Allergy and Intolerance Decisions for C-CDA R1.1/C-CDA R2.0/C-CDA R2.1 Review with Patient Care WG As of September 10, 2015 Submitted by the Patient Care WG Original DSTU numbers are for R1.1 – 643 and for R2.0 644 – September 16 – look for typos, or incorrect cardinalities as technical errata, vs. new functionality. Allergies and Intolerances Section Item Decision DSTU Comment C-CDA R1.1 DSTU Comment C-CDA R2.0 DSTU Comment R2.1 1. Clarify the section name. Fix C-CDA R1.1 to match C-CDA R2.0 DSTU Comment 576 Current name is: Allergies Section UPDATE AS ERRATA Rename to Allergies and Intolerance Section 2.16.840.1.113883.10.20.22.2.6.1 This section lists and describes any medication allergies or intolerance, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to medications, 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 NO ACTION REQUIRED Section Name Already fixed e.g Allergies and Intolerances Section This section lists and describes any medication allergies or intolerance, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to medications, 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 No action required
LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:New). b. Add -- This code SHALL contain exactly one [1..1] @code="Need New" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (). NEW LOINC CODE: What is the adverse reaction description? Motion to add conformance statement with new LOINC code. 3/18/15 Move: Russ/Stephen Abstain – 0, Neg – 0, Approve - 4 b. Add -- This code contain exactly one [1..1] @code="Need New" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:New). NEW LOINC CODE: What is the adverse reaction description? 2.1 as a constraint of an assertion There is an observation type for adverse reaction in V3 (ADV_REACTION) No binding or an assertion does not make it usable. Uses template id as the semantic reference. New Criticality Template Item Decision DSTU Comment C-CDA R1.1 DSTU Comment C-CDA R2.0 C-CDA r2.1 12. ADD A NEW CRITICALITY OBSERVATION TEMPLATE [observation: templateId 2.16.840.1.113883.13.275.1 (open)] (New OID created) Criticality Observation [observation: templateId 2.16.840.1.113883.13.275.1 (open)] Description: This observation represents the gravity of the potential risk for future adverse reactions when exposed to a substance to cause an adverse reaction in that individual. Motion – approve new template with description for R1.1 and R 2.0 3/18/15 Criticality Observation [observation: templateId (open)] Description: This observation represents the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance to cause an adverse reaction in that individual. Motion – approve new template with This change was made in C-CDA R2.1 threatening
Move: Stephen/Rob Abstain – 0, Neg – 0, Approve - 4 description for R1.1 and R 2.0 3/18/15 Move: Stephen/Rob Abstain – 0, Neg – 0, Approve - 4 13. ADD NEW CRITICALITY VALUE SET DEFINITION AND CONCEPTS DEFINTION OF CRITICALITY A clinical judgment as to the case result of a future exposure (including substance administration). When the worst case result is assessed to have a or organ system potential, it is considered to be of high criticality. PC WG 6/10/15 Stephen/Russ 7/0/0 VALUE SET CONCEPTS: Consists of Four Concepts Criticality) Worst case result of a future exposure is not assessed to be (NEW TERM) 2. (High Criticality) Worst case result of a future exposure is assessed to be life-threatening. (NEW TERM) 3. (Unable to Assess Criticality) Unable to assess the worst case result of a future exposure. (NEW TERM) DEFINTION OF CRITICALITY A clinical judgment as to the worst case result of a future exposure (including substance administration). When the worst case result is assessed to have a or organ system threatening potential, it is considered to be of high criticality. PC WG 6/10/15 Stephen/Russ 7/0/0 VALUE SET CONCEPTS: Consists of Four Concepts Criticality) Worst case result of a future exposure is not assessed to be life-threatening. (NEW TERM) 2. (High Criticality) Worst case result of a future exposure is assessed to be life-threatening. (NEW TERM) This change was made in R2.1
4. Null PC WG 6/10/15 Russ/Rob 5/0/0 3. (Unable to Assess Criticality) Unable to assess the worst case result of a future exposure. (NEW TERM) 4. Null value PC WG 6/10/15 Russ/Rob 5/0/0 14. ADD OBSERVATION CONSTRAINTS TO CRITICALITY TEMPLATE SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:New). SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:New). SHALL contain exactly one [1..1] templateId (CONF:New) such that it SHALL contain exactly one [1..1] (CONF:New). SHALL contain exactly one [1..1] code (CONF:19168). This code SHALL contain exactly one [1..1] @code="Need New" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:New). SHOULD contain zero or one [0..1] text (CONF:New). Add observation constraints to criticality template (see items 1-7) Motion: Add conformance items 1-7 as detailed. (Pending LOINC code) and new template ID. 4/15/15: Move: Lisa/Rob Abstain – 0, Neg – 0, Approve - 3 Add observation constraints to criticality template (see 1-7) Motion: Add conformance items 1-7 as detailed. (Pending LOINC code) and new template ID. 4/15/15: Move: Lisa/Rob Abstain – 0, Neg – 0, Approve - 3 This change was made in R2.1