Share With Patient or Proxy

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 2/16/2023
  • SDWG: 3/9/2023

C-CDA 2.1 Example:

  • N/A

Reference to full CDA sample:

  • N/A

Validation location

Comments

  • This is an example of how to mark information in an entry as shareable or not shareable with a patient and/or their proxies. This example uses a Note Activity, but the information below could go inside any entry.

Custodian

  • Matt Szczepankiewicz, mszczepa@epic.com (GitHub: mjszczep)

Keywords

  • share, hide, proxy

Permalink

  • TBD

 

Example: download example view on GitHub 

<?xml version="1.0" encoding="UTF-8"?>
<section>
  <templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
  <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
    displayName="Relevant diagnostic tests and/or laboratory data"/>
  <title>Results</title>
  <!-- Some sensitive information, like a positive HIV result, may not be appropriate
         to disclose to the patient or their proxies until a certain point in time. -->
  <text>
    <list>
      <item>
        <caption>HIV 1 and 2 Ab panel - Serum, Plasma or Blood by Rapid
          immunoassay</caption>
        <table>
          <thead>
            <tr>
              <th>Description</th>
              <th>Value / Unit</th>
              <th>Interpretation</th>
              <th>Reference Range</th>
            </tr>
          </thead>
          <tbody>
            <tr ID="LabResult1">
              <td>HIV 1 Ab [Presence] in Serum, Plasma or Blood by Rapid
                immunoassay</td>
              <td>Reactive</td>
              <td>Abnormal</td>
              <td>Reference (Normal) for this test is not detected</td>
            </tr>
          </tbody>
        </table>
        <br />
        <table>
          <caption>Disclosure Details</caption>
          <thead>
            <tr>
              <th>Subject</th>
              <th>Information safe to disclose?</th>
              <th>Effective Until</th>
            </tr>
          </thead>
          <tbody>
            <tr ID="DisclosureDetails1">
              <td>Patient</td>
              <td>No</td>
              <td>01/29/2023 12:00 PM CST</td>
            </tr>
            <tr ID="DisclosureDetails2">
              <td>Proxies</td>
              <td>Not without patient authorization</td>
              <td>Indefinite</td>
            </tr>
          </tbody>
        </table>
      </item>
    </list>
  </text>
  <entry>
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.22.4.1"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.1" extension="2015-08-01"/>
      <id root="b4a47651-8375-44f8-89fd-0261a72a0698"/>
      <code code="89365-1"
        displayName="HIV 1 and 2 Ab panel - Serum, Plasma or Blood by Rapid immunoassay"
        codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
      <statusCode code="completed"/>
      <effectiveTime>
        <low value="202003221426-0500"/>
        <high value="202003221426-0500"/>
      </effectiveTime>
      <component>
        <observation classCode="OBS" moodCode="EVN">
          <!-- Positive HIV result... -->
        </observation>
      </component>
      <component>
        <!-- Don't share with patient until 12:00 PM on 2023-01-29 -->
        <observation classCode="OBS" moodCode="EVN">
          <!-- Security Observation -->
          <templateId root="2.16.840.1.113883.3.445.21" assigningAuthorityName="HL7 CBCC"/>
          <!-- Refrain Policy Code template -->
          <templateId root="2.16.840.1.113883.3.445.23" assigningAuthorityName="HL7 CBCC"/>
          <code code="SECCONOBS" codeSystem="2.16.840.1.113883.1.11.20457"
            displayName="Security Classification"
            codeSystemName="HL7 SecurityObservationTypeCodeSystem"/>
          <text>
            <reference value="#DisclosureDetails1" />
          </text>
          <effectiveTime>
            <!-- Instant result was finalized -->
            <low value="20230125120924-0600"/>
            <!-- Instant result can be shared -->
            <high value="20230129120000-0600"/>
          </effectiveTime>
          <value xsi:type="CE" code="NOPAT" codeSystem="2.16.840.1.113883.5.1063"
            codeSystemName="SecurityObservationValueCodeSystem"
            displayName="no disclosure to patient, family or caregivers without attending provider's authorization"
          />
        </observation>
      </component>
      <component>
        <!-- Share with patient, but hide from their proxies indefinitely -->
        <observation classCode="OBS" moodCode="EVN">
          <!-- Security Observation -->
          <templateId root="2.16.840.1.113883.3.445.21" assigningAuthorityName="HL7 CBCC"/>
          <!-- Refrain Policy Code template -->
          <templateId root="2.16.840.1.113883.3.445.23" assigningAuthorityName="HL7 CBCC"/>
          <code code="SECCONOBS" codeSystem="2.16.840.1.113883.1.11.20457"
            displayName="Security Classification"
            codeSystemName="HL7 SecurityObservationTypeCodeSystem"/>
          <text>
            <reference value="#DisclosureDetails2" />
          </text>
          <!-- This one applies indefinitely -->
          <effectiveTime>
            <low value="20230125120924-0600"/>
          </effectiveTime>
          <!-- Don't share it with anyone but the patient -->
          <value xsi:type="CE" code="NOAUTH" codeSystem="2.16.840.1.113883.5.1063"
            codeSystemName="SecurityObservationValueCodeSystem"
            displayName="no disclosure without subject authorization"/>
        </observation>
      </component>
    </organizer>
  </entry>
</section>

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