Monday, February 25, 2013

Consent Data Elements from CDA R2

This analysis shall provide a comprehensive list of either the Clinical Object or Data Element identified in the Clinical Document Architecture (CDA) Release 2 (R2) Draft Standard for Use (DSTU) for expressing Data Segmentation for Privacy (DS4P) preferences.  A Clinical Object contains several pieces of data and a Data Element contains a single piece of data.


HEADER
 Clinical Object/Data Element
Example 
Description 
 ClinicalDocument/recordTarget
 <patientRole>
            <id extension="266666666" root="2.16.840.1.113883.3.933"/>
            <addr>
                <streetAddressLine>5555 Home Street</streetAddressLine>
                <city>Ann Arbor</city>
                <state>MI</state>
                <postalCode>99999</postalCode>
                <country>USA</country>
            </addr>
            <patient>
                <name>
                    <prefix>Mrs.</prefix>
                    <given>Susan</given>
                    <family>Everyperson</family>
                </name>
                <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
                <birthTime value="19600127"/>
            </patient>
        </patientRole>
The healthcare client whose IIHI is affected by the consent directive
 ClinicalDocument/custodian
<custodian>
        <assignedCustodian>
            <representedCustodianOrganization>
                <id root="1.3.6.4.1.4.1.2835.2" extension="980983"/>
                <name>Level Seven Healthcare, Inc.</name>
                <telecom value="409-444-2353"/>
                <addr>
                    <streetAddressLine>4444 Healthcare Drive</streetAddressLine>
                    <city>Ann Arbor</city>
                    <state>MI</state>
                    <postalCode>99999</postalCode>
                    <country>US</country>
                </addr>
            </representedCustodianOrganization>
        </assignedCustodian>
    </custodian>
Custodian of the Consent Directive document
ClinicalDocument/informationRecipient
 <informationRecipient typeCode="PRCP">
        <intendedRecipient classCode="ASSIGNED">
            <id root="1.3.6.4.1.4.1.2835.2" extension="7878"/>
            <addr>
                <streetAddressLine>999999 Healthcare Drive</streetAddressLine>
                <city>Ann Arbor</city>
                <state>MI</state>
                <postalCode>99999</postalCode>
            </addr>
            <informationRecipient classCode="PSN" determinerCode="INSTANCE">
                <name>
                    <prefix>Mr.</prefix>
                    <family>Hippocrates</family>
                    <given>Harold</given>
                    <suffix>MD</suffix>
                </name>
            </informationRecipient>
            <receivedOrganization classCode="ORG" determinerCode="INSTANCE">
                <id root="1.3.6.4.1.4.1.2835.2" extension="09809" assigningAuthorityName="NPI"/>
                <name>Ann Arbor Hospital</name>
            </receivedOrganization>
        </intendedRecipient>
    </informationRecipient>
person/entity as the intended recipient of the client’s IIHI that is disclosed as a result of the authorization provided using the Consent Directive.
 ClinicalDocument/legalAuthenticator
 <legalAuthenticator contextControlCode="OP" typeCode="LA">
        <time value="20091025"/>
        <!--  Signed, signature on file-->
        <signatureCode code="S"/>
        <assignedEntity classCode="ASSIGNED">
            <id extension="11111111" root="1.3.5.35.1.4436.7"/>
            <assignedPerson classCode="PSN">
                <name>
                    <given>Bernard</given>
                    <family>Everyperson</family>
                    <suffix>Sr.</suffix>
                </name>
            </assignedPerson>
        </assignedEntity>
    </legalAuthenticator>
The consenter is either the client or their representative (e.g. substitute decision maker).  
 ClinicalDocument/authenticator
 <authenticator>
        <time value="20091025"/>
        <signatureCode code="S"/>
        <assignedEntity>
            <id extension="112" root="1.3.5.35.1.4436.7"/>
            <assignedPerson>
                <name>
                    <prefix>Ms.</prefix>
                    <given>Assigned</given>
                    <family>Amanda</family>
                </name>
            </assignedPerson>
        </assignedEntity>
    </authenticator>
 signature of a person who witnessed the consenter’s signature
ClinicalDocument/documentationOf/serviceEvent
 <serviceEvent moodCode="EVN">
            <templateId root="2.16.840.1.113883.3.445.3"/>
            <id root="2.16.840.1.113883.3.445.3"/>
            <code code="57016-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Privacy Policy Acknowledgement Document"/>
            <effectiveTime>
                <low value="20091020"/>
                <high value="20100221"/>
            </effectiveTime>
        </serviceEvent>
The effective duration of a Consent Directive establishes the valid period for the consent or authorization as directed by the client or substitute decision maker.
ClinicalDocument/relatedDocument

<relatedDocument typeCode="RPLC">
        <parentDocument classCode="DOCCLIN" moodCode="EVN">
            <id root="1.3.6.1.4.1.19376.1.5.3.1.2.6" extension="2345"/>
        </parentDocument>
    </relatedDocument>
A Consent Directive may replace a previou (revoked) or expired Consent Directive. This element references a Consent Directive that is intended to be replaced by the current document



Consent Directive Sections
Clinical Object/Data Element
Example 
Description
<content ID="Patient_Name">
Boo Radley

<content ID="permit">
Not Authorize
The example implementation has positive statements about consent and uses the value of "Authorize"
<content ID="Operation">
disclose
<content ID="ReceiverOrganization_#">

Organization(s) that can receive consented information
content ID="CustodianOrganization"

Organization that can disclose consented information
<content ID="Information_#">

Information(s) that can be disclosed
<content ID="purpose">
Treatment

informant

<informant typeCode="INF" contextControlCode="OP">
                                <templateId root="2.16.840.1.113883.3.445.6"/>
                                <assignedEntity>
                                    <id root="1.3.6.4.1.4.1.2835.2" extension="980983"/>
                                    <representedOrganization>
                                        <name>Level Seven Healthcare, Inc.</name>
                                        <telecom value="409-444-2353"/>
                                        <addr>
                                            <streetAddressLine>4444 Healthcare Drive</streetAddressLine>
                                            <city>Ann Arbor</city>
                                            <state>MI</state>
                                            <postalCode>99999</postalCode>
                                            <country>US</country>
                                        </addr>
                                    </representedOrganization>
                                </assignedEntity>
                            </informant>
Name and Address of the provider disclosing information
participant

<participant typeCode="IRCP" contextControlCode="OP">
                                <templateId root="2.16.840.1.113883.3.445.7"/>
                                <participantRole classCode="ASSIGNED">
                                    <id extension="4564" root="1.3.5.35.1.4436.7"/>
                                    <!-- Role code - optional -->
                                    <code code="ATND" displayName="Attending Physician" codeSystemName="HL7 HealthcareProviderRole Type" codeSystem="2.16.840.1.113883.11.19682"/>
                                    <addr>
                                        <streetAddressLine>999999 Healthcare Drive</streetAddressLine>
                                        <city>Ann Arbor</city>
                                        <state>MI</state>
                                        <postalCode>99999</postalCode>
                                        <country>USA</country>
                                    </addr>
                                    <!-- Organization
                                    <playingEntity classCode="ORG">
                                        <name>Ann Arbor Hospital</name>
                                        </playingEntity> -->
                                    <!-- Person -->
                                    <playingEntity classCode="PSN" determinerCode="INSTANCE">
                                        <name>
                                            <prefix>Mr.</prefix>
                                            <family>Hippocrates</family>
                                            <given>Harold</given>
                                            <suffix>MD</suffix>
                                        </name>
                                    </playingEntity>
                                </participantRole>
                            </participant>
Name and Address of ther provider receiving information
Observation\code


Observation\precondition\criterion





















































































































































































































Related Sources:
  1. HL7 CDAR2 Privacy Specifications:  http://gforge.hl7.org/gf/project/cbcc/frs/
  2. Tony's Wikispace http://tonycalice.wikispaces.com/CDAR2+Analysis

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