This specification is a library of the HITSP defined data elements that are used for mapping to data elements from the HITSP selected standards. It defines data elements that have been constrained or used in other HITSP documents (such as Components, Transactions, Transaction Packages) and facilitates the consistent use of these data elements across the various HITSP selected standards. It does not attempt to specify all the data elements for the standards selected by HITSP (i.e. only those constrained). The Data Elements are organized into modules to simplify navigation, such as Medications, Advance Directives, Immunizations, etc.
This specification does not enable the use of the data elements; this is accomplished by a HITSP construct that is based upon a specific standard (such as HL7, X12N, NCPDP, etc.). In order to facilitate harmonization of value sets across the various selected standards, this specification may define value set constraints. When this does not occur, it is because the data element does not require a value set or a harmonized value set was not determined. These value sets in turn reference standard terminologies in HITSP/C80 Clinical Document Message Terminology. HITSP/C154 does not define any other constraints (such as optionality) as those constraints are identified in the HITSP construct that enables the data element.
There are many ways that various HITSP documents may constrain a data element, some examples include:
HITSP/TN903 Data Architecture provides a more detailed explanation about the use of data elements (and other data architecture concepts) within HITSP.
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Certain materials contained in this Component are reproduced from HL7 Implementation Guide: CDA Release 2 - Continuity of Care Document (CCD) with permission of Health Level Seven, Inc. No part of the material may be copied or reproduced in any form outside of the Interoperability Specification documents, including an electronic retrieval system, or made available on the Internet without the prior written permission of Health Level Seven, Inc. Copies of standards included in this Component may be purchased from the Health Level Seven, Inc. Material drawn from these standards is credited where used.
A list of key reference documents and background material is provided in the table below. HITSP-maintained reference documents can be retrieved from the HITSP Web Site
|Reference Document||Document Description|
|HITSP Acronyms List [publicaa.ansi.org]||Lists and defines the acronyms used in this document|
|HITSP Glossary [publicaa.ansi.org]||Provides definitions for relevant terms used by HITSP documents|
|TN901 - Clinical Documents||TN901 is a reference document that provides the overall context for use of the HITSP Care Management and Health Records constructs|
|TN903 - Data Architecture||TN903 is a reference document that provides the overall context for use of the HITSP Data Architecture constructs|
|TN904 - Harmonization Framework and Exchange Architecture||TN904 is a reference document that provides the overall context for use of the HITSP Harmonization Framework and Exchange Architecture|
This section describes the conformance criteria, which are objective statements of requirements that can be used to determine if a specific behavior, function, interface, or code set has been implemented correctly.
In order to claim conformance to this construct specification, an implementation must satisfy all the requirements and mandatory statements listed in this specification, the associated HITSP Interoperability Specification or Capability, its associated construct specifications, as well as conformance criteria from the selected base and composite standards. A conformant system must also implement all of the required interfaces within the scope, subset or implementation option that is selected from the associated Interoperability Specification.
Claims of conformance may only be made for the overall HITSP Interoperability Specification or Capability with which this construct is associated.
A HITSP Interoperability Specification or Capability must be implemented in its entirety for an implementation to claim conformance to the specification. HITSP may define the permissibility for interface scoping, subsetting or implementation options by which the specification may be implemented in a limited manner. Such scoping, subsetting and options may extend to associated constructs, such as this construct. This construct must implement all requirements within the selected scope, subset or options as defined in the associated Interoperability Specification or Capability to claim conformance.
The key words SHALL, SHALL NOT, SHOULD, SHOULD NOT and MAY are to be interpreted as described in RFC 2119 and will appear when used in that fashion in this TYPEFACE.
The key words REQUIRED and OPTIONAL are also to be interpreted as described in RFC 2119 when they are used to indicate the optionality of components used in an exchange.
Constraints in this document will appear as shown below.
|C83-[DE-7.04-1]||The problem type SHALL be coded as specified in HITSP/C80 section 22.214.171.124.4.1.2 Problem Type. The first portion identifies the type of artifact being constrained. The second portion is the identifier for that artifact, and the final portion is the sequence number of the constraint on that artifact within this document. Constraints specific to CDA usage will contain the string CDA before the final number|
This section provides an introduction to the concepts used in describing the data elements used in HITSP specifications. The HITSP Data Elements in this document are organized into modules described in Table 2-1 below. The module identifier number is given in the first column, followed by the name and definition of what appears in that module. These modules are described in more detail below in Section 2.1.2 HITSP Data Elements.
|1||Person Information||This includes name, address, contact information, personal identification information, ethnic and racial affiliation and marital status of a person|
|2||Language||This includes the language spoken by subject|
|3||Support||This includes the patient's sources of support, such as immediate family, relatives and/or guardians. This includes next of kin, caregivers, support organizations, and key contacts relative to healthcare decisions. Support providers may include providers of healthcare related services, such as a personally controlled health record, or registry of emergency contacts|
|4||Healthcare Providers||This includes a list of the healthcare providers and organizations that provide or have provided care to the patient|
|5||Insurance Providers and Players||This includes data about the organizations or individuals who may pay for a patient's healthcare, and the relationships, demographics and identifiers of those individuals with respect to the payer. Such organizations or individuals may be health insurance plans, other payers, guarantors, parties with financial responsibility, some combination of payers or the patient directly|
|6||Allergies and Drug Sensitivities||This includes the allergy or intolerance conditions, severity and associated adverse reactions suffered by the patient|
|7||Conditions||This includes relevant clinical problems and conditions for which the patient is receiving care, including information about onset, severity, and providers treating the condition. Conditions are broader than, but include diagnoses|
|8||Medications||This includes the patient's prescription or non-prescription medications and medication history, and may include prescriptions, fulfillments and medication administration activities|
|9||Pregnancy||This includes information about the patient's current and past pregnancy status|
|10||Information Source||This includes information about the author or creator of the information contained within the exchange|
|12||Advanced Directive||This includes data defining the patient.s advance directives and supporting documentation. It can include information about the existence of living wills, healthcare proxies, and CPR and resuscitation status|
|13||Immunizations||This includes data describing the patient's immunization history|
|14||Vital Signs||This includes data about the patient's vital signs|
|15||Test Results||This includes data about current and historical test results from laboratory or other diagnostic testing performed on the patient|
|16||Encounter||This includes data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and email|
|17||Procedures||This includes data describing procedures performed on a patient|
|18||Family History||This includes data defining the patient's genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient's health|
|19||Social History||This includes data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history that have a potential impact on the patient's health|
|20||Medical Equipment||This includes implanted and external medical devices and equipment that a patient's health status depends on, as well as any pertinent equipment or device history|
|21||Functional Status||This includes data defining the patient.s functional status with respect to, Ambulatory ability, Mental status or competency, Activities of Daily Living, including bathing, dressing, feeding, grooming, Home/living situation having an effect on the health status of the patient, Ability to care for self|
|22||Plan of Care||This includes data defining prospective or intended orders, interventions, encounters, services, and procedures for the patient|
|23||Clinical Research||This includes data elements and common identifier variables that pertain to research-specific workflow|
|24||Order||This includes data describing orders for a patient|
|25||Specimen||This includes data describing the specimen information associated with an order and the results|
The HITSP Data Dictionary defines the library of Data Elements that may be used by HITSP constructs in standards based exchanges. The Data Elements are organized into modules to simplify navigation, such as Medications, Advance Directives, Immunizations, etc.
The personal information module contains the name, address, contact information, personal identification information, ethnic and racial affiliation and marital status of the person. See the HL7 Continuity of Care Document Section 2.5 for constraints applicable to this module.
This module indicates the language spoken by the subject.
This module contains the patient's sources of support, such as immediate family, relatives and guardians. Support information also includes next of kin, caregivers and support organizations. Support providers may include providers of healthcare related services, such as a personally controlled health record, or registry of emergency contacts.
This module contains the healthcare providers involved in the current or pertinent historical care of the patient.
This insurance provider module contains data about the entities or other individuals who may pay for a patient's healthcare. Such entities or individuals may be health insurance plans, other payers, and guarantors, parties with financial responsibility, some combination of payers or the patient directly. This module is used to define which entity or combination of entities has any financial responsibility for a patient's care.
This module contains the allergy or intolerance conditions and the associated adverse reactions suffered by the patient.
This module contains relevant clinical problems. See the HL7 Continuity of Care Document Section 3.5 for constraints applicable to this module.
This module contains a patient's prescription or non-prescription medications and pertinent medication history. See the HL7 Continuity of Care Document Section 3.9 for constraints applicable to this module.
This module contains information about the patient's current and historical pregnancy status.
This module describes information about the original author of the exchange and reference to source materials that can be provided in an exchange.
This collection of data elements applies to a variety of exchanges.
This module contains data describing the patient's Advance Directive and any reference to supporting documentation. This section contains data such as the existence of living wills, healthcare proxies and CPR and resuscitation status. The custodian of these documents may be described.
This module contains data describing the patient's immunization history.
This module contains current and relevant historical vital signs for the patient. Vital Signs are a subset of Results (see Section 126.96.36.199), but are reported in this section to follow clinical conventions. The differentiation between Vital Signs and Results varies by clinical context. Common examples of vital signs include temperature, height, weight, blood pressure, etc. However, some clinical contexts may alter these common vital signs, for example in neonatology "height" may be replaced by "crown-to-rump" measurement.
This module contains current and relevant historical result observations for the patient. The scope of "observations" is broad with the exception of "vital signs" which are contained in the Vital Signs sections (see Section 188.8.131.52 above).
This module contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and email communication.
This module contains a coded entry indicating a procedure performed on a patient.
This module contains data defining the patient's genetic risk factors.
The text adapted from HL7 CDA Release 2 - Continuity of Care Document (CCD), Section 3.7 Social History, begins here:
This module contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.
The text adapted from HL7 CDA Release 2 - Continuity of Care Document (CCD), Section 3.7 Social History, ends here.
Table 2-39 Social History Data Mapping Table - Definitions: Social History Event Entry
Medical Equipment includes implanted and external medical devices and equipment that a patient's health status depends on, as well as any pertinent equipment or device history.
The functional status module contains data defining the patient's functional status with respect to Ambulatory ability, Mental status or competency, Activities of Daily Living, including bathing, dressing, feeding, grooming, Home/living situation having an effect on the health status of the patient or their Ability to care for themselves.
The plan of care contains data defining prospective or intended orders, interventions, encounters, services, and procedures for the patient.
The clinical research module contains data defining data elements and common identifier variables that pertain to research-specific workflow.
This module contains data defining the patient's order.
This module contains data defining the Specimen related to an Order.