Section 1a: Clinical Document Architecture (CDA®)
Section 3: Implementation Guides
HL7 CDA® R2 Implementation Guide: Data Provenance, Release 1 - US Realm
DESCRIPTION
The Implementation Guide for CDA (R) Release 2: Data Provenance, Release 1, September 2014 is the result of collaborative efforts between HL7 and the US Health and Human Services Office of National Coordinators Standards and Interoperability Framework Data Provenance Initiative (DPROV). This IG is the result of a focused effort to identify existing opportunities within CDA R2 where basic provenance information about clinical (and other care related information), who created it, when was it created, where was it created, how it was created, and why it was created, can be conveyed in a consistent and interoperable manner. Also conveyed is what action was taken - resulting in (documented by) the information captured. In particular, this IG builds upon the provenance preserving constraints in the Consolidated CDA and Data Segmentation for Privacy IGs, as well as reusing the CDA Consent Directive IG. This IG provides guidance to any CDA R2 implementer on the use of CDA templates to represent data provenance. These templates may also be used as building blocks for conveying provenance using other information exchange Standards.
ALTERNATIVE NAMES
HL7 CDA® R2 Implementation Guide: Data Provenance, Release 1 - US Realm may also go by the following names or acronyms:
TARGETS
- Clinical and Public Health Laboratories
- Regulatory Agency
- Standards Development Organizations (SDOs)
- Payors
- EHR, PHR Vendors
- Health Care IT Vendors
- Clinical Decision Support Systems Vendors
- Lab Vendors
- HIS Vendors
- Local and State Departments of Health
- Medical Imaging Service Providers
- Healthcare Institutions (hospitals, long term care, home care, mental health)
BENEFITS
-
Enables interoperable and consistent capture and conveyance of provenance, including:
- Who contributed to the generation of a CDA, e.g., the participating: authors, authenticators, legal authenticators, custodians, data enterers, performers, and other participants, including assembly and composing software, and scoping organizations at the document, section, and entry levels.
- When an information event recorded in a CDA occurred
- Where an information event recorded in a CDA occurred
- Why an information event recorded in a CDA occurred
- How an information event recorded in a CDA differs from a predecessor or successor information event, and the context surrounding that change including any privacy or security policies that influenced the manner in which the information event was changed
- What provenance metadata about the information event that a recipient system may need to evaluate its authenticity, integrity, and trustworthiness, and to establish the receivers confidence that this information is fit for use within its enterprise
IMPLEMENTATIONS/CASE STUDIES
- LPHI/GNOHIE is the Louisiana Public Health Institute- Greater New Orleans Health Information Exchange
- RAIN is RAIN Live Oak Technology
DEVELOPMENT BACKGROUND
The DPROV Initiative is sponsored by the Office of the Chief Privacy Officer within the ONC to develop standards and guidance by which health information technology can support clinical, organizational, and jurisdictional requirements to capture, and convey provenance about health information instances. Please visit the Initiative http://wiki.siframework.org/Data+Provenance+Initiative and HL7 sources noted throughout this document for further information and current status of activities. For documentation specific to the development of this IG see the Data Provenance Tiger Team wiki http://wiki.siframework.org/Data+Provenance+Tiger+Team.
This IG is the result of a focused effort to identify existing opportunities within CDA R2 where basic provenance information about clinical (and other care related information), who created it, when was it created, where was it created, how it was created, and why it was created, can be conveyed in a consistent and interoperable manner. Also conveyed is what action was taken - resulting in (documented by) the information captured. In particular, this IG builds upon the provenance preserving constraints in the Consolidated CDA and Data Segmentation for Privacy IGs, as well as reusing the CDA Consent Directive IG. Also within scope, the provenance patterns established in HL7 v.2 and v.3 such as v.3 Control Acts, Medical Records Domain, and RIM State Machines as well as similar specifications in v.2 Chapter 2 Control, Chapter 5 Queries, and Chapter 9 Medical Records/Information Management were leveraged as appropriate.
In addition, a wealth of EHR Functional Model Lifecycle Events, and Records Management and Evidentiary Support functional requirements have been gleaned from the invaluable input of experts in these areas including the HL7 EHR Work Group http://wiki.hl7.org/index.php?title=EHR_Interoperability_WG, US Realm participants in ISO TC 215 [ISO/TC 215 Health Informatics], CDISC, W3C PROV, and AHIMA. Standards focused on record lifecycle and trusted information flow requirements were reviewed including: ISO 21089 Trusted End-to-End Information Flows, ISO/HL7 10781 Electronic Health Record (EHR) System Functional Model Release 2 and the HL7 EHR Lifecycle Model DSTU.
This IG represents a consensus approach to meeting the requirements for conveyance of provenance data within any CDA at the document, section and entry level.
RELATED DOCUMENTS
HL7 CDA® R2 Implementation Guide: Data Provenance, Release 1 - US Realm |
STU DOCUMENTS
HL7 CDA® R2 Implementation Guide: Data Provenance, Release 1, DSTU Release 1 - US Realm | Expiration Oct 2018 |
(Download) (1.04 MB) |
TOPIC
- Community-Based Health
BALLOT TYPE
- DSTU
STATUS DATE
2015-12-15RESPONSIBLE WORK GROUP
STAKEHOLDERS
- Clinical and Public Health Laboratories
- Clinical Decision Support Systems Vendors
- EHR, PHR Vendors
- Health Care IT Vendors
- Healthcare Institutions
- HIS Vendors
- Lab Vendors
- Local and State Departments of Health
- Medical Imaging Service Providers
- Payors
- Regulatory Agency
- Standards Development Organizations (SDOs)
FAMILY
- CDA
CURRENT STATE
- Active
REALM
- US Realm