[Category: C-CDA Templates]The article
Concern acts in C-CDA, introduces and overviews the two special "concern act"
templates named Allergy Problem Act and Problem Concern Act, in
C-CDA.
As explained in that article, the
observation clinical act statements for problems and allergies do not appear directly under the
entry XML element in the Problems Section or Allergies Section
C-CDA templates. Instead, there is an intervening
act clinical act statement that serves as a "concern act wrapper" for the observations.
As further explained in the article
Is a single allergy or problem observation wrapped in a concern act?, this construct of "wrapping" every problem or allergy observation in a "concern act" is required even if there is only one observation per "concern act".
Health Concern TrackingThe two C-CDA "concern act" templates (for problems and allergies) are an early-stage manifestation of an important concept called "health concern tracking" which features prominently in the theoretical models that CDA and C-CDA derive from (
HL7 v3).
The current version of C-CDA (R1.1) doesn't support the full "health concern tracking" model. The newer C-CDA R2 that is still being finalized at the time of the writing of this article (refer to the article
What is C-CDA 2.0?, for additional information) contains a new template named Health Concern Act that more broadly aligns with the "health concern tracking model".
Intepreting the Concern ActsGiven that the "concern act" templates in C-CDA R1.1 can't be used for "health concern tracking" in the broad sense, but at the same time given that they are required to be used with every problem or allergy observation in C-CDA, it is a bit challenging to understand how exactly they should be used and interpreted. That is the focus of this article.
Note: The information in this article reflects an evolving understanding of "best practice" based on extensive discussion in relevant HL7 forums. It is still a work in progress...Allergy Problem Act TemplateOne observation Per Concern ActThe current recommendation is to only place one
observation in each Allergy Problem Act in the Allergies Section. This seems a bit counter-intuitive as a key stated purpose of the concern act is to contain multiple observations and other clinical statements (refer to the excerpted text from the C-CDA
implementation guide that is quoted in the article
Concern acts in C-CDA). However, as a practical matter, this is the current best practice for allergies, for reasons that will become clearer in the next paragraph.
Allergy Problem Act Extends the Allergy ObservationSince there is a recommended one-to-one relationship of Allergy Problem Act templates and Allergy - Intolerance Observation templates (see previous paragraph), the data contained in the concern
act clinical statement can be viewed as an extension of the data in the (single) allergy
observation that it contains.
Use of the Allergy Problem Act statusCode Sub-ElementIn particular, the
statusCode sub-element of the
act can take on either the value
"active" (for an active allergy concern) or
"completed" (for an inactive allergy concern). The
statusCode in the
observation is required to always be set to
"completed" by the rules of the Allergy - Intolerance Observation template (requiring a
statusCode of
"completed" is common for observation templates in C-CDA).
There is some debate about when exactly it makes sense to set the
statusCode of the allergy concern act to
"completed". The primary use-case for this appears to be a situation where an allergy concern was incorrectly noted and there is a need to communicate this to other systems (as opposed to just removing it from the list).
The
statusCode element can potentially take on the value
"suspended" or
"aborted", in addition to
"active" and
"completed". However, there are no known use-cases for these values in the Allergy Problem Act template, and they should not be used.
Use of the Allergy Problem Act effectiveTime Sub-ElementThe
effectiveTime sub-element of the Allergy Problem Act template should be used to capture the period of time in which the allergy was of concern to the clinician.
So, for example, if a patient visiting a physician on March 1, 2014 reports an allergic reaction they had in 1970 as a child, the
effectiveTime in the Allergy - Intolerance Observation template would be 1970. The
effectiveTime in the Allergy Problem Act template (more correctly, its "lower bound") would be March 1, 2014.
The
effectiveTime in the Allergy Problem Act is a "time period" (refer to the article
Time intervals in CDA, for additional information). The
low sub-element indicates "when the clinician's concern began". For concerns with
statusCode set to
"active" there is no
high sub-element. If
statusCode is set to
"completed" then the
high sub-element indicates when it no longer was of concern.
Use of the Allergy Problem Act author Sub-ElementThe template rules for Allergy Problem Act do not explicitly call out the use of the
author sub-element. However, this is a standard sub-element of any clinical act statement. In the Allergy Problem Act template, the
author sub-element can be used to indicate which clinician "put this allergy on the list" (or took it off, in the case of
statusCode set to
"completed").
Problem Concern Act TemplateThe guidance for using the Problem Concern Act template is generally the same as for the Allergy Problem Act template, as was just described above.
However, the recommendation noted above of "One
observation Per Concern Act" is less clear for problems. It is apparently more common/recommended to use the Problem Concern Act template to group together multiple related problem observations, than it is in the case of the Allergy Problem Act.
Multiple Problem Observation Templates in One Problem Concern ActIt's not completely clear what guiding principles should be used to decide if multiple problem observations should be placed in the same concern act, or not. As noted above, the full "health concern tracking" model is not available in C-CDA R1.1. Attempts to do "partial problem concern tracking" in the spirit of the broader "health concern tracking", using the Problem Concern Act template, have proven to be quite challenging.
Still, the grouping of multiple problem observations in a single problem concern act can be done in the "spirit of health concern tracking" to capture multiple observations over time that all support the same (perhaps, evolving) underlying "problem concern".
Challenges With Multiple Observations in One Concern ActNote, however, that if this is done (and also if it done in the Allergy Problem Act template - where it is less recommended/common), it needs to be kept in mind that the
statusCode,
effectiveTime, and
author sub-elements of the "concern act" will be applied (from an "interpretation of the document" perspective) to each of the observations it contains.
In other words, what is noted above under "Allergy Problem Act Extends the Allergy Observation" and subsequent paragraphs remains correct - only now what is being "extended" in this way are all of the contained observations. If it's not appropriate to apply the information in the Problem Concern Act or Allergy Problem Act to all of the observations it contains, the observations should be split out into multiple concern acts.
For example, if it is desired to place multiple problem observations in a single problem concern act to reflect the observations made over time, where some older observations are no longer "active" and have been superseded by more recent observations - this won't really work, since the
statusCode of the concern act has to be applied to all of the observations it contains. Thus, it's not possible to have some of the observations associated with a
statusCode of
"active" and others with a
statusCode of
"completed".
So, either the observations need to be split into separate concern acts, or they all need to be in an "active" concern act with the implicit understanding that more recent observations supersede earlier ones in importance/relevance.
Section Narrative Text CompletenessRegardless of how the Allergy Problem Act template and/or Problem Concern Act template are ultimately used in a given C-CDA document, it is an absolute requirement of all
CDA documents that the
section narrative text completely capture all the information represented in the structured elements within the section.
Thus, information from the concern act templates (such as the
statusCode,
effectiveTime, and
author) must be presented in the section narrative text - not only the information from the Allergy - Intolerance Observation and Problem Observation templates contained within the concern act templates.
Other CDA PRO Know Articles Referenced In This Article
