BgZ CDA Implementation Guide
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This version is not final yet. Do not use. |
1 Introduction
TODO
2 Actors involved
| Persons | Systems | ||
|---|---|---|---|
| Name | Description | Name | Description |
| Referring medical specialist | Medical specialist who sends a BgZ along with a referral | EHR | Electronic health record |
| Receiving medical specialist | Medical specialist receives a BgZ along with a referral | EHR | Electronic health record |
3 Use cases
4 Metadata
The functional description requires metadata for the BgZ. This chapter outlines the technical implementation of those metadata.
4.1 Document metadata
4.2 HCIM (zib) metadata
4.2.1 Basic Elements
The 2017 HCIM all have the following implicit Basic Elements which provide metadata:
- IdentificationNumber
- DateTime
- Author
- Subject
- InformationSource
Metadata are often already present in the HCIMs themselves: in that case there is no need to add them to the HCIM again. In other cases, the metadata is not relevant. The table below lists the various Basic Elements against the HCIMs.
Legend:
| Required |
|
|---|---|
| Optional | This is for metadata items which are not crucial to interoperability. I.e. when a measurement already has an Author, the Information Source is not relevant. |
| Not relevant | For certain HCIMs the metadata items are not important. I.e. for the contact persons of a Patient, it is not relevant who or when recorded this. |
| Named data elements | Often the metadata items from the Basic Elements are already present in the HCIM itself. In this case these data items double as metadata, i.e. there is no need for a separate metadata item. All those metadata items are considered Required. |
| Other / textual | On other cases textual clarification is given in the table. |
4.2.2 Metadata table
| Id | Zib | HCIM | IdentificationNumber | DateTime | Author | Subject | InformationSource |
|---|---|---|---|---|---|---|---|
| NL-CM:0.1.1 | Patient | Patient | PatientIdentificationNumber | DateOfBirth | Not Relevant | Patient | Not Relevant |
| NL-CM:1.1.1 | Betaler | Payer | BankCode+AccountNumber OR IdentificationNumber+InsurantNumber | StartDateTime+EndDateTime | Not Relevant | Patient | Not Relevant |
| NL-CM:2.1.1 | BehandelAanwijzing | TreatmentDirective | Required | VerificationDate | Patient OR patient's authorized representative | Patient | Patient OR patient's authorized representative |
| NL-CM:7.15.1 | Wilsverklaring | AdvanceDirective | Required | LivingWillDate | Patient OR patient's authorized representative | Patient | Patient OR patient's authorized representative |
| NL-CM:3.1.1 | Contactpersoon | Contactperson | Not Relevant | Not Relevant | Not Relevant | Contactpersoon | Not Relevant |
| NL-CM:4.26.1 | FunctioneleOfMentaleStatus | FunctionalOrMentalStatus | Required | StatusDate | Required | Patient | ? |
| NL-CM:5.1.1 | Probleem | Problem | Required | ProblemStartDate | Required | Patient | Optional |
| NL-CM:7.8.1 | Woonsituatie | LivingSituation | Optional | Not Relevant | Not Relevant | Patient | Not Relevant |
| NL-CM:7.4.1 | DrugsGebruik | DrugUse | Required | StartDate | empty OR equal to Source | Patient | Required |
| NL-CM:7.3.1 | AlcoholGebruik | AlcoholUse | Required | StartDate | empty OR equal to Source | Patient | Required |
| NL-CM:7.2.1 | TabakGebruik | TobaccoUse | Required | StartDate | empty OR equal to Source | Patient | Required |
| NL-CM:7.11.1 | Voedingsadvies | NutritionAdvice | Required | Not Relevant | Optional | Patient | Required |
| NL-CM:8.3.1 | Alert | Alert | Required | StartDateTime | empty OR equal to Source | Patient | Required |
| NL-CM:8.2.1 | AllergieIntolerantie | AllergyIntolerance | Required | StartDateTime | empty OR equal to Source | Patient | Required |
| NL-CM:9.6.9580 | Medicatieafspraak | MedicationAgreement | Required | MedicationAgreementDateTime | Prescriber::HealthProfessional | Patient | Optional |
| NL-CM:9.8.20132 | Toedieningsafspraak | AdministrationAgreement | Required | AdministrationAgreementDateTime | Supplier::HealthProfessional | Patient | Optional |
| NL-CM:9.11.21338 | MedicatieGebruik | MedicationUse2 | Required | MedicationUseDateTime | Prescriber::HealthProfessional | Patient | Required |
| NL-CM:10.1.1 | MedischHulpmiddel | MedicalDevice | ProductID | StartDate | HealthProfessional | Patient | Optional |
| NL-CM:11.1.1 | Vaccinatie | Vaccination | ProductCode+VaccinationDate | VaccinationDate | Administrator::Healthprofessional | Patient | Optional |
| NL-CM:12.4.1 | Bloeddruk | BloodPressure | BloodPressureDateTime | BloodPressureDateTime | Required | Patient | Optional |
| NL-CM:12.1.1 | Lichaamsgewicht | BodyWeight | WeightDateTime | WeightDateTime | Required | Patient | Optional |
| NL-CM:12.2.1 | Lichaamslengte | BodyHeight | HeightValue OR HeightDateTime | HeightDateTime | Required | Patient | Optional |
| NL-CM:14.1.1 | Verrichting | Procedure | Required | ProcedureStartDate | Performer::HealthProfessional | Patient | Requireduired when performer is not known |
| NL-CM:15.1.1 | Contact | Encounter | ContactType + StartDateTime | StartDateTime | ContactWith::HealthProfessional | Patient | Not Relevant |
| NL-CM:17.1.1 | Zorgverlener | HealthProfessional | HealthProfessionalIdentificationNumber | Not Relevant | Not Relevant | HealthProfessional | Not Relevant |