Cross Border Data Exchange IG
1.0.0 - CI Build
Cross Border Data Exchange IG
1.0.0 - CI Build
Cross Border Data Exchange IG, published by IEHR-Workgroup. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/InteropEHRate-project/cross-border-data-exchange/ and changes regularly. See the Directory of published versions
TThe following table shows the requirements for the profiles defined in this ImplementationGuide as well as the profiles used for realization and links to the handling instructions.
| Super-category | Sub-category | Data | Used Profiles | Instructions | Rationale |
|---|---|---|---|---|---|
| Demographics | General Data | Name, Surname | Patient-IEHR | Patient Instructions | - |
| administrative gender | |||||
| Backup Contacts | |||||
| Date of Birth | |||||
| Allergies | General Data | Allergies (ATC drug codes, LOINC), intolerance codes | AllergyIntolerance-IEHR | Allergy/Intolerance Instructions | - |
| Allergies (ATC drug codes, LOINC), intolerance notes | |||||
| Diseases | Main chronic conditions | Hypertension | Condition-IEHR | Disease Instructions | - |
| Hypertension starting date | |||||
| Ischemic heart disease | |||||
| General Data | Heart failure | ||||
| Pulmonary disease | |||||
| Abnormal kidney function | |||||
| Abnormal liver function | |||||
| Active malignancy | |||||
| Diseases | Eventual acute (ongoing) Diseases | Eventual acute (ongoing) Diseases | |||
| Diseases | General Data | Previous major surgery | Procedure-IPS Condition-IEHR |
Previous major surgery Instructions | - |
| Previous major surgery date | |||||
| Medications | General Data | Current Medications, previous medications | MedicationStatement-IEHR | Medication Instructions | - |
| History | previous visits (pdf and structured data) | diagnosis | MedicalVisit - IEHR and DiagnosticReportImaging - IEHR or DiagnosticReportLaboratoryResult - IEHR depending on type of diagnosis |
Previous Visits | - |
| diagnostic conclusion (text) | DiagnosticConclusion-IEHR | ||||
| treatment plan (next visits, exams, etc) | MedicalVisit - IEHR and TreatmentPlan - IEHR | ||||
| current Medications, previous medications | MedicalVisit - IEHRand MedicationStatement-IEHR | ||||
| visit prescription | current visit prescribed drugs | prescribed drugs | MedicationRequest-Prescription | MedicationRequest-Prescription Instructions | - |
| Vital Signs | Vital parameters for the last ambulatory | weight (Kg) | VitalSigns | VitalSigns Instructions | - |
| height (cm) | |||||
| blood pressure (mmHg) | |||||
| resting heart rate (bpm) | |||||
| peripheral edema (presence/absence) | |||||
| signs of lung congestion (presence/absence) | |||||
| pleural effusion (presence/absence) | |||||
| sign of ascites (presence/absence) | |||||
| jugular vein distension (presence/absence); | |||||
| Cardiac and lung auscultation (normal/abnormal) | |||||
| EKG | Latest EKG | rhythm (eg sinus rhythm, atrial fibrillation, paced, etc.) | DiagnosticReport-BioSignalReport-IEHR and Observation-BioSignal-IEHR | BioSignalReport Instructions / Biosignal Instructions | - |
| heart rate (bpm) | |||||
| PR | |||||
| QRS intervals (msec) | |||||
| QTc intervals (msec)(optional) | |||||
| left bundle branch block (presence/absence) | |||||
| EKG | Latest EKG | EKG signal waveform | DiagnosticReport-BioSignalReport-IEHR and Media-IEHR | BioSignalReport Instructions / Biosignal Instructions | - |
| EKG signal pdf/other | |||||
| EKG | Latest EKG | EKG report (text) | DiagnosticReport-BioSignalReport-IEHR | BioSignalReport Instructions / Biosignal Instructions | - |
| EKG report (pdf/other) | |||||
| Echo | Latest echocardiogram | LVEF (%) | BioSignal-IEHR in BioSignalReport-IEHR | BioSignalReport Instructions | - |
| septum thickness | |||||
| left ventricular end systolic/diastolic volume (mL) | |||||
| grade of diastolic dysfunction (0/1/2/3) | |||||
| estimated pulmonary artery pressure (mmHg) | |||||
| degree of mitral regurgitation (no, mild, moderate, severe) | |||||
| degree of tricuspid regurgitation (no, mild, moderate, severe) | |||||
| Echo | Latest echocardiogram | DICOM movie | DiagnosticReport-BioSignalReport-IEHR and Imagingstudy | BioSignalReport Instructions | - |
| Echo | Latest echocardiogram | Report pdf | DiagnosticReport-BioSignalReport-IEHR | BioSignalReport Instructions | - |
| Report text | |||||
| X-Ray | Latest chest X-Ray | report | DiagnosticReport-ImagingReport-IEHR | ImagingReport Instructions | - |
| image | |||||
| Latest Holter monitoring | Latest Holter monitoring | mean heart rate (bpm) | DiagnosticReport-BioSignalReport-IEHR | BioSignalReport Instructions | - |
| Latest Holter monitoring | Latest Holter monitoring | number of premature ventricular beats | DiagnosticReport-BioSignalReport-IEHR | BioSignalReport Instructions | - |
| number of ventricular tachycardias (with max length in bpm) | |||||
| atrial fibrillation (presence/absence) | |||||
| Latest bio-humoral values | Latest bio-humoral values | hemoglobin (g/dl) | DiagnosticReport-LaboratoryReport-IEHR | LaboratoryReport Instructions | - |
| white blood count | |||||
| creatinine (mg/dl) | |||||
| eGFR (ml/min/1.73m2) | |||||
| AST | |||||
| ALT | |||||
| GGT | |||||
| bilirubin | |||||
| BNP (ng/L) | |||||
| NT-proBNP (ng/L) | |||||
| Latest cardiac magnetic resonance | Latest cardiac magnetic resonance | LVEF (%) | DiagnosticReport-BioSignalReport-IEHR | BioSignalReport Instructions | - |
| left ventricular end systolic/diastolic volumes | |||||
| late gadolinium enhancement (presence/absence). | |||||
| Surgical history | Surgical history | Surgical history | Procedure-IPS | Procedures Instructions | - |
| Encounter | Encounter | Encounter | Encounter-IEHR | Encounter Instructions | - |