1. Group C – HL7 France Objective : Definition of CDA implementation guides. 17 participants Public entities DHOS, GIP-CPS, GIP-GMSIH Primary care sector 7 participants. Hospital sector 4 participants Shared EHR, Exchange infrastructure providers 3 participants

2. « Volet Médical » Project Objectives : – Synthesis of essential patient data (allergies, drug treatments,…). – It represents a patient clinical synthesis relevant for any Healthcare Professional that will have to treat the patient independently of a specific care plan or a current care workflow. – Hence in practice, the CDA-R2 “Volet Médical” will need to be associated with complementary information (maybe another CDA documents) to reflect exchange context (referral between a GP and a specialist, consultation report, pathology orientated baseline …). – This project give a first practical field for HL7 France members to develop CDA know-how. –Structured data exchange between Primary care applications for essential data References : – Formalism Electronic Medical Summary (e-MS): CDA Implementation Guide Care Record Summary (CRS – HL7 US Realm) – Medical Consensus made by HL7 France members

3. Sections (first proposal) French titleLOINC codeLOINC termCard Antécédents personnels0..1 Antécédents médicaux11348 ‑ 0HISTORY OF PAST ILLNESS0..1 Antécédents chirurgicaux10167 ‑ 5HISTORY OF SURGICAL PROCEDURES0..1 Antécédents obstétricaux10149-6PREGNANCY STATUS0..1 Autres antécédents11329-0HISTORY GENERAL0..1 Antécédents familiaux10157 ‑ 6HISTORY OF FAMILY MEMBER DISEASES0..1 Allergies10155 ‑ 0HISTORY OF ALLERGIES0..1 Allergies médicamenteuses11382 ‑ 9MEDICATION ALLERGY0..1 Allergies alimentairesX ‑ DTALRTDIETARY ALERTS0..1 Autres allergiesX ‑ ALERTGENERAL ALERTS0..1 Episodes de soins ouverts0..1 Pathologies associées11450-5PROBLEM LIST0..1 Traitements de fond????0..1 Trt. médicamenteux19009 ‑ 0MEDICATION.CURRENT0..1 Autres traitements29554-3PROCEDURE0..1 Informations diverses Données biométriques8716-3PHYSICAL FINDINGS0..1 Vaccinations11369 ‑ 6HISTORY OF IMMUNIZATION0..1 Facteurs de risque29762-2SOCIAL HISTORY0..1 Décès??DEATH ?0..1 ? : means that we have not find an equivalent Loinc Code for this section or we are not sure to have used the right one. Semantic interpretation does not depend of section hierarchy. Top level sections are empty and used only for compositional purpose.

4. Sections (new proposal) French titleLOINC codeLOINC term Antécédents personnels ???? Antécédents médicaux11348 ‑ 0HISTORY OF PAST ILLNESS Antécédents chirurgicaux10167 ‑ 5HISTORY OF SURGICAL PROCEDURES Antécédents obstétricaux10149-6PREGNANCY STATUS Antécédents psychiatriques ???? Autres antécédents11329-0HISTORY GENERAL Antécédents familiaux10157 ‑ 6HISTORY OF FAMILY MEMBER DISEASES Allergies et intolérances10155 ‑ 0HISTORY OF ALLERGIES ? : means that we have not find an equivalent Loinc Code for this section or we are not sure to have used the right one. Semantic interpretation does not depend of section hierarchy. Top level sections are empty and used only for compositional purpose.

5. Sections (new proposal) French titleLOINC codeLOINC term Liste des problèmes11450-5PROBLEM LIST Trt. De fod médicamenteux19009 ‑ 0MEDICATION.CURRENT Autres Traitements de fond???? Autres traitements29554-3PROCEDURE Autres données médicales???? Données biométriques8716-3PHYSICAL FINDINGS Vaccinations11369 ‑ 6HISTORY OF IMMUNIZATION Habitus29762-2SOCIAL HISTORY Décès??DEATH ?

6. CDA R2 – Header Ongoing localization (Group C HL7 France) – Vocabulary for document type LOINC codes or alternative French localization vocabulary ? –LOINC codes may fit with “pure” clinical documents, but we will have to manage medico-administrative documents (related with the social insurance system) that are associated with a codification managed by French Administration (cerfa code). – Identifier for Patients, Healthcare Professionals, Hospitals…

7. CDA R2 – Body Body : – Different hierarchy of sections than CRS : ex : CRS : Procedures (History of surgical procedures) HL7 France : Personal History / Surgical History – Only leaf sections can have medical content (narrative part and/or entries) – Other sections are only used to describe hierarchical structure of leaf sections Mixture of the “Flat approach” of section of e-MS structure and hierarchical description of the US CRS to enable an interpretation of the meaning of entries independently of the position of a section in the hierarchy. We anticipate that it could be difficult to define a medical summary order that will be accepted by all medical specialties and that significant sections of the Medical Summary may be reused in other document models.

8. CDA R2 – Body Section codes : LOINC codes are available for nearly all cases (need few extensions for ex. : –Active episode of care – Personal history … ) Specification of CDA level 3 for each section (like e-MS canadian project) –Improving significantly alerts and safety of care (interactions, contra- indications …). –Anticipated need for fine confidentiality granularity control (e.g. voluntary termination of pregnancy will need different confidentiality level than diabetes in the personal history section. –Supported by association of ambulatory care suppliers.

9. Narrative section only <code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PAST ILLNESS"/> Antécédents médicaux Le patient a été sujet dans son enfance à de fortes crises d’asthme et a une Méningite bactérienne en 1979 sans séquelles. If a sending application that is not able to manage level 3 data for a section than only the narrative part should be used. Instances will be not extracted from the text by receiving systems.

10. Level 3 Asthme lors de l’enfance Fortes crises. Narrative part is fully derived from level 3. Structured Instances without codes.

11. Level 3 <code code="H26.8" codeSystem="2.16.840.1.113883.6.5" codeSystemName="CISP" displayName="Méningite bactérienne, sans précision"> <translation code="G00.9" codeSystem="2.16.840.1.113883.6.3" codeSystemName="ICD10"/> <translation code="H00.10" codeSystem="2.16.840.1.113883.6.3" codeSystemName="ICD10"/> Méningite (if synonym used by HCP ) Pas de séquelles. Narrative part is fully derived from level 3. Structured Instances with codes –Recommendation for codifications with sometimes a preferred codification system (Equivalence).