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Primary Health Care
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0
Business View
Who We AreEstablished in 1994, CIHI is an independent, not-for-profit corporation that provides essential information on Canada’s health system and the health of Canadians. Funded by federal, provincial and territorial governments, we are guided by a Board of Directors made up of health leaders across the country.
Our VisionTo help improve Canada’s health system and the well-being of Canadians by being a leading source of unbiased, credible and comparable information that will enable health leaders to make better-informed decisions.
Table of Contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
About the Canadian Institute for Health Information . . . . . . . . . . . . . . . . .viii
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Benefits to Patient Care and the Health System . . . . . . . . . . . . . . . . . . . . . 7
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Business Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Use Case Category 1: PHC Clinic Visits and Program Management . . . . . . . . 19
Use Case Category 2: Referral to a Specialist and Wait Times Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Use Case Category 3: Patient Self-Reporting and Chronic Disease Prevention and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Data Elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Adoption, Maintenance and Governance . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Contact Information and Links . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Appendix A: Draft Conceptual Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Appendix B: Data Element Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Appendix C: Pan-Canadian Primary Health Care Indicators . . . . . . . . . . . 89
Appendix D: Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
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Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
AcknowledgementsThe Canadian Institute for Health Information (CIHI) would like to acknowledge and thank the many individuals and organizations that contributed to the development of this product. In particular, CIHI would like to acknowledge and express its appreciation to the members of the Jurisdictional Advisory Group (JAG) and the Content Standards Working Group (CSWG), who provided invaluable guidance in developing the core content for the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard. As of September 1, 2010, these groups consisted of the following members:
Jurisdictional Advisory Group Members
Mr. Jeff AitkenDirector, First Nations eHealth, BC Ministry of Health Services (December 2009–September 2010)
Mr. Thomas P. AlteenProject Manager,Newfoundland and Labrador Centre for Health Information (December 2009–September 2010)
Ms. Pat BoothManager of Information Management Unit, Information Services Division, Department of Health and Social Services, Government of the Northwest Territories (February 2010–June 2010)
Ms. Claire BernatchezSenior Program Manager, Federal Healthcare Partnership (December 2009–September 2010)
Ms. Sandra CascaddenChief Information Officer, Nova Scotia Department of Health (December 2009–September 2010)
Mr. Neil GardnerChief Information Officer, Saskatchewan Health (December 2009–September 2010)
Mr. Dennis GiokasChief Technology Officer, Canada Health Infoway (December 2009–September 2010)
Ms. Cheryl HansenExecutive Director, Innovation, New Brunswick Department of Health (December 2009–September 2010)
Mr. Richard Johnstone Senior Delivery Manager, Shared Health Network, Alberta Health and Wellness (December 2009–June 2010)
Mr. Martin JoyActing Director, Nunavut Department of Health and Social Services (December 2009–September 2010)
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Ms. Heather E. N. CooperHealth Information Standards Coordinator, Alberta Health and Wellness (June 2010–September 2010)
Mr. Tom Fogg (Co-Chair)Director of Strategy and Planning, Manitoba eHealth (December 2009–September 2010)
Mr. Randy FrancisDirector, Program Management, Prince Edward Island Department of Health (December 2009–September 2010)
Mr. John McKinleyAssistant Deputy Minister, Ontario Ministry of Health and Long-Term Care (December 2009–July 2010)
Ms. Janet NybergChief Information Officer, Yukon Department of Health (December 2009–September 2010)
Mr. Greg Webster (Co-Chair) Director, Primary Health Care Information, Canadian Institute for Health Information (December 2009–September 2010)
Content Standards Working Group Members
Mr. Jeff AitkenDirector, First Nations Health, British Columbia Ministry of Health Services(February 2010–September 2010)
Mr. Thomas P. AlteenProject Manager, EHR Projects, Health Information Network, Newfoundland and Labrador Centre for Health Information (February 2010–September 2010)
Ms. Claire BernatchezSenior Program Manager, Federal Healthcare Partnership (February 2010–September 2010)
Dr. Richard BirtwhistleDirector of Centre for Studies in Primary Care, Queen’s University and Principal Investigator, Canadian Primary Care Sentinel Surveillance Network (February 2010–April 2010)
Ms. Mary Ann JuurlinkeHealth Standards, Lead,eHealth Ontario (February 2010–September 2010)
Ms. Beverly KnightTerminology Services Manager, Canada Health Infoway (February 2010–September 2010)
Ms. Jan LabovichManager, Information Architecture, Manitoba eHealth (February 2010–September 2010)
Dr. Marion LyverPresident, Healthy Futures Inc.; Associate Clinical Professor, McMaster University Faculty of Medicine (February 2010–September 2010)
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Ms. Pat BoothManager of Information Management Unit, Information Services Division, Department of Health and Social Services, Government of the Northwest Territories (February 2010–June 2010)
Dr. Denise Campbell-SchererAssociate Professor, Department of Family Medicine, University of Alberta (February 2010–September 2010)
Ms. Heather E. N. CooperHealth Information Standards Coordinator, Alberta Health and Wellness (February 2010–September 2010)
Dr. Sisira De SilvaElectronic Health Record Standards Specialist, Newfoundland and Labrador Centre for Health Information (February 2010–September 2010)
Mr. Finnie FloresSenior Standards Analyst, eHealth Ontario (April 2010–September 2010)
Ms. Irene A. K. GillisHealth Information Specialist, Prince Edward Island Department of Health (February 2010–September 2010)
Ms. Beverly GreenePrimary Health Care Consultant, New Brunswick Department of Health (February 2010–September 2010)
Ms. Michelina MancusoExecutive Director of Performance Management, New Brunswick Health Council (February 2010–September 2010)
Mr. Ken MartinSenior Data Manager, CPCSSN Project, Queen’s University (April 2010–September 2010)
Ms. Patti McManusNurse Practitioner, Federal Healthcare Partnership and First Nations and Inuit (April 2010–September 2010)
Ms. Lynn MillerNurse Practitioner, Cumberland North Rural Practice Network (April 2010–September 2010)
Ms. Lisa NapierPHIM Program Manager, Nova Scotia Department of Health (February 2010–September 2010)
Dr. Ray SimkusPhysician, Brookswood Family Practice Biomedical Informatics, British Columbia (February 2010–September 2010)
Ms. Karen OldfordPHC Nurse Practitioner, Labrador–Grenfell Health (April 2010–September 2010)
Mr. Pavel PlatonovSenior EMR Technical Specialist, Manitoba eHealth (February 2010–September 2010)
Dr. Morgan PriceUniversity of British Columbia, Department of Family Practice (February 2010–September 2010)
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Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Dr. Roger HamiltonPhysician, Nova Scotia (February 2010–September 2010)
Ms. Cindy HollisterClinical Leader, Clinical Adoption, Canada Health Infoway (February 2010–September 2010)
Dr. R. Liisa JaakkimainenFamily Physician; Scientist, Institute for Clinical Evaluative Sciences, Ontario (February 2010–September 2010)
Ms. Brenda JackmanClinical Business Analyst, Primary Health Care, Health Information Solutions, Saskatchewan Ministry of Health (February 2010–September 2010)
Ms. Donna ShanleyPhysician eHealth Program, eHealth Ontario (February 2010–September 2010)
Ms. Cynthia SmithSenior Manager, Primary Health Care Unit, Alberta Health and Wellness (February 2010–September 2010)
Ms. Patricia Sullivan-Taylor (Chair)Manager, Primary Health Care Information, Canadian Institute for Health Information (February 2010–September 2010)
Ms. Valerie RossActing Manager,Information Management, Department of Health and Social Services, Northwest Territories(June 2010–September 2010)
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Canada Health Infoway
CIHI would like to thank Canada Health Infoway (Infoway) for its collaboration on this project, with special thanks to Sukhi Burgen, Linda Dentay, Shari Dworkin, Dennis Giokas, Beverly Knight, Alex Mair, Julie Richards and Lynne Zucker. CIHI would also like to thank members of the Infoway Standards Collaborative Strategic and Coordinating Committees and Working Groups 2, 3 and 9 for their input and contributions to various phases of the project.
CIHI Project Team
The core CIHI project team responsible for developing the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0 included
Mr. Louis Barré, Vice President, Strategy, Planning and Outreach
Mr. Ted Harrison, Project Lead, Primary Health Care Information
Mr. Scott Murray, Vice President and Chief Technology Officer, Information Technology and Services
Ms. Patricia Sullivan-Taylor, Manager, Primary Health Care Information
Mr. Gavin Tong, Project Manager, Primary Health Care Information
Mr. Greg Webster, Director, Primary Health Care Information
Significant project contributions were also made by Zee Hua Cheung, Tanya Flanagan, Azra Kulenovic, Shaheena Mukhi, Marco Neri, Dawn Nicholson, Christine Proietti, Michael Terner, Christina Tomsa, Jennifer Trebell and Vicky Walker.
This product could not have been completed without the generous support and assistance of many other CIHI staff members, including classifications, information technology and services, CIHI standards working group, layout and design, translation, communications and distribution, who provided ongoing support to the core team.
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About the Canadian Institute for Health Information The Canadian Institute for Health Information (CIHI) collects and analyzes information on health and health care in Canada and makes it publicly available. Canada’s federal, provincial and territorial governments created CIHI as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI’s goal: to provide timely, accurate and comparable information. CIHI’s data and reports inform health policies, support the effective delivery of health services and raise awareness among Canadians of the factors that contribute to good health.
For more information, visit our website at www.cihi.ca.
Executive SummaryPrimary health care (PHC) is the most common type of health care experienced by Canadians. Efforts to improve PHC hold the greatest potential to positively impact the health of Canadians and the sustainability of the health care system. Stakeholders across Canada are facing increased demands to improve primary health care (PHC) and to demonstrate fiscal responsibility. However, there is relatively little high-quality information available with which to guide efforts to prevent chronic diseases and to improve the quality, efficiency and accessibility of PHC. Across Canada, jurisdictions and clinicians are increasingly using Electronic Medical Records (EMRs) to support improvements in PHC.
Interoperable EMRs will play a key role in ensuring that PHC clinicians have the information they need to deliver, coordinate and administer care. Using EMR information to support clinicians at the point of service is generally considered its primary use. However, the information generated at the point of service can also be used to support quality improvement initiatives, such as clinical program management, research, and monitoring the health of the population, as well as to improve the efficiency of the health care system overall. The use of information for these purposes is often referred to as “health system use.”
The availability of high-quality information to support PHC improvements can be achieved only if a subset of priority, standardized data is present in PHC EMRs. With increased funds going toward the adoption of EMRs, it has become imperative that standardized data capture is occurring in order to support the priority information needs now and into the future. At present, most EMRs support free text data capture, with little regard for aligning
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with common content standards. This approach limits the EMR’s ability to provide point of care benefits, such as patient safety reminders and alerts for patients who require close monitoring. The absence of standardized PHC data compromises the quality and comparability of all forms of information that can be created—an issue that affects all stakeholders, regardless of type (for example, clinician or health system planner) and regardless of their intended use of that information.
To support the EMR adoption initiatives, stakeholders identified the need for a pan-Canadian PHC EMR content standard that would define a common approach to capturing a priority set of data elements in a structured manner that supports both primary and health system uses of the data. Supporting a single pan-Canadian standard was seen by stakeholders as a way to maximize the value and efficiency associated with development, implementation and maintenance.
In collaboration with stakeholders from across the country, the Canadian Institute for Health Information (CIHI) led the project to establish the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0 (PHC EMR CS). The PHC EMR CS is composed of 106 data elements that are commonly captured in EMRs and that support both primary uses of EMR data, such as reminders and alerts for patients with chronic conditions, and health system uses, such as a jurisdictional diabetes management registry. These data elements are required to support the many facets of PHC, including treatment of illnesses, as well as health promotion and disease prevention.
The creation of the PHC EMR CS marks a key milestone on the path to improving PHC in Canada. The next step along this path is to ensure that the PHC EMR CS is properly and widely implemented in EMRs. Two future steps involve ensuring that implementation of the PHC EMR CS supports care delivery and PHC system improvements in a privacy-sensitive manner; and ensuring that PHC EMR data is privacy-protected when employed for health system uses.
CIHI will continue to work with stakeholders to establish additional products and services to facilitate the adoption and implementation of the PHC EMR CS. In parallel, strategies and plans for the longer-term governance and maintenance of the PHC EMR CS will be established to ensure it remains clinically and technically relevant to meet evolving stakeholder needs in the years to come.
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Introduction
The Challenge
Primary health care (PHC) is the most common type of health care experienced by Canadians. Efforts to improve PHC hold the greatest potential to positively impact the health of Canadians and the sustainability of the health care system.1 As health care costs continue to rise, all stakeholders are increasingly accountable to demonstrate value for health care spending while improving the quality and outcomes of care. Accountabilities in this area are far-reaching and extend to jurisdictions, i PHC clinicians and electronic medical records (EMR) vendors. At the same time that stakeholders are experiencing a greater demand to demonstrate improvements in health care delivery and fiscal responsibility, information on PHC remains limited. Currently, there is limited evidence-based information to inform better practice and health system management on how to improve the quality, effectiveness and efficiency of patient care.
Across Canada, the increased use of EMRs has been promoted to support improvements in PHC quality and efficiency. However, in the absence of a pan-Canadian PHC EMR content standard, multiple EMR standards have been developed to support jurisdictional needs. The lack of a pan-Canadian approach to EMR standards to date has resulted in
Increased costs to the system associated with developing, implementing • and maintaining multiple standards;
Fewer benefits realized from EMRs, including limited information to support • clinical decision-making at the point of care; and
Limited comparable information to support health system evaluation and • management across the country.
i. The term “jurisdiction” broadly refers to the provincial and territorial ministries of health, as well as the Federal Healthcare Partnership, which comprises Citizenship and Immigration Canada, Correctional Service Canada, Department of National Defence, Health Canada, Public Health Agency of Canada, Royal Canadian Mounted Police and Veterans Affairs Canada.
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The Solution
Stakeholders from across the country developed a set of priority data elements to ensure that the necessary subset of standardized information is available to improve access, quality, outcomes and chronic disease prevention and management across Canada. These priority data elements formed the core content of the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0, henceforth referred to as the PHC EMR CS.
The PHC EMR CS is composed of 106 data elements that are commonly captured in EMRs and support primary uses, such as reminders and alerts for patients with chronic conditions and health system uses of EMR data, such as a jurisdictional diabetes management registry. These data elements are required to support the many facets of PHC, which include not only treatment of illnesses but also include health promotion and disease prevention activities.
About This Document
This document is intended for clinicians and decision-makers from public and private sector organizations with an interest in effective PHC EMRs, with a goal of aiding these stakeholders in understanding the purpose and development process of the PHC EMR CS. To this end, the document has been written from a business perspective as opposed to a technical one. ii
ii. Technical information that is of interest to implementers and standards experts is available on CIHI’s Primary Health Care Information Program website at www.cihi.ca/phc.
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Background
Primary Health Care Indicators to Support Measurement for Improvement
Primary health care (PHC) has been called the foundation of Canada’s health system and is the most common type of health care that Canadians experience.2 Currently, we know little about the way services are delivered, the results that these services yield or how our PHC system is evolving. Broadly, PHC indicators and the data required to report on these indicators contribute to the measurement and management of PHC in Canada. Measuring PHC in Canada will require harnessing and enhancing data sources at the local, regional, provincial/territorial and pan-Canadian levels.
In 2005, the Canadian Institute for Health Information (CIHI) received funding from the Primary Health Care Transition Fund and partnered with a broad range of PHC experts across Canada to develop an agreed-upon set of pan-Canadian indicators that could be used to measure PHC at multiple levels within jurisdictions across Canada. The resulting 105 indicators were published in the two-volume report Pan-Canadian Primary Health Care Indicators in 2006. A companion report recommended options for enhancing the infrastructure required to collect the data associated with the PHC indicators. CIHI built on this work in 2007 by exploring the feasibility of various options to improve PHC data sources, including data on quality and outcomes from clinical sources.
CIHI PHC Indicators EMR Content Standards, Version 1.1 to Support Quality Measurement and Improvement
In 2007, CIHI conducted an environmental scan to assess the feasibility of collecting data on these 105 PHC indicators from a variety of sources, including electronic medical records (EMRs), existing CIHI databases and other administrative databases, as well as patient, provider and organizational surveys.
The environmental scan found that data for the PHC quality indicators—representing approximately one-third of the 105—could potentially be collected from EMRs plus diagnostic imaging, prescription drug and lab data sources. However, the scan also highlighted the need to establish EMR content standards in order to standardize data collection across PHC settings. In response to provincial, territorial and federal needs, CIHI led the PHC Indicators EMR Content Standards Project, which included pan-Canadian collaboration with PHC clinicians, researchers, standards experts and health system managers to identify the priority data elements for the preliminary
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standard (Version 1.1). The focus of the project was to establish a new pan-Canadian data stream for populating and reporting on a subset of the PHC quality indicators in order to improve the understanding of PHC across the country and inform health policy and decision-making at various levels.
In early 2009, CIHI issued Version 1.1 of the PHC Indicators EMR Content Standards to facilitate the standardized capture of a priority subset of EMR data associated with 12 quality PHC indicators. Over the past year, pilot testing in PHC settings informed the need for a subsequent iteration of the standard.
Draft Pan-Canadian PHC EMR Content Standard, Version 2.0 to Support Primary and Health System Use
In the fall of 2009, stakeholders identified the need to expand the scope of Version 1.1 to include both primary and health system uses of EMR data and to improve alignment of the data elements with the pan-Canadian Electronic Health Record (EHR) Messaging and Terminology Standards, as well as with Infoway’s Physician Office System Requirements.3 In response to the needs of the jurisdictions promoting the use of PHC EMRs, CIHI launched a project to work with stakeholders to develop Version 2.
Two Types of “Use”
Primary useThe data are currently and commonly required to support the delivery and/or administration of primary health care.
Health system useThe data are commonly required to support PHC clinical program management, health system management, research and monitoring the health of the population.
To achieve this goal, a jurisdictional advisory group (JAG)—with representation from the jurisdictions, Infoway and CIHI—was established to help set the strategic direction for the project. The JAG was supported by a pan-Canadian Content Standards Working Group (CSWG), which provided input and advice on the data elements to ensure that they were clinically relevant, aligned with existing standards where appropriate, met the needs of stakeholders and were implementable. The JAG and CSWG were also responsible for informing strategies and plans for the longer term adoption, governance and maintenance of the PHC EMR CS.
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The collaborative approach was intended to reduce duplication of effort in the development of EMR content standards at the jurisdictional level and to minimize the burden on EMR vendors who would otherwise have to incorporate and maintain multiple standards in their EMRs. The draft standard was given a slightly different name than its predecessor to reflect the fact that it is a pan-Canadian standard that supports both primary and health system uses of EMR data.
Content Standard Naming Convention
The PHC EMR CS is considered a “draft pan-Canadian standard” because it meets the following criteria:
It is governed by a body with pan-Canadian representation.•
Its scope is to meet pan-Canadian requirements.•
It was developed with pan-Canadian input on clinical content, jurisdictional • priorities and standards expertise.
It was established by a pan-Canadian, consensus-based approval process.•
It is considered “draft” because it has not yet been implemented and there • are areas for further refinement that require implementation experience.
In this context, the term “pan-Canadian” means “across Canada”; generally, in the health field, the term often implies representation from the majority of the health jurisdictions and other stakeholder categories from across Canada. The title “Draft Pan-Canadian Standard” was recommended by the CSWG in order to avoid confusion with labels used by the Infoway Standards Collaborative (“Canadian Draft for Use”) and other standards bodies, such as HL7 (“Draft Standard for Trial Use”).
ScopeThe purpose of the PHC EMR CS is to provide a minimum data set that, when implemented in PHC EMRs, will yield data that enables EMR functionality and provides information that will lead to quality improvements in patient care and the broader health care system.
Once the PHC EMR CS has been implemented, PHC EMRs can make better use of EMR data to drive application functionality—such as the functions described in Infoway’s Physician Office System Requirements (e.g. the EMR can graph lab results over time)—and to generate information. They can also extract data to support a variety of needs ranging from interoperating with a jurisdictional EHR to providing data to a chronic disease management repository.
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Scope Criteria
The main criterion for the inclusion of a data element in the PHC EMR CS was its ability to support both primary and health system uses of EMR data.
Examples of data elements that support both primary and health system uses of EMR data are shown in Figure 1. Data elements that appear in the overlapping area of the two circles support both uses, and are therefore deemed to be in scope for the PHC EMR CS.
Figure 1: PHC EMR CS Scope
Patient StreetNumber and Name
ClinicianBilling Number
Number of PrescribedMedication Refills
PatientPostal Code
ClinicianRole Type
PrescribedMedication
Patient Socio-EconomicNeighbourhood
Clinician HighestDegree Obtained
DispensedMedication Cost
Primary Use Health System Use
In Scope
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Benefits to Patient Care and the Health SystemThe PHC EMR CS directly supports patient care improvements by enabling EMR functionality (for example, clinical decision support) and providing information that clinicians and health care system decision-makers can use to improve quality of care (for example, prevention, outcomes and access to care). Without the PHC EMR CS, it would not be possible to efficiently monitor and evaluate efforts to improve PHC across the country in a comparable way.
“Data standards allow comparisons between patients within the practice, as well as comparisons across practices, and facilitate surveillance and a population health approach to primary health care.”
Dr. Alan KatzFamily PhysicianWinnipeg, Manitoba
A pan-Canadian approach to the PHC EMR CS mitigates duplication of effort to develop jurisdictional-specific standards, which otherwise increases costs to EMR vendors who would have to support the implementation of multiple standards in their products. By supporting both primary and health system uses of EMR data, the PHC EMR CS will reduce data collection costs by reusing data captured at the point of care for clinical program management, health system management, research, and monitoring the health of the population.
“Collecting information in a structured way helps manage our precious resources in the most effective way.”
Dr. Roger HamiltonFamily PhysicianWolfville, Nova Scotia
While clinicians, jurisdictions and PHC EMR vendors receive the benefits described above, they also derive unique benefits from the adoption of the PHC EMR CS. These benefits can only be fully realized through incorporation into software and systems that are properly designed and used by all stakeholders.
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Clinician BenefitsImprove patient care and safety• through the use of clinical decision support functions in their PHC EMR. Examples of clinical decision support functions include, but are not limited to, drug-to-drug interaction alerts, reminders for follow-up care and suggested treatment plans for specific conditions.
Facilitate patient care coordination• through electronic communications with other clinicians via interoperable systems, such as electronic referrals, and ordering of lab tests using standardized, comparable and clinician-friendly terms.
Improve the quality of care and efficiency in their PHC practice • by examining reports on their patient population and quality of care indicators over time. Understanding trends in patient demographics, quality of care, patient-centred care and disease prevalence can help clinicians plan for quality improvement and optimize resource allocation in their practice.
“Standardized data in the EMR helps those of us working in primary health care to work more collaboratively as a team. The easy retrieval of information in the EMR also gives me more time to deal with issues that my patients have.”
Denise MossRegistered Nurse andCertified Diabetes EducatorAlgoma Diabetes Education and Care ProgramSault Ste. Marie, Ontario
Jurisdiction Benefits
Improve availability of comparable, standardized data in order to
Evaluate and monitor chronic disease prevention and management • (CDPM) initiatives. Improvements to CDPM will not only improve the lives of patients but also decrease costs to the jurisdictional health care system.
Analyze PHC delivery and administration to identify areas to improve• quality, outcomes, safety and efficiency and to ensure that patients have optimal access to care.
Monitor the health of the population to identify, prevent and contain• outbreaks of disease.
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“This standard enables the consistent capture of information in EMRs that will help inform efforts to better manage the health system.”
Tom FoggDirector of Strategy and Planning, Manitoba eHealth Co-chair of the Pan-Canadian EMR Content Standard Jurisdictional Advisory Group
PHC EMR Vendor BenefitsLower the implementation and maintenance costs of EMRs• through support of a single standard. Otherwise, vendors must consume considerable resources in evaluating jurisdictional requirements that conform to different standards. The vendors then have to expend resources to maintain each of these standards in their products and support mapping between these standards.
Improve product offerings• by providing innovative features and functionality that rely on the underlying standardized data (clinical decision-support tools, quality indicator reporting).
Increase the speed• at which products can be brought to the market by decreasing development and conformance-testing efforts.
When properly implemented, the PHC EMR CS offers numerous benefits to stakeholders, such as ensuring that PHC clinicians have the information they need to deliver, coordinate and administer optimal care, and providing the information required to manage the PHC system in an efficient and effective manner.
“I want to know how I can get good data out of my EMR without disrupting the work flow. Pan-Canadian standardized data allows you to identify work flow issues and patients’ needs and gives you an opportunity to compare models of care not only within your own province, but models operating across Canada.”
Dr. Lewis O’BrienFamily Physician Sault Ste. Marie, Ontario
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ApproachThe PHC EMR CS project followed a robust framework to ensure that stakeholders were actively engaged in every step, from establishing the project’s strategic directions to approving the final deliverables. The following diagram depicts the project framework, which is described in further detail below.
Figure 2: PHC EMR CS Project Framework
Clinicians
Researchers
Other EHR Standards
Vendors
Standards Experts
Jurisdictions
Infoway
Ongoing Development
and Maintenance
Jurisdictions
Clinicians
Vendors
StakeholderInputs
1. Education
2. Implementation Support
3. Conformance and Quality Testing
Stakeholder engagement strategy and plan
Communication material
Conceptual data model
Use cases
Specifications for each data element
Terminologies options analysis andrecommendations report
Implementation planning
Work Packages
CIHI
Promotion, Adoption and Implementation
Information Requirements Gathering
1. Conduct gap analysis of other EHR/ EMR standards
2. Identify agreed list of PHC data elements
3. Develop options for clinical concept lists and explore mappings to clinical terminologies and classification systems for clinical data
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Stakeholder Inputs
The stakeholder engagement process was initiated by the creation of a Jurisdictional Advisory Group (JAG) that was formed with senior representatives from the provinces and territories, Infoway and the Federal Healthcare Partnership. The role of the JAG was to provide strategic direction to the project and inform the stakeholder engagement and communication strategies. These strategies engaged the most influential and interested representatives from the jurisdictions, clinicians, standards organizations, vendors, researchers, Infoway and CIHI to contribute to the requirements and content of project deliverables. A key component of the stakeholder engagement strategy was the creation of the Content Standards Working Group (CSWG), which consisted of subject matter experts representing the key stakeholders from across the country. The CSWG was ultimately responsible for ensuring that the core content of the PHC EMR CS reflected stakeholders’ needs.
The JAG and CSWG members were also tasked with acting as liaisons to their stakeholders to create awareness and solicit input on various aspects of the project. In support of these efforts, the PHC EMR CS project team collaborated with JAG and CSWG members to deliver several jurisdictional face-to-face workshops, which resulted in the identification of additional requirements for the PHC EMR CS.
The PHC EMR CS project team presented to standards bodies, such as the Infoway Standards Collaborative Working Groups, Coordinating Committee, Clinical Sub-Committee and Partnership Conferences. In addition, jurisdictional health information standards councils were directly engaged in collaboration with CSWG members.
A face-to-face workshop with PHC EMR vendors was held in June 2010 to discuss adoption challenges and solutions for the PHC EMR CS. The workshop provided an opportunity to deliver consistent messaging regarding the alignment of the project with other jurisdictional and national EMR standards initiatives. JAG and CSWG representatives also contributed to the in-depth discussions on the best methods for facilitating adoption of the PHC EMR CS.
In an effort to increase the project’s exposure to an even broader range of stakeholders, the PHC EMR CS project information was also presented at conferences such as eHealth 2010 and the Canadian Institutes of Health Research Primary Healthcare Summit.
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Information Gathering and Priority Setting
A baseline set of data elements was compared with EMR and EHR jurisdictional and national standards to assess the size of the alignment gap. The gap analysis also identified opportunities to reuse existing standards, particularly from the pan-Canadian EHR messaging and terminology standards. This information was coupled with the input from the stakeholder engagement process, described above, to form the core requirements and scope of the PHC EMR CS.
The CSWG acted as the main body for reviewing and agreeing on requirements and solutions for meeting stakeholders’ needs. The CSWG held three review cycles of iterative drafts of the PHC EMR CS. Each cycle generated additional requirements and solutions, which were tracked to completion using a defined methodology and supporting database. This process allowed CSWG members to track the evolution of the PHC EMR CS against their proposed requirements and solutions to ensure that their needs were being met.
The CSWG review cycles resulted in a priority list consisting of 106 data elements, which formed the core content of the PHC EMR CS and were recommended to the JAG for approval. The JAG endorsed the CSWG recommendations regarding the data elements to be included in the PHC EMR CS. During the requirements review process, stakeholders identified the need to analyze options for selecting terminologies for six high-priority clinical concepts, including diagnoses, reason for encounter and interventions. In response to this need, CIHI launched a parallel project to identify and assess options regarding the development or adaptation of one or more standard sets of terminology or coding standards for use in PHC EMRs.
Work Packages
As previously discussed, the stakeholder engagement strategy and plan were the first project deliverables. It should be noted that the strategy and plans were refined throughout the project based on stakeholder feedback. Bilingual communication materials, such as a one-page project overview and a list of frequently asked questions, were developed to assist stakeholders in promoting the project within their respective areas. These materials are available from CIHI’s Primary Health Care Information Program website, at www.cihi.ca/phc.
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A conceptual model was developed to help stakeholders understand how PHC business concepts referenced by the 106 data elements related to each other. (See Appendix A: Draft Conceptual Model.)
High-level use cases were developed to clarify how data that had been collected to support the delivery and administration of PHC could be reused to support quality improvement, policy development and health system management. (See the Business Context section for more information on the use cases.)
The 106 data elements that form the core of the PHC EMR CS are summarized in the Data Elements section. (See Appendix B: Data Element Matrix for a complete list.) A data extract specification was in development at the time of writing this document. The purpose of the data extract specification is to provide the additional information that implementers need in order to be able to extract EMR data for health system use.
The report regarding the terminology options analysis and recommendations was one of the final project deliverables. At the time of writing this document, the recommendations were under review. Similarly, implementation support planning was just being launched at the time of writing. Initial plans on the type of implementation support that may be required to facilitate adoption of the PHC EMR CS are discussed later on in this document. (See the Adoption, Maintenance and Governance section.)
Promotion, Adoption and Implementation
The benefits of the PHC EMR CS will be fully realized only if it is implemented in vendors’ products, such as PHC EMRs and PHC data repositories, and if these products are ultimately used by clinicians and jurisdictions. Promotion and education efforts are therefore required to ensure that stakeholders are aware of the PHC EMR CS and its benefits. Once stakeholders have made the decision to adopt the PHC EMR CS, they will need guidance and support to facilitate the efficient and accurate implementation of the PHC EMR CS. Finally, conformance and quality testing will be required on vendors’ products to ensure that the PHC EMR CS has been implemented correctly.
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Business Context
Background
At the point of service, the primary use of EMR information is to support clinical decision-making and interdisciplinary collaboration in the delivery and administration of PHC. However, the same data is essential to improving patient care through research and clinical program management, and will support monitoring the health of the population and the overall effectiveness of the health care system. The reuse of PHC EMR data for these purposes is often referred to as “health system use.” The types of PHC EMR data that can serve dual purposes include, among others,
Patient and clinician demographics;•
Patient health status and history;•
Lab orders and results;•
Medication prescription and fills; and•
Diagnostic imaging orders and results.•
This section provides examples—in the form of high-level use cases—of how a common set of data elements collected at the point of service can directly support both patient care and health system uses of PHC EMR data. The use cases illustrate a future state of standardized PHC EMR data flow to support patient care coordination and integration of services, and generate aggregate reports for use by clinicians and by jurisdictions to aid with population planning for chronic disease prevention and management.
What Is a Use Case?
Use cases provide one or more scenarios that convey electronic transmission points of a common set of data elements between an end user and another system to link knowledge and achieve a specific business goal. For example, connecting clinical knowledge to prompt alerts or reminders facilitates clinicians in achieving their goal of improving the quality of care for their patients.
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Chronic disease prevention and management forms the overarching context for the use cases described in this section. Within this context, three use case categories are provided:
Use Case Category 1: PHC Clinic Visits and Program Management1.
Use Case Category 2: Referral to a Specialist and Wait Times Management2.
Use Case Category 3: Patient Self-Management and Chronic Disease 3. Prevention and Management
Each category consists of a primary use case and a health system use case. As a whole, each category demonstrates how data collected at the point of service for the purpose of delivering and administrating care can also be used by clinicians and health system managers to help improve patient care and the broader health care system. Figure 3 shows the relationship between the three use case categories and their corresponding use cases.
Figure 3: Use Case Categories
Health SystemManagement
Referral WaitTimes Management
Referral to a Specialist
Use Case Category 2: Referral to a Specialist and Wait Times Management
Research/Monitoringthe Health of
the Population
Patient Self-Management
Chronic Disease Prevention and Management
Use Case Category 3:Patient Self-Management
and Chronic Disease Prevention and Management
Prim
ary
Use
Heal
th S
yste
m U
se
Clinical ProgramManagement
PHC Clinic Visit
PHC ClinicalProgram
Management
Use Case Category 1: PHC Clinic Visits and Program Management
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Each use case is composed of three parts:
Narrative:1. A brief story about people’s interactions with specific aspects of the PHC system.
Swim lane diagram: 2. A picture of the people, systems and EMR data involved in specific aspects of the PHC systems. Each swim lane represents the action of a person or a system (called an “Actor”). In each lane, actions are initiated by an Actor and result in data outputs or inputs to the system.
Flow of events sidebar:3. A sequential flow of actions derived from the narrative that corresponds to key points in the swim lane diagram. Each step in the sequential flow of actions is referenced in the diagram as red numbered circles.
Caveats
The following caveats should be kept in mind while reading the use cases:
The example data shown in the use cases represent a business view of 1. the data elements in the PHC EMR CS. Please note that the use cases reference the common names of the data elements, which are non-technical labels that are easily understood by a broad audience. Each data element also has a standard name, which in many cases may be a longer but more precise label than the common name. Appendix B includes both the common and standard names for cross-referencing.
The Electronic Health Records swim lane depicts a simplified 2. representation of the systems that constitute the EHR; it is not a comprehensive list of all potential jurisdictional systems.
Jurisdictions are at different stages of development of their EHR system; 3. therefore, no assumptions are made regarding the existence or lack thereof of EHR system components. As a result, the diagrams depict information flows directly between Point of Service (PoS) systems as well as flows between PoS systems and other systems.
The use cases assume that all the necessary consent, privacy and security 4. measures that are required to use the data for multiple purposes have been adhered to.
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Use Case Example: From Primary to Health System Use of EMR Data
The following use case example introduces the reader to the swim lane diagrams while providing a holistic view of how EMR data that is used in the delivery and administration of care (primary use) can also support various health system uses.
Narrative
At the point of service, clinicians capture clinical information on risk factors, symptoms and assessment measurements in an EMR and use this information to support care coordination activities electronically. In this example, a clinician is electronically issuing a lab requisition, referral and prescription to facilitate care for a single patient.
The data collected by the various point of service systems can be aggregated and presented to clinicians in the form of practice-level feedback reports on their population, which can help clinicians to assess clinical quality of care, utilization and care coordination. This is an example of a health system use for PHC clinical program management.
The same data is used to support PHC health system management. It is used to inform improvements in access, coordination, delivery models, resource and service utilization, and quality of care outcomes. Ultimately, the data can be used to inform policy for PHC and to support sound decision-making. Overall, standardized PHC EMR data collection will expand the country’s understanding of emerging PHC information needs through monitoring the health of the population and research.
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Figure 4: Example Swim Lane Diagram
PATI
ENT
PHC
CLIN
ICIA
N(S)
PHC
EMR
(Dat
a St
ore)
EHR
EXTE
RNAL
PO
INT
OF S
ERVI
CEHE
ALTH
SYS
TEM
US
E (H
SU)
AlternativeData Flow
Data Store
PHARMACY• Medication
Dispense Date
SPECIALIST • Consult Note
Nurse assesses patient
Physicianassesses patient
Patient calls to book appointment for
annual assessment
• Patient Name• Patient Identification Number• Identification Issuer• Date of Birth• Gender• Reason for Encounter• Postal Code• Encounter Date
• Blood Pressure• Symptoms• Family History• Vitals, etc
• Diagnosis• Prescription• Lab Request• Referral• Intervention
SYMPTOMS EXAMINATION
Jurisdictional Lab Information System
e-Lab
PHC EMR
Jurisdictional Shared Health Record System
e-Referral
Jurisdictional Drug Information System
e-Prescription
RESEARCHCLINICAL PROGRAMMANAGEMENT
HEALTH SYSTEMMANAGEMENT
• Provider Level Feedback Report
• Practice Level Feedback Report (Includes PHC Indicator and Utilization Analysis)
• Access and Coordination of Care to PHC Services
• Wait Times and Referral Patterns
• Drug Prescription Patterns• Patient Outcomes
• Diabetes Management• Wait Times
• Diabetes and Hypertension Incidence and Prevalence Rates
MONITORING THE HEALTH OF THE POPULATION
RISK FACTORS
Patient arrivesat PHC clinic
• Excessive Thirst
• Fatigue• Frequent
Urination
• Height• Weight• Blood
Pressure
• Physical Inactivity
• Advanced Age • Obesity
Report
SwimLanes
Data Flow
PATIENT AND ENCOUNTER DETAILS
• Lab Test Performed Date• Lab Test Result Value• Lab Test Result Low Range• Lab Test Result High Range
LAB FACILITY/ LAB REPOSITORY
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Figure 4: Example Swim Lane Diagram (cont’d)
Flow of Events
The Patient arrives at a PHC clinic for a scheduled appointment.1.
The Nurse assesses the Patient and captures risk factor data 2. in the EMR.
The Physician reviews the pre-assessment information in the EMR.3.
The Physician performs an examination on the Patient. 4. The Physician notes that the Patient has risk factors and symptoms that suggest the patient may have diabetes.
The Physician enters the Patient’s health status in the EMR and 5. electronically orders a lab test and a prescription medication, and creates a referral to a specialist.
The data from the point of service systems is aggregated to 6. create information that supports clinical program management, health system management, research or monitoring of the health of the population.
Use Case Category 1: PHC Clinic Visits and Program ManagementThe following use cases demonstrate how data that is created at the point of service during an encounter (primary use) can also be used to support clinical program management (health system use).
PHC Clinic Visit (Primary Use)
At an annual medical appointment, the Patient describes frequent episodes of excessive thirst, fatigue and urination. The Nurse assesses the Patient and captures risk factors (such as the Patient’s physical inactivity and obesity) and symptoms in a standardized manner in the EMR. Subsequently, a risk factor alert is generated by the EMR and prompts the Physician to review the clinical information that suggests a potential diagnosis of diabetes. To confirm this clinical assessment, the Physician electronically issues a lab test for fasting blood glucose levels and HbA1C.
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Figure 5: PHC Clinic Visit
PATI
ENT
LAB
FACI
LITY
PHC
CLIN
ICIA
N(S)
PHC
EMR
(Dat
a St
ore)
EHR
Nurse assesses Patient
Physicianassesses Patient
Patient calls to book appointment for
annual assessment
• Patient Identifier• Patient Date of Birth• Patient Gender• Patient Postal Code• Reason for Encounter• Encounter Date
• Blood Pressure• Symptoms• Family History• Vitals, etc.
• Immunizations• Diagnosis• Prescriptions• Lab request• Intervention
SYMPTOMS EXAMINATION
Jurisdictional Lab Information System (JLIS)
e-Lab
PHC EMR
LAB
• Lab Test Name Ordered• Lab Test Ordered Date
RISK FACTORS
Patient arrivesat PHC clinic
• Excessive Thirst
• Fatigue• Frequent
Urination
• Height• Weight• Blood
Pressure
• Physical Inactivity
• Advanced Age • Obesity
PATIENT AND ENCOUNTER DETAILS
Flow of Events
The Patient arrives at a PHC clinic for a scheduled appointment.1.
The Nurse assesses the Patient and captures risk factor data 2. in the EMR.
The Physician reviews the Nurse’s assessment information in the EMR.3.
The Physician performs an examination on the Patient. The Physician 4. notes that the Patient has risk factors and symptoms that suggest the Patient may have diabetes.
The Physician enters the Patient’s health status in the EMR and 5. electronically orders a lab test for fasting blood glucose levels and Hemoglobin A1c (HbA1C).
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PHC Clinical Program Management (Health System Use)
The PHC EMR data captured during a face-to-face encounter between a patient and a PHC provider can be used by the PHC clinic or other organizations to generate a variety of reports, such as provider feedback reports and practice level feedback reports that include PHC indicators and utilization analysis.
Through the PHC clinic, a number of quality improvement initiatives are coordinated to monitor and manage patients with chronic diseases, including those with diabetes. To support care coordination efforts, the PHC Clinic Administrator routinely extracts EMR data from a local server and generates provider-level feedback reports. In this example, the Physician receives and reviews the provider feedback report to determine the percentage of adult Patients with diabetes who have not had their routine assessment for HbA1C, blood pressure, weight, full fasting lipid profile and nephropathy screening. Subsequently, the Clinic Administrator organizes follow-up calls (or emails) to Patients to schedule reassessment visits. The Clinic Administrator also organizes a meeting of the interdisciplinary team to discuss modifiable risk factors in adults with diabetes that can help improve their quality of life and prevent additional health complications. The report also supports improvements to practice efficiency by identifying resourcing needs required to optimally care for the patient population within the clinic’s catchment area and to maximize jurisdictional incentives for vulnerable patient populations.
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Figure 6: PHC Clinical Program Management
PHC
CLIN
ICIA
N(S)
PHC
EMR
(Dat
a St
ore)
Automatically Extracts Data
Automated Automated
Physician enters Patient’s health
concern data into EMR
Performs Data Quality and Statistical Analysis
Automatically Generates Provider-Level Feedback
Report (Annual Comparative Reports)
PHC
DATA
SER
VICE
S
Provider-Level Feedback Report (Annual
Comparative Reports)
PHC EMR
• Diagnosis
HEALTH CONCERNS
PHC ClinicAdministrator
Flow of Events
The Patient arrives at a PHC clinic for a scheduled appointment.1.
Patient data is captured in the EMR by Clinicians throughout the 2. course of delivering care.
The PHC Clinic Administrator extracts aggregated patient data 3. from the EMR and generates the provider-level feedback report.
The Physician reviews the provider-level feedback report to 4. determine the percentage of adult patients with diabetes who have not had their annual assessments.
The Physician asks the PHC Clinic Administrator to contact patients 5. who have not had their annual assessments in the last 12 months in order to remind them to schedule an appointment.
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Use Case Category 2: Referral to a Specialist and Wait Times Management
Referral to a Specialist (Primary Use)
The Physician accesses a centralized, real-time patient referral system to coordinate care for a Patient with diabetes who would benefit from a consultation with a Specialist. The generated wait list from the patient referral system provides a range of waiting periods with corresponding names of available Specialists. Upon retrieving this information, the Physician reviews the list with the Patient and confirms the Patient’s preferred wait time and location. The Patient chooses to see the first available Specialist with a six-week wait time. Immediately, the Physician processes the referral and secures an appointment time with a Specialist.
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Figure 7: Referral to a Specialist
PHC
CLIN
ICIA
N(S)
PHC
EMR
(Dat
a St
ore)
SPEC
IALI
ST
Physician diagnoses Patient with type 2 diabetes mellitus
EHR
Physician looks for a Specialist with the
shortest wait timePhysician recommends
Specialist and discusses availability options
Physician processes referral and books
referral appointment
PHC EMR
EHR Data and Services
Specialist EMR
SPECIALIST
• Consult Note
Available SpecialistWait Times Report
• Referral Service• Referral Requested Date
REFERRAL
Flow of Events
After reviewing the Patient’s lab test results, the Physician diagnoses 1. the Patient with type 2 diabetes mellitus and recommends that the Patient see a Specialist (diabetes educator) for a follow-up visit.
The Physician uses the EMR to check a centralized, real-time, 2. Patient referral system to find a Specialist with the shortest wait time.
The Physician receives an immediate feedback report indicating that 3. the first available Specialist has a wait time of six weeks.
The Physician discusses the Specialist options with the Patient 4. based on wait times and locations. The Patient chooses to see the first available Specialist with a six-week wait time.
The Physician uses the EMR to book the appointment.5.
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Referral Wait Times Management (Health System Use)
The PHC EMR data captured during a face-to-face encounter and a subsequent referral to a Specialist by a PHC provider to a Patient can be aggregated and used by the jurisdictions and CIHI to generate a variety of reports, such as wait times for specific services and referral patterns. Primary health care information can be used by jurisdictions for health system management to support improvements in access, coordination, delivery models, resource and service utilization and quality of care outcomes. To support the country’s need to manage health systems and set benchmarks, the PHC Clinic Administrator extracts data on a quarterly basis in accordance with privacy and security guidelines and submits the data to the jurisdiction and/or CIHI for analysis. Data quality and statistical analysis is performed to generate health service access and utilization reports. The reports identify average patient wait times for an appointment with a Specialist, referral patterns and utilization of health services. Next, the health service access and utilization reports are confidentially disseminated to individual jurisdictions. The jurisdictions use the information to evaluate health policies, inform PHC improvement efforts and allocate resources.
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Figure 8: Referral Wait Times Management
JURI
SDIC
TION
(S)
PHC
DATA
SER
VICE
SPH
C EM
R(D
ata
Stor
e)JU
RISD
ICTI
ON/C
IHI P
HC
REPO
SITO
RYEH
R
AutomaticallyExtracts Data
Compresses and Encrypts Data File
Submits/Uploads Data Files via Electronic Data Submission Process (eDSS)
De-Identifies Data
Automated Automated
Retrieves, Verifies and PerformsData Quality and Statistical Analysis
Generates Referral to ServicesWait-Times/Referral Patterns Reports
PHC EMR
Jurisdictional/CIHIPHC Repository
Jurisdictional SharedHealth Record
• Referral to Services Wait-Times Reports• Referral Patterns Reports
• Referral Service• Referral Requested • Date
REFERRAL
PHC ClinicAdministrator
Jurisdictional Health System Administrator
Jurisdictional/CIHIData Administrator
Flow of Events
The PHC Clinic Administrator extracts aggregated patient data from 1. the EMR and electronically submits the data to the jurisdictional/CIHI PHC repository.
The Jurisdictional/CIHI Data Administrator retrieves the submitted 2. data files, performs data quality and statistical analysis, and generates the health service access and utilization reports.
The Jurisdictional/CIHI Data Administrator disseminates the health 3. service access and utilization reports to Jurisdictional Health System Administrators.
The Jurisdictional Health System Administrators receive the health 4. service access and utilization reports.
The Jurisdictional Health System Administrators use the reports to 5. help inform decisions on how to improve access to care.
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Use Case Category 3: Patient Self-Reporting and Chronic Disease Prevention and Management
Patient Self-Management (Primary Use)
During the Patient’s previous diabetes follow-up visit at the PHC clinic, the Physician asked the Patient a number of questions regarding her family health history, social behaviours and other potential risk factors. But due to a combination of nervousness and lack of knowledge of her family’s health history, the Patient was unable to answer all of the Physician’s questions.
The Physician requests that the Patient speak to family members regarding the family history of other diseases and to enter this information into her Personal Health Record (PHR) as it becomes available. Over the course of the next three months, the Patient learns that there is a history of hypertension and heart disease in the family. She enters her family health history, social behaviours and other risk factor information into the PHR web portal. The data in the PHR is shared electronically with the Physician’s EMR for verification and discussion at a subsequent visit.
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Figure 9: Patient Self-Reporting
PHR
(Dat
a St
ore)
PATI
ENT
EMR
(Dat
a St
ore)
PHC
CLIN
ICIA
NSEH
R
Patient entershealth history and
risk factor data
Physician reviews health history and risk factor data with patient
PHR
EMR
Jurisdictional SharedHealth Record
• Patient Identifier• Patient Date of Birth• Family Health History• Social Behaviours
PATIENT HEALTH HISTORY
Flow of Events
The Patient enters health history and risk factor data into the PHR.1.
The data in the PHR is shared electronically with the Physician’s EMR. 2.
The Physician discusses the Patient’s risk factors and health history 3. at a follow-up appointment.
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Chronic Disease Prevention and Management(Health System Use)
The Physician is asked to join a voluntary research collaborative that uses EMR data to better understand chronic diseases and to improve care and prevention for Patients with chronic conditions. The Physician works with the PHC Clinic Administrator to contribute anonymized data to a centralized repository on a routine basis.
A Researcher is investigating correlations between the health status of Patients with diabetes and risk factors for hypertension and heart disease. The Researcher queries the repository to identify populations of people with diabetes who also have a family history of hypertension and heart disease. The Researcher then queries the repository to determine how many Patients within the population have received nutrition and exercise counselling to help prevent hypertension and heart disease. The findings are published as part of a comprehensive report on the quality of care for people living with chronic diseases.
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Figure 10: Chronic Disease Prevention and Management
PHC
DATA
SER
VICE
SPH
C EM
R(D
ata
Stor
e)RE
SEAR
CHRE
POSI
TORY
CPDM
REP
ORT
EHR
AutomaticallyExtracts Data
Compresses and Encrypts Data File
Submits/Uploads Data Files via Electronic Data Submission Process (eDSS)
De-Identifies Data
Automated Automated
Retrieves, Verifies and PerformsData Quality and Statistical Analysis
PHC EMR
ResearchRepository
Jurisdictional SharedHealth Record
CPDM Quality of Care Report
• Health Concerns• Family Health History• Interventions
HEALTH STATUS AND HISTORY
PHC ClinicAdministrator
Researcher
Flow of Events
The PHC Clinic Administrator extracts the anonymized data 1. for submission to the voluntary research collaborative.
The Researcher queries the repository to identify populations 2. of people with diabetes who also have a family history of hypertension and heart disease.
The findings are published as part of a comprehensive report 3. on the quality of care for people living with chronic diseases.
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Summary
The preceding high-level use cases demonstrate how data captured at the point of service for primary uses can also support health system uses. However, the reuse of PHC EMR data can be achieved only if it is captured and shared in a standardized manner.
Data ElementsThe data elements listed in Table 1 form the core (normative) content for the PHC EMR CS. Table 1 provides a simplified view of the data elements by using their common names (meaning the names that are recognizable from a business perspective). Please see Appendix B: Data Element Matrix for a detailed view of the 106 data elements, including their standard name, definition, domain values and alignment to pan-Canadian EHR Messaging and Terminology standards and Physician Office System Requirements.
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Table 1: PHC EMR CS Business View
Demographics
Patient Clinician Clinic
Identifier Identifier Identifier
Identifier Type Identifier Type Name
Identifier Assigning Authority Identifier Assigning Authority Type of Services
Date of Birth Status Last Name Postal Code
Gender Date of Death First Name
Highest Education Rostered (Start/End Date) Middle Name
Housing Status Ethnicity Role
Primary Language Postal/Zip Code Expertise
Patient Care Activities
Patient
Health Concern(s) (Date of Onset/Resolution Date)
Social Behaviour(s) (Date of Onset/Resolution Date)
Allergy/Intolerance Type Agent Severity Status (Date of Onset/Resolution Date)
Vaccine Administered Date Administered Lot # Reason Not Given
Encounter Specific
Appointment Requested Date Reason for Visit Visit Date Visit Type
Systolic/Diastolic Blood Pressure Site Position Representative
Height* Weight* Waist Circumference*
Intervention (Treatment) Date Reason for Refusing Intervention
Clinician Assessment Payment Source Payment Type Billing Code
Medications
Prescribed Prescribed DateEstimated Completed Date
Stop Date Repeat
Strength* Dosage* Form Frequency Route
Reason Not Prescribed Medication Compliance
Medication Dispensed
Dispensed Date
Lab
Lab Test Name Ordered
Order Date Performed Date
Result Name Result Value* Low/High Range*
Diagnostic Imaging
Diagnostic Imaging Test Ordered Order Date Performed Date
Referral
Referral Service Request Date Occurred Date
Family History
Relationship to Patient Ethnicity Deceased Date Cause of Death
Health History Concern(s) (Age at Onset or [Start/End Date])
Social Behaviour(s) (Age at Onset or [Start/End Date])
Intervention (Treatments) (Age at Onset or [Start/End Date])
Note* These data elements are associated with additional data elements to express Unit of Measure (e.g. cm, kg).
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The data elements listed in Table 1: PHC EMR CS Business View do not represent mandatory or optional data elements. Requirements for mandatory and optional data elements will be specific to implementations of the PHC EMR CS and are expected to vary somewhat by jurisdiction.
Adoption, Maintenance and Governance
Adoption
Three stakeholder groups need to collaborate in their adoption of the PHC EMR CS in order to achieve its maximum benefits:
PHC EMR Vendors: • Need to incorporate the PHC EMR CS in their products in a user-friendly manner so that there are no additional burdens for data collection placed on clinicians and that tools are intuitive and easy to use.
PHC Clinicians:• Need to use the EMRs to capture and exchange PHC data to enable EMR functionality and generate information.
Jurisdictions:• Need to ensure that the PHC EMR CS are included in their vendor requirements and subsequently use information generated from PHC EMR data to help manage the health care system and monitor the health of the population and inform future versions.
Each of these groups has unique adoption goals and challenges. CIHI will continue to collaborate with stakeholders to provide implementation support products and services that will assist them in the adoption of the PHC EMR CS as described above. At the time of writing this document, the following implementation support resources are expected to be available from CIHI’s Primary Health Care Information Program website at www.cihi.ca/phc:
A data extraction specification to support health system uses of EMR data;•
Detailed use cases depicting primary and health system uses of • PHC EMR data;
A logical data model; and•
Known challenges and suggested resolutions.•
34
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
The implementation support resources will be established through the CSWG and JAG, with input from other stakeholders. It is expected that some of the implementation resources will be packaged with the 106 data elements to form the final publication of the PHC EMR CS. Additional implementation support services are also anticipated and may include workshops, e-learning and implementation help desk.
Maintenance
Maintenance of the PHC EMR CS is required to ensure that it remains clinically and technically relevant as stakeholders’ needs evolve. Broadly speaking, maintenance of the PHC EMR CS encompasses four interdependent processes.4
Problem Management: 1. Recording and managing feedback/comments/issues;
Change Management:2. Managing requests for changes to the PHC EMR CS and related artefacts;
Configuration Management: 3. Ensuring that the PHC EMR CS and its related artefacts remain in sync as changes are made; and
Release Management: 4. Implementing and releasing changes to the PHC EMR CS and related artefacts.
These processes will apply to interim “hot fixes” to support the immediate needs of implementers, as well as new versions of the PHC EMR CS.
Governance
PHC is a strategic priority for CIHI. To this end, CIHI will continue to support the PHC EMR CS to ensure that it remains clinically and technically relevant as stakeholders’ needs evolve over time. This will entail engaging stakeholders through the same (or similar) governance structure and processes described in the Approach section.
CIHI’s Primary Health Care Information Program website (www.cihi.ca/phc) will be updated with information on the adoption, maintenance and governance of the PHC EMR CS as it becomes available. If you would like to participate in a working group to refine future versions of the PHC EMR CS, please send an email to [email protected].
35
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Next StepsThe PHC EMR CS will be shared with stakeholders, and efforts will be made to support its adoption and uptake through meetings with Infoway, jurisdictions, standards collaborative working groups, vendor forums, PHC organizations, researchers and clinicians. CIHI will also conduct a privacy impact assessment of the PHC EMR CS to guide implementers on privacy considerations when using PHC EMR data for health system use. Ancillary communication and education materials will be developed to support stakeholders’ awareness and understanding of the PHC EMR CS. The PHC EMR CS will also be shared at international levels where it can be compared with other initiatives in an attempt to refine and improve future releases.
It will be necessary to continue to update the PHC EMR CS based on information gathered through pilot testing and implementations and on indicator refinements, and as clinical guidelines change. The evolution of e-health projects, provincial registries, EMRs and care delivery practices will also necessitate changes to the PHC EMR CS over time, based on priority information needs. Maintenance and publication release processes will be defined and implemented in order to support stakeholders’ evolving needs for the PHC EMR CS.
CIHI will continue to work with stakeholders to determine the ideal approach and necessary resources to establish standard value sets for use with priority clinical data elements. This work will include examination of the value propositions for clinical user interface terminologies and mappings from the terminology value sets to classifications.
Contact Information and LinksFor more information on the PHC EMR CS or to learn more about PHC in Canada, please contact CIHI’s Primary Health Care Information program via email ([email protected]) or visit the website at www.cihi.ca/phc. This online resource provides easy access to important pan-Canadian PHC information, including the Primary Health Care Indicators Chartbook and recent analyses (for example, Diabetes Care Gaps and Disparities in Canada and Experiences With Primary Health Care in Canada).
37
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Appendix A: Draft Conceptual Model A draft conceptual model was developed to provide an overview of primary health care business entities (for example, Clients, Health Service Events) and the relationships between these entities. A conceptual model is independent of technology (databases, files, etc.) and usage context.5 It was developed by examining the business processes illustrated in the Business Context section of this document and after receiving input from a variety of subject matter experts.
The draft conceptual model was structured with the Client at the centre to reflect the needs of patient-centric health care.
How to Read the Model
Boxes represent business entities, and lines connecting the boxes represent the relationships between the business entities. Solid lines denote mandatory relationships whereas dashed lines denote optional relationships. The symbols described in the legend below represent the number of times a business entity can participate in a relationship with another business entity.6
Figure 11: Draft Conceptual Model
Client
Organization
Health Service Event
MedicationPrescribed
ReferralRequest
DI RequestLab RequestInterventionObservationEncounter Immunization
MeasuredObservation
MedicationDispensedReferral ResultDI ResultLab Result
CodedObservation
ProviderService Delivery Location
One or Many to One or Many(e.g. an Organization may have one or more Providers and the Providers may belong to one or more Organizations)
Represents a supertype/subtype relationship. A subtype is subordinate to a supertypeand inherits attributes and relationships of the supertype.
One to Zero, One, or Many (e.g. one Organization may have zero, one or many Service Delivery Locations)
38
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
The conceptual model contains the following business entities:
Client: A person that has received, is receiving or is eligible to receive health care–related services or goods. A Client can have many Providers and can participate in zero, one or multiple Health Service Events. A Client is dependent on a Provider to receive a Health Service Event. A Client also has a relationship with an Organization because Clients can be eligible to receive health services even though they may not have actually received any.
Health Service Event: The act that is being done, has been done, can be done or is intended/requested to be done for a Client. This entity is effectively a “supertype” of the following business entities: Encounter, Observation, Intervention, Lab Request and Result, Diagnostic Imaging Request and Result, Referral Request and Result, Prescribed and Dispensed Medications, and Immunizations. A Health Service Event (and its subtypes) can have none, one or multiple relationships with other Health Service Events.
Encounter:• An interaction between a Client and one or more Providers for the purpose of providing one or more health care–related services or goods.
Observation:• Information derived from performance of a health-related activity. This business entity is effectively a supertype of the following business entities: Coded Observation and Measured Observation.
Coded Observation: – Information derived from the performance of a health-related activity that is represented by predefined symbols associated with a specific value or meaning. A codified recording of a Client’s allergy to shellfish is an example of a Coded Observation.
Measured Observation: – Information derived from the performance of a health-related activity that is represented by a numeric value. Recordings of a Client’s height, weight and blood pressure are examples of Measured Observations (they can be expressed as numerical values).
Intervention:• An activity that is intended to assess and/or change the state of a Client’s health.
Laboratory Orders:• A request for analytical services, typically performed by medical laboratories in areas such as chemistry, serology, haematology, microbiology, histology, anatomic pathology, cytology and virology.
Laboratory Results:• The results of analytical services typically performed by medical laboratories in areas such as chemistry, serology, haematology, microbiology, histology, anatomic pathology, cytology and virology.
Diagnostic Imaging Orders:• Requests for diagnostic imaging services to be performed on a Client.
Diagnostic Imaging Results:• The results of diagnostic imaging services performed on a Client.
39
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Referral Request:• A request from one Provider to another to deliver one or more health services for a Client. The scope of referrals includes requests for clinical care or evaluation, as well as requests for community services such as home care.
Referral Result:• A description of the health services performed for the Client in response to a referral request; can include additional information such as subjective and objective notes about the Client and the recommended treatment plan.
Prescribed Medication:• The medication ordered by a Provider for a Client.
Dispensed Medication:• The medication dispensed by a Provider to a Client.
Immunization:• The administration of vaccines to a Client for the purpose of preventing the spread of infectious disease.
Organization: A formalized group of people with a common purpose or function. An Organization can have none, one or multiple Providers, Clients and Service Delivery Locations.
Provider: A person who has delivered, is delivering or has the potential to deliver health care–related services or goods. A Provider can have many Clients and can participate in many Health Service Events. A Provider can belong to many Organizations.
Service Delivery Location: A Place, administered by an Organization, that assembles the resources required for the provision of health care–related services or goods. A Service Delivery Location can be the site of none, one or multiple Health Service Events.
Each business entity described above has specific attributes. For example, a Client has attributes such as a date of birth and gender. Some attributes have a finite set of values (for example, gender can only be male, female or unknown). The complete set of all values for an attribute is often called the “domain values.”7 The instantiation of a business entity with an attribute and its domain values results in a data element such as Client Gender. The list of data elements in Appendix B: Data Element Matrix reflects the instantiation of business entities in the conceptual model with their attributes and domain values. It should be noted that Appendix B: Data Element Matrix does not describe every possible attribute and domain value required to fully describe each of the business entities; only attributes that support both primary and health system uses of PHC EMR data were examined. Attributes are not normally displayed on a conceptual model, therefore data elements presented in Appendix B: Data Element Matrix are not displayed as attributes in the conceptual model.
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
41
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Ap
pen
dix
B: D
ata
Ele
men
t Mat
rixTa
ble
2 p
rovi
des
a d
etai
led
vie
w o
f the
106
dat
a el
emen
ts th
at c
omp
rise
the
core
con
tent
of t
he P
HC
EM
R C
S. T
he ta
ble
is
div
ided
into
thre
e se
ctio
ns:
Info
rmat
ive
Co
nte
nt:
XR
ef—
1.
This
sec
tion
cont
ains
a U
niq
ue Id
entif
ier
(for
exa
mp
le, A
1) a
nd th
e C
omm
on D
ata
Ele
men
t Nam
e fo
r ea
ch o
f the
dat
a el
emen
ts.
No
rmat
ive
Co
nte
nt:
2.
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd
Ext
ract
ed f
or
Hea
lth
Sys
tem
Use
—Th
is s
ectio
n co
ntai
ns th
e co
re c
onte
nt o
f the
PH
C E
MR
CS
—th
e D
ata
Ele
men
t Sta
ndar
d N
ame,
Def
initi
on, E
xam
ple
of P
rimar
y U
se, P
HC
Ind
icat
or
Map
pin
g, iii a
nd T
erm
inol
ogy
or D
ata
Typ
e N
ame
and
Exa
mp
le V
alue
s. N
ote
that
con
tent
in th
e ce
lls u
nder
the
colu
mn
Term
inol
ogy
or D
ata
Typ
e N
ame
and
Exa
mp
le V
alue
s us
ually
sta
rts
with
the
nam
e of
the
root
cod
e sy
stem
(fo
r ex
amp
le,
SN
OM
ED
CT®
, HL7
v3,
pC
LOC
D),
follo
wed
by
the
nam
e of
the
corr
esp
ond
ing
con
cep
t dom
ain
in th
e S
tand
ard
s C
olla
bor
ativ
e M
aste
r Te
rmin
olog
y W
orks
heet
, and
follo
wed
by
an e
xam
ple
val
ue. T
he p
atte
rn is
rep
eate
d if
the
dat
a el
emen
t val
ue d
omai
n co
vers
mor
e th
an o
ne c
once
pt d
omai
n. A
ltern
ativ
ely,
the
appr
opria
te H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Typ
e S
pec
ifica
tion
refe
renc
e is
pro
vid
ed, f
ollo
wed
by
an e
xam
ple
val
ue.
Info
rmat
ive
Co
nte
nt:
Alig
nm
ent
to t
he
Pan
-Can
adia
n E
HR
—3.
Th
is s
ectio
n co
ntai
ns r
efer
ence
s to
the
pan
-Can
adia
n E
HR
mes
sag
es a
nd te
rmin
olog
y th
at th
e d
ata
elem
ent s
upp
orts
, as
wel
l as
a re
fere
nce
to th
e P
hysi
cian
Off
ice
Sys
tem
R
equi
rem
ents
(P
OS
R) iv
that
the
dat
a el
emen
t sup
por
ts.
Man
y of
the
stan
dar
ds
refe
renc
ed in
the
Dat
a E
lem
ent M
atrix
are
acc
essi
ble
from
the
Info
way
Sta
ndar
ds
Col
lab
orat
ive.
For
mor
e in
form
atio
n on
how
to a
cces
s th
ese
stan
dar
ds,
con
tact
the
Sta
ndar
ds
Col
lab
orat
ive
Info
des
k vi
a em
ail a
t sta
ndar
ds@
info
way
-in
foro
ute.
ca o
r vi
sit t
he w
ebsi
te a
t htt
p://w
ww
.info
way
-info
rout
e.ca
/lang
-en/
stan
dar
ds-
colla
bor
ativ
e.
iii.
See
Ap
pen
dix
C fo
r th
e na
mes
and
def
initi
ons
of t
he in
dic
ato
rs s
upp
ort
ed b
y th
e P
HC
EM
R C
S.
iv.
See
Ap
pen
dix
D fo
r m
ore
info
rmat
ion
abo
ut P
OS
R, i
nclu
din
g a
sta
tem
ent r
egar
din
g p
ote
ntia
l lim
itatio
ns o
f use
.
42
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
Co
ntex
t: C
lient
Def
initi
on:
A p
erso
n w
ho
has
rec
eive
d, i
s re
ceiv
ing
or
is e
ligib
le t
o r
ecei
ve h
ealth
car
e–re
late
d s
ervi
ces
or
go
od
s.
A1
Pat
ient
Id
entif
ier
Clie
nt
Iden
tifie
rR
epre
sent
s a
uniq
ue
iden
tifie
r as
sign
ed to
th
e C
lient
.
Use
d in
the
prov
isio
n an
d ad
min
istr
atio
n of
ca
re. C
an b
e us
ed to
as
soci
ate
adm
inis
trat
ive
(e.g
. dem
ogra
phic
s)
and
heal
th in
form
atio
n (e
.g. l
ab r
esul
ts)
with
th
e C
lient
.
13, 3
6,
39–4
4,
48–6
0,
62 a
nd 6
3
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 4—
Iden
tifie
rs +
C
odes
Exa
mpl
e:66
1116
8070
NN
Foun
d in
:R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l Mar
ch 1
6, 2
009.
Rec
ord
38, P
atie
nt
look
-ups
can
be
done
by
last
nam
e, fi
rst
nam
e, m
iddl
e na
me,
P
HN
, cha
rt n
umbe
r, da
te o
f birt
h, te
leph
one
num
ber,
alte
rnat
e ID
, al
ias,
pho
netic
sea
rch,
pa
rtia
l sea
rche
s an
d m
ultip
le c
ombi
natio
ns.
A2
Pat
ient
Id
entif
ier
Type
Clie
nt
Iden
tifie
r Ty
pe C
ode
Rep
rese
nts
the
type
of
Clie
nt Id
entif
ier
(e.g
. Jur
isdi
ctio
nal
Hea
lthca
re Id
entif
ier,
Pas
spor
t).
Use
d in
the
prov
isio
n an
d ad
min
istr
atio
n of
ca
re. H
elps
diff
eren
tiate
th
e ty
pe o
f ide
ntifi
er
used
to id
entif
y th
e C
lient
. In
conj
unct
ion
with
the
Clie
nt Id
entif
ier,
can
be u
sed
to
asso
ciat
e ad
min
istr
ativ
e (e
.g. d
emog
raph
ics)
an
d he
alth
info
rmat
ion
(e.g
. lab
res
ults
) w
ith
the
Clie
nt.
13, 3
6,
39–4
4,
48–6
0,
62 a
nd 6
3
MTW
—In
fow
ay
Sta
ndar
ds C
olla
bora
tive
(SC
TEM
P)
Con
cept
Dom
ain:
Oth
erId
entif
iers
Rol
eTyp
e
Exa
mpl
e:JH
N (J
uris
dict
iona
l H
ealth
Num
ber)
Foun
d in
:R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l Mar
ch 1
6, 2
009.
Rec
ord
38, P
atie
nt
look
-ups
can
be
done
by
last
nam
e, fi
rst
nam
e, m
iddl
e na
me,
P
HN
, cha
rt n
umbe
r, da
te o
f birt
h, te
leph
one
num
ber,
alte
rnat
e ID
, al
ias,
pho
netic
sea
rch,
pa
rtia
l sea
rche
s an
d m
ultip
le c
ombi
natio
ns.
43
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceA
3P
atie
nt
Iden
tifie
r A
ssig
ning
A
utho
rity
Clie
nt
Iden
tifie
r A
ssig
ning
A
utho
rity
Cod
e
Rep
rese
nts
the
lega
l en
tity
resp
onsi
ble
for
assi
gnin
g th
e C
lient
Id
entif
ier.
Use
d in
the
prov
isio
n an
d ad
min
istr
atio
n of
ca
re. H
elps
iden
tify
the
orga
niza
tion
that
is
sued
the
iden
tifie
r w
hen
a C
lient
can
hav
e m
ultip
le id
entif
iers
. In
conj
unct
ion
with
the
Clie
nt Id
entif
ier,
can
be u
sed
to a
ssoc
iate
ad
min
istr
ativ
e (e
.g.
dem
ogra
phic
) an
d he
alth
info
rmat
ion
(e.g
. la
bora
tory
res
ults
) w
ith
the
Clie
nt.
13, 3
6,
39–4
4,
48–6
0, 6
2 an
d 63
MTW
—In
fow
ay
Sta
ndar
ds C
olla
bora
tive
(SC
TEM
P)
Con
cept
Dom
ain:
Juris
dict
ionT
ypeC
ode
Exa
mpl
e:A
B (
Alb
erta
)
Foun
d in
:P
RPA
_MT1
0110
1CA
—Q
uery
by
Clie
nt ID
M
arch
16,
200
9.
Rec
ord
38, P
atie
nt
look
-ups
can
be
done
by
last
nam
e, fi
rst
nam
e, m
iddl
e na
me,
P
HN
, cha
rt n
umbe
r, da
te o
f birt
h, te
leph
one
num
ber,
alte
rnat
e ID
, al
ias,
pho
netic
sea
rch,
pa
rtia
l sea
rche
s an
d m
ultip
le c
ombi
natio
ns.
A4
Pat
ient
D
ate
of
Birt
h
Clie
nt
Birt
h D
ate
Rep
rese
nts
the
Clie
nt’s
da
te o
f birt
h.U
sed
in b
oth
the
prov
isio
n an
d ad
min
istr
atio
n of
car
e.
Birt
h D
ate
is u
sed
to
valid
ate
the
iden
tity
of
the
Clie
nt.
It is
als
o us
ed to
ens
ure
that
the
right
dru
g an
d la
b re
fere
nce
rang
es
are
used
for
the
Clie
nt.
13, 3
6,
39–4
4,
48–6
0 an
d 63
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1010
01
Foun
d in
:R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l Mar
ch 1
6, 2
009.
Rec
ord
38, P
atie
nt
look
-ups
can
be
done
by
last
nam
e, fi
rst
nam
e, m
iddl
e na
me,
P
HN
, cha
rt n
umbe
r, da
te o
f birt
h, te
leph
one
num
ber,
alte
rnat
e ID
, al
ias,
pho
netic
sea
rch,
pa
rtia
l sea
rche
s an
d m
ultip
le c
ombi
natio
ns.
A5
Pat
ient
G
ende
rC
lient
A
dmin
istr
ativ
e G
ende
r C
ode
Rep
rese
nts
a re
port
ed
gend
er c
ateg
ory
of
the
Clie
nt a
t a g
iven
po
int i
n tim
e us
ed
for
adm
inis
trat
ive
purp
oses
.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
C
an b
e us
ed to
filte
r dr
ugs,
lab
test
and
re
fere
nce
rang
es.
49–5
3H
L7 v
3
Con
cept
Dom
ain:
A
dmin
istr
ativ
eGen
der
Exa
mpl
e:M
(M
ale)
Foun
d in
:R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l Mar
ch 1
6, 2
009.
Rec
ord
57, D
ispl
ay
patie
nt’s
gen
der
at
poin
t of s
ched
ulin
g.
44
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceA
6P
atie
nt
Hig
hest
E
duca
tion
Clie
nt H
ighe
st
Edu
catio
n C
ode
Rep
rese
nts
the
high
est
leve
l of e
duca
tion
com
plet
ed b
y th
e C
lient
.
Use
d in
the
adm
inis
trat
ion
of c
are.
O
n av
erag
e, th
e m
ore
educ
atio
n a
pers
on
has,
the
mor
e lik
ely
they
are
to u
nder
stan
d he
alth
cho
ices
.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
SN
OM
ED
CT®
cod
es
unde
r th
e fin
ding
of
educ
atio
n re
ceiv
ed in
th
e pa
st (
findi
ng)
Exa
mpl
e:22
4300
008
(rec
eive
d un
iver
sity
edu
catio
n)
Not
foun
d in
any
of
the
pan-
Can
adia
n E
HR
Mes
sagi
ng a
nd
Term
inol
ogy
Sta
ndar
ds.
Not
cur
rent
ly r
equi
red
to s
uppo
rt a
ny o
f the
P
OS
R r
ecor
ds.
A7
Pat
ient
H
ousi
ng
Sta
tus
Clie
nt
Hou
sing
S
tatu
s C
ode
Rep
rese
nts
the
hous
ing
stat
us o
f the
Clie
nt.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Hou
sing
sta
tus
is im
port
ant s
ince
it
can
also
dire
ctly
rel
ate
to h
ealth
out
com
es.
Clie
nts
who
are
ho
mel
ess
or w
ithou
t a
perm
anen
t add
ress
(r
ente
rs) a
re m
uch
mor
e lik
ely
to b
e de
pres
sed
and
unab
le to
affo
rd
a he
alth
y lif
esty
le.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
SN
OM
ED
CT®
cod
es
unde
r th
e fin
ding
of
hous
ing
owne
rshi
p an
d te
nure
(fin
ding
)
Exa
mpl
e:32
9110
00 (
hom
eles
s)
Not
foun
d in
any
of
the
pan-
Can
adia
n E
HR
Mes
sagi
ng a
nd
Term
inol
ogy
Sta
ndar
ds.
Not
cur
rent
ly r
equi
red
to s
uppo
rt a
ny o
f the
P
OS
R r
ecor
ds.
A8
Pat
ient
P
rimar
y La
ngua
ge
Clie
nt P
rimar
y La
ngua
ge
Cod
e
Rep
rese
nts
the
pref
erre
d sp
oken
la
ngua
ge o
f the
C
lient
.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
La
ngua
ge is
ass
ocia
ted
with
hea
lth c
are
acce
ss
and
com
plia
nce
issu
es.
If a
Clie
nt c
an fi
nd a
P
rovi
der
that
they
can
co
mm
unic
ate
with
, it
can
redu
ce s
igni
fican
t ba
rrie
rs th
at m
ay
prev
ent a
nd/o
r im
prov
e th
eir
over
all h
ealth
.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
ISO
639-
3
Con
cept
Dom
ain:
Hum
anLa
ngua
ge
Exa
mpl
e:en
g (E
nglis
h)
Foun
d in
:P
RPA
_MT1
0100
1CA
—A
dd C
lient
M
arch
16,
200
9.
Rec
ord
202,
Abi
lity
to
sele
ctiv
ely
pre-
popu
late
re
ferr
al r
eque
st le
tters
w
ith a
min
imum
set
of
exi
stin
g pa
tient
da
ta w
ithin
the
patie
nt
reco
rd, i
nclu
ding
de
mog
raph
ics,
m
edic
atio
ns, a
llerg
ies,
pr
oble
m li
st, m
edic
al
and
surg
ical
his
tory
, an
d vi
sit n
otes
.
45
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceA
9P
atie
nt
Sta
tus
Clie
nt
Sta
tus
Cod
eR
epre
sent
s w
heth
er
or n
ot th
e P
HC
P
rovi
der
cons
ider
s th
e C
lient
to b
e ac
tivel
y se
ekin
g P
HC
ser
vice
s th
roug
h th
em.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Ens
ures
that
in
appr
opria
te r
emin
ders
ar
e no
t sen
t to
Clie
nts
with
a s
tatu
s of
inac
tive
for
the
Pro
vide
r.
13, 3
6,
39–4
4,
48–6
0, 6
2 an
d 63
TBD
Exa
mpl
es:
Act
ive
Inac
tive
Not
foun
d in
any
of
the
pan-
Can
adia
n E
HR
Mes
sagi
ng a
nd
Term
inol
ogy
Sta
ndar
ds.
Rec
ord
27, P
rovi
des
abili
ty to
doc
umen
t pa
tient
–pro
vide
r re
latio
nshi
ps.
A10
Pat
ient
D
ate
of
Dea
th
Clie
nt
Dec
ease
d D
ate
Rep
rese
nts
the
Clie
nt’s
da
te o
f dea
th.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Rec
ords
can
be
arch
ived
bas
ed o
n th
is
date
plu
s a
num
ber
of
days
as
dete
rmin
ed
by th
e C
linic
ian/
Org
aniz
atio
n. E
nsur
es
that
Clie
nt d
oes
not
rece
ive
appo
intm
ent
rem
inde
rs in
the
futu
re.
13, 3
6,
39–4
4,
48–6
0, 6
2 an
d 63
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
:P
RPA
_MT1
0100
1CA
—A
dd C
lient
M
arch
16,
200
9.
Rec
ord
52,
App
oint
men
ts
upda
ted
base
d on
sta
tus
of th
e pa
tient
from
act
ive
to d
ecea
sed.
A11
Pat
ient
R
oste
red
Sta
rt D
ate
Clie
nt
Ros
tere
d S
tart
Dat
e
Rep
rese
nts
the
date
the
Clie
nt w
as in
clud
ed o
n th
e ro
ster
.
Use
d in
the
adm
inis
trat
ion
of c
are.
Use
d by
P
rovi
ders
to s
uppo
rt
pay-
for-
perfo
rman
ce
prog
ram
s, p
hysi
cian
’s
billi
ng q
ualit
y ch
eck
and
accu
racy
.
36, 3
9–41
, 49
, 52
and
54–5
9
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
n S
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
foun
d in
any
of
the
pan-
Can
adia
n E
HR
Mes
sagi
ng a
nd
Term
inol
ogy
Sta
ndar
ds.
Rec
ord
50, A
bilit
y to
rec
ord
that
a
patie
nt is
ros
tere
d.
46
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceA
12P
atie
nt
Ros
tere
d E
nd D
ate
Clie
nt
Ros
tere
d E
nd
Dat
e
Rep
rese
nts
the
date
th
e C
lient
was
rem
oved
fro
m th
e ro
ster
.
Use
d in
the
adm
inis
trat
ion
of c
are.
Use
d by
P
rovi
ders
to s
uppo
rt
pay-
for-
perfo
rman
ce
prog
ram
s, p
hysi
cian
’s
billi
ng q
ualit
y ch
eck
and
accu
racy
.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
foun
d in
any
of
the
pan-
Can
adia
n E
HR
Mes
sagi
ng a
nd
Term
inol
ogy
Sta
ndar
ds.
Rec
ord
50, A
bilit
y to
rec
ord
that
a
patie
nt is
ros
tere
d.
A13
Pat
ient
E
thni
city
Clie
nt
Adm
inis
trat
ive
Eth
nici
ty
Cod
e
Rep
rese
nts
the
Clie
nt’s
sel
f-rep
orte
d et
hnic
gro
up to
whi
ch
he o
r sh
e be
long
s,
for
adm
inis
trat
ive
purp
oses
. The
refo
re,
the
ethn
ic o
rigin
re
fers
to a
per
son’
s “r
oots
” an
d sh
ould
no
t be
conf
used
with
hi
s or
her
citi
zens
hip
or n
atio
nalit
y.
Use
d in
the
adm
inis
trat
ion
of c
are
to h
elp
unde
rsta
nd th
e de
mog
raph
ic p
rofil
e of
a P
rovi
der’s
clie
nt
base
. Not
e: k
now
ing
a C
lient
’s e
thni
city
ca
n al
so a
ssis
t in
the
prov
isio
n of
car
e.
How
ever
, the
pro
visi
on
of c
are
need
s sh
ould
be
met
thro
ugh
the
Fam
ily H
isto
ry F
amili
al
Eth
nici
ty C
ode
in th
e Fa
mily
His
tory
sec
tion,
w
hich
allo
ws
for
the
expr
essi
on o
f add
ition
al
deta
ils s
uch
as th
e et
hnic
ity o
f mul
tiple
fa
mily
mem
bers
and
th
eir
fam
ilial
rel
atio
nshi
p w
ith th
e C
lient
.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Sta
tistic
s C
anad
a 20
06 C
ensu
s—et
hnic
ca
tego
ries
and
subc
ateg
orie
s
Exa
mpl
e:In
uit
An
equi
vale
nt c
once
pt
was
not
foun
d in
th
e pa
n-C
anad
ian
EH
R M
essa
ging
and
Te
rmin
olog
y S
tand
ards
.
This
dat
a el
emen
t do
es n
ot c
urre
ntly
su
ppor
t any
of t
he
PO
SR
rec
ords
.
47
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceA
14P
atie
nt
Pos
tal/Z
ip
Cod
e
Clie
nt
Res
iden
ce
Pos
tal C
ode
Rep
rese
nts
the
post
al
code
of t
he C
lient
’s
perm
anen
t res
iden
ce.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
P
art o
f the
Clie
nt’s
ad
dres
s, w
hich
can
be
use
d to
hel
p fin
d se
rvic
e de
liver
y lo
catio
ns th
at a
re c
lose
to
the
Clie
nt’s
hom
e.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 7—
Dem
ogra
phic
s x_
FullA
ddre
ssP
artT
ype
Exa
mpl
e C
anad
ian
Pos
tal C
ode:
K0K
3R
0
Exa
mpl
e A
mer
ican
Zi
p C
ode:
2000
3
Foun
d in
:R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l Mar
ch 1
6, 2
009.
Rec
ord
57, P
art o
f pa
tient
’s a
ddre
ss.
Co
ntex
t: P
rovi
der
Def
initi
on:
An
ind
ivid
ual w
ho
has
del
iver
ed, i
s d
eliv
erin
g o
r h
as t
he
po
tent
ial t
o d
eliv
er h
ealth
car
e–re
late
d s
ervi
ces
or
go
od
s.
B1
Clin
icia
n La
st N
ame
Pro
vide
r Fa
mily
Nam
e Te
xt
Rep
rese
nts
the
Pro
vide
r’s le
gal
fam
ily n
ame.
Use
d in
the
prov
isio
n of
ca
re. T
he fa
mily
nam
e of
the
Pro
vide
r th
at
asse
ssed
the
Clie
nt
durin
g an
enc
ount
er.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 7—
Dem
ogra
phic
sx_
Bas
icP
erso
nNam
eP
artT
ype
Exa
mpl
e:D
oe
Foun
d in
:S
C-2
003-
EN
—R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l—20
0903
16.
Rec
ord
102,
Abi
lity
to
man
age
a ph
ysic
ian
on-
call
sche
dule
, inc
ludi
ng
docu
men
ting
nam
e an
d co
ntac
t inf
orm
atio
n of
w
ho is
pro
vidi
ng a
fter-
ho
urs
call
for
prac
tice.
B2
Clin
icia
n Fi
rst n
ame
Pro
vide
r G
iven
Nam
e Te
xt
Rep
rese
nts
the
Pro
vide
r’s le
gal
give
n na
me.
Use
d in
the
prov
isio
n of
car
e. N
ame
of th
e P
rovi
der
used
on
refe
rral
req
uest
s.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 7—
Dem
ogra
phic
sx_
Bas
icP
erso
nNam
eP
artT
ype
Exa
mpl
e:Jo
hn
Foun
d in
:S
C-2
003-
EN
—R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l—20
0903
16
as H
ealth
care
.
Rec
ord
102,
Abi
lity
to
man
age
a ph
ysic
ian
on-
call
sche
dule
, inc
ludi
ng
docu
men
ting
nam
e an
d co
ntac
t inf
orm
atio
n of
w
ho is
pro
vidi
ng a
fter-
ho
urs
call
for
prac
tice.
48
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceB
3C
linic
ian
Mid
dle
Nam
e
Pro
vide
r M
iddl
e N
ame
Text
Rep
rese
nts
the
Pro
vide
r’s m
iddl
e na
me.
Use
d in
the
prov
isio
n of
car
e. N
ame
of th
e P
rovi
der
used
on
refe
rral
req
uest
s.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 7—
Dem
ogra
phic
sx_
Bas
icP
erso
nNam
eP
artT
ype
Exa
mpl
e:E
dwar
d
Foun
d in
:S
C-2
003-
EN
—R
EP
C_
MT5
0000
4CA
—C
are
Com
posi
tion
Det
ail—
2009
0316
.
Rec
ord
102,
Abi
lity
to
man
age
a ph
ysic
ian
on-
call
sche
dule
, inc
ludi
ng
docu
men
ting
nam
e an
d co
ntac
t inf
orm
atio
n of
w
ho is
pro
vidi
ng a
fter
- ho
urs
call
for
prac
tice.
B4
Clin
icia
n Id
entif
ier
Pro
vide
r Id
entif
ier
Rep
rese
nts
the
uniq
ue
iden
tifie
r as
sign
ed to
th
e P
rovi
der.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
C
an b
e us
ed to
link
C
lient
rec
ords
and
bi
lling
info
rmat
ion
to a
sp
ecifi
c P
rovi
der.
Can
be
use
d to
sup
port
au
thor
izat
ion
acce
ss to
se
nsiti
ve r
ecor
ds.
13, 3
6,
39–4
4,
48–6
0, 6
2 an
d 63
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 4—
Iden
tifie
rs +
C
odes
Exa
mpl
e:82
3567
43
Foun
d in
:S
C-2
003-
EN
—P
RP
M_
MT3
0101
0CA
—A
dd
Pro
vide
r—20
0903
16.
Rec
ord
186,
Gen
erat
e pa
per
pres
crip
tion
with
pr
ovid
er d
etai
ls.
B5
Clin
icia
n Id
entif
ier
Type
Pro
vide
r Id
entif
ier
Type
C
ode
Rep
rese
nts
the
type
of
Pro
vide
r Id
entif
ier.
Use
d in
bot
h th
e ad
min
istr
atio
n an
d pr
ovis
ion
of c
are.
In
con
junc
tion
with
th
e P
rovi
der
Iden
tifie
r, it
can
be u
sed
to li
nk
Clie
nt r
ecor
ds a
nd
billi
ng in
form
atio
n to
a s
peci
fic P
rovi
der.
Can
be
used
to s
uppo
rt
auth
oriz
atio
n ac
cess
to
sen
sitiv
e re
cord
s.
58TB
D—
a co
de s
et n
eeds
to
be
iden
tifie
d
Exa
mpl
e:B
illin
g N
umbe
r
Not
foun
d in
any
of
the
pan-
Can
adia
n E
HR
Mes
sagi
ng a
nd
Term
inol
ogy
Sta
ndar
ds.
Rec
ord
356,
Acc
ess
cont
rol m
anag
ed b
y ro
le ty
pes.
49
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceB
6C
linic
ian
Iden
tifie
r A
ssig
ning
A
utho
rity
Pro
vide
r Id
entif
ier
Ass
igni
ng
Aut
horit
y C
ode
Rep
rese
nts
the
lega
l en
tity
resp
onsi
ble
for
assi
gnin
g th
e un
ique
id
entif
ier
to th
e P
rovi
der.
Use
d in
bot
h th
e ad
min
istr
atio
n an
d pr
ovis
ion
of c
are.
In
con
junc
tion
with
th
e P
rovi
der
Iden
tifie
r, it
can
be u
sed
to li
nk
Clie
nt r
ecor
ds a
nd
billi
ng in
form
atio
n to
a s
peci
fic P
rovi
der.
Can
be
used
to s
uppo
rt
auth
oriz
atio
n ac
cess
to
sen
sitiv
e re
cord
s.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
MTW
—In
fow
ay
Sta
ndar
ds C
olla
bora
tive
(SC
TEM
P)
Con
cept
Dom
ain:
Juris
dict
ionT
ypeC
ode
Exa
mpl
e:A
B (
Alb
erta
)
Foun
d in
: S
C-2
003-
EN
—R
EP
C_
MT5
0000
4CA
—C
are
Com
posi
tion
Det
ail—
2009
0316
.
Rec
ord
356,
Acc
ess
cont
rol m
anag
ed b
y ro
le ty
pes.
B7
Clin
icia
n R
ole
Pro
vide
r R
ole
Type
Cod
eR
epre
sent
s th
e ro
le
of th
e P
rovi
der
in
rela
tion
to h
is/h
er
part
icip
atio
n in
a
spec
ific
heal
th c
are
even
t.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
U
sed
to d
istin
guis
h ro
les
with
in a
hea
lth
care
set
ting,
can
be
used
to r
estr
ict a
cces
s to
Clie
nt d
ata
by r
ole
type
, and
can
be
used
for
iden
tifyi
ng
spec
ialis
ts.
13, 3
6,
39–4
4,
48–6
0, 6
2 an
d 63
MTW
—In
fow
ay
Sta
ndar
ds C
olla
bora
tive
(SC
PTY
PE
)
Con
cept
Dom
ain:
H
ealth
Car
ePro
vide
rR
oleT
ype
Exa
mpl
e:R
N (
Reg
iste
red
Nur
se)
Foun
d in
:S
C-2
003-
EN
—R
EP
C_
MT5
0000
4CA
—C
are
Com
posi
tion
Det
ail—
2009
0316
.
Rec
ord
356,
Acc
ess
cont
rol m
anag
ed b
y ro
le ty
pes.
B8
Clin
icia
n E
xper
tise
Pro
vide
r E
xper
tise
Cod
e
Rep
rese
nts
the
expe
rtis
e or
qua
lific
atio
ns
of th
e P
rovi
der.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
U
sed
to d
istin
guis
h ex
pert
ise
with
in a
hea
lth
care
set
ting.
Use
d to
id
entif
y th
e pa
rtic
ular
ex
pert
ise
requ
ired
for
a re
ferr
al.
13, 3
6,
39–4
4,
48–6
0, 6
2 an
d 63
MTW
—In
fow
ay
Sta
ndar
ds C
olla
bora
tive
(SC
PQ
UA
L)
Con
cept
Dom
ain:
Q
ualif
iedR
oleT
ype
Exa
mpl
e:30
5 (C
ardi
ovas
cula
r an
d Th
orac
ic S
urge
ry)
Foun
d in
: PR
PM
_M
T301
010C
A—
Add
P
rovi
der—
2009
0316
.
Not
cur
rent
ly r
equi
red
to s
uppo
rt a
ny o
f the
P
OS
R r
ecor
ds.
50
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceC
ont
ext:
Ser
vice
Del
iver
y Lo
catio
nD
efin
itio
n: A
loca
tion
wh
ere
the
pro
visi
on
of
hea
lth c
are
rela
ted
ser
vice
s o
r g
oo
ds
may
occ
ur.
C1
Ser
vice
D
eliv
ery
Iden
tifie
r
Ser
vice
D
eliv
ery
Loca
tion
Iden
tifie
r C
ode
Rep
rese
nts
the
uniq
ue
iden
tifie
r of
the
PH
C
prac
tice
(Ser
vice
D
eliv
ery
Loca
tion)
w
here
the
Clie
nt
rece
ived
car
e.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
N
ame
of th
e S
ervi
ce
Del
iver
y Lo
catio
n is
re
fere
nced
on
lette
rs
sent
to C
lient
s.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 4—
Iden
tifie
rs +
C
odes
Exa
mpl
e:A
46B
7356
743
Foun
d in
:P
RLO
_MT2
0201
5CA
—U
pdat
e S
ervi
ce D
eliv
ery.
Rec
ord
55,
Sch
edul
ing
feat
ures
al
low
use
r-de
finab
le
appo
intm
ent t
ypes
th
at c
an b
e de
fined
by
crit
eria
: ser
vice
, pr
ogra
m, p
rovi
der,
equi
pmen
t, lo
catio
n.
C2
Ser
vice
D
eliv
ery
Nam
e
Ser
vice
D
eliv
ery
Loca
tion
Nam
e Te
xt
Rep
rese
nts
the
nam
e of
the
PH
C p
ract
ice
(Ser
vice
Del
iver
y Lo
catio
n) w
here
the
Clie
nt r
ecei
ved
care
.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
N
ame
of th
e S
ervi
ce
Del
iver
y Lo
catio
n is
re
fere
nced
in le
tters
se
nt to
Clie
nts.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
N/A
Exa
mpl
e:G
lend
ale
Fam
ily H
ealth
C
linic
Foun
d in
: S
C-2
003-
EN
—P
RLO
_M
T000
002C
A—
Ser
vice
Del
iver
y Lo
catio
n D
etai
l—20
0903
16.
Rec
ord
55,
Sch
edul
ing
feat
ures
al
low
use
r-de
finab
le
appo
intm
ent t
ypes
th
at c
an b
e de
fined
by
crit
eria
: ser
vice
, pr
ogra
m, p
rovi
der,
equi
pmen
t, lo
catio
n.
C3
Ser
vice
D
eliv
ery
Type
of
Ser
vice
s
Ser
vice
D
eliv
ery
Loca
tion
Type
C
ode
Rep
rese
nts
the
type
of
PH
C (
Ser
vice
Del
iver
y Lo
catio
n) lo
catio
n w
here
the
Clie
nt
rece
ived
car
e.
Use
d in
the
adm
inis
trat
ion
of c
are.
In
dica
tes
the
type
of
faci
lity
whe
re c
are
is
prov
ided
to a
Clie
nt.
13, 3
6,
39–4
4,
48–6
0, 6
2 an
d 63
HL7
v3
Con
cept
Dom
ain:
S
ervi
ceD
eliv
eryL
ocat
ion
Rol
eTyp
e
Exa
mpl
e:P
C (
Prim
ary
care
clin
ic)
Foun
d in
:S
C-2
003-
EN
—P
RLO
_MT0
0000
2CA
—S
ervi
ce D
eliv
ery
Loca
tion
Det
ail—
2009
0316
.
Rec
ord
55,
Sch
edul
ing
feat
ures
al
low
use
r-de
finab
le
appo
intm
ent t
ypes
th
at c
an b
e de
fined
by
crit
eria
: ser
vice
, pr
ogra
m, p
rovi
der,
equi
pmen
t, lo
catio
n.
51
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceC
4S
ervi
ce
Del
iver
y P
osta
l C
ode
Ser
vice
D
eliv
ery
Loca
tion
Pos
tal C
ode
Rep
rese
nts
the
post
al c
ode
whe
re
the
Clie
nt r
ecei
ved
the
PH
C s
ervi
ce.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
P
art o
f the
Ser
vice
D
eliv
ery
Loca
tion
Add
ress
, whi
ch h
elps
C
lient
s kn
ow w
here
to
go fo
r th
e se
rvic
e.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 7—
Dem
ogra
phic
s x_
FullA
ddre
ssP
artT
ype
Exa
mpl
e C
anad
ian
Pos
tal C
ode:
K0K
3R
0
Foun
d in
:R
EP
C_M
T610
001C
A—
Pro
fess
iona
l Ser
vice
P
roce
dure
Rec
ord
May
8, 2
007.
Rec
ord
55,
Sch
edul
ing
feat
ures
al
low
use
r-de
finab
le
appo
intm
ent t
ypes
th
at c
an b
e de
fined
by
crit
eria
: ser
vice
, pr
ogra
m, p
rovi
der,
equi
pmen
t, lo
catio
n.
Co
ntex
t: E
nco
unte
rD
efin
itio
n: A
per
iod
of
hea
lth c
are
bet
wee
n a
clie
nt(s
) an
d a
pro
vid
er(s
).A
dditi
onal
dat
a el
emen
ts th
at m
ay b
e re
quire
d to
sup
port
the
use
and
extr
actio
n of
Enc
ount
er d
ata
in P
HC
EM
Rs:
Pro
vide
r(s)
(e.
g. th
e P
rovi
der[
s] in
volv
ed in
the
Enc
ount
er):
Pro
vide
r Id
entif
ier
Cod
e, P
rovi
der
Iden
tifie
r A
ssig
ning
Aut
horit
y, P
rovi
der
Rol
e Ty
pe a
nd P
rovi
der
Exp
ertis
e ex
pres
sed
in th
e co
ntex
t of t
he E
ncou
nter
.C
lient
(s)
(e.g
. the
Clie
nt[s
] in
volv
ed in
the
Enc
ount
er):
Clie
nt Id
entif
ier
Cod
e, C
lient
Iden
tifie
r Ty
pe a
nd C
lient
Iden
tifie
r A
ssig
ning
Aut
horit
y ex
pres
sed
in th
e co
ntex
t of t
he E
ncou
nter
.S
ervi
ce D
eliv
ery
Loca
tion
(e.g
. the
pla
ce w
here
an
in-p
erso
n E
ncou
nter
occ
urre
d): S
ervi
ce D
eliv
ery
Loca
tion
Iden
tifie
r C
ode
and
Ser
vice
Del
iver
y Lo
catio
n N
ame
in
the
cont
ext o
f the
Enc
ount
er.
Enc
ount
er Id
entif
ier:
A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e E
ncou
nter
.
D1
App
oint
-m
ent
Cre
atio
n D
ate
Enc
ount
er
Req
uest
Dat
eR
epre
sent
s th
e da
te o
n w
hich
an
appo
intm
ent
was
cre
ated
for
the
Clie
nt b
y th
e P
rovi
der
(or
his/
her
staf
f).
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
H
elps
iden
tify
wai
t tim
es
for
spec
ific
prov
ider
s.
55–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
Sta
ndar
ds—
Dat
a Ty
pe S
peci
ficat
ion
Sec
tion
3—D
ates
+
Tim
ing
Exa
mpl
e:20
1004
30
Not
Fou
nd: N
ot
curr
ently
in th
e se
t of
iEH
R m
essa
ges.
Rec
ord
93, R
etai
ns
a co
mpl
ete
patie
nt
appo
intm
ent h
isto
ry
and
audi
t tra
il.
52
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceD
2R
easo
n fo
r V
isit
Clie
nt
Enc
ount
er
Rea
son
Cod
e
Rep
rese
nts
reas
on
for
the
Enc
ount
er a
s co
nvey
ed b
y th
e C
lient
.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
C
an b
e us
ed to
giv
e th
e P
rovi
der
adva
nce
notic
e of
info
rmat
ion
that
may
ne
ed to
be
addr
esse
d w
ith th
e C
lient
dur
ing
the
enco
unte
r. C
an
assi
st in
sch
edul
ing
the
amou
nt o
f tim
e a
Clie
nt m
ay n
eed
with
th
e P
rovi
der.
63S
NO
ME
D C
T®C
once
pt D
omai
n:
Dia
gnos
isVa
lue
Exa
mpl
e:23
7734
007
(AC
TH-
depe
nden
t Cus
hing
’s
synd
rom
e)
Con
cept
Dom
ain:
Sym
ptom
Valu
e
Exa
mpl
e:43
3640
01 (
Abd
omin
al
disc
omfo
rt)
Con
cept
Dom
ain:
A
ctP
rofe
ssio
nal
Ser
vice
Cod
e
Exa
mpl
e:40
8952
002
(Acu
te p
ain
cont
rol a
sses
smen
t)
Not
e: W
hile
con
cept
do
mai
ns h
ave
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Rec
ord
59, D
ocum
ent
reas
on fo
r vi
sit w
hen
book
ing
appo
intm
ent.
D3
Vis
it D
ate
Enc
ount
er
Dat
eR
epre
sent
s th
e da
te th
e C
lient
had
an
Enc
ount
er
with
the
Pro
vide
r.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Can
rep
ort o
n C
lient
wai
t tim
es fo
r sc
hedu
led
Clie
nts
and
trac
k th
e co
ntin
uum
of
car
e pr
ovid
ed to
C
lient
s.
13, 3
6, 3
9,
40, 4
9,
54–6
0 an
d 63
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
: R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l May
8, 2
007.
Rec
ord
37, C
an fi
lter
on a
dat
e ra
nge
and
prin
t the
cha
rt b
ased
on
dat
e ra
nge.
D4
Vis
it Ty
peE
ncou
nter
M
ode
Cod
eA
des
crip
tion
of th
e ty
pe o
f con
tact
bet
wee
n th
e P
rovi
der
and
the
Clie
nt fo
r a
regi
ster
ed
Enc
ount
er o
r vi
sit.
Use
d in
the
adm
inis
trat
ion
of c
are.
C
an b
e us
ed to
trac
k se
rvic
es p
rovi
ded
that
m
ay r
equi
re s
peci
al
billi
ng p
roce
sses
.Tr
ack
perc
enta
ge o
f C
lient
s tr
eate
d th
roug
h va
rious
mod
es o
f vis
its.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
MTW
—In
fow
ay
Sta
ndar
ds C
olla
bora
tive
(SC
TE
MP
)
Con
cept
Dom
ain:
Act
Car
eEve
ntTy
pe
Exa
mpl
e:W
LKIN
(W
alk-
in C
linic
)
Foun
d in
:C
OC
T_M
T011
001C
A—
Car
e E
vent
iden
tifie
d—M
arch
16,
200
9.
Rec
ord
212,
Allo
ws
trac
king
of t
elep
hone
ca
ll or
con
tact
atte
mpt
s in
the
patie
nt r
ecor
d.
53
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceD
5P
aym
ent
Sou
rce
Enc
ount
er
Pay
or S
ourc
e C
ode
Rep
rese
nts
the
sour
ce
of p
aym
ent f
or th
e E
ncou
nter
.
Use
d in
the
adm
inis
trat
ion
of c
are
for
billi
ng p
urpo
ses.
D
eter
min
es th
e so
urce
of p
aym
ent f
or
Enc
ount
er.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
TBD
Exa
mpl
e:P
rovi
ncia
l or
terr
itoria
l in
sura
nce
Not
Fou
nd: L
ikel
y P
OS
-spe
cific
due
to
adm
inis
trat
ive
natu
re.
Rec
ord
289,
Fee
sc
hedu
le lo
ok-u
p by
co
de, d
escr
iptio
n an
d al
tern
ate
desc
riptio
n.
D6
Pay
men
t Ty
peE
ncou
nter
R
emun
erat
ion
Mod
e C
ode
Rep
rese
nts
the
type
of
reim
burs
emen
t pai
d to
the
Pro
vide
r fo
r th
e E
ncou
nter
.
Use
d in
the
adm
inis
trat
ion
of c
are
for
billi
ng p
urpo
ses.
D
eter
min
e ty
pe
of p
aym
ent t
o th
e P
rovi
der.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Nat
iona
l Phy
sici
an
Dat
abas
e D
ata
Sub
mis
sion
S
peci
ficat
ion
Vers
ion
4.0
Exa
mpl
e:00
(Fe
e fo
r S
ervi
ce)
Not
Fou
nd: L
ikel
y P
OS
-spe
cific
due
to
adm
inis
trat
ive
natu
re.
Rec
ord
289,
Fee
sc
hedu
le lo
ok-u
p by
co
de, d
escr
iptio
n an
d al
tern
ate
desc
riptio
n.
D7
Bill
ing
Cod
eE
ncou
nter
B
illin
g (F
ee)
Cod
e
Rep
rese
nts
the
Juris
dict
iona
l Bill
ing
Cod
e.
Use
d in
the
adm
inis
trat
ion
of c
are
for
billi
ng p
urpo
ses.
D
eter
min
es th
e so
urce
of p
aym
ent f
or
Enc
ount
er.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
N/A
As
per
juris
dict
ion-
spec
ific
set o
f val
ues
Not
Fou
nd: L
ikel
y P
OS
spe
cific
due
to
adm
inis
trat
ive
natu
re.
Rec
ord
289,
fee
sche
dule
look
up b
y co
de, d
escr
iptio
n an
d al
tern
ate
desc
riptio
n.
54
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceC
ont
ext:
Ob
serv
atio
nD
efin
itio
n: A
Hea
lth S
ervi
ce E
vent
th
at is
inte
nded
to
res
ult
in n
ew in
form
atio
n ab
out
th
e su
bje
ct. (
So
urce
HL7
v3)
. Th
e m
ain
diff
eren
ce b
etw
een
ob
serv
atio
ns
and
inte
rven
tions
as
des
crib
ed in
th
e P
HC
EM
R C
ont
ent
Sta
ndar
ds
is t
hat
ob
serv
atio
ns h
ave
a re
sult
(val
ue)
wh
erea
s in
terv
entio
ns d
o n
ot.
Add
ition
al d
ata
elem
ents
that
may
be
requ
ired
to s
uppo
rt th
e us
e an
d ex
trac
tion
of O
bser
vatio
n da
ta in
PH
C E
MR
s:P
rovi
der(
s) (
e.g.
the
Pro
vide
r[s]
who
per
form
ed th
e O
bser
vatio
n[s]
): P
rovi
der
Iden
tifie
r C
ode,
Pro
vide
r Id
entif
ier
Ass
igni
ng A
utho
rity,
Pro
vide
r R
ole
Type
and
Pro
vide
r E
xper
tise
expr
esse
d in
the
cont
ext o
f the
Obs
erva
tion.
Clie
nt (
e.g.
the
Clie
nt w
ho w
as th
e su
bjec
t of t
he O
bser
vatio
n): C
lient
Iden
tifie
r C
ode,
Clie
nt Id
entif
ier
Type
and
Clie
nt Id
entif
ier
Ass
igni
ng A
utho
rity
expr
esse
d in
the
cont
ext o
f the
Obs
erva
tion.
Enc
ount
er Id
entif
ier:
A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e en
coun
ter
in w
hich
the
Obs
erva
tion
took
pla
ce.
E1
Fam
ily
Mem
ber
Hea
lth
Con
cern
Obs
erva
tion
Fam
ily
His
tory
Hea
lth
Con
cern
C
ode
Rep
rese
nts
the
rele
vant
he
alth
con
cern
s of
a
pers
on s
harin
g co
mm
on a
nces
try
with
th
e C
lient
.
Use
d in
the
prov
isio
n of
car
e. F
amily
His
tory
H
ealth
Con
cern
is
ofte
n re
cord
ed to
not
e th
at th
e C
lient
may
ha
ve a
ris
k fa
ctor
for
dise
ases
. For
exa
mpl
e,
a w
oman
who
se m
othe
r ha
d br
east
can
cer
may
be
at h
ighe
r ris
k of
dev
elop
ing
brea
st c
ance
r.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
SN
OM
ED
CT®
Con
cept
Dom
ain:
D
iagn
osis
Valu
e
Exa
mpl
e:23
7734
007
(AC
TH-d
epen
dent
C
ushi
ng’s
syn
drom
e)
Con
cept
Dom
ain:
Sym
ptom
Valu
e
Exa
mpl
e:24
9543
005
(Abd
omen
sof
t)
Not
e: W
hile
a c
once
pt
dom
ain
has
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle
sum
mar
y vi
ew
(def
ault
view
and
ab
ility
to c
usto
miz
e).
55
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
2Fa
mily
M
embe
r S
ocia
l B
ehav
iour
(s)
Obs
erva
tion
Fam
ily
His
tory
Soc
ial
Beh
avio
ur
Cod
e
Rep
rese
nts
the
rele
vant
so
cial
beh
avio
urs
of a
per
son
shar
ing
com
mon
anc
estr
y w
ith
the
Clie
nt. T
his
can
incl
ude
risk
fact
ors,
su
ch a
s to
bacc
o us
e,
alco
hol u
se, a
buse
of
illic
it or
pre
scrip
tion
drug
s, a
nd o
ccup
atio
n.
Use
d in
the
prov
isio
n of
car
e. F
amily
His
tory
S
ocia
l Beh
avio
ur is
of
ten
reco
rded
to n
ote
that
the
Clie
nt m
ay h
ave
a ris
k fa
ctor
for
soci
al
beha
viou
rs a
nd/o
r di
seas
es. F
or e
xam
ple,
st
udie
s ha
ve s
how
n th
at
peop
le w
hose
par
ents
w
ere
alco
holic
s ha
ve a
hi
gher
ris
k of
bec
omin
g al
coho
lics
them
selv
es.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
SN
OM
ED
CT®
Con
cept
Dom
ain:
Com
mon
Clin
ical
Obs
er-
vatio
nAss
ertio
nVal
ue
Exa
mpl
e:56
4520
08 (
Adu
lt D
ysso
cial
Beh
avio
ur)
Nat
iona
l Occ
upat
ion
Cla
ssifi
catio
n (N
OC
)
Exa
mpl
e:
2211
(C
hem
ical
Te
chno
logi
sts
and
Tech
nici
ans)
Not
e: W
hile
a c
once
pt
dom
ain
has
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
E3
Fam
ilyM
embe
r In
-te
rven
tions
(T
reat
men
ts)
Obs
erva
tion
Fam
ily H
isto
ry
Inte
rven
tion
Cod
e
Rep
rese
nts
the
rele
vant
in
terv
entio
ns p
erfo
rmed
on
a p
erso
n sh
arin
g co
mm
on a
nces
try
with
the
Clie
nt.
Use
d in
the
prov
isio
n of
car
e. F
amily
His
tory
In
terv
entio
ns is
ofte
n re
cord
ed to
not
e th
at
the
Clie
nt m
ay h
ave
a ris
k fa
ctor
for
dise
ases
. In
som
e ca
ses,
Clie
nts
may
kno
w th
at th
e fa
mily
mem
ber
had
a sp
ecifi
c in
terv
entio
n bu
t not
kno
w th
e he
alth
con
cern
beh
ind
the
inte
rven
tion.
For
ex
ampl
e, a
Clie
nt m
ight
kn
ow th
at h
is/h
er fa
ther
ha
d a
trip
le b
y-pa
ss
surg
ery
but n
ot k
now
th
e ex
act u
nder
lyin
g he
alth
con
cern
that
the
surg
ery
was
atte
mpt
ing
to tr
eat.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
SN
OM
ED
CT®
Con
cept
Dom
ain:
A
ctP
rofe
ssio
nalS
ervi
ce-
Cod
e
Exa
mpl
e:40
8952
002
(Acu
te p
ain
cont
rol a
sses
smen
t)
Not
e: W
hile
a c
once
pt
dom
ain
has
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
56
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
4Fa
mily
M
embe
r R
elat
ions
hip
to P
atie
nt
Obs
erva
tion
Fam
ily H
isto
ry
Fam
ilial
R
elat
ions
hip
Cod
e
Rep
rese
nts
the
rela
tions
hip
betw
een
the
Clie
nt a
nd
a pe
rson
who
sha
res
a co
mm
on a
nces
try.
Use
d in
the
prov
isio
n of
car
e. F
amily
His
tory
Fa
mili
al R
elat
ions
hip
is
ofte
n re
cord
ed to
not
e th
at th
e C
lient
may
hav
e a
risk
fact
or fo
r dis
ease
s an
d so
cial
beh
avio
urs.
Fo
r ex
ampl
e, s
tudi
es
have
sho
wn
that
peo
ple
who
se p
aren
ts w
ere
alco
holic
s ha
ve a
hi
gher
ris
k of
bec
omin
g al
coho
lics
as w
ell.
Sim
ilarly
, a w
oman
w
hose
mot
her
had
brea
st c
ance
r m
ay
be a
t hig
her
risk
of
deve
lopi
ng it
.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
HL7
v3
Con
cept
Dom
ain:
Fa
mily
Mem
berR
elat
ion-
ship
Rol
eTyp
e
Exa
mpl
e:N
FTH
(N
atur
al F
athe
r)
Not
e: W
hile
a c
once
pt
dom
ain
has
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
E5
Fam
ily
Mem
ber
Hea
lth
Con
cern
, In
terv
entio
n or
Soc
ial
Beh
avio
ur
Age
at
Ons
et
Obs
erva
tion
Fam
ily H
isto
ry
Effe
ctiv
e O
nset
Age
N
umbe
r
Rep
rese
nts
the
age
of th
e fa
mily
mem
ber
(in y
ears
) w
hen
the
heal
th c
once
rn,
inte
rven
tion
or s
ocia
l be
havi
our
star
ted.
Use
d in
the
prov
isio
n of
car
e. F
amily
His
tory
E
ffect
ive
End
Dat
e is
ofte
n re
cord
ed to
no
te th
at th
e C
lient
m
ay b
e at
a h
ighe
r ris
k of
dev
elop
ing
a he
alth
con
cern
or
soc
ial b
ehav
iour
at
a c
erta
in a
ge.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
N/A
Exa
mpl
e:82
Not
e: T
he p
an-
Can
adia
n E
HR
M
essa
ging
Sta
ndar
ds
do n
ot c
urre
ntly
con
tain
an
y m
essa
ges
that
use
th
is d
ata
elem
ent.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
57
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
6Fa
mily
M
embe
r H
ealth
C
once
rn,
Inte
rven
tion
or S
ocia
l B
ehav
iour
S
tart
Dat
e
Obs
erva
tion
Fam
ily H
isto
ry
Effe
ctiv
e S
tart
D
ate
Rep
rese
nts
the
date
on
whi
ch th
e he
alth
co
ncer
n, in
terv
entio
n or
so
cial
beh
avio
ur s
tart
ed
for
the
fam
ily m
embe
r.
Use
d in
the
prov
isio
n of
car
e. F
amily
His
tory
E
ffect
ive
End
Dat
e is
ofte
n re
cord
ed to
no
te th
at th
e C
lient
m
ay b
e at
a h
ighe
r ris
k of
dev
elop
ing
a he
alth
con
cern
or
soc
ial b
ehav
iour
at
a c
erta
in a
ge.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
e: T
he p
an-
Can
adia
n E
HR
M
essa
ging
Sta
ndar
ds
do n
ot c
urre
ntly
con
tain
an
y m
essa
ges
that
use
th
is d
ata
elem
ent.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
E7
Fam
ily
Mem
ber
Hea
lth
Con
cern
, In
terv
entio
n or
Soc
ial
Beh
avio
ur
End
Dat
e
Obs
erva
tion
Fam
ily H
isto
ry
Effe
ctiv
e E
nd
Dat
e
Rep
rese
nts
the
date
on
whi
ch th
e he
alth
co
ncer
n, in
terv
entio
n or
so
cial
beh
avio
ur e
nded
fo
r th
e fa
mily
mem
ber.
Use
d in
the
prov
isio
n of
car
e. F
amily
His
tory
E
ffect
ive
End
Dat
e is
ofte
n re
cord
ed to
no
te th
at th
e C
lient
m
ay b
e at
a h
ighe
r ris
k of
dev
elop
ing
a he
alth
con
cern
or
soc
ial b
ehav
iour
at
a c
erta
in a
ge.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
e: T
he p
an-
Can
adia
n E
HR
M
essa
ging
Sta
ndar
ds
do n
ot c
urre
ntly
con
tain
an
y m
essa
ges
that
use
th
is d
ata
elem
ent.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
E8
Fam
ily
Mem
ber
Dec
ease
d D
ate
Obs
erva
tion
Fam
ily H
isto
ry
Effe
ctiv
e D
ecea
sed
Dat
e
Rep
rese
nts
the
date
on
whi
ch th
e fa
mily
m
embe
r di
ed.
Use
d in
the
prov
isio
n of
car
e. F
amily
His
tory
E
ffect
ive
End
Dat
e is
ofte
n re
cord
ed to
no
te th
at th
e C
lient
m
ay b
e at
a h
ighe
r ris
k of
dev
elop
ing
a he
alth
con
cern
or
soc
ial b
ehav
iour
at
a c
erta
in a
ge.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
e: T
he p
an-
Can
adia
n E
HR
M
essa
ging
Sta
ndar
ds
do n
ot c
urre
ntly
con
tain
an
y m
essa
ges
that
use
th
is d
ata
elem
ent.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
58
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
9Fa
mily
M
embe
r C
ause
of
Dea
th
Obs
erva
tion
Fam
ily H
isto
ry
Dea
th C
ause
C
ode
Rep
rese
nts
the
clin
ical
ca
use
of d
eath
for
the
fam
ily m
embe
r.
Use
d in
the
prov
isio
n of
car
e. F
amily
His
tory
D
eath
Cau
se C
ode
is
ofte
n re
cord
ed to
not
e th
at th
e C
lient
may
ha
ve a
ris
k fa
ctor
for
dise
ases
. For
exa
mpl
e,
a w
oman
who
se m
othe
r di
ed o
f bre
ast c
ance
r m
ay b
e at
hig
her
risk
of d
evel
opin
g it.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
SN
OM
ED
CT®
Con
cept
Dom
ain:
Dia
gnos
isVa
lues
Exa
mpl
e:23
7734
007
(AC
TH-
depe
nden
t Cus
hing
’s
synd
rom
e)
Not
e: W
hile
a c
once
pt
dom
ain
has
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
E10
Fam
ily
Mem
ber
Eth
nici
ty
Obs
erva
tion
Fam
ily H
isto
ry
Fam
ilial
E
thni
city
C
ode
Rep
rese
nts
the
ethn
icity
of
the
fam
ily m
embe
r.U
sed
in th
e pr
ovis
ion
of c
are.
Fam
ily H
isto
ry
Fam
ilial
Eth
nici
ty C
ode
is o
ften
reco
rded
to
note
that
the
Clie
nt
may
hav
e a
risk
fact
or
for
dise
ases
and
so
cial
beh
avio
urs.
Fo
r ex
ampl
e, s
ome
heal
th c
ondi
tions
are
m
ore
prom
inen
t in
cert
ain
ethn
ic g
roup
s su
ch a
s si
ckle
cel
l an
aem
ia in
peo
ple
with
Afri
can
orig
ins.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Sta
tistic
s C
anad
a 20
06 C
ensu
s—et
hnic
ca
tego
ries
and
subc
ateg
orie
s
Exa
mpl
e:H
ispa
nic
An
equi
vale
nt c
once
pt
was
not
foun
d in
th
e pa
n-C
anad
ian
EH
R M
essa
ging
and
Te
rmin
olog
y S
tand
ards
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
59
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
11H
ealth
C
once
rnO
bser
vatio
n H
ealth
C
once
rn
Cod
e
Rep
rese
nts
the
Clie
nt’s
re
leva
nt c
linic
al
prob
lem
s, c
ondi
tions
, di
agno
ses,
sym
ptom
s,
findi
ngs
and
com
plai
nts.
Use
d in
the
prov
isio
n of
car
e. P
rovi
des
a lo
ngitu
dina
l rec
ord
of
prob
lem
s or
sym
ptom
s fo
r a
Clie
nt. C
linic
ians
ca
n us
e th
is in
form
atio
n to
mon
itor
the
heal
th
of th
eir
clie
nts,
re
com
men
d tr
eatm
ents
an
d as
sist
in th
e fo
rmat
ion
of d
iagn
oses
.
36, 3
9, 4
0,
50, 5
5–60
, 62
and
63
SN
OM
ED
CT®
Con
cept
Dom
ain:
Dia
gnos
isVa
lue
valu
es
Exa
mpl
e:23
7734
007
(AC
TH-
depe
nden
t Cus
hing
’s
synd
rom
e)
Con
cept
Dom
ain:
S
ympt
omVa
lue
Exa
mpl
e:24
9543
005
(Abd
omen
sof
t)
Foun
d in
:R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l May
8, 2
007.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
E12
Hea
lth
Con
cern
D
ate
of
Ons
et
Obs
erva
tion
Hea
lth
Con
cern
Sta
rt
Dat
e
Rep
rese
nts
the
date
on
whi
ch th
e C
lient
’s
heal
th c
once
rn s
tart
ed.
Use
d in
the
prov
isio
n of
car
e. P
rovi
des
a lo
ngitu
dina
l rec
ord
of
prob
lem
s or
sym
ptom
s fo
r a
Clie
nt. C
linic
ians
ca
n us
e th
is in
form
atio
n to
mon
itor
the
heal
th
of th
eir
Clie
nts,
re
com
men
d tr
eatm
ents
an
d as
sist
in th
e fo
rmat
ion
of d
iagn
oses
.
36, 3
9, 4
0,
55–5
8, 6
2 an
d 63
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
:S
C-2
003-
EN
—R
EP
C_M
T000
003C
A—
Hea
lth C
ondi
tion
Rec
ord—
2009
0316
.doc
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
60
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
13H
ealth
C
once
rn
Dat
e of
R
esol
utio
n
Obs
erva
tion
Hea
lth
Con
cern
End
D
ate
Rep
rese
nts
the
date
on
whi
ch th
e C
lient
’s
heal
th c
once
rn e
nded
.
Use
d in
the
prov
isio
n of
car
e. P
rovi
des
a lo
ngitu
dina
l rec
ord
of
prob
lem
s or
sym
ptom
s fo
r a
Clie
nt. C
linic
ians
ca
n us
e th
is in
form
atio
n to
mon
itor
the
heal
th
of th
eir
clie
nts,
re
com
men
d tr
eatm
ents
an
d as
sist
in th
e fo
rmat
ion
of d
iagn
oses
.
36, 3
9, 4
0,
55–5
8 an
d 63
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
:S
C-2
003-
EN
—R
EP
C_
MT0
0000
3CA
—H
ealth
C
ondi
tion
Rec
ord—
2009
0316
.doc
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
E14
Soc
ial
Beh
avio
urO
bser
vatio
n S
ocia
l B
ehav
iour
C
ode
Rep
rese
nts
a ty
pe o
f C
lient
soc
ial b
ehav
iour
th
at in
crea
ses
the
poss
ibili
ty o
f dis
ease
or
inju
ry fo
r th
e C
lient
. Th
is c
an in
clud
e ris
k fa
ctor
s su
ch a
s to
bacc
o us
e, a
lcoh
ol u
se, a
buse
of
illic
it or
pre
scrip
tion
drug
s, a
nd o
ccup
atio
n.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to id
entif
y C
lient
be
havi
ours
that
, if
trea
ted,
cou
ld le
ad to
im
prov
emen
ts in
the
Clie
nt’s
hea
lth a
nd
wel
lnes
s. F
or e
xam
ple,
th
e id
entif
icat
ion
and
trea
tmen
t of d
rug
and
alco
hol p
robl
ems
can
impr
ove
a C
lient
’s
men
tal a
nd p
hysi
cal
heal
th a
nd s
ocia
l fu
nctio
ning
.
13 a
nd 4
3S
NO
ME
D C
T®
Con
cept
Dom
ain:
Com
mon
Clin
ical
Obs
er-
vatio
nAss
ertio
nVal
ue
Exa
mpl
e:56
4520
08 (
Adu
lt D
ysso
cial
Beh
avio
ur)
Nat
iona
l Occ
upat
ion
Cla
ssifi
catio
n (N
OC
)
Exa
mpl
e:
2211
(C
hem
ical
Te
chno
logi
sts
and
Tech
nici
ans)
Exa
mpl
e N
OC
Val
ue:
2211
(C
hem
ical
Te
chno
logi
sts
and
Tech
nici
ans)
Not
e: W
hile
a c
once
pt
dom
ain
has
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
61
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
15S
ocia
l B
ehav
iour
D
ate
of
Ons
et
Obs
erva
tion
Soc
ial
Beh
avio
ur
Sta
rt D
ate
Rep
rese
nts
the
effe
ctiv
e da
te th
e C
lient
sta
rted
th
e so
cial
beh
avio
ur.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to id
entif
y C
lient
be
havi
ours
that
, if
trea
ted,
cou
ld le
ad to
im
prov
emen
ts in
the
Clie
nt’s
hea
lth a
nd
wel
lnes
s. F
or e
xam
ple,
th
e id
entif
icat
ion
and
trea
tmen
t of d
rug
and
alco
hol p
robl
ems
can
impr
ove
a C
lient
’s
men
tal a
nd p
hysi
cal
heal
th a
nd s
ocia
l fu
nctio
ning
.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
e: W
hile
a d
ata
type
ha
s be
en r
efer
ence
d,
this
exa
ct d
ata
elem
ent
does
not
cur
rent
ly e
xist
in
the
pan-
Can
adia
n E
HR
Mes
sagi
ng
Sta
ndar
ds.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
E16
Soc
ial
Beh
avio
ur
Dat
e of
R
esol
utio
n
Obs
erva
tion
Soc
ial
Beh
avio
ur
End
Dat
e
Rep
rese
nts
the
effe
ctiv
e da
te th
e C
lient
cea
sed
the
soci
al b
ehav
iour
.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to id
entif
y C
lient
be
havi
ours
that
, if
trea
ted,
cou
ld le
ad to
im
prov
emen
ts in
the
Clie
nt’s
hea
lth a
nd
wel
lnes
s. F
or e
xam
ple,
th
e id
entif
icat
ion
and
trea
tmen
t of d
rug
and
alco
hol p
robl
ems
can
impr
ove
a C
lient
’s
men
tal a
nd p
hysi
cal
heal
th a
nd s
ocia
l fu
nctio
ning
.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
e: W
hile
a d
ata
type
ha
s be
en r
efer
ence
d,
this
exa
ct d
ata
elem
ent
does
not
cur
rent
ly e
xist
in
the
pan-
Can
adia
n E
HR
Mes
sagi
ng
Sta
ndar
ds.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
(d
efau
lt vi
ew a
nd
abili
ty to
cus
tom
ize)
.
62
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
17A
llerg
y/In
tole
ranc
e Ty
pe
Obs
erva
tion
Alle
rgy/
Into
lera
nce
Type
Cod
e
Rep
rese
nts
the
type
of
alle
rgy
or in
tole
ranc
e a
Clie
nt h
as.
Use
d in
the
prov
isio
n of
ca
re. U
sed
to p
reve
nt
adve
rse
reac
tions
an
d ca
n be
use
d fo
r re
min
ders
and
ale
rts.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
SN
OM
ED
CT®
Con
cept
Dom
ain:
O
bser
vatio
nInt
oler
an-
ceTy
pe
Exa
mpl
e:23
5719
002
(Foo
d In
tol-
eran
ce)
Foun
d in
:R
EP
C_M
T000
001C
A—
Alle
rgy
Into
lera
nce—
2009
0316
.
Rec
ord
347,
Pro
vide
s au
tom
ated
dec
isio
n su
ppor
t rem
inde
rs o
r ru
les
from
alle
rgie
s.
E18
Alle
rgy/
Into
lera
nce
Age
nt
Obs
erva
tion
Alle
rgy/
Into
lera
nce
Age
nt C
ode
Rep
rese
nts
the
spec
ific
alle
rgen
or
othe
r ag
ent/
subs
tanc
e to
whi
ch th
e C
lient
has
an
alle
rgic
re
actio
n or
into
lera
nce.
Use
d in
the
prov
isio
n of
car
e. U
sed
to p
reve
nt
adve
rse
reac
tions
an
d al
lerg
y to
dru
g in
tera
ctio
ns a
nd c
an
be u
sed
for
rem
inde
rs
and
aler
ts.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
SN
OM
ED
CT®
Con
cept
Dom
ain:
Non
Dru
gAge
ntE
ntity
Exa
mpl
e:22
7150
003
(Mus
sels
)
HC
-AIG
C, H
C-A
IGN
, H
C-D
IN, H
C-N
PN
, G
TIN
, SN
OM
ED
CT®
Con
cept
Dom
ain:
Clin
ical
Dru
g
Exa
mpl
e:37
3270
004
(Pen
icill
in)
Foun
d in
:R
EP
C_M
T000
001C
A—
Alle
rgy
Into
lera
nce—
2009
0316
.
Rec
ord
347,
Pro
vide
s au
tom
ated
dec
isio
n su
ppor
t rem
inde
rs o
r ru
les
from
alle
rgie
s.
E19
Alle
rgy/
Into
lera
nce
Sev
erity
Obs
erva
tion
Alle
rgy/
Into
lera
nce
Sev
erity
Cod
e
Rep
rese
nts
the
leve
l of
seve
rity
a C
lient
has
in
rela
tion
to a
n al
lerg
y or
in
tole
ranc
e.
Use
d in
the
prov
isio
n of
ca
re. U
sed
to p
reve
nt
adve
rse
reac
tions
an
d ca
n be
use
d fo
r re
min
ders
and
ale
rts.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
SN
OM
ED
CT®
Con
cept
Dom
ain:
S
ever
ityO
bser
vatio
n
Exa
mpl
e:24
4840
00 (
Sev
ere)
Foun
d in
SC
-200
3-E
N—
RE
PC
_MT0
0000
1CA
—A
llerg
y In
tole
ranc
e—20
0903
16.
Rec
ord
347,
Pro
vide
s au
tom
ated
dec
isio
n su
ppor
t rem
inde
rs o
r ru
les
from
alle
rgie
s.
63
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
20A
llerg
y/In
tole
ranc
e S
tatu
s
Obs
erva
tion
Alle
rgy/
Into
lera
nce
Sta
tus
Cod
e
Rep
rese
nts
whe
ther
an
alle
rgy/
into
lera
nce
is
“act
ive”
or
”com
plet
ed”
(indi
catin
g no
long
er
activ
e).
Use
d in
the
prov
isio
n an
d ad
min
istr
atio
n of
ca
re. A
n E
MR
can
be
prog
ram
med
to p
rovi
de
aler
ts fo
r al
lerg
ies/
into
lera
nces
that
ar
e ac
tive.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
HL7
v3
Con
cept
Dom
ain:
A
ctS
tatu
s
Exa
mpl
e:A
CTI
VE
Foun
d in
:R
EP
C_M
T000
001C
A—
Alle
rgy
Into
lera
nce—
Mar
ch 1
6, 2
009.
Rec
ord
347,
Pro
vide
s au
tom
ated
dec
isio
n su
ppor
t rem
inde
rs o
r ru
les
from
alle
rgie
s.
E21
Alle
rgy/
Into
lera
nce
Dat
e of
O
nset
Obs
erva
tion
Alle
rgy
and/
or In
tole
ranc
e S
tart
Dat
e
Rep
rese
nts
the
date
on
whi
ch th
e re
cord
ed
alle
rgy/
into
lera
nce
is
cons
ider
ed a
ctiv
e.
Use
d in
the
prov
isio
n an
d ad
min
istr
atio
n of
ca
re. A
n E
MR
can
be
prog
ram
med
to p
rovi
de
aler
ts fo
r al
lerg
ies/
into
lera
nces
that
ar
e ac
tive.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
:R
EP
C_M
T000
001C
A—
Alle
rgy
Into
lera
nce—
Mar
ch 1
6, 2
009.
Rec
ord
347,
Pro
vide
s au
tom
ated
dec
isio
n su
ppor
t rem
inde
rs o
r ru
les
from
alle
rgie
s.
E22
Alle
rgy/
Into
lera
nce
Dat
e of
R
esol
utio
n
Obs
erva
tion
Alle
rgy
and/
or In
tole
ranc
e E
nd D
ate
Rep
rese
nts
the
date
on
whi
ch th
e re
cord
ed
alle
rgy/
into
lera
nce
is
no lo
nger
con
side
red
activ
e.
Use
d in
the
prov
isio
n an
d ad
min
istr
atio
n of
ca
re. A
n E
MR
can
be
prog
ram
med
to p
rovi
de
aler
ts fo
r al
lerg
ies/
into
lera
nces
that
ar
e ac
tive.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
:R
EP
C_M
T000
001C
A—
Alle
rgy
Into
lera
nce—
Mar
ch 1
6, 2
009.
Rec
ord
347,
Pro
vide
s au
tom
ated
dec
isio
n su
ppor
t rem
inde
rs o
r ru
les
from
alle
rgie
s.
64
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
23S
ysto
lic
Blo
od
Pre
ssur
e
Obs
erva
tion
Sys
tolic
Blo
od
Pre
ssur
e N
umbe
r
Rep
rese
nts
the
Clie
nt’s
sy
stol
ic b
lood
pre
ssur
e va
lue
(in m
mH
g)
mea
sure
d. T
he u
nit
of m
easu
re (
mm
Hg)
is
impl
ied
whe
n re
pres
entin
g th
e va
lue.
Use
d in
the
prov
isio
n of
car
e. A
dis
cret
e va
lue
prov
ides
the
abili
ty to
gra
ph a
nd
tren
d va
lues
ove
r tim
e. A
mea
sure
men
t th
at s
uppo
rts
clin
ical
de
cisi
ons.
40 a
nd
54–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
Sta
ndar
ds—
Dat
a Ty
pe S
peci
ficat
ion
Sec
tion
6—N
umer
icP
Q.B
AS
IC .
Bas
ic
Phy
sica
l Qua
ntity
Exa
mpl
e:12
0
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d M
arch
16,
200
9.
Rec
ord
127,
Gra
ph
and
prin
t cod
ed a
nd
mea
sure
d el
emen
ts
over
tim
e.
E24
Dia
stol
ic
Blo
od
Pre
ssur
e
Obs
erva
tion
Dia
stol
ic
Blo
od
Pre
ssur
e N
umbe
r
Rep
rese
nts
the
Clie
nt’s
di
asto
lic b
lood
pre
ssur
e va
lue
(in m
mH
g)
mea
sure
d. T
he u
nit
of m
easu
re (
mm
Hg)
is
impl
ied
whe
n re
pres
entin
g th
e va
lue.
Use
d in
the
prov
isio
n of
car
e. A
dis
cret
e va
lue
prov
ides
the
abili
ty to
gra
ph a
nd
tren
d va
lues
ove
r tim
e. A
mea
sure
men
t th
at s
uppo
rts
clin
ical
de
cisi
ons.
40 a
nd
54–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
Sta
ndar
ds—
Dat
a Ty
pe S
peci
ficat
ion
Sec
tion
6—N
umer
icP
Q.B
AS
IC. B
asic
P
hysi
cal Q
uant
ity
Exa
mpl
e:80
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d M
arch
16,
200
9.
Rec
ord
127,
Gra
ph
and
prin
t cod
ed a
nd
mea
sure
d el
emen
ts
over
tim
e.
E25
Blo
od
Pre
ssur
e B
ody
Loca
tion
Obs
erva
tion
Blo
od
Pre
ssur
e M
easu
rem
ent
Ana
tom
ical
Lo
catio
n C
ode
Rep
rese
nts
the
anat
omic
al lo
catio
n of
whe
re th
e bl
ood
pres
sure
was
mea
sure
d on
the
Clie
nt’s
bod
y.
Use
d in
the
prov
isio
n of
car
e. Id
entif
ies
whe
re
the
bloo
d pr
essu
re
was
take
n.
40 a
nd
55–5
7S
NO
ME
D C
T®
Con
cept
Dom
ain:
O
bser
vatio
nMet
hod
Exa
mpl
e:50
7692
010
(rig
ht u
pper
ar
m s
truc
ture
)
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d—20
0903
16.d
oc.
Not
cur
rent
ly r
equi
red
to s
uppo
rt a
ny o
f the
P
OS
R r
ecor
ds.
65
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
26B
lood
P
ress
ure
Bod
y P
ositi
on
Obs
erva
tion
Blo
od
Pre
ssur
e M
easu
rem
ent
Bod
y P
ositi
on
Cod
e
Rep
rese
nts
the
posi
tion
the
Clie
nt’s
bod
y w
as
in w
hen
bloo
d pr
essu
re
was
mea
sure
d (e
.g.
stan
ding
, sitt
ing,
lyin
g).
Use
d in
the
prov
isio
n of
car
e. Id
entif
ies
the
posi
tion
the
Clie
nt w
as
in w
hen
bloo
d pr
essu
re
was
take
n.
40 a
nd
55–5
7S
NO
ME
D C
T®
Con
cept
Dom
ain:
O
bser
vatio
nMet
hod
Exa
mpl
e:16
3035
008
(sitt
ing
bloo
d pr
essu
re)
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d—20
0903
16.d
oc.
Not
cur
rent
ly r
equi
red
to s
uppo
rt a
ny o
f the
P
OS
R r
ecor
ds.
E27
Blo
od
Pre
ssur
e R
epre
-se
ntat
ive
Rea
ding
Obs
erva
tion
Rep
rese
nta-
tive
Blo
od
Pre
ssur
e R
eadi
ng
Cod
e
Rep
rese
nts
whe
ther
th
e C
lient
’s b
lood
pr
essu
re r
eadi
ng is
re
pres
enta
tive
of th
e C
lient
’s c
urre
nt h
ealth
co
nditi
on.
Use
in th
e pr
ovis
ion
of c
are.
Iden
tifie
s a
bloo
d pr
essu
re r
eadi
ng
that
app
ears
to b
e no
n-re
pres
enta
tive
at th
e tim
e th
e re
adin
g w
as ta
ken.
40 a
nd
55–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
Sta
ndar
ds—
Dat
a Ty
pe S
peci
ficat
ion
Sec
tion
8.4—
BL—
Boo
lean
Exa
mpl
e:F
(Fal
se)
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d—20
0903
16.
Rec
ord
127,
Gra
ph
and
prin
t cod
ed a
nd
mea
sure
d el
emen
ts
over
tim
e.
E28
Hei
ght
Obs
erva
tion
Hei
ght
Num
ber
Rep
rese
nts
the
heig
ht o
f the
Clie
nt
as m
easu
red.
Use
d in
the
prov
isio
n of
car
e. A
dec
reas
e in
fem
ale
heig
ht
coul
d be
an
early
si
gn o
f ost
eopo
rosi
s an
d tr
igge
r a
need
fo
r a
bone
min
eral
de
nsity
test
.
13 a
nd
55–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
Sta
ndar
ds—
Dat
a Ty
pe S
peci
ficat
ion
Sec
tion
6.9—
PQ
.H
EIG
HTW
EIG
HT
Hei
ght
or W
eigh
t Qua
ntity
Exa
mpl
e:1.
25
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d M
arch
16,
200
9.
Rec
ord
127,
Gra
ph
and
prin
t cod
ed a
nd
mea
sure
d el
emen
ts
over
tim
e.
66
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceE
29H
eigh
t Uni
t of
Mea
sure
Obs
erva
tion
Hei
ght U
nit
of M
easu
re
Cod
e
Rep
rese
nts
the
Clie
nt
heig
ht u
nit o
f mea
sure
ca
ptur
ed.
Use
d in
the
prov
isio
n of
car
e. A
dec
reas
e in
fem
ale
heig
ht
coul
d be
an
early
si
gn o
f ost
eopo
rosi
s,
and
trig
ger
a ne
ed
for
a bo
ne m
iner
al
dens
ity te
st.
13 a
nd
55–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
Sta
ndar
ds—
Dat
a Ty
pe S
peci
ficat
ion
Sec
tion
6.9—
PQ
.H
EIG
HTW
EIG
HT
Hei
ght
or W
eigh
t Qua
ntity
Exa
mpl
e:m
(m
eter
)
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d M
arch
16,
200
9.
Rec
ord
6, U
ser
can
ente
r an
d di
spla
y bo
th
met
ric a
nd im
peria
l m
easu
rem
ents
.
E30
Wei
ght
Obs
erva
tion
Wei
ght
Num
ber
Rep
rese
nts
the
wei
ght o
f the
Clie
nt
as m
easu
red.
Use
d in
the
prov
isio
n of
car
e. W
eigh
t use
d to
ca
lcul
ate
body
mas
s in
dex
(BM
I).
13 a
nd
55–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.9—
PQ
.H
EIG
HTW
EIG
HT
Hei
ght o
r W
eigh
t Q
uant
ity
Exa
mpl
e:75
.6
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d M
arch
16,
200
9.
Rec
ord
200,
Dis
play
co
nsis
tent
and
ac
cura
te d
osag
e w
hen
calc
ulat
ing
the
dose
ba
sed
on w
eigh
t.
E31
Wei
ght
Uni
t of
Mea
sure
Obs
erva
tion
Wei
ght U
nit
of M
easu
re
Cod
e
Rep
rese
nts
the
Clie
nt
wei
ght u
nit o
f mea
sure
ca
ptur
ed.
Use
d in
the
prov
isio
n of
car
e. W
eigh
t use
d to
cal
cula
te B
MI.
13 a
nd
55–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.9—
PQ
.H
EIG
HTW
EIG
HT
Hei
ght o
r W
eigh
t Q
uant
ity
Exa
mpl
e:kg
(ki
logr
am)
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d M
arch
16,
200
9.
Rec
ord
6, U
ser
can
ente
r an
d di
spla
y bo
th
met
ric a
nd im
peria
l m
easu
rem
ents
.
67
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
E32
Wai
st
Circ
um-
fere
nce
Obs
erva
tion
Wai
st C
ir-cu
mfe
renc
e N
umbe
r
Rep
rese
nts
the
wai
st
circ
umfe
renc
e of
the
Clie
nt a
s m
easu
red.
Use
d in
the
prov
isio
n of
car
e. U
sed
to
mon
itor
and
prev
ent
onse
t of c
hron
ic
dise
ases
for
Clie
nts
with
a fa
mily
hea
lth
hist
ory
of a
spe
cific
ch
roni
c di
seas
e.
13 a
nd
55–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
Sta
ndar
ds—
Dat
a Ty
pe S
peci
ficat
ion
Sec
tion
6.6—
PQ
.BA
SIC
—B
asic
P
hysi
cal Q
uant
ity
Exa
mpl
e:70
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d M
arch
16,
200
9.
Rec
ord
127,
Abi
lity
to g
raph
and
prin
t co
ded
and
mea
sure
d el
emen
ts fo
r a
patie
nt’s
ch
art o
ver
time
from
la
bora
tory
, cod
ed
hist
oric
al e
lem
ents
, co
ded
phys
ical
ex
am fi
ndin
gs, a
nd
med
icat
ions
to o
bser
ve
tren
ds. P
ropo
nent
to
desc
ribe
the
abili
ty
to d
ispl
ay m
ultip
le
elem
ents
on
one
grap
h.
E33
Wai
st
Circ
um-
fere
nce
Uni
t of
Mea
sure
Obs
erva
tion
Wai
st C
ircum
-fe
renc
e U
nit
of M
easu
re
Cod
e
Rep
rese
nts
the
Clie
nt
Wai
st C
ircum
fere
nce
unit
of m
easu
re
capt
ured
.
Use
d in
the
prov
isio
n of
car
e. U
sed
to
mon
itor
and
prev
ent
onse
t of c
hron
ic
dise
ases
for
Clie
nts
with
a fa
mily
hea
lth
hist
ory
of a
spe
cific
ch
roni
c di
seas
e.
13 a
nd
55–5
7D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
Sta
ndar
ds—
Dat
a Ty
pe S
peci
ficat
ion
Sec
tion
6.6—
PQ
.BA
SIC
—B
asic
P
hysi
cal Q
uant
ity
Foun
d in
:R
EP
C_M
T410
001C
A—
Mea
sure
d O
bser
vatio
n R
ecor
d M
arch
16,
200
9.
Rec
ord
6, U
ser
can
ente
r an
d di
spla
y bo
th
met
ric a
nd im
peria
l m
easu
rem
ents
.
68
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
E34
Clin
icia
n A
sses
s-m
ent
Obs
erva
tion
Enc
ount
er
Clin
ical
A
sses
smen
t C
ode
Rep
rese
nts
the
Pro
vide
r’s p
rofe
ssio
nal
opin
ion
of th
e m
ost
rele
vant
clin
ical
find
ings
re
late
d to
the
Clie
nt’s
E
ncou
nter
. The
mos
t re
leva
nt c
linic
al fi
ndin
g fo
r th
e E
ncou
nter
can
in
clud
e di
agno
ses,
sy
mpt
oms
and
prof
essi
onal
ser
vice
s.
Use
d in
the
prov
isio
n an
d ad
min
istr
atio
n of
car
e. T
he c
linic
al
asse
ssm
ent o
f the
E
ncou
nter
can
be
used
to
hel
p tr
ack
epis
odes
of
car
e. C
an a
lso
supp
ort s
hado
w b
illin
g.
13, 3
6, 3
9,
40, 4
3, 4
9,
55–6
0 an
d 63
SN
OM
ED
CT®
Con
cept
Dom
ain:
Dia
gnos
isVa
lue
Exa
mpl
e:23
7734
007
(AC
TH-
depe
nden
t Cus
hing
’s
synd
rom
e)
SN
OM
ED
CT®
Con
cept
Dom
ain:
Sym
ptom
Valu
e
Exa
mpl
e:43
3640
01 (
Abd
omin
al
disc
omfo
rt)
SN
OM
ED
CT®
Con
cept
Dom
ain:
Act
Pro
fess
iona
lSer
vice
-C
ode:
Exa
mpl
e:40
8952
002
(Acu
te p
ain
cont
rol a
sses
smen
t)
Not
e: W
hile
con
cept
do
mai
ns h
ave
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Rec
ord
num
ber
122,
S
umm
ary
of p
atie
nt
info
rmat
ion
rela
ted
to a
hea
lth c
ondi
tion
(pro
blem
or
diag
nosi
s).
69
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceC
ont
ext:
Inte
rven
tion
Def
initi
on:
An
activ
ity p
erfo
rmed
by
one
or
mo
re p
rovi
der
s o
f a
ther
apeu
tic o
r o
ther
hea
lth c
are–
rela
ted
ser
vice
fo
r a
clie
nt.
Add
ition
al d
ata
elem
ents
that
may
be
requ
ired
to s
uppo
rt th
e us
e an
d ex
trac
tion
of In
terv
entio
n da
ta in
PH
C E
MR
s:P
rovi
der
(e.g
. the
Pro
vide
r w
ho p
erfo
rmed
the
Inte
rven
tion)
: Pro
vide
r Id
entif
ier
Cod
e, P
rovi
der
Iden
tifie
r A
ssig
ning
Aut
horit
y, P
rovi
der
Rol
e Ty
pe a
nd P
rovi
der
Exp
ertis
e ex
pres
sed
in th
e co
ntex
t of t
he In
terv
entio
n.C
lient
(e.
g. th
e C
lient
who
was
the
subj
ect o
f the
Inte
rven
tion)
: Clie
nt Id
entif
ier
Cod
e, C
lient
Iden
tifie
r Ty
pe a
nd C
lient
Iden
tifie
r A
ssig
ning
Aut
horit
y ex
pres
sed
in th
e co
ntex
t of t
he In
terv
entio
n.E
ncou
nter
Iden
tifie
r: A
bus
ines
s id
entif
ier
that
uni
quel
y id
entif
ies
the
Enc
ount
er in
whi
ch th
e In
terv
entio
n to
ok p
lace
.
F1In
terv
entio
n (T
reat
men
t)In
terv
entio
n C
ode
Rep
rese
nts
the
serv
ices
/act
iviti
es
perfo
rmed
by
the
Pro
vide
r fo
r th
e C
lient
.
Use
d in
the
prov
isio
n of
car
e. T
rack
ed
Inte
rven
tions
pe
rform
ed o
n a
Clie
nt c
an h
elp
guid
e fu
ture
Inte
rven
tions
. U
sed
to tr
ack
Clie
nt’s
pro
gres
sive
im
prov
emen
t on
the
cont
inuu
m o
f car
e tim
elin
e. C
ouns
ellin
g fo
r sm
okin
g ce
ssat
ion
deliv
ered
in 2
008,
bl
ood
pres
sure
, and
dr
ug a
dmin
iste
red
show
pos
itive
im
prov
emen
t tod
ay.
13, 4
3, 4
9 an
d 50
SN
OM
ED
CT®
Con
cept
Dom
ain:
A
ctP
rofe
ssio
nalS
ervi
ce-
Cod
e
Exa
mpl
e:40
8952
002
(Acu
te p
ain
cont
rol a
sses
smen
t)
Foun
d in
:R
EP
C_M
T610
001C
A—
Pro
fess
iona
l Ser
vice
.
Rec
ord
342,
Pro
vide
us
er-d
efin
ed p
atie
nt
info
rmat
ion
for c
omm
on
inte
rven
tions
.
70
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
F2In
terv
entio
n(T
reat
men
t)
Dat
e
Inte
rven
tion
Dat
eR
epre
sent
s th
e da
te
the
Inte
rven
tion
was
pe
rform
ed b
y th
e P
rovi
der
for
the
Clie
nt.
Use
d in
the
prov
isio
n of
car
e to
trac
k th
e da
te
a pa
rtic
ular
inte
rven
tion
was
per
form
ed b
y th
e P
rovi
der.
13, 4
9 an
d 50
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng
Sta
ndar
ds—
Dat
a Ty
pe
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
:R
EP
C_M
T610
001C
A—
Pro
fess
iona
l Ser
vice
A
ctP
rofe
ssio
nalS
ervi
ce-
Cod
e.
Rec
ord
342,
Pro
vide
us
er-d
efin
ed p
atie
nt
info
rmat
ion
for c
omm
on
inte
rven
tions
.
F3In
terv
entio
n (T
reat
men
t)
Ref
usal
R
easo
n
Inte
rven
tion
Ref
usal
R
easo
n C
ode
Rep
rese
nts
the
reas
on
the
Clie
nt r
efus
ed a
n In
terv
entio
n.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to p
reve
nt in
appr
opria
te
rem
inde
rs a
nd a
lert
s fo
r C
lient
s.
13, 4
3, 4
9 an
d 50
TBD
—co
de s
et n
eeds
to
be
iden
tifie
d. P
o-te
ntia
l to
use
HL7
v3.
P
oten
tial t
o us
e va
lues
fro
m th
e co
ncep
t do
mai
n:A
ctN
oIm
mun
izat
ion-
Rea
son
Exa
mpl
e:R
ELI
G (
Rel
igio
us
Obj
ectio
n)
Not
foun
d in
any
of
the
pan-
Can
adia
n E
HR
Mes
sagi
ng a
nd
Term
inol
ogy
Sta
ndar
ds.
Not
cur
rent
ly r
equi
red
to s
uppo
rt a
ny o
f the
P
OS
R r
ecor
ds.
71
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
Co
ntex
t: L
abo
rato
ry O
rder
sD
efin
itio
n: R
eque
sts
for
the
pro
visi
on
of
anal
ytic
al s
ervi
ces
typ
ical
ly p
erfo
rmed
by
lab
ora
tori
es in
are
as s
uch
as
chem
istr
y, h
aem
ato
log
y, s
ero
log
y, h
isto
log
y,
cyto
log
y, a
nato
mic
pat
ho
log
y, m
icro
bio
log
y an
d v
iro
log
y. (
So
urce
HL7
v3)
. A
dditi
onal
dat
a el
emen
ts th
at m
ay b
e re
quire
d to
sup
port
the
use
and
extr
actio
n of
Lab
orat
ory
Ord
er d
ata
in P
HC
EM
Rs:
Pro
vide
r(e.
g. th
e P
rovi
der
who
aut
hore
d th
e or
der
for
the
lab
test
[s])
: Pro
vide
r Id
entif
ier
Cod
e, P
rovi
der
Iden
tifie
r A
ssig
ning
Aut
horit
y, P
rovi
der
Rol
e Ty
pe a
nd P
rovi
der
Exp
ertis
e ex
pres
sed
in th
e co
ntex
t of t
he L
abor
ator
y O
rder
.C
lient
(e.
g. th
e C
lient
who
was
the
subj
ect o
f the
Lab
orat
ory
Ord
er):
Clie
nt Id
entif
ier
Cod
e, C
lient
Iden
tifie
r Ty
pe a
nd C
lient
Iden
tifie
r A
ssig
ning
Aut
horit
y ex
pres
sed
in th
e co
ntex
t of
the
Labo
rato
ry O
rder
.E
ncou
nter
Iden
tifie
r: A
bus
ines
s id
entif
ier
that
uni
quel
y id
entif
ies
the
Enc
ount
er a
ssoc
iate
d w
ith th
e La
bora
tory
Ord
er.
Labo
rato
ry O
rder
Iden
tifie
r: A
bus
ines
s id
entif
ier
that
uni
quel
y id
entif
ies
the
Labo
rato
ry O
rder
.
G1
Lab
Test
O
rder
edLa
bora
tory
Te
st N
ame
Ord
ered
C
ode
Rep
rese
nts
the
lab
test
or
dere
d by
the
Pro
vide
r fo
r th
e C
lient
.
Use
d in
the
prov
isio
n of
car
e. L
ab te
sts
are
orde
red
in th
e pr
ovis
ion
of c
are
for
man
y re
ason
s, in
clud
ing
conf
irmat
ion
of
susp
ecte
d di
agno
ses.
Th
e la
b te
st n
ame
is
requ
ired
to k
now
wha
t te
st is
bei
ng o
rder
ed.
Cle
ar id
entif
icat
ion
of la
b te
st n
ame
and
valu
e.
48, 5
2, 5
3 an
d 55
–57
pCLO
CD
Con
cept
Dom
ain:
O
bser
vatio
nOrd
erab
le-
LabT
ype
(for
Ord
ered
Te
st)
Exa
mpl
e:24
358-
4 (H
emog
ram
pa
nel)
Foun
d in
:P
OLB
_MT0
0100
0CA
—La
bora
tory
Pla
cer
Ord
er—
2009
0316
.
Rec
ord
4, R
econ
cile
s te
st r
esul
ts w
ith o
rder
s us
ing
disc
rete
dat
a el
emen
ts s
o th
at
mis
sing
, non
-res
ulte
d or
ders
are
hig
hlig
hted
.
G2
Lab
Test
O
rder
ed
Dat
e
Labo
rato
ry
Test
Ord
er
Dat
e
Rep
rese
nts
the
date
the
lab
test
was
ord
ered
by
the
Pro
vide
r.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Sch
edul
e fu
ture
ap
poin
tmen
t bas
ed o
n th
e tr
ack
turn
arou
nd
time
of la
b te
st.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng
Sta
ndar
ds—
Dat
a Ty
pe
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
:S
C-2
003-
EN
—P
OLB
_MT0
0100
0CA
—La
bora
tory
Pla
cer
Ord
er—
2009
0316
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
.
72
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
Co
ntex
t: L
abo
rato
ry R
esul
tsD
efin
itio
n: T
he
resu
lts o
f an
alyt
ical
ser
vice
s ty
pic
ally
per
form
ed b
y la
bo
rato
ries
in a
reas
suc
h a
s ch
emis
try,
hae
mat
olo
gy,
ser
olo
gy,
his
tolo
gy,
cyt
olo
gy,
ana
tom
ic
pat
ho
log
y, m
icro
bio
log
y an
d v
iro
log
y. (
So
urce
HL7
v3)
.A
dditi
onal
dat
a el
emen
ts th
at m
ay b
e re
quire
d to
sup
port
the
use
and
extr
actio
n of
Lab
orat
ory
Res
ult d
ata
in P
HC
EM
Rs:
Pro
vide
r(e.
g. th
e P
rovi
der
who
aut
hore
d th
e or
der
for
the
lab
test
[s])
: Pro
vide
r Id
entif
ier
Cod
e, P
rovi
der
Iden
tifie
r A
ssig
ning
Aut
horit
y, P
rovi
der
Rol
e Ty
pe a
nd P
rovi
der
Exp
ertis
e ex
pres
sed
in th
e co
ntex
t of t
he L
abor
ator
y O
rder
that
re
late
s to
the
Lab
Res
ults
. Clie
nt (
e.g.
the
Clie
nt w
ho w
as th
e su
bjec
t of t
he L
abor
ator
y O
rder
): C
lient
Iden
tifie
r C
ode,
Clie
nt Id
entif
ier
Type
and
Clie
nt Id
entif
ier
Ass
igni
ng A
utho
rity
expr
esse
d in
the
cont
ext o
f the
Lab
orat
ory
Ord
er. L
abor
ator
y O
rder
Iden
tifie
r: A
bus
ines
s id
entif
ier
that
uni
quel
y id
entif
ies
the
Labo
rato
ry O
rder
that
the
Labo
rato
ry R
esul
ts fu
lfills
. La
bora
tory
Res
ult I
dent
ifier
: A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e La
bora
tory
Res
ults
.
H1
Lab
Test
P
erfo
rmed
D
ate
Labo
rato
ry
Test
P
erfo
rmed
D
ate
Rep
rese
nts
the
date
the
lab
test
was
per
form
ed.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Sch
edul
e fu
ture
ap
poin
tmen
t bas
ed o
n th
e tr
ack
turn
arou
nd
time
of la
bora
tory
test
.
39, 4
8, 5
2,
53 a
nd
55–5
7
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng
Sta
ndar
ds—
Dat
a Ty
pe
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
: P
OLB
_MT0
0400
0CA
—La
bora
tory
Res
ult
Eve
nt—
2009
0316
1.6
.3
Res
ult O
bser
vatio
n D
ate/
Tim
e.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
.
H2
Lab
Test
N
ame
Labo
rato
ry
Test
Res
ult
Nam
e C
ode
Rep
rese
nts
the
nam
e of
th
e la
b te
st p
erfo
rmed
.U
sed
in b
oth
the
prov
isio
n an
d ad
min
istr
atio
n of
car
e to
ens
ure
that
the
nam
e of
the
test
per
form
ed
is u
nder
stoo
d by
the
Pro
vide
r, re
sear
cher
s, e
tc.
39pC
LOC
D
Con
cept
Dom
ain:
O
bser
vatio
nRes
ulta
ble-
LabT
ype
Exa
mpl
e:71
8-7
(Hae
mog
lobi
n)
Foun
d in
:P
OLB
_MT0
0400
0CA
—La
bora
tory
Res
ult
Eve
nt—
2009
0316
.
Rec
ord
4, R
econ
cile
s te
st r
esul
ts w
ith o
rder
s us
ing
disc
rete
dat
a el
emen
ts s
o th
at
mis
sing
, non
-res
ulte
d or
ders
are
hig
hlig
hted
.
73
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
H3
Lab
Test
R
esul
t Va
lue
Labo
rato
ry
Test
Res
ult
Valu
e Te
xt
(Num
ber,
Cod
e)
Rep
rese
nts
the
resu
lt of
the
lab
test
.U
sed
in th
e pr
ovis
ion
of c
are.
Lab
test
s ar
e or
dere
d in
the
prov
isio
n of
car
e fo
r m
any
reas
ons,
incl
udin
g co
nfirm
atio
n of
su
spec
ted
diag
nose
s.
Blo
od-s
ugar
mon
itorin
g (A
ccu-
Che
k) v
alue
s ar
e tr
acke
d ov
er ti
me
and
com
pare
d w
ith y
early
H
b1A
c te
st r
esul
ts a
t a
Cen
tral
Lab
.
39S
NO
ME
D C
T®
(for
cod
ed r
esul
ts)
Con
cept
Dom
ain:
La
bora
tory
Res
ultC
ode-
Valu
e
Exa
mpl
e:16
4020
00 (
Sic
kle
cell
trai
t)
Foun
d in
:P
OLB
_MT0
0400
0CA
—La
bora
tory
Res
ult
Eve
nt—
2009
0316
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
.
H4
Lab
Test
R
esul
t Uni
t of
Mea
sure
Labo
rato
ry
Test
Res
ult
Valu
e U
nit
of M
easu
re
Cod
e
Rep
rese
nts
the
unit
of m
easu
re o
f the
lab
resu
lt fo
r th
e la
b te
st
perfo
rmed
.
Use
d in
the
prov
isio
n of
car
e. E
nsur
es th
at
the
unit
of m
easu
re
asso
ciat
ed w
ith th
e va
lue
is p
rovi
ded.
39D
ata
Type
Ref
eren
ce
(for
num
eric
res
ults
):H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng
Sta
ndar
ds—
Dat
a Ty
pe
Spe
cific
atio
nS
ectio
n 6.
11—
PQ
.LA
B
Labo
rato
ry Q
uant
ity
Exa
mpl
e:m
g/m
ol
Foun
d in
:P
OLB
_MT0
0400
0CA
—La
bora
tory
Res
ult
Eve
nt—
2009
0316
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
.
74
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
H5
Lab
Test
R
esul
t Low
R
ange
Labo
rato
ry
Test
Res
ult
Ref
eren
ce
Ran
ge L
ow
Num
ber
Rep
rese
nts
the
low
end
of a
nor
mal
re
fere
nce
rang
e la
b re
sult
for
a pa
rtic
ular
te
st p
erfo
rmed
in
a pa
rtic
ular
lab.
Use
d in
the
prov
isio
n of
car
e. L
ab te
sts
are
orde
red
in th
e pr
ovis
ion
of c
are
for
man
y re
ason
s, in
clud
ing
conf
irmat
ion
of
susp
ecte
d di
agno
ses.
Th
e re
fere
nce
rang
e is
re
quire
d to
det
erm
ine
whe
ther
the
lab
test
re
sult
is n
orm
al o
r no
t. Fl
ag a
nd a
lert
pro
vide
r. H
bA1C
is 6
.5 b
ut C
lient
ha
s a
fam
ily h
isto
ry o
f di
abet
es. P
reve
ntiv
e m
easu
res
are
initi
ated
.
39D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.11
—P
Q.L
AB
La
bora
tory
Qua
ntity
Exa
mpl
e:0.
5
Foun
d in
:S
C-2
003-
EN
—P
OLB
_M
T004
000C
A—
Labo
rato
ry R
esul
t E
vent
—20
0903
16.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
.
H6
Lab
Test
R
esul
t Uni
t of
Mea
sure
Labo
rato
ry
Test
Res
ult
Ref
eren
ce
Ran
ge
Low
Uni
t of
Mea
sure
C
ode
Rep
rese
nts
the
unit
of
mea
sure
ass
ocia
ted
with
the
Lab
Test
Res
ult
Ref
eren
ce R
ange
Low
N
umbe
r.
Use
d in
the
prov
isio
n of
car
e. E
nsur
es th
at
the
unit
of m
easu
re
is a
ssoc
iate
d w
ith th
e va
lue
as p
rovi
ded.
39D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.11
—P
Q.L
AB
La
bora
tory
Qua
ntity
Exa
mpl
e:m
g
Foun
d in
:P
OLB
_MT0
0400
0CA
—La
bora
tory
Res
ult
Eve
nt—
2009
0316
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
.
75
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
H7
Lab
Test
R
esul
t H
igh
Ran
ge
Labo
rato
ry
Test
Res
ult
Ref
eren
ce
Ran
ge H
igh
Num
ber
Rep
rese
nts
the
high
en
d of
a n
orm
al
refe
renc
e ra
nge
lab
resu
lt fo
r a
part
icul
ar
test
per
form
ed in
a
part
icul
ar la
b.
Use
d in
the
prov
isio
n of
car
e. L
ab te
sts
are
orde
red
in th
e pr
ovis
ion
of c
are
for
man
y re
ason
s, in
clud
ing
conf
irmat
ion
of
susp
ecte
d di
agno
ses.
Th
e re
fere
nce
rang
e is
re
quire
d to
det
erm
ine
whe
ther
the
lab
test
re
sult
is n
orm
al o
r no
t. Fl
ag a
nd a
lert
pro
vide
r. H
bA1C
is 6
.5 b
ut C
lient
ha
s a
fam
ily h
isto
ry o
f di
abet
es. P
reve
ntiv
e m
easu
res
are
initi
ated
.
39D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.11
—P
Q.L
AB
La
bora
tory
Qua
ntity
Exa
mpl
e:2.
5
Foun
d in
:S
C-2
003-
EN
—P
OLB
_M
T004
000C
A—
Labo
rato
ry R
esul
t E
vent
—20
0903
16.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
.
H8
Lab
Test
R
esul
t R
ange
Uni
t of
Mea
sure
Labo
rato
ry
Test
Res
ult
Ref
eren
ce
Ran
ge
Hig
h U
nit
of M
easu
re
Cod
e
Rep
rese
nts
the
unit
of m
easu
re a
ssoc
iate
d w
ith th
e La
b Te
st R
esul
t R
efer
ence
Ran
ge H
igh
Num
ber.
Use
d in
the
prov
isio
n of
car
e. E
nsur
es th
at
the
unit
of m
easu
re
is a
ssoc
iate
d w
ith th
e va
lue
as p
rovi
ded.
39D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.11
—P
Q.L
AB
La
bora
tory
Qua
ntity
Exa
mpl
e:m
g
Foun
d in
:P
OLB
_MT0
0400
0CA
—La
bora
tory
Res
ult
Eve
nt—
2009
0316
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
.
76
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
Co
ntex
t: D
iag
nost
ic Im
agin
g O
rder
sD
efin
itio
n: R
eque
sts
for
dia
gno
stic
imag
ing
ser
vice
s, w
hic
h t
ypic
ally
res
ult
in im
agin
g p
roce
dur
es p
erfo
rmed
to
th
e C
lient
. (S
our
ce H
L7 v
3).
Add
ition
al d
ata
elem
ents
that
may
be
requ
ired
to s
uppo
rt th
e us
e an
d ex
trac
tion
of D
iagn
ostic
Imag
ing
Ord
er d
ata
in P
HC
EM
Rs:
Pro
vide
r (e
.g. t
he P
rovi
der
who
aut
hore
d th
e or
der
for
the
diag
nost
ic im
agin
g te
st[s
]): P
rovi
der
Iden
tifie
r C
ode,
Pro
vide
r Id
entif
ier
Ass
igni
ng A
utho
rity,
Pro
vide
r R
ole
Type
and
P
rovi
der
Exp
ertis
e ex
pres
sed
in th
e co
ntex
t of t
he D
iagn
ostic
Imag
ing
Ord
er.
Clie
nt (
e.g.
the
Clie
nt w
ho w
as th
e su
bjec
t of t
he D
iagn
ostic
Imag
ing
Ord
er):
Clie
nt Id
entif
ier
Cod
e, C
lient
Iden
tifie
r Ty
pe a
nd C
lient
Iden
tifie
r A
ssig
ning
Aut
horit
y ex
pres
sed
in th
e co
ntex
t of t
he D
iagn
ostic
Imag
ing
Ord
er.
Enc
ount
er Id
entif
ier:
A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e E
ncou
nter
ass
ocia
ted
with
the
Dia
gnos
tic Im
agin
g O
rder
.D
iagn
ostic
Imag
ing
Ord
er Id
entif
ier:
A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e D
iagn
ostic
Imag
ing
Ord
er.
I1D
iagn
ostic
Im
agin
g Te
st
Ord
ered
Dia
gnos
tic
Imag
ing
Test
O
rder
ed
Cod
e
Rep
rese
nts
the
type
of
diag
nost
ic im
agin
g te
st
orde
red
by th
e P
rovi
der
for
the
Clie
nt.
Use
d in
the
prov
isio
n of
ca
re. D
iagn
ostic
imag
es
can
be u
sed
to a
ssis
t in
the
conf
irmat
ion
of
susp
ecte
d di
agno
sis.
49 a
nd 5
1S
NO
ME
D C
T®
Con
cept
Dom
ain:
Act
Pro
fess
iona
lSer
vice
-C
ode
Exa
mpl
e:36
3000
009
(car
diov
as-
cula
r di
agno
stic
ima-
ging
pro
cedu
re)
Not
e: W
hile
con
cept
do
mai
ns h
ave
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Rec
ord
108,
C
onso
lidat
es p
atie
nt
hist
ory,
rec
ent t
est
resu
lts a
nd in
form
atio
n di
spla
yed
in a
sin
gle,
su
mm
ary
view
.
I2D
iagn
ostic
Im
agin
g Te
st
Ord
ered
D
ate
Dia
gnos
tic
Imag
ing
Test
O
rder
ed D
ate
Rep
rese
nts
the
date
th
e di
agno
stic
imag
ing
test
was
ord
ered
by
the
Pro
vide
r.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Sch
edul
e fu
ture
ap
poin
tmen
t bas
ed o
n th
e tr
ack
turn
arou
nd
time
of d
iagn
ostic
im
agin
g te
st.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng S
tand
ards
—D
ata
Type
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
e: W
hile
a d
ata
type
ha
s be
en r
efer
ence
d,
this
exa
ct d
ata
elem
ent
does
not
cur
rent
ly e
xist
in
the
pan-
Can
adia
n E
HR
Mes
sagi
ng
Sta
ndar
ds.
Rec
ord
267,
Abi
lity
to
disp
lay,
sor
t and
sea
rch
hist
oric
al D
I dat
a us
ing
a us
er-d
efin
ed s
elec
tion
crite
ria.
77
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
Co
ntex
t D
iag
nost
ic Im
agin
g R
esul
tsD
efin
itio
n: T
he
resu
lts o
f d
iag
nost
ic im
agin
g s
ervi
ces,
wh
ich
are
typ
ical
ly t
he
resu
lts o
f im
agin
g p
roce
dur
es p
erfo
rmed
on
the
Clie
nt. (
So
urce
HL7
v3)
.A
dditi
onal
dat
a el
emen
ts th
at m
ay b
e re
quire
d to
sup
port
the
use
and
extr
actio
n of
Dia
gnos
tic Im
agin
g R
esul
ts d
ata
in P
HC
EM
Rs:
Pro
vide
r (e
.g. t
he P
rovi
der
who
aut
hore
d th
e or
der
for
the
diag
nost
ic im
agin
g te
st[s
]): P
rovi
der
Iden
tifie
r C
ode,
Pro
vide
r Id
entif
ier
Ass
igni
ng A
utho
rity,
Pro
vide
r R
ole
Type
and
Pro
vide
r E
xper
tise
expr
esse
d in
the
cont
ext
of th
e D
iagn
ostic
Imag
ing
Ord
er th
at r
elat
es to
the
Dia
gnos
tic Im
agin
g R
esul
ts. C
lient
(e.
g. th
e C
lient
who
was
the
subj
ect o
f the
Dia
gnos
tic Im
agin
g O
rder
): C
lient
Iden
tifie
r C
ode,
C
lient
Iden
tifie
r Ty
pe a
nd C
lient
Iden
tifie
r A
ssig
ning
Aut
horit
y ex
pres
sed
in th
e co
ntex
t of t
he D
iagn
ostic
Imag
ing
Ord
er th
at r
elat
es to
the
Dia
gnos
tic Im
agin
g R
esul
ts.
J1D
I Tes
t P
erfo
rmed
D
ate
Dia
gnos
tic
Imag
ing
Test
P
erfo
rmed
D
ate
Rep
rese
nts
the
date
the
diag
nost
ic im
agin
g te
st
was
per
form
ed.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Sch
edul
e fu
ture
ap
poin
tmen
t bas
ed o
n th
e tr
ack
turn
arou
nd
time
of d
iagn
ostic
im
agin
g te
st.
49D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
3—D
ates
+
Tim
ing
Exa
mpl
e:20
1004
30
Not
e: W
hile
a d
ata
type
ha
s be
en r
efer
ence
d,
this
exa
ct d
ata
elem
ent
does
not
cur
rent
ly e
xist
in
the
pan-
Can
adia
n E
HR
Mes
sagi
ng
Sta
ndar
ds.
Rec
ord
267,
Abi
lity
to
disp
lay,
sor
t and
sea
rch
hist
oric
al D
I dat
a us
ing
a us
er-d
efin
ed
sele
ctio
n cr
iteria
.
78
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceC
ont
ext:
Ref
erra
l Req
uest
Def
initi
on:
A r
eque
st f
rom
one
Pro
vid
er t
o a
noth
er t
o d
eliv
er o
ne o
r m
ore
hea
lth s
ervi
ces
for
a C
lient
. Th
e sc
op
e in
clud
es r
efer
rals
fo
r cl
inic
al c
are
or
eval
uatio
n,
as w
ell a
s re
ferr
als
for
com
mun
ity s
ervi
ces
such
as
mea
ls o
n w
hee
ls o
r h
om
e ca
re. (
So
urce
HL7
v3)
.A
dditi
onal
dat
a el
emen
ts th
at m
ay b
e re
quire
d to
sup
port
the
use
and
extr
actio
n of
Ref
erra
l Req
uest
dat
a in
PH
C E
MR
s:R
efer
ring
Pro
vide
r (e
.g. t
he a
utho
r of
the
refe
rral
): P
rovi
der
Iden
tifie
r C
ode,
Pro
vide
r Id
entif
ier
Ass
igni
ng A
utho
rity,
Pro
vide
r R
ole
Type
and
Pro
vide
r E
xper
tise
expr
esse
d in
the
cont
ext o
f the
Ref
erra
l Req
uest
.R
efer
red
to P
rovi
der
(e.g
. the
targ
et o
f the
ref
erra
l): P
rovi
der
Iden
tifie
r C
ode,
Pro
vide
r Id
entif
ier
Ass
igni
ng A
utho
rity,
Pro
vide
r R
ole
Type
and
Pro
vide
r E
xper
tise
expr
esse
d in
the
cont
ext o
f the
Ref
erra
l Req
uest
.C
lient
(e.
g. th
e su
bjec
t of t
he r
efer
ral):
Clie
nt Id
entif
ier
Cod
e, C
lient
Iden
tifie
r Ty
pe a
nd C
lient
Iden
tifie
r A
ssig
ning
Aut
horit
y ex
pres
sed
in th
e co
ntex
t of t
he R
efer
ral R
eque
st.
Enc
ount
er Id
entif
ier:
A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e E
ncou
nter
ass
ocia
ted
with
the
Ref
erra
l Req
uest
.R
efer
ral R
eque
st Id
entif
ier:
A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e R
efer
ral R
eque
st.
K1
Ref
erra
l R
efer
ral
Ser
vice
Cod
eR
epre
sent
s th
e ty
pe
of s
ervi
ce r
equi
red
for
the
Clie
nt.
Cod
es th
at id
entif
y di
ffere
nt ty
pes
of
refe
rral
req
uest
s.
Iden
tify
the
gene
ral
type
of c
are
or c
ateg
ory
of s
ervi
ces
requ
este
d.
Not
use
d to
rep
rese
nt
the
indi
catio
n or
di
agno
sis
that
trig
gere
d th
e ne
ed fo
r th
e re
ferr
al.
58S
NO
ME
D C
T®
Con
cept
Dom
ain:
A
ctC
areP
rovi
sion
Re-
ques
tTyp
e
Exa
mpl
e:31
0149
003
(Ear
, Nos
e an
d Th
roat
Ser
vice
)
Foun
d in
:R
EP
C_M
T210
001C
A—
Ref
erra
l Rec
ord—
Mar
ch 1
6, 2
009.
Rec
ord
105,
Allo
w
docu
men
tatio
n of
cr
iteria
for
acce
ptan
ce
of r
efer
rals
and
to
docu
men
t crit
eria
ag
ains
t eac
h re
ferr
al r
ecei
ved.
K2
Ref
erra
l R
eque
sted
D
ate
Ref
erra
l R
eque
sted
D
ate
Rep
rese
nts
the
date
the
Ref
erra
l Req
uest
was
cr
eate
d by
the
Prim
ary
Hea
lth C
are
Pro
vide
r.
Use
d in
pro
visi
on o
f ca
re a
nd a
dmin
istr
atio
n of
car
e. A
ssis
ts
Pro
vide
rs in
trac
king
w
hen
a re
ques
t to
obta
in a
con
sult
was
fir
st r
eque
sted
.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng
Sta
ndar
ds—
Dat
a Ty
pe
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
e: W
hile
a d
ata
type
ha
s be
en r
efer
ence
d,
this
exa
ct d
ata
elem
ent
does
not
cur
rent
ly e
xist
in
the
pan-
Can
adia
n E
HR
Mes
sagi
ng
Sta
ndar
ds.
Rec
ord
275,
Abi
lity
to
log
whe
n a
refe
rral
has
be
en s
ent a
nd w
hich
pr
ovid
er(s
) ha
ve b
een
sent
the
refe
rral
lette
r;
incl
udes
dat
e an
d tim
e st
amp.
79
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
Co
ntex
t: R
efer
ral R
esul
tD
efin
itio
n: A
des
crip
tion
of
the
hea
lth s
ervi
ces
per
form
ed f
or
the
Clie
nt in
res
po
nse
to t
he
Ref
erra
l Req
uest
; oft
en in
clud
es a
dd
itio
nal i
nfo
rmat
ion
such
as
the
sub
ject
ive
and
ob
ject
ive
note
s ab
out
th
e C
lient
and
th
e re
com
men
ded
tre
atm
ent
pla
n.A
dditi
onal
dat
a el
emen
ts th
at m
ay b
e re
quire
d to
sup
port
the
use
and
extr
actio
n of
Ref
erra
l Res
ult d
ata
in P
HC
EM
Rs:
Ref
errin
g P
rovi
der
(e.g
. the
aut
hor
of th
e re
ferr
al):
Pro
vide
r Id
entif
ier
Cod
e, P
rovi
der
Iden
tifie
r A
ssig
ning
Aut
horit
y, P
rovi
der
Rol
e Ty
pe a
nd P
rovi
der
Exp
ertis
e ex
pres
sed
in th
e co
ntex
t of t
he R
efer
ral R
eque
st th
at r
elat
es to
the
resu
lts.
Ref
erre
d to
Pro
vide
r (e
.g. t
he ta
rget
of t
he r
efer
ral):
Pro
vide
r Id
entif
ier
Cod
e, P
rovi
der
Iden
tifie
r A
ssig
ning
Aut
horit
y, P
rovi
der
Rol
e Ty
pe a
nd P
rovi
der
Exp
ertis
e ex
pres
sed
in th
e co
ntex
t of t
he R
efer
ral R
eque
st th
at r
elat
e to
the
resu
lts. C
lient
(e.
g. th
e su
bjec
t of t
he r
efer
ral):
Clie
nt Id
entif
ier
Cod
e, C
lient
Iden
tifie
r Ty
pe a
nd C
lient
Iden
tifie
r A
ssig
ning
Aut
horit
y ex
pres
sed
in th
e co
ntex
t of t
he R
efer
ral R
eque
st th
at r
elat
e to
the
resu
lts. R
efer
ral R
eque
st Id
entif
ier:
A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e R
efer
ral R
eque
st th
at is
as
soci
ated
with
the
Ref
erra
l Res
ult.
Ref
erra
l Res
ult I
dent
ifier
: A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e R
efer
ral R
esul
t.
L1R
efer
ral
Occ
urre
d D
ate
Ref
erra
l O
ccur
red
Dat
e
Rep
rese
nts
the
actu
al
date
the
Clie
nt h
ad
the
Enc
ount
er w
ith th
e re
ferr
ed to
Pro
vide
r.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
A
ssis
ts p
rovi
ders
in
unde
rsta
ndin
g w
hich
re
ferr
al p
artn
ers
have
lo
nger
wai
t tim
es.
Det
erm
ine
the
wai
t tim
e of
Clie
nts
and
deve
lop
accu
rate
futu
re
sche
dulin
g tim
es fo
r se
lect
ed r
easo
ns fo
r vi
sit a
nd r
efer
rals
.
58D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
Sta
ndar
ds—
Dat
a Ty
pe S
peci
ficat
ion
Sec
tion
3—D
ates
+
Tim
ing
Exa
mpl
e:20
1004
30
To b
e de
term
ined
. Th
e da
te o
f the
ref
erra
l E
ncou
nter
cou
ld s
how
in
sev
eral
mes
sage
s de
pend
ing
on w
hat
the
refe
rral
is fo
r. R
EP
C_M
T500
004C
A—
Car
e C
ompo
sitio
n D
etai
l May
8, 2
007.
Rec
ord
279,
Mai
ntai
n hi
stor
ical
pat
ient
-bas
ed
reco
rd o
f ref
erra
ls, s
ent
and/
or r
ecei
ved
and
disp
ositi
on/o
utco
me.
A
ble
to v
iew
/prin
t lis
t.
80
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ceC
ont
ext:
Pre
scri
bed
Med
icat
ion
Def
initi
on:
Th
e m
edic
atio
n o
rder
ed f
or
a C
lient
by
a P
rovi
der
. (S
our
ce H
L7 v
3).
Add
ition
al d
ata
elem
ents
that
may
be
requ
ired
to s
uppo
rt th
e us
e an
d ex
trac
tion
of P
resc
ribed
Med
icat
ion
data
in P
HC
EM
Rs:
Pro
vide
r (e
.g. t
he P
rovi
der
who
pre
scrib
ed th
e m
edic
atio
n): P
rovi
der
Iden
tifie
r C
ode,
Pro
vide
r Id
entif
ier
Ass
igni
ng A
utho
rity,
Pro
vide
r R
ole
Type
and
Pro
vide
r E
xper
tise
expr
esse
d in
the
cont
ext o
f pre
scrib
ing
med
icat
ion.
Clie
nt (
e.g.
the
Clie
nt th
at is
pre
scrib
ed th
e m
edic
atio
n): C
lient
Iden
tifie
r C
ode,
Clie
nt Id
entif
ier
Type
and
Clie
nt Id
entif
ier
Ass
igni
ng A
utho
rity
expr
esse
d in
the
cont
ext
of p
resc
ribin
g m
edic
atio
n.E
ncou
nter
Iden
tifie
r: A
bus
ines
s id
entif
ier
that
uni
quel
y id
entif
ies
the
Enc
ount
er a
ssoc
iate
d w
ith th
e pr
escr
iptio
n.M
edic
atio
n P
resc
riptio
n Id
entif
ier:
A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e m
edic
atio
n pr
escr
iptio
n.
M1
Pre
scrib
ed
Med
icat
ion
Med
icat
ion
Pre
scrib
ed
Nam
e C
ode
Rep
rese
nts
the
med
icat
ions
pre
scrib
ed
(or
inte
nded
to b
e pr
escr
ibed
) to
the
Clie
nt.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to c
reat
e a
long
itudi
nal
med
icat
ion
reco
rd to
su
ppor
t the
pro
visi
on
of c
are.
59, 6
0, 6
2 an
d 63
MTW
—In
fow
ay
Sta
ndar
ds C
olla
bora
tive
(SN
OM
ED
CT®
HC
-AIG
C, H
C-A
IGN
, H
C-D
IN, H
C-N
PN
, G
TIN
)
Con
cept
Dom
ain:
C
linic
alD
rug
Exa
mpl
e:03
741
(Am
oxic
illin
)
Foun
d in
:P
OR
X_M
T010
120C
A—
Rx
Dru
g O
rder
—20
0903
16.
Rec
ord
169,
Mai
ntai
n ea
ch m
edic
atio
n fo
r a
give
n pa
tient
as
disc
rete
dat
a el
emen
ts.
M2
Pre
scrip
-tio
n D
ate
Med
icat
ion
Pre
scrib
ed
Dat
e
Rep
rese
nts
the
date
th
e pr
escr
iptio
n fo
r th
e m
edic
atio
n w
as c
reat
ed
for
the
Clie
nt.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to c
reat
e a
long
itudi
nal
med
icat
ion
reco
rd to
su
ppor
t the
pro
visi
on
of c
are.
59, 6
0, 6
2 an
d 63
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng
Sta
ndar
ds—
Dat
a Ty
pe
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Rep
rese
nts
the
first
da
te in
the
inte
rval
de
fined
by
the
“Dis
pens
ing
Allo
wed
P
erio
d” fo
und
in:
PO
RX
_MT0
1012
0CA
—R
x D
rug
Ord
er—
2009
0316
.
Rec
ord
169,
Mai
ntai
n ea
ch m
edic
atio
n fo
r a
give
n pa
tient
as
disc
rete
dat
a el
emen
ts.
81
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
M3
Pre
scrip
-tio
n E
xpec
ted
Com
ple-
tion
Dat
e
Med
icat
ion
Pre
scrib
ed
Exp
ecte
d C
ompl
etio
n D
ate
Rep
rese
nts
the
last
da
te th
e P
resc
ribed
M
edic
atio
n is
exp
ecte
d to
fini
sh.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to c
reat
e a
long
itudi
nal
med
icat
ion
reco
rd to
su
ppor
t the
pro
visi
on
of c
are.
62D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
3—D
ates
+
Tim
ing
Exa
mpl
e:20
1004
30
Rep
rese
nts
the
last
da
te in
the
inte
rval
de
fined
by
the
“Dis
pens
ing
Allo
wed
P
erio
d” fo
und
in:
PO
RX
_MT0
1012
0CA
—R
x D
rug
Ord
er—
2009
0316
.
Rec
ord
169,
Mai
ntai
n ea
ch m
edic
atio
n fo
r a
give
n pa
tient
as
disc
rete
dat
a el
emen
ts.
M4
Pre
scrip
-tio
n S
top
Dat
e
Med
icat
ion
Pre
scrib
ed
Sto
pped
Dat
e
Rep
rese
nts
the
last
da
te th
e C
lient
took
the
Pre
scrib
ed M
edic
atio
n.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
P
rovi
des
hist
oric
al a
nd
curr
ent m
edic
atio
n pr
ofile
for
the
clie
nt.
59, 6
0, 6
2 an
d 63
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng
Sta
ndar
ds—
Dat
a Ty
pe
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Not
e: W
hile
a d
ata
type
re
fere
nce
has
been
pr
ovid
ed, t
his
exac
t da
ta e
lem
ent d
oes
not
curr
ently
exi
st in
the
pan-
Can
adia
n E
HR
M
essa
ging
Sta
ndar
ds.
Rec
ord
169,
Mai
ntai
n ea
ch m
edic
atio
n fo
r a
give
n pa
tient
as
disc
rete
dat
a el
emen
ts.
M5
Med
icat
ion
Str
engt
hM
edic
atio
n P
resc
ribed
S
tren
gth
Num
ber
Rep
rese
nts
the
pote
ncy
of th
e dr
ug/c
hem
ical
, us
ually
mea
sure
d in
m
etric
wei
ght (
e.g.
m
icro
gram
s, m
illig
ram
s,
gram
s) a
nd d
escr
ibed
as
the
stre
ngth
of
the
prod
uct’s
act
ive
(med
icin
al)
ingr
edie
nt.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Con
veys
the
pote
ncy
of th
e dr
ug to
be
dis
pens
ed fo
r th
e C
lient
’s tr
eatm
ent.
59D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.7—
PQ
.DR
UG
Exa
mpl
e:10
0
Rep
rese
nts
the
num
eric
co
mpo
nent
of t
he
“Dru
g In
gred
ient
Q
uant
ity”
foun
d in
:C
OC
T_M
T220
200C
A—
Med
icat
ion
adm
inis
trab
le—
2009
0316
.
Rec
ord
180,
Pro
vide
s su
ppor
t to
pres
crip
tion
writ
ing
incl
udin
g:
reco
mm
ende
d do
sage
, rou
te, r
efill
s,
repe
ats,
etc
.
82
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
M6
Med
icat
ion
Str
engt
h U
nit o
f M
easu
re
Med
icat
ion
Pre
scrib
ed
Str
engt
h U
nit
of M
easu
re
Cod
e
Rep
rese
nts
the
units
of
mea
sure
for
Pre
scrib
ed
Med
icat
ion
Str
engt
h.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
C
onve
ys th
e un
it of
mea
sure
for
the
Str
engt
h (p
oten
cy)
of th
e dr
ug to
be
disp
ense
d fo
r th
e C
lient
’s tr
eatm
ent.
59D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.7—
PQ
.DR
UG
Exa
mpl
e:m
g
Rep
rese
nts
the
unit
of
mea
sure
com
pone
nt
of th
e “D
rug
Ingr
edie
nt
Qua
ntity
” fo
und
in:
CO
CT_
MT2
2020
0CA
—M
edic
atio
n ad
min
istr
able
—20
0903
16.
Rec
ord
180,
Pro
vide
s su
ppor
t to
pres
crip
tion
writ
ing
incl
udin
g:
reco
mm
ende
d do
sage
, rou
te, r
efill
s,
repe
ats,
etc
.
M7
Med
icat
ion
Dos
age
Med
icat
ion
Pre
scrib
ed
Dos
e N
umbe
r
Rep
rese
nts
the
mea
sure
d po
rtio
n of
a
drug
to b
e ta
ken
at a
ny
one
time
that
per
tain
s to
the
drug
pre
scrib
ed.
Use
d in
the
prov
isio
n of
car
e. U
sed
with
C
lient
wei
ght a
nd a
ge
to d
eter
min
e id
eal d
ose
for
the
Clie
nt.
59D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.7—
PQ
.DR
UG
Exa
mpl
e:10
0
Foun
d in
:P
OR
X_M
T010
120C
A—
Rx
Dru
g O
rder
—20
0903
16.
Rec
ord
180,
Pro
vide
s su
ppor
t to
pres
crip
tion
writ
ing
incl
udin
g:
reco
mm
ende
d do
sage
, rou
te, r
efill
s,
repe
ats,
etc
.
M8
Med
icat
ion
Dos
e U
nit
of M
easu
re
Med
icat
ion
Pre
scrib
ed
Dos
e U
nit
of M
easu
re
Cod
e
Rep
rese
nts
the
unit
of
mea
sure
of a
dru
g do
se
take
n at
any
one
tim
e.
Use
d in
the
prov
isio
n of
car
e. U
sed
with
C
lient
wei
ght a
nd a
ge
to d
eter
min
e id
eal d
ose
for
the
Clie
nt.
59D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.7—
PQ
.DR
UG
Exa
mpl
e:m
g
Foun
d in
:P
OR
X_M
T010
120C
A—
Rx
Dru
g O
rder
—20
0903
16.
Rec
ord
180,
Pro
vide
s su
ppor
t to
pres
crip
tion
writ
ing
incl
udin
g:
reco
mm
ende
d do
sage
, rou
te, r
efill
s,
repe
ats,
etc
.
83
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
M9
Med
icat
ion
Form
Med
icat
ion
Pre
scrib
ed
Form
Cod
e
The
phys
ical
co
nfig
urat
ion,
pr
esen
tatio
n of
sta
te
of m
atte
r of
any
gi
ven
drug
pro
duct
. Th
e do
sage
form
in
whi
ch th
e m
edic
atio
n is
adm
inis
tere
d (e
.g. t
able
t, liq
uid,
su
ppos
itory
, sol
utio
n).
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of c
are.
E
nsur
es th
at th
e rig
ht
form
of t
he P
resc
ribed
M
edic
atio
n is
pro
vide
d to
the
Clie
nt a
s re
quire
d fo
r tr
eatm
ent.
59H
L7 v
3
Con
cept
Dom
ain:
O
rder
able
Dru
gFor
m
Exa
mpl
e:N
DR
OP
(N
asal
Dro
ps)
Foun
d in
:P
OR
X_M
T010
120C
A—
Rx
Dru
g O
rder
—20
0903
16.
Rec
ord
180,
Pro
vide
s su
ppor
t to
pres
crip
tion
writ
ing
incl
udin
g:
reco
mm
ende
d do
sage
, rou
te, r
efill
s,
repe
ats,
etc
.
M10
Med
icat
ion
Freq
uenc
yM
edic
atio
n P
resc
ribed
Fr
eque
ncy
Text
Rep
rese
nts
the
num
ber
of o
ccur
renc
es w
ithin
a
give
n tim
e pe
riod
that
a
dose
of a
dru
g is
to b
e ad
min
iste
red.
Use
d in
the
prov
isio
n of
car
e to
ens
ure
that
th
e C
lient
take
s th
e m
edic
atio
n as
req
uire
d du
ring
a sp
ecifi
ed
perio
d of
tim
e, h
elpi
ng
to e
nsur
e th
e ef
ficie
ncy
of th
e tr
eatm
ent a
nd to
pr
even
t any
uni
nten
ded
med
icat
ion
over
dose
.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng
Sta
ndar
ds—
Dat
a Ty
pe
Spe
cific
atio
nS
ectio
n 6.
14—
Dru
g Q
uant
ity p
er T
ime
Dur
atio
n
Exa
mpl
e:2
tabl
ets/
24 h
ours
Foun
d in
:P
OR
X_M
T010
120C
A—
Rx
Dru
g O
rder
—20
0903
16.
Rec
ord
180,
Pro
vide
s su
ppor
t to
pres
crip
tion
writ
ing
incl
udin
g:
reco
mm
ende
d do
sage
, rou
te, r
efill
s,
repe
ats,
etc
.
M11
Med
icat
ion
Rou
teM
edic
atio
n P
resc
ribed
R
oute
Cod
e
Rep
rese
nts
the
part
of
the
body
on
whi
ch,
thro
ugh
whi
ch o
r in
to
whi
ch a
dru
g pr
oduc
t is
to b
e in
trod
uced
. A
drug
pro
duct
can
hav
e m
ore
than
one
rou
te o
f ad
min
istr
atio
n.
Use
d in
the
prov
isio
n of
car
e. P
rovi
de
inst
ruct
ions
to th
e C
lient
reg
ardi
ng h
ow
the
med
icat
ion
is to
be
take
n (a
s a
supp
osito
ry
vers
us o
rally
).
59H
L7 v
3
Con
cept
Dom
ain:
R
oute
ofA
dmin
istr
atio
n
NA
SIN
HL
(nas
al
inha
lant
)
Foun
d in
:P
OR
X_M
T010
120C
A—
Rx
Dru
g O
rder
—20
0903
16.
Rec
ord
180,
Pro
vide
s su
ppor
t to
pres
crip
tion
writ
ing
incl
udin
g:
reco
mm
ende
d do
sage
, rou
te, r
efill
s,
repe
ats,
etc
.
84
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
M12
Med
icat
ion
Num
ber
of R
epea
t/R
efill
(s)
Med
icat
ion
Pre
scrib
ed
Rep
eat
Num
ber
Rep
rese
nts
the
num
ber
of ti
mes
th
e pr
escr
iptio
n ca
n be
use
d to
ref
ill th
e P
resc
ribed
Med
icat
ion.
Use
d in
the
prov
isio
n of
car
e. P
rovi
de
inst
ruct
ions
on
how
of
ten
a pa
rtic
ular
pr
escr
iptio
n ca
n be
ref
illed
and
the
pote
ntia
l nee
d fo
r a
follo
w-u
p re
min
der
to th
e P
rovi
der
for
this
Clie
nt.
59D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
6.2—
Non
-ne
gativ
e In
tege
r
Exa
mpl
e:2
Foun
d in
:P
OR
X_M
T010
120C
A—
Rx
Dru
g O
rder
—20
0903
16.
Rec
ord
180,
Pro
vide
s su
ppor
t to
pres
crip
tion
writ
ing
incl
udin
g:
reco
mm
ende
d do
sage
, rou
te, r
efill
s,
repe
ats,
etc
.
M13
Med
icat
ion
Not
P
resc
ribed
R
easo
n
Med
icat
ion
Pre
scrib
ed
Not
Giv
en
Rea
son
Cod
e
Rep
rese
nts
the
reas
on
why
a p
refe
rred
m
edic
atio
n w
as n
ot
pres
crib
ed to
a C
lient
.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Exp
lain
s w
hy
a P
rovi
der
was
not
ab
le to
pre
scrib
e a
med
icat
ion
at th
e tim
e of
an
enco
unte
r. C
an
serv
e as
a r
emin
der
for
futu
re p
rovi
sion
of
car
e as
to w
hy a
pa
rtic
ular
med
icat
ion
may
not
be
suita
ble
for
an in
divi
dual
.
62H
L7 v
3
Con
cept
Dom
ain:
Sub
stan
ceA
dmin
istr
a-tio
nPer
mis
sion
Ref
usal
-R
easo
nCod
e
Exa
mpl
e:PA
TIN
ELI
G (
patie
nt n
ot
elig
ible
)
HL7
v3
Con
cept
Dom
ain:
Act
Det
ecte
dIss
ue
Exa
mpl
e:A
GE
(A
ge A
lert
)
Not
e: W
hile
con
cept
do
mai
ns h
ave
been
re
fere
nced
, thi
s ex
act
data
ele
men
t doe
s no
t cu
rren
tly e
xist
in th
e pa
n-C
anad
ian
EH
R
Mes
sagi
ng S
tand
ards
.
Not
cur
rent
ly r
equi
red
to s
uppo
rt a
ny o
f the
P
OS
R r
ecor
ds.
85
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
M14
Med
icat
ion
Com
pli-
ance
Med
icat
ion
Pre
scrib
ed
Adh
eren
ce
Cod
e
Rep
rese
nts
whe
ther
or
not
the
Clie
nt h
as
been
adm
inis
terin
g th
e pr
escr
ibed
m
edic
atio
n(s)
as
inst
ruct
ed.
Use
d in
bot
h th
e pr
ovis
ion
and
adm
inis
trat
ion
of
care
. Doc
umen
ts
that
a C
lient
did
not
ta
ke th
e pr
escr
ibed
dr
ug a
nd c
an b
e us
ed
to in
form
sub
sequ
ent
prov
isio
n of
car
e.
Exa
mpl
e: U
pon
taki
ng
Pre
vaci
d, a
Clie
nt
deve
lope
d di
arrh
ea
and
disc
ontin
ued
use
of th
e dr
ug.
60 a
nd 6
3D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
8.4—
BL—
Boo
lean
Exa
mpl
e:T
(Tru
e)
Not
e: W
hile
a d
ata
type
ha
s be
en r
efer
ence
d,
this
exa
ct d
ata
elem
ent
does
not
cur
rent
ly e
xist
in
the
pan-
Can
adia
n E
HR
Mes
sagi
ng
Sta
ndar
ds.
Rec
ord
170,
Mai
ntai
ns
patie
nt m
edic
atio
nlis
t, in
clud
ing
pres
crib
ing
and
disp
ensi
ng e
vent
s.
Co
ntex
t: D
isp
ense
d M
edic
atio
nD
efin
itio
n: T
he
med
icat
ion
dis
pen
sed
to
a C
lient
by
a P
rovi
der
. (S
our
ce H
L7 v
3).
Add
ition
al d
ata
elem
ents
that
may
be
requ
ired
to s
uppo
rt th
e us
e an
d ex
trac
tion
of D
ispe
nsed
Med
icat
ion
data
in P
HC
EM
Rs:
Pro
vide
r (e
.g. t
he P
rovi
der
who
pre
scrib
ed th
e m
edic
atio
n): P
rovi
der
Iden
tifie
r C
ode,
Pro
vide
r Id
entif
ier
Ass
igni
ng A
utho
rity,
Pro
vide
r R
ole
Type
and
Pro
vide
r E
xper
tise
expr
esse
d in
the
cont
ext o
f the
Pre
scrib
ed M
edic
atio
n th
at
rela
tes
to th
e D
ispe
nsed
Med
icat
ion.
Clie
nt (
e.g.
the
Clie
nt th
at is
pre
scrib
ed th
e m
edic
atio
n): C
lient
Iden
tifie
r C
ode,
Clie
nt Id
entif
ier
Type
and
Clie
nt Id
entif
ier
Ass
igni
ng A
utho
rity
expr
esse
d in
the
cont
ext o
f the
Pre
scrib
ed M
edic
atio
n th
at r
elat
es to
the
Dis
pens
ed M
edic
atio
n. M
edic
atio
n P
resc
riptio
n Id
entif
ier:
A b
usin
ess
iden
tifie
r th
at u
niqu
ely
iden
tifie
s th
e m
edic
atio
n pr
escr
iptio
n. M
edic
atio
n D
ispe
nsed
Iden
tifie
r: A
bus
ines
s id
entif
ier
that
uni
quel
y id
entif
ies
the
med
icat
ion
disp
ense
d.
N1
Med
icat
ion
Dis
pens
edM
edic
atio
n D
ispe
nsed
C
ode
Rep
rese
nts
the
med
icat
ion
that
was
di
spen
sed
to th
e C
lient
.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to c
reat
e a
long
itudi
nal
med
icat
ion
reco
rd to
su
ppor
t the
pro
visi
on
of c
are.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
HC
-DIN
[H
C-N
PN
]
Con
cept
Dom
ain:
M
anuf
actu
redD
rug
Exa
mpl
e:02
2377
22 (
gen-
aceb
utol
ol 2
00 m
g)
Foun
d in
:P
OR
X_M
T020
070C
A—
Dru
g D
ispe
nse—
2009
0316
.
Rec
ord
170,
Mai
ntai
ns
patie
nt m
edic
atio
n lis
t, in
clud
ing
pres
crib
ing
and
disp
ensi
ng e
vent
s.
86
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
N2
Med
icat
ion
Dis
pens
ed
Dat
e
Med
icat
ion
Dis
pens
ed
Dat
e
Rep
rese
nts
the
date
th
e m
edic
atio
n w
as
disp
ense
d to
the
Clie
nt.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to c
reat
e a
long
itudi
nal
med
icat
ion
reco
rd to
su
ppor
t the
pro
visi
on
of c
are.
59, 6
0 an
d 63
Dat
a Ty
pe R
efer
ence
:H
L7 v
3 pa
n-C
anad
ian
Mes
sagi
ng
Sta
ndar
ds—
Dat
a Ty
pe
Spe
cific
atio
nS
ectio
n 3—
Dat
es +
Ti
min
g
Exa
mpl
e:20
1004
30
Foun
d in
:P
OR
X_M
T020
070C
A—
Dru
g D
ispe
nse—
2009
0316
.
Rec
ord
170,
Mai
ntai
ns
patie
nt m
edic
atio
n lis
t, in
clud
ing
pres
crib
ing
and
disp
ensi
ng e
vent
s.
Co
ntex
t: Im
mun
izat
ion
Def
initi
on:
Th
e ad
min
istr
atio
n o
f va
ccin
es (
and
/or
antis
era)
to
Clie
nts
to p
reve
nt in
fect
ious
dis
ease
. (S
our
ce H
L7 v
3).
Add
ition
al d
ata
elem
ents
that
may
be
requ
ired
to s
uppo
rt th
e us
e an
d ex
trac
tion
of Im
mun
izat
ion
data
in P
HC
EM
Rs:
Pro
vide
r (e
.g. t
he P
rovi
der
who
per
form
s th
e Im
mun
izat
ion)
: Pro
vide
r Id
entif
ier
Cod
e, P
rovi
der
Iden
tifie
r A
ssig
ning
Aut
horit
y, P
rovi
der
Rol
e Ty
pe a
nd P
rovi
der
Exp
ertis
e ex
pres
sed
in th
e co
ntex
t of t
he Im
mun
izat
ion.
Clie
nt (
e.g.
the
Clie
nt th
at r
ecei
ves
the
Imm
uniz
atio
n): C
lient
Iden
tifie
r C
ode,
Clie
nt Id
entif
ier
Type
and
Clie
nt Id
entif
ier
Ass
igni
ng A
utho
rity
expr
esse
d in
the
cont
ext o
f the
Imm
uniz
atio
n.E
ncou
nter
Iden
tifie
r: A
bus
ines
s id
entif
ier
that
uni
quel
y id
entif
ies
the
Enc
ount
er a
ssoc
iate
d w
ith th
e Im
mun
izat
ion.
O1
Vacc
ine
Adm
inis
-te
red
Vacc
ine
Adm
inis
tere
d N
ame
Cod
e
Rep
rese
nts
the
nam
e of
the
vacc
ine
that
w
as a
dmin
iste
red
to th
e C
lient
.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to c
reat
e re
min
ders
to
offe
r a
vacc
ine,
or
to fl
ag th
at a
vac
cine
ha
s al
read
y be
en g
iven
an
d do
es n
ot n
eed
to
be r
e-ad
min
iste
red
until
a
spec
ific
futu
re d
ate.
41, 4
2, 4
4S
NO
ME
D C
T®
Con
cept
Dom
ain:
Va
ccin
eEnt
ityTy
pe
3964
2500
6 (In
fluen
za
viru
s va
ccin
e [s
ubst
ance
])
Foun
d in
:P
OIZ
_MT0
3005
0CA
—Im
mun
izat
ion—
Febr
uary
7, 2
008.
Rec
ord
224,
Pro
vide
a
quer
y te
mpl
ate
that
ca
n ge
nera
te a
list
of
patie
nts
who
rec
eive
d a
vacc
ine.
87
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Tab
le 2
: Dat
a E
lem
ent M
atrix
(con
t’d)
Info
rmat
ive
Co
nten
t: X
Ref
No
rmat
ive
Co
nten
t:
Ava
ilab
le in
EM
R f
or
Pri
mar
y U
se a
nd E
xtra
cted
fo
r H
ealth
Sys
tem
Use
Info
rmat
ive
Co
nten
t:A
lignm
ent
to t
he
Pan
-Can
adia
n E
HR
UI
Dat
a E
lem
ent
Com
mon
N
ame
Dat
a E
lem
ent
Sta
ndar
d N
ame
Dat
a E
lem
ent
Def
initi
onE
xam
ple
of P
rimar
y U
se
PH
C
Indi
cato
r M
appi
ng
Term
inol
ogy
or D
ata
Type
Nam
e an
d E
xam
ple
Valu
esE
HR
MS
G a
nd T
erm
S
tand
ards
PO
SR
Ref
eren
ce
O2
Vacc
ine
Adm
inis
-te
red
Dat
e
Vacc
ine
Adm
inis
tere
d D
ate
Rep
rese
nts
the
date
the
vacc
ine
was
adm
inis
tere
d to
the
Clie
nt.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed to
en
sure
that
onl
y C
lient
s w
ho h
ave
not r
ecei
ved
an o
ffer
to v
acci
nate
re
ceiv
e re
min
ders
, or
to fl
ag th
at a
vac
cine
ha
s al
read
y be
en g
iven
an
d do
es n
ot n
eed
to
be r
e-ad
min
iste
red
until
a
spec
ific
futu
re d
ate.
41, 4
2, 4
4D
ata
Type
Ref
eren
ce:
HL7
v3
pan-
Can
adia
n M
essa
ging
S
tand
ards
—D
ata
Type
S
peci
ficat
ion
Sec
tion
3—D
ates
+
Tim
ing
Exa
mpl
e:20
1004
30
Foun
d in
:P
OIZ
_MT0
3005
0CA
—Im
mun
izat
ion—
Febr
uary
7, 2
008.
Rec
ord
26, A
bilit
y to
do
cum
ent m
edic
atio
ns
pres
crib
ed,
imm
uniz
atio
ns g
iven
an
d pr
oced
ures
pe
rform
ed o
utsi
de th
e ph
ysic
ian’
s cl
inic
to
capt
ure
a co
mpl
ete
patie
nt r
ecor
d.
O3
Vacc
ine
Adm
inis
-te
red
Lot
Num
ber
Vacc
ine
Adm
inis
tere
d Lo
t Num
ber
Rep
rese
nts
the
batc
h id
entif
icat
ion
num
ber
of th
e va
ccin
e.
Use
d in
the
prov
isio
n of
car
e. C
an b
e us
ed
to c
onta
ct C
lient
s w
ho
rece
ived
a p
artic
ular
lo
t num
ber
of a
va
ccin
e su
bsta
nce.
Sup
ple-
men
tary
—us
ed fo
r an
alys
is
and
repo
rtin
g
HL7
v3
N/A
Foun
d in
:P
OIZ
_MT0
3005
0CA
—Im
mun
izat
ion.
Rec
ord
224,
Pro
vide
a
quer
y te
mpl
ate
that
ca
n ge
nera
te a
list
of
patie
nts
who
rec
eive
d a
vacc
ine.
O4
Rea
son
Vacc
ine
Not
Giv
en
Vacc
ine
Not
G
iven
Rea
son
Cod
e
Rep
rese
nts
the
reas
on a
vac
cine
w
as n
ot a
dmin
iste
red
to a
Clie
nt.
Use
d in
the
prov
isio
n of
car
e. E
xpla
ins
why
a
Clie
nt m
ay h
ave
been
of
fere
d a
vacc
inat
ion
but r
efus
ed o
r w
hy
the
vacc
ine
was
not
gi
ven
for
othe
r re
ason
s.
Can
be
requ
ired
for
phys
icia
ns w
ho
part
icip
ate
in p
ay-fo
r-pe
rform
ance
pro
gram
s.
41, 4
2, 4
4H
L7 v
3
Con
cept
Dom
ain:
Act
-N
oIm
mun
izat
ionR
easo
n
Exa
mpl
e:PA
TOB
J (P
atie
nt O
bjec
tion)
Foun
d in
:P
OIZ
_MT0
3005
0CA
—Im
mun
izat
ion—
Febr
uary
7, 2
008.
Not
cur
rent
ly r
equi
red
to s
uppo
rt a
ny o
f the
P
OS
R r
ecor
ds.
89
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Appendix C: Pan-Canadian Primary Health Care IndicatorsSource Document: Pan-Canadian Primary Health Care Indicators, volume 2, www.cihi.ca/phc
Indicator Number Indicator Definition
13
% of PHC clients/patients, 12 years and over, who were screened by their PHC provider for the following common health risks over the past 12 months:• Tobacco use;• Unhealthy eating habits;• Problem drug use;• Physical inactivity;• Overweight status;• Problem alcohol drinking;• Unintentional injuries (home risk factors);• Unsafe sexual practices; and• Unmanaged psychosocial stress and/or depression.
36% of PHC clients/patients, ages 18 to 64, with established diabetes mellitus (type 1 and type 2) who have had an acute myocardial infarction or above or below knee amputation or began chronic dialysis within the past 12 months.
39% of PHC clients/patients,18 years and over, with diabetes mellitus in whom the last HbA1C was 7.0% or less (or equivalent test/reference range depending on local laboratory) in the last 15 months.
40 % of PHC clients/patients,18 years and over, with hypertension for duration of at least one year, who have blood pressure measurement control (i.e. less than 140/90 mmHg).
41 % of PHC clients/patients, 65 years and over, who received an influenza immunization within the past 12 months.
42 % of PHC clients/patients, 65 years and over, who have received a pneumococcal immunization.
43 % of PHC clients/patients who received screenings for congenital hip displacement, eye and hearing problems by 3 years of age.
44 % of PHC clients/patients who received required primary childhood immunizations by 7 years of age.
48 % of PHC clients/patients, 50 years and over, who received screening for colon cancer with Hemoccult test within the past 24 months.
49 % of women PHC clients/patients, ages 50 to 69, who received mammography and clinical breast examination within the past 24 months.
50 % of women PHC clients/patients, ages 18 to 69, who received a papanicolaou smear within the past 3 years.
51 % of women PHC clients/patients, 65 years and older, who received screening for low bone mineral density at least once.
52 % of women PHC clients/patients, 55 years and over, who had a full fasting lipid profile measured within the past 24 months.
53 % of men PHC clients/patients, 40 years and over, who had a full fasting lipid profile measured within the past 24 months.
54 % of PHC clients/patients, 18 years and over, who had their blood pressure measured within the past 24 months.
90
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Indicator Number Indicator Definition
55
% of PHC clients/patients,18 years and over, with coronary artery disease (CAD) who received annual testing, within the past 12 months, for all of the following:• Fasting blood sugar;• Full fasting lipid profile screening;• Blood pressure measurement; and• Obesity/overweight screening.
56
% of PHC clients/patients,18 years and over, with hypertension who received annual testing, within the past 12 months, for all of the following:• Fasting blood sugar;• Full fasting lipid profile screening;• Test to detect renal dysfunction (e.g. serum creatinine);• Blood pressure measurement; and• Obesity/overweight screening.
57
% of PHC clients/patients,18 years and over, with diabetes mellitus who received annual testing, within the past 12 months, for all of the following:• Hemoglobin A1c testing (HbA1c);• Full fasting lipid profile screening;• Nephropathy screening (e.g. albumin/creatinine ratio, microalbuminuria);• Blood pressure (BP) measurement; and• Obesity/overweight screening.
58 % of PHC clients/patients, 18 to 75 years, with diabetes mellitus who saw an optometrist or ophthalmologist within the past 24 months.
59
% of PHC clients/patients, ages 6 to 55, with asthma, who were dispensed high amounts (greater than 4 canisters) of short-acting beta2-agonist (SABA) within the past 12 months and who received a prescription for preventer/controller medication (e.g. inhaled corticosteroid—ICS).
60 % of PHC clients/patients, 18 years and over, with CHF who are using ACE inhibitors or ARBs.
62 % of PHC clients/patients who have had an AMI and are currently prescribed a beta blocking drug.
63% of PHC clients/patients with depression who are taking antidepressant drug treatment under the supervision of a PHC provider68 who had follow-up contact by a PHC provider for review within two weeks of initiating antidepressant drug treatment.
91
Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0—Business View
Appendix D: Glossary of Terms v
TermAcronym(if applicable) Description
Canadian Institute for Health Information
CIHIThe Canadian Institute for Health Information is an independent, not-for-profit organization that provides essential data and analysis on Canada’s health system and the health of Canadians.
Clinical Data Warehouse CDW
An overarching term for Health Information Data Warehouse. This is an enterprise-level system to facilitate query and analysis of health care data.
Clinical Program Management
Use of data for direct management of health services and programs, including quality improvement and decision support (program level).
Electronic Health Record EHR
An electronic health record (commonly known as an EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health care providers.8
Electronic Medical Record EMR
The electronic medical record is provider-centric, focuses on medical or physician-specific information and is configured to reflect the needs of individual physicians or groups of physicians who are directly caring for a patient. The EMR is a record of each and every patient encounter and will detail encounter information. This is also the system where patient results (such as laboratory, diagnostic imaging and other reports ordered by a provider) are delivered to that provider’s electronic in-box (that is, this information is pushed to the provider, negating the need for the provider to go out and seek it).9
Health Level 7 HL7
A comprehensive framework and related standards for the exchange, integration, sharing and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services.10
Health System Use HSU
Health system use of information refers to the use of health information to monitor, manage and improve the health of Canadians and the health care system. Health system use of information also supports the delivery of care and patient outcomes.
International Organization for Standardization
ISOISO is an international developer and publisher of standards and consists of a network of national standards institutes in 163 countries.11
Master Terminology Worksheet
MTW
An Excel file developed and maintained by the Infoway Standards Collaborative that provides the classification and status for all coded Concept Domains and Value Sets for the following pan-Canadian EHR HL7 v3 messaging domains:Infrastructure, Shared Interactions, Client Registry, Provider Registry, Location Registry, Shared Health Record, Pharmacy, Laboratory, Immunization, Claims and Record Access (includes Consent) domains.12
Pan-Canadian Laboratory Observation Code Database
pCLOCD
The pan-Canadian LOINC Observation Code Database (pCLOCD) Nomenclature Standard was created using the LOINC® records and attributes that specifically meet Canadian laboratory-ordering and -reporting requirements.13
v. All definitions are from CIHI unless otherwise noted.
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TermAcronym(if applicable) Description
Physician Office System Requirements
POSR
The purpose of the pan-Canadian “physician office system requirements (POSR)” exercise was to collaboratively identify core requirements based on experiences from across the country to assist jurisdictions in the management of electronic medical record (EMR) specifications. Stakeholders for this initiative include individual physicians and jurisdictions that are preparing for or are in the midst of the procurement process.14
The Standards Collaborative Strategic Committee recommended that, due to known POSR limitations, stakeholders should be aware of these limitations and exercise diligence in use of POSR. For more information, contact the Standards Collaborative Infodesk at [email protected] or call 1-877-595-3417 (toll free) or 416-595-3417 (local).
Point of Service PoS Refers to clinical systems used by a clinical provider at the point of care.
Secondary UseExpression sometimes employed to describe the use of data for additional purposes other than the primary reason for its collection, adding value to this data.
Statistics CanadaStatistics Canada is a federal organization responsible for producing statistics that help Canadians better understand characteristics of Canada’s population, resources, economy, society and culture.15
Surveillance Use of data for population health surveillance.
Systematized Nomenclature of Medicine-Clinical Terms
SNOMED CT®
SNOMED CT® provides the core general terminology for the electronic health record (EHR) and contains over 311,000 concepts with unique meanings and formal logic-based definitions organized into hierarchies. When implemented in software applications, SNOMED CT® can be used to represent clinically relevant information consistently, reliably and comprehensively as an integral part of producing electronic health records.16
Unified Code for Units of Measure UCUM A code system intended to include all units of measure currently
in use in international science.17
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ReferencesHealth Canada, 1. Primary Health Care and Health System Renewal, accessed on October 27, 2010, from <http://www.hc-sc.gc.ca/hcs-sss/prim/renew-renouv-eng.php>.
Health Council of Canada, 2. Primary Health Care: A Background Paper to Accompany Health Care Renewal in Canada—Accelerating Change (Toronto, Ont: Health Council of Canada, 2005).
Canada Health Infoway, 3. Physician Office System Requirements (August 24, 2009), pp. 3–5, accessed on October 27, 2010, from < http://forums.infoway-inforoute.ca/POSR/Physician%20Office%20System%20Requirements%20(POSR).pdf>.
Canada Health Infoway, 4. Product Release Management White Paper (July 7, 2007), p. 7, accessed on October 27, 2010, from <http://forums.infoway-inforoute.ca/[email protected]@.ef03d69>.
DAMA International, 5. The DAMA Guide to The Data Management Body of Knowledge, 1st Edition (Bradley Beach, New Jersey: Technics Publications, 2009).
DAMA International, 6. The DAMA Guide to The Data Management Body of Knowledge, 1st Edition (Bradley Beach, New Jersey: Technics Publications, 2009).
DAMA International, 7. The DAMA Guide to The Data Management Body of Knowledge, 1st Edition (Bradley Beach, New Jersey: Technics Publications, 2009).
Canada Health Infoway, 8. EHRS Blueprint: An Interoperable EHR Framework (April 2006), pp. 10–13, accessed on October 27, 2010, from <http://www2.infoway-inforoute.ca/Documents/EHRS-Blueprint-v2-Exec-Overview.pdf>.
The College of Family Physicians of Canada, 9. Primary Care Toolkit for Family Physicians, accessed on October 27, 2010, from <http://toolkit.cfpc.ca/en/information-technology/electronic-medical-record.php>.
Health Level 7, 10. About HL7, accessed on October 27, 2010, from <http://www.hl7.org/about/index.cfm>.
International Organization for Standardization, 11. About ISO, accessed on October 27, 2010, from <http://www.iso.org/iso/about.htm>.
Canada Health Infoway, 12. R02.04.00 Read Me (2009), p. 14, accessed on October 27, 2010, from <http://forums.infoway-inforoute.ca/[email protected]@.ef098ed>.
Canada Health Infoway, 13. Pan Canadian LOINC Observation Code Database (April 14, 2009), pp. 3–6, accessed on October 27, 2010, from <http://forums.infoway-inforoute.ca/[email protected]@.ef0cff6>.
Canada Health Infoway, 14. Physician Office System Requirements (August 24, 2009), pp. 3–5, accessed on October 27, 2010, from <http://forums.infoway-inforoute.ca/POSR/Physician%20Office%20System%20Requirements%20(POSR).pdf>.
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Statistics Canada, 15. About Us, accessed on October 27, 2010, from <http://www.statcan.gc.ca/about-apercu/about-apropos-eng.htm>.
International Health Terminology Standards Development Organisation, 16. SNOMED CT, accessed on October 27, 2010, from <http://www.ihtsdo.org/snomed-ct/>.
Regenstrief Institute, 17. The Unified Codes for Units of Measure, accessed on October 27, 2010, from <http://www.unitsofmeasure.org/wiki/WikiStart>.
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the intended use is for non-commercial purposes and full acknowledgement is
given to the Canadian Institute for Health Information.
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How to cite this document:
Canadian Institute for Health Information, Draft Pan-Canadian Primary Health
Care Electronic Medical Record Content Standard, Version 2.0—Business View
(Ottawa, Ont.: CIHI, 2011).
Cette publication est aussi disponible en français sous le titre Norme pancanadienne
provisoire relative au contenu du dossier médical électronique en lien avec les soins
de santé primaires, version 2.0 — perspective opérationnelle.
ISBN 978-1-55465-876-3 (PDF)
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