Transaction: Summarised Electronic Healthcare Record v1.1

General information

STATUS:

Published

OWNER:

eHealth Platform

STANDARD:

KMEHR

VERSION:

1.1

DATE:

2010-09-20

DEFINITION:

The Summarised Electronic Health Record (or SumEHR) is the minimal set of data that a physician needs to understand the medical status of the patient in a few minutes and to ensure the continuity of care.

The content of this new version has been defined by a group of experts and the sub-group “GP Label Group” of the eHealth Platform’s G19 Group in 2009. The latter did validate this new SumEHR version in December 2009. The resulting specification was published in a draft status on January 2010. It was published on June 2010 with some minor corrections. At the request of software providers, some corrections are made on Augustus 2010 leading to the current specification. At the request of Prorec and G19, the specification is extended on September 2010 to support the 'patient's will' items.

This version is the one that will be used during the coming certification process of GP software packages foreseen in 2010.

SumEHR 1.1 content specification.

Sumehr 1.1 requires the use of Kmehr 20100601 (or a more recent version).

To support the elaboration of messages that fullfill the Sumehr 1.1 specification, a tool has been developped. This tool is available here.

Each version of the Sumehr specification leads to a release of this tool.

Version 1.0.0 validates a message according to the specification published in June 2010 (Kmehr standard 20100601).
Version 1.0.1 validates a message according to the specification published in Augustus 2010 (Kmehr standard 20100601).
Version 1.1.0 validates a message according to the specification published in September 2010 (Kmehr standard 20100901).
Version 2.0.0 validates a message according to the specification published in July 2011 (Kmehr standard 20110701).

Guidelines

Generalities

This transaction requires a level 3-4 of kmehr normalization: content are preferably coded however some textual contents are still allowed.

Patient

The patient is, as usual, represented by the patient element of the folder. In the case of a sumehr, the attribute id must contain the INSS number of the patient. The birthdate is also required and must be complete.

Transaction elements

id	id of the transaction according to the ID-KMEHR conventions.
cd	Indicates that the transaction is a sumehr by the use of the value 'sumehr' from CD-TRANSACTION.
date	Date of creation of the sumehr (must be complete).
time	Time of creation of the sumehr.
author	Describes the author of the sumehr. This author must be a health care professional. It is usually a general practitioner. The author is the person that assumes the responsibility of the medical content of the sumehr. The author is, as usual represented, by a hcparty element. In the case of a sumehr, the id element must contain the INAMI/RIZIV/NIHII number of the healthcare professional. Furthermore, the cd element will usually refer to the value ‘persphysician’ of CD-HCPARTY. The use of the address and telecom elements is recommended.
iscomplete	By definition, a sumehr record must be complete. Therefore, the value must be true.
isvalidated	By definition, a sumehr record must be validated. Therefore, the value must be true.

Structure overview

A sumehr is only composed of recognized items and headings. It should at least contain one item.

Headings

The following headings values from CD-HEADING should be used.

assessment	The items describing the ‘problems’ should be placed under this heading value.
history	The items describing the ‘relevant passive care elements’ should be placed under this heading value.

Items

The following items from CD-ITEM must be used to compose a sumehr transaction. Optional attributes are set within squared braces.

Item type (cd)	Item purpose	Item structure
adr	Specifies a risk relative to a an adverse drug reaction.	content (text+) [content (cd+)] For each risk, an item is provided. This item contains textual content with the label of the risk at least. It should also contain one cd elements content corresponding to the available codifications. Recommended codifications: IBUI, ICPC-2, ICD-10.
allergy	Specifies a risk relative to an allergy.	same structure as 'adr'
socialrisk	Specifies a social risk factor.	same structure as 'adr'
risk	Specifies other risk factors.	same structure as 'adr'
contactperson An additional cd element with a value from CD-CONTACT-PERSON may be used to describe the link with the patient.	Specifies a patient related person (family, etc ...)	content (person) The contact person is described by a person element.
contacthcparty	Specifies a healthcare professional contact.	content (hcparty) The healthcare professional is described by, at least, one hcparty element. This HCParty should contain the INAMI/RIZIV number of the healthcare professional (if available). The role of the contact must be described within the cd element by a value from CD-HCPARTY.
gmdmanager	Specifies the manager of the DMG/GMD	content (hcparty) The GMD manager is described by an hcparty element whose id element must contain a INAMI/RIZIV number. If the GMD owner is a physical person, it also contains a familyname and firstname elements. If the GMD owner is a medical practice, it also contains a name element.
patientwill	Specifies a therapeutic limitation expressed for the patient (specified only if registered).	content (cd+) [content (text+)] The therapeutic limitations are described using the values of CD-PATIENTWILL.
healthcareelement	Specifies either a 'current problem' or a 'relevant passive care element'	content (text+) [content (cd+)] For each healthcare element, an item is provided. This item contains at least a textual content with the label of the risk. It should also contain one cd elements content corresponding to the available codifications. Recommended codifications: IBUI,ICPC-2, ICD-10.
		[beginmoment] Specifies when the problem started.
		[endmoment] Specifies when the problem ended.
		lifecycle Must be used to distinguish between a current problem (value ‘ active’ from CD-LIFECYCLE) and a relevant passive medical antecedent (value ‘inactive’). If needed to describe the absence of a specific problem: the value ‘notpresent’ must be used.
		If needed to explicitly express there are NO KNOWN relevant medical antecedents, include the following item (nullFlavor 'NA' = not applicable) <item> <id S="ID-KMEHR" SV="1.0">1</id> <cd S="CD-ITEM" SV="1.10" nullFlavor="NA">problem</cd> <lifecycle> <cd S="CD-LIFECYCLE" SV="1.0">inactive</cd> </lifecycle> </item> (If it is needed to express the absence of a specific problem: use the lifecycle value as described supra.)
medication	Specifies the patient's medication known to be current by the Sumehr author at the moment of creation. Note if there is inactive medication that might be relevant, this can be best clarified as a relevant therapeutical antecedent.	content (text) Textual description of the medication.
		[content (cd)] Value from CD-ATC corresponding to the medication.
		All the item elements (such as medicinalproduct, substanceproduct, compound, posology, frequency etc.) described in pharmaceutical prescription 2.1 may be used.
vaccine	Specifies a relevant administrated vaccine	[content (medicinalproduct \| substanceproduct)] This content should correspond to the medicinal product administrated for this vaccine (when available) The element medicinalproduct supports the identification the prepacked medicinal product by a code from CD-DRUG-CNK (element intendeddcc) and a textual description (element intendedname) whereas the element substanceproduct describes the INN or substance based cluster prescribed by using a value from CD-INNCLUSTER.
		content (cd+) Description of indications for the vaccine, using values from CD-VACCINEINDICATION.
		[content (cd)] Value from CD-ATC corresponding to the vaccine.
		beginmoment Specifies when the vaccine has been administrated.

Examples

Name	XML
simplesumehrwithoutwarning_1_1	xml
simplesumehrwithwarnings_1_1-	xml
amorecompletesumehr_1_2	xml