Problem Statement
The HCER supports the patient summary extension use case In this use case, after a PS is retrieved by country B, country A is informed on the healthcare encounter in country B, so country A is able to update the history of treatment events (according to its own policies).
Users Involved
Physician/Doctor
List Of Features
Use Case NR | Title | To be implemented in OpenNCP |
---|---|---|
UC1 | The doctor is authenticated by the portal | Basic functionality already present in OpenNCP portal and in epsos-web.
|
UC2 | The doctor will identify the user. Its covered now from OpenNCP Portal | Functionality already present in OpenNCP portal and in epsos-web. XCPD binding. |
UC3 | The doctor asks to create a HCER document, He also can see the patient summary document (TRCA and consent must be applied) | Assumption: Use case starts by fetching the patient summary. Then a HCER can be created as a modification of the fetched PS. Reuse the eP+eD idea for the user interface in the portal. Extension in a later sprint: If the patient does not have a PS, a HCER can be created from scratch. |
UC4 | The system will be able to generate a new type of document HCER. The system provides the correct UI to do this |
|
UC5 | The system will create this new type of cda document and will upload it in the relevant NCP |
The following operations are apparently not required, as in the NCP-B client connector operations and WSDLs are content-agnostic and can handle HCER documents without changes:
|
UC6 | NCP-A must accept this document and provide info for the result |
|
UC7 | Doctor can merge the HCER information into PatientSummary Document | Implemented as part of UC4 implementation. |
UC8 | The doctor can query for HCER Documents of a patient | Assumption: it is the responsibility of the country A to integrate the previously submitted HCER to the patient's PS. Therefore the doctor can query PS for getting HCER information. |
What must it be implemented
- Guidelines for the new document type of HCER
- User Interface for filling the HCER document (OpenNCP Portal)
- Method for constructing a valid CDA document (OpenNCP Portal)
- Method for accepting HCER documents (NCP-A, national connector part)
- Method for merging HCER documents into Patient Summary (NCP-A). This can be decided in NCP-A method that will accept HCER document
Questions / Open Issued
- A new document type must be addressed for HCER Document
- It has to be decided which type of Audit Message will be used for logging this action
CDA-related guidelines
Taken from https://service.projectplace.com/pp/pp.cgi/r844355914
Template id:
<!-- conforms to epSOS HCER requirements -->Code:
<templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.1.4"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/>
<author>
<time value="20120519234435+0300"/>
<assignedAuthor classCode="ASSIGNED">
<id root="1.3.6.1.4.1.28284.6.2.4.32"/>
<assignedPerson>
<name>
<given>Patient Summary</given>
<family>Fetcher</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="1.3.6.1.4.1.28284.6.2.4.1" extension="90009016"/>
<name>Eesti E-Tervise SA</name>
<telecom use="WP" value="tel:+3726943900"/>
<telecom use="WP" value="mailto:e-tervis@e-tervis.ee"/>
<addr>
<country>EE</country>
<city>Tallinn</city>
<postalCode>10134</postalCode>
<streetAddressLine>Uus-Tatari 25 / Veerenni 13</streetAddressLine>
<state nullFlavor="NI"/>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
The same data is stored in documentationOf section. In addition to that, values of <low> and <high> elements must be editable. Default values: current time.
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20120519234435+0300"/>
<high value="20120619234435+0300"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="222" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Nursing and midwifery professionals"/>
<assignedEntity>
<id root="1.3.6.1.4.1.28284.6.2.4.32"/>
<assignedPerson>
<name>
<given>Patient Summary</given>
<family>Fetcher</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>