director, Disparities
Solution Center, Massachusetts General Hospital
Membership 7
Jean Bernhardt, MHSA, MSN, NHA, CNAA, APRN-BC, Director of Nursing and Chief Compliance
Officer, North End Community Health Center
Douglas Brooks, Vice President, Sidney Borum Health Center – JRI Health
Nancy Bucken, RN, MSN, Executive Director, Neponset Community Health Center
Alice Coombs, MD, Vice President, Massachusetts Medical Society Corporation
Anita Crawford, Chief Executive Officer, Roxbury Comprehensive Community Health Center
Sherry Dong, Director, Community Health Improvement Programs
Tom Dooley, Quality Improvement Specialist, Boston Medical Center
John Erwin, Executive Director, Conference of Boston Teaching Hospitals
Matt Fishman, Director, Community Benefit Programs, Partners Health Care
Ediss Gandelman, Director, Community Benefits, Beth Israel Deaconess Medical Center
John Halamka, MD, MS, Chief Information Officer of the CareGroup Health System; Chief
Information Officer and Dean for Technology at Harvard Medical School
Anne Levine, Vice President of External Affairs, Dana-Farber Cancer Institute
Mary Leach, Director of Public Affairs, Massachusetts Eye and Ear Infirmary
Karen Kennedy, Vice President, Communications, Marketing & Community Benefits, Caritas
Christi Health Care System
Thomas Kieffer, MPH, Executive Director, Southern Jamaica Plain Health Center
Wanda McClain, Director, Community Health and Health Equity, Brigham and Women’s
Hospital
Judy Parlato, Clinical Advisor, Health Data Policy, Division of Health Care Finance and Policy,
Executive Office of Health and Human Services, Commonwealth of Massachusetts
Joan Pernice, RN, Director of Clinical Affairs, Massachusetts League of Community Health
Centers
Jody Reifenberger, PA-C, Program Coordinator, East Boston Community Health Center
Joyce Sackey, MD, Dean for Multicultural Affairs and Global Health, Tufts University
Nisha Thakar, MD, Medical Director, South Boston Community Health Center
Karen Van Unen, EdM, MBA, Chief Operating Officer, DotWell
Joel Weissman, Massachusetts Department of Public Health
Ronald Wilkinson, Manager of Decision Support Systems, Information Services Department,
Children’s Hospital Boston
7
Listed titles and organizational affiliations for Committee members refers to the period of time during the convening of the
Boston Health Equity Committee, 2011.
Page 253 of 256
Appendix E: Boston Health Equity Measure Set Revision History
#
Draft Measure
Final Measure
1
2
4
Total number of diabetes visits
5
Total number of hypertension visits
6
Weight assessment and counseling
for nutrition and physical activity for
children and adolescents (Age 2-17)
7
Use of appropriate medication for
persons with asthma (Age 5-64)
8
Comprehensive diabetes care (Age
18-75):
(HEDIS) Yearly screening: HbA1c; LDLC, retinal eye exam, nephropathy
screen, blood pressure
Controlling high blood pressure (Age
18-85):
(HEDIS) Patient with a diagnosis of
hypertension whose most recent
blood pressure reading was
controlled
Well-child visits (Ages 0-15 months
and 6 years or more)
Well-child visits (Ages 3-6 years, 12-21
years annual)
Number of patients with high ED
utilization (4 or more visits in one
year)
Number of emergent ED visits by day
of week and time of day
Total number of patients (include
patients with one or more visits in the
reporting period)
Total number of primary care visits by
asthma patients (5-64), as defined by
HEDIS
diabetic patients, as defined by HEDIS
hypertension patients, as defined by
HEDIS
(HEDIS) Weight assessment and
counseling for nutrition and physical
activity for children and adolescents (Age
2-17)
(HEDIS) Use of an asthma controller
medication for persons with asthma (Age
5-64)
Comprehensive diabetes care (Age 1875):
(HEDIS) Yearly screening: HbA1c; LDL-C,
retinal eye exam, nephropathy screen,
blood pressure
Controlling high blood pressure (Age 1885):
(HEDIS) Patient with a diagnosis of
hypertension whose most recent blood
pressure reading was controlled
N/A
N/A
3
Total number of patients (include
patients with one or more visits in the
reporting period)
Total number of asthma visits
(HEDIS) Well-child visits (Ages 0-15
months and 3-6 years)
(HEDIS) Adolescent well-child visits (Age
12-21 years)
Number of patients with high ED
utilization (4 or more visits in one year)
Alignment with HEDIS
measure
Alignment with HEDIS
measure
N/A
N/A
Number of ED visits by day of week and
time of day for the top ten “nonemergent conditions” as defined by the
MA Division of Healthcare Finance and
Policy in Massachusetts Health Care Cost
Trends: Efficiency of Emergency
Department Utilization in Massachusetts;
August, 2012
Number of ED visits by day of week and
time of day for the top ten “emergency
Clarification
9
10
11
12
13
14
15
Number of non-emergent ED visits by
day of week and time of day
Reason for Change
Clarification
Clarification
Clarification
N/A
Clarification
N/A
N/A
Clarification
Page 254 of 256
16
17
18
Discharge status (home, observation
and inpatient admissions)
Number of visits to the ED for
asthma-related conditions and
symptoms
a) EKG within 5 minutes for all
patients over 30 years old with
non-traumatic chest pain.
b) Lytics within 20 minutes after
EKG performed (only if lytics
given)
19
8
c) Aspirin administered within 24
hours (documented)
Syncope Guideline:
EKG for all patients over 60 with
syncope
but primary care treatable conditions” as
defined by the MA Division of Healthcare
Finance and Policy in Massachusetts
Health Care Cost Trends: Efficiency of
Emergency Department Utilization in
Massachusetts; August, 2012
Discharge status (home, observation and
inpatient admissions)
Number of visits to the ED for asthmarelated conditions
N/A
Clarification
a) CMS PQRS: Measure #54: 12-Lead
Electrocardiogram (ECG) Performed
for Non-traumatic Chest Pain (in
patients 40 years and older)
b) CMS OPPS: OP-5: ED Median Time to
ECG
c) AMI-8: Median Time to PCI (Door to
Balloon time)
d) AMI – 8a: Primary PCI within 90
minutes of hospital arrival
e) AMI-1: Aspirin at Arrival
Alignment with NQFendorsed measures
Syncope Guideline:
CMS PQRS: Measure #55: 12-Lead
Electrocardiogram (ECG) Performed for
Alignment with NQFendorsed measure
Alignment with CMS8
implemented measure
Alignment with NQFendorsed measures
Alignment with NQFendorsed measure
Centers for Medicaid and Medicare Services, US Department of Health and Human Services
Page 255 of 256
Acknowledgements
Primary BPHC staff for this project include Jeanne Cannata; Huy Nguyen, MD; Dan Obendorfer;
Meghan Patterson, MPH; Elizabeth Russo, MD, MPH; Snehal Shah, MD, MPH; and Horace
Wong.
Special thanks to the Boston Health Equity Committee; Joseph Betancourt, MD, MPH, Aswita
Tan-McGrory, MBA, MSPH, and Alden Landry, MD, MPH, of the Disparities Solutions Center at
Massachusetts General Hospital; and Katherine Flaherty, ScD.
Technical support provided by Strategic Solutions Group, LLC.
Page 256 of 256

Boston Public Health Commission Data Collection Regulation: Boston Health Equity Measure Set

Transcription

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