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Functional Status Templates Consolidation Updates

Functional Status Templates Consolidation Updates. March 13, 2012 Brett Marquard, Gaye Dolin, Zabrina Gonzaga. Heuristics . Align with ONC recommended vocabulary Align with NQF Quality Data Model (QDM) Concepts and vocabularies

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Functional Status Templates Consolidation Updates

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  1. Functional Status Templates Consolidation Updates March 13, 2012 Brett Marquard, Gaye Dolin, Zabrina Gonzaga

  2. Heuristics • Align with ONC recommended vocabulary • Align with NQF Quality Data Model (QDM) Concepts and vocabularies • Support communication of functional status for people of all ages and stages of life • Conform to: • Problem Observation (2.16.840.1.113883.10.20.22.4.4) or • Result Observation (2.16.840.1.113883.10.20.22.4.2) • Maintain backward compatibility with existing templates • New templates will NOT include instrument-specific valueSets • New CDA templates will focus on structure needed to convey the concepts • New CDA templates can be re-used within specific instruments and further constrained with specific valueSets.

  3. New Functional Status Section Level Constraints • SHALL contain exactly one [1..1] templateId (CONF:XXXX) such that it • SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.14" (CONF:XXXX). • SHALL contain exactly one [1..1] code/@code="47420-5" Functional Status (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:7921). • SHALL contain exactly one [1..1] title (CONF:7922). • SHALL contain exactly one [1..1] text (CONF:7923). • MAY contain zero or more [0..*] entry (CONF:XXXX) such that it • SHALL contain exactly one [1..1] Functional Status Result Observation(2.16.840.1.113883.10.20.22.4.2) (CONF:XXXX). • MAY contain zero or more [0..*] entry (CONF:9081XX) such that it • SHALL contain exactly one [1..1] Functional Status Result Organizer(2.16.840.1.113883.10.20.22.4.2XX) (CONF:XXXX). • MAY contain zero or more [0..*] entry (CONF:XXXX) such that it • SHALL contain exactly one [1..1] Functional Status Problem Observation(2.16.840.1.113883.10.20.22.4.2) (CONF:XXXX). • MAY contain zero or more [0..*] entry (CONF:9081XX) such that it • SHALL contain exactly one [1..1] Problem Concern Act (Condition) (2.16.840.1.113883.10.20.22.4.3) (CONF:XXXX).

  4. Functional Status Section Level New Constraint • MAYcontain zero or more [0..*] entry such that ita. SHALLcontain exactly one [1..1] Functional Status Result Organizer • This Result Organizer will group like functional status concepts in a functional status section • While recommended in a functional status section – its use would not be precluded in another appropriate section of any document (eg in a CARE CDA)

  5. Functional Status Result Organizer • Will Conform to Result Organizer [organizer: templateId2.16.840.1.113883.10.20.22.4.1 • Will restrict (SHALL) the type of organizer class to a “CLUSTER” (An ACT that organizes a set of component acts into a semantic grouping that have a shared subject.) • Will recommend (SHOULD) or restrict (SHALL) the organizer/code to be from ICF(International Classification of Functioning, Disability, and Health) or SNOMED-CT

  6. Functional Status Result Organizer • <organizer classCode=“CLUSTER" moodCode="EVN"> • <!– Functional Status Result organizer template --> • <templateId root="2.16.840.1.113883.10.20.22.4.1"/> • <id root="7d5a02b0-67a4-11db-bd13-0800200c9a66"/> • <code code=“d5" displayName=“Self-Care“ codeSystem="2.16.840.1.113883.6.254“ • codeSystemName=“ICF"/> • <statusCode code="completed"/> <component> <observation classCode="OBS" moodCode="EVN"> <!– Functional Result observation template (such as toileting-)-> <templateId root="2.16.840.1.113883.10.20.22.4.xx"/> ... </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!– Functional Status Result observation template (such as eating)--> <templateId root="2.16.840.1.113883.10.20.22.4.xx"/> ... </observation> </component> ... </organizer>

  7. Functional Status Result Observation • Will Conform to Result Observation : templateId 2.16.840.1.113883.10.20.22.4.2 • Will recommend (SHOULD) the observation/code be from LOINC • Will recommend (SHOULD) the observation/value be an integer, or a value from SNOMED-CT

  8. Functional Status Problem Observation • May be “wrapped” in a concern act:ProblemConcern Act (Condition) [act: templateId2.16.840.1.113883.10.20.22.4.3] This allows monitoring of the same problem over time (eg Acute MI in ‘98 is same as history of History of MI) • Will Conform to Problem Observation [templateId2.16.840.1.113883.10.20.22.4.4

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