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HL7 Implementation Guide for CDA Release 2: NHSN Healthcare Associated Infection (HAI) Reports, Release 2 (U.S

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HL7 Implementation Guide for CDA Release 2: NHSN Healthcare Associated Infection (HAI) Reports, Release 2 (U.S CDAR2L3_IG_HAIRPT_R2_D2_2009FEB HL7 Implementation Guide for CDA Release 2: NHSN Healthcare Associated Infection (HAI) Reports, Release 2 (U.S. Realm) Draft Standard for Trial Use February 2009 © 2009 Health Level Seven, Inc. Ann Arbor, MI All rights reserved HL7 Implementation Guide for CDA R2 NHSN HAI Reports Page 1 Draft Standard for Trial Use Release 2 February 2009 © 2009 Health Level Seven, Inc. All rights reserved. Co-Editor: Marla Albitz Contractor to CDC, Lockheed Martin [email protected] Co-Editor/Co-Chair: Liora Alschuler Alschuler Associates, LLC [email protected] Co-Chair: Calvin Beebe Mayo Clinic [email protected] Co-Chair: Keith W. Boone GE Healthcare [email protected] Co-Editor/Co-Chair: Robert H. Dolin, M.D. Semantically Yours, LLC [email protected] Co-Editor Jonathan Edwards CDC [email protected] Co-Editor Pavla Frazier RN, MSN, MBA Contractor to CDC, Frazier Consulting [email protected] Co-Editor: Sundak Ganesan, M.D. SAIC Consultant to CDC/NCPHI [email protected] Co-Editor: Rick Geimer Alschuler Associates, LLC [email protected] Co-Editor: Gay Giannone M.S.N., R.N. Alschuler Associates LLC [email protected] Co-Editor Austin Kreisler Consultant to CDC/NCPHI [email protected] Primary Editor: Kate Hamilton Alschuler Associates, LLC [email protected] Primary Editor: Brett Marquard Alschuler Associates, LLC [email protected] Co-Editor: Daniel Pollock, M.D. CDC [email protected] HL7 Implementation Guide for CDA R2 NHSN HAI Reports Page 2 Draft Standard for Trial Use Release 2 February 2009 © 2009 Health Level Seven, Inc. All rights reserved. Acknowledgments This DSTU was produced and developed in conjunction with the Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases (NCPDCID), and Centers for Disease Control and Prevention (CDC). Its development and ultimate deployment is a result of the dedication of the team, led by Daniel A. Pollock, M.D., Surveillance Branch Chief, Division of Healthcare Quality Promotion, NCPDCID, CDC, and their support of the development of interoperable data standards for the CDC’s National Healthcare Safety Network (NHSN). The best standards are those driven by business requirements. Each stage of the development of this DSTU has been monitored, evaluated, and tested by a strong set of HAI surveillance application vendors. Those vendors who participated in the 2007-2008 pilot activities of Bloodstream Infection Reports and Surgical Site Infection deserve special thanks and acknowledgment: MedMined™ services from Cardinal Health, EpiQuest, ICPA, Premier, TheraDoc, Vecna Technologies. Throughout the development of this guide, Marla Albitz, Lockheed Martin, Jonathan Edwards, CDC, Maggie Dudeck, Northrup Grumman, and Dawn Sievert, CDC, provided essential translation of NHSN business and technical requirements so that Kate Hamilton, Brett Marquard and Rick Geimer could turn those requirements into a CDA- compliant specification. Liora Alschuler, and Gay Giannone provided oversight and review. Additional contributors to the IG were Teresa Horan and Mary Andrus (data specifications), Wenkai Li (vocabulary), Pavla Frazier (vocabulary), Sundak Ganesan (vocabulary and linkage to the Public Health Information Network Vocabulary Access and Distribution System [PHIN VADS]), Kelly Peterson (database administration), and Venu Sarraff (data importation). Special thanks also to Ted Klein, Cecil Lynch, and Daniel Vreeman for timely issuance of identifiers and codes. This specification is a set of constraints on existing work and the extent to which it can accommodate the expressive requirements of HAI reporting over time is a function of the richness of the model on which it is built, the HL7 Reference Information Model (RIM) and the RIM document standard, and the Clinical Document Architecture Release 2 (CDA R2). Many thanks to all those who have worked for over a decade to produce these fundamental specifications and special thanks to structured documents co-chairs Bob Dolin, Keith Boone, and Calvin Beebe for their support of this project. HL7 Implementation Guide for CDA R2 NHSN HAI Reports Page 3 Draft Standard for Trial Use Release 2 February 2009 © 2009 Health Level Seven, Inc. All rights reserved. Revision History Rev Date Notes 1 28 February 2008 First release of the DSTU 2 6 August 2008 Updated version of 4 Reports, MDRO Infection Report added 4 December 2008 Updated version of 5 Reports, 8 Reports added 3 27 February 2009 Updated to integrate January 2009 comment resolutions, Second relase of DSTU HL7 Implementation Guide for CDA R2 NHSN HAI Reports Page 4 Draft Standard for Trial Use Release 2 February 2009 © 2009 Health Level Seven, Inc. All rights reserved. Table of Contents 1 INTRODUCTION............................................................................................................... 16 1.1 Purpose...................................................................................................................... 16 1.2 Audience.................................................................................................................... 16 1.3 Approach ................................................................................................................... 16 1.3.1 CDA R2................................................................................................................ 17 1.3.2 Development of This Specification ........................................................................ 17 1.3.3 Change Notification Process ................................................................................. 18 1.4 Future Work .............................................................................................................. 18 1.5 Organization of This Implementation Guide ............................................................... 19 1.5.1 General HAI Report Requirements........................................................................ 19 1.5.2 Report-specific Requirements............................................................................... 19 1.5.3 Section Library..................................................................................................... 19 1.5.4 Clinical Statement Library ................................................................................... 19 1.5.5 Vocabularies and Value Sets................................................................................ 19 1.5.6 TemplateIds ......................................................................................................... 20 1.5.7 Changed TemplateIds........................................................................................... 20 1.5.8 Example Instance Identifiers ................................................................................ 20 1.6 Conventions Used in This Implementation Guide ....................................................... 20 1.6.1 Keywords ............................................................................................................. 20 1.6.2 Conformance Requirements ................................................................................. 20 1.6.3 Explanatory Remarks........................................................................................... 21 1.6.4 Requirements from Other Specifications .............................................................. 21 1.6.5 Sample XML Code................................................................................................ 21 1.6.6 Succession Management ...................................................................................... 22 1.6.7 Vocabulary Tables and Value Sets ....................................................................... 22 1.6.8 XPath Notation..................................................................................................... 22 1.7 Use of Templates........................................................................................................ 23 1.7.1 Originator Responsibilities: General Case............................................................. 23 1.7.2 Recipient Responsibilities: General Case .............................................................. 23 1.7.3 Templates for NHSN Validation ............................................................................ 23 1.8 Supporting Tools........................................................................................................ 24 1.8.1 Validation ............................................................................................................ 24 1.8.2 Generation of Narrative Block .............................................................................. 24 HL7 Implementation Guide for CDA R2 NHSN HAI Reports Page 5 Draft Standard for Trial Use Release 2 February 2009 © 2009 Health Level Seven, Inc. All rights reserved. 1.8.3 Display Transforms.............................................................................................. 25 1.9 Content of the DSTU .................................................................................................. 25 2 NHSN HAI GENERIC CONSTRAINTS ................................................................................ 26 2.1 Generic Document Constraints .................................................................................. 27 2.2 Generic Header Constraints ....................................................................................... 27 2.2.1 Top-level
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