source: qrda/CCR/M1-QRDA/PAT_100146_QRDA_V1_0_0.xml@ 990

Last change on this file since 990 was 983, checked in by George Lilly, 14 years ago

testing QRDA Incidence documents for PQRI Measure 1
File size: 22.4 KB
Line 
1<?xml version="1.0" encoding="utf-8"?>
2<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
3<realmCode code="US"/>
4<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
5<templateId root="2.16.840.1.113883.10.20.12"/>
6<templateId root="2.16.840.1.113883.3.249.11.100.1"/>
7<id root="d010c8bd-eda0-4e36-8a53-c7c677666b29"/>
8<code code="55182-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Quality Measure Report"/>
9<title>QRDA Incidence Report</title>
10<effectiveTime value="20100703"/>
11<confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
12<languageCode code="en-US"/>
13<setId root="2.16.840.1.113883.3.543" extension="01.01.01.100000001"/>
14<versionNumber value="1"/>
15<recordTarget>
16<patientRole>
17<id extension="666000200" root="SSN"/>
18<addr use="H">
19<streetAddressLine>Any Street</streetAddressLine>
20<city>Any Town</city>
21<state>WEST VIRGINIA</state>
22<postalCode/>
23</addr>
24<telecom use="" value="tel:+1-222-555-8235"/>
25<patient>
26<name>
27<given>MALE-D</given>
28<family>MEASURE-TWO</family>
29</name>
30<administrativeGenderCode displayName="MALE" code="M" codeSystemName="HL7 AdministrativeGender" codeSystem=""/>
31<birthTime value="1960111200"/>
32</patient>
33</patientRole>
34</recordTarget>
35<author>
36<time value="20100703"/>
37<assignedAuthor>
38<id root="2.16.840.1.113883.3.249.6" extension="100001"/>
39<assignedPerson>
40<name>
41<given>Nancy</given>
42<family>Anthracite</family>
43<suffix>MD</suffix>
44</name>
45</assignedPerson>
46<representedOrganization>
47<id root="2.16.840.1.113883.3.543" extension="1558574526"/>
48<name>WorldVistA Test Clinic</name>
49</representedOrganization>
50</assignedAuthor>
51</author>
52<informant>
53<assignedEntity>
54<id nullFlavor="NA"/>
55<representedOrganization>
56<id root="2.16.840.1.113883.3.543" extension="1558574526"/>
57<name>World VistA Test Clinic</name>
58</representedOrganization>
59</assignedEntity>
60</informant>
61<custodian>
62<assignedCustodian>
63<representedCustodianOrganization>
64<id root="2.16.840.1.113883.3.543" extension="1558574526"/>
65<name>WorldVistA Test Clinic</name>
66</representedCustodianOrganization>
67</assignedCustodian>
68</custodian>
69<legalAuthenticator>
70<time value="20100703"/>
71<signatureCode code="S"/>
72<assignedEntity>
73<id root="2.16.840.1.113883.3.543" extension="111111"/>
74<assignedPerson>
75<name>
76<given>Nancy</given>
77<family>Anthracite</family>
78<suffix>MD</suffix>
79</name>
80</assignedPerson>
81<representedOrganization>
82<id root="2.16.840.1.113883.3.543" extension="1558574526"/>
83<name>WorldVistA Test Clinic</name>
84</representedOrganization>
85</assignedEntity>
86</legalAuthenticator>
87<participant typeCode="PRF">
88<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>
89<associatedEntity classCode="PROV">
90<id root="2.16.840.1.113883.3.249.6" extension="111111"/>
91<associatedPerson>
92<name>
93<prefix>Dr.</prefix>
94<given>Nancy</given>
95<family>Anthracite</family>
96</name>
97</associatedPerson>
98</associatedEntity>
99</participant>
100<documentationOf>
101<serviceEvent>
102<code code="99202" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
103<effectiveTime>
104<low value="20100205"/>
105<high value="20100205"/>
106</effectiveTime>
107<performer typeCode="PRF">
108<assignedEntity>
109<id root="2.16.840.1.113883.3.543" extension="6558574524"/>
110<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
111<addr>
112<streetAddressLine>123 Maple Ave</streetAddressLine>
113<city>Gaithersburg</city>
114<state>MD</state>
115<postalCode>20877</postalCode>
116</addr>
117<assignedPerson>
118<name>
119<given>Nancy</given>
120<family>Anthracite</family>
121<suffix>MD</suffix>
122</name>
123</assignedPerson>
124</assignedEntity>
125</performer>
126</serviceEvent>
127</documentationOf>
128<documentationOf>
129<serviceEvent>
130<code code="99204" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
131<effectiveTime>
132<low value="20100703"/>
133<high value="20100703"/>
134</effectiveTime>
135<performer typeCode="PRF">
136<assignedEntity>
137<id root="2.16.840.1.113883.3.543" extension="6558574524"/>
138<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
139<addr>
140<streetAddressLine>123 Maple Ave</streetAddressLine>
141<city>Gaithersburg</city>
142<state>MD</state>
143<postalCode>20877</postalCode>
144</addr>
145<assignedPerson>
146<name>
147<given>Nancy</given>
148<family>Anthracite</family>
149<suffix>MD</suffix>
150</name>
151</assignedPerson>
152</assignedEntity>
153</performer>
154</serviceEvent>
155</documentationOf>
156<component>
157<structuredBody>
158<component>
159<section>
160<templateId root="2.16.840.1.113883.3.249.11.12"/>
161<code code="55185-3" codeSystem="2.16.840.1.113883.6.1"/>
162<title>Measure set: CMS EHR Measure Set</title>
163<text>2010 Measures Set Measures</text>
164<component>
165<section>
166<templateId root="2.16.840.1.113883.3.249.11.2"/>
167<templateId root="2.16.840.1.113883.3.249.11.3"/>
168<templateId root="2.16.840.1.113883.3.249.11.4"/>
169<templateId root="2.16.840.1.113883.3.249.11.5"/>
170<templateId root="2.16.840.1.113883.3.249.11.6"/>
171<templateId root="2.16.840.1.113883.3.249.11.7"/>
172<templateId root="2.16.840.1.113883.3.249.11.8"/>
173<templateId root="2.16.840.1.113883.3.249.11.9"/>
174<templateId root="2.16.840.1.113883.3.249.11.10"/>
175<templateId root="2.16.840.1.113883.3.249.11.11"/>
176<templateId root="2.16.840.1.113883.3.249.11.15"/>
177<code code="55186-1" codeSystem="2.16.840.1.113883.6.1"/>
178<title>Measure Section</title>
179<text>
180<list>
181<item>CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus</item>
182<item>CMS Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus</item>
183<item>CMS Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus</item>
184<item>CMS Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)</item>
185<item>CMS Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)</item>
186<item>CMS Measure #110: Preventive Care and Screening: Influenza Immunization for Patients &gt;= 50 Years</item>
187<item>CMS Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older</item>
188<item>CMS Measure #112: Preventive Care and Screening: Screening Mammography</item>
189<item>CMS Measure #113: Preventive Care and Screening: Colorectal Cancer Screening</item>
190<item>CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)</item>
191<item>CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure</item>
192</list>
193</text>
194<entry typeCode="DRIV">
195<act classCode="ACT" moodCode="DEF">
196<id root="3944fd20-865c-11df-a4ee-0800200c9a66"/>
197<code code="PQRI-1" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
198<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0%</text>
199<statusCode code="completed"/>
200</act>
201</entry>
202<entry typeCode="DRIV">
203<act classCode="ACT" moodCode="DEF">
204<id root="3944fd21-865c-11df-a4ee-0800200c9a66"/>
205<code code="PQRI-2" codeSystem="2.16.840.1.113883.3.249.12" displayName="Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus"/>
206<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL)</text>
207<statusCode code="completed"/>
208</act>
209</entry>
210<entry typeCode="DRIV">
211<act classCode="ACT" moodCode="DEF">
212<id root="3944fd22-865c-11df-a4ee-0800200c9a66"/>
213<code code="PQRI-3" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
214<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg)</text>
215<statusCode code="completed"/>
216</act>
217</entry>
218<entry typeCode="DRIV">
219<act classCode="ACT" moodCode="DEF">
220<id root="3944fd23-865c-11df-a4ee-0800200c9a66"/>
221<code code="PQRI-5" codeSystem="2.16.840.1.113883.3.249.12" displayName="Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)"/>
222<text>Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy</text>
223<statusCode code="completed"/>
224</act>
225</entry>
226<entry typeCode="DRIV">
227<act classCode="ACT" moodCode="DEF">
228<id root="3944fd24-865c-11df-a4ee-0800200c9a66"/>
229<code code="PQRI-7" codeSystem="2.16.840.1.113883.3.249.12" displayName="Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction"/>
230<text>Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy</text>
231<statusCode code="completed"/>
232</act>
233</entry>
234<entry typeCode="DRIV">
235<act classCode="ACT" moodCode="DEF">
236<id root="3944fd25-865c-11df-a4ee-0800200c9a66"/>
237<code code="PQRI-110" codeSystem="2.16.840.1.113883.3.249.12" displayName="Influenza Immunization for Patients &gt;= 50 Years"/>
238<text>Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February)</text>
239<statusCode code="completed"/>
240</act>
241</entry>
242<entry typeCode="DRIV">
243<act classCode="ACT" moodCode="DEF">
244<id root="3944fd26-865c-11df-a4ee-0800200c9a66"/>
245<code code="PQRI-111" codeSystem="2.16.840.1.113883.3.249.12" displayName="Pneumonia Vaccination for Patients 65 Years and Older"/>
246<text>Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine</text>
247<statusCode code="completed"/>
248</act>
249</entry>
250<entry typeCode="DRIV">
251<act classCode="ACT" moodCode="DEF">
252<id root="3944fd27-865c-11df-a4ee-0800200c9a66"/>
253<code code="PQRI-112" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening Mammography"/>
254<text>Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months</text>
255<statusCode code="completed"/>
256</act>
257</entry>
258<entry typeCode="DRIV">
259<act classCode="ACT" moodCode="DEF">
260<id root="3944fd28-865c-11df-a4ee-0800200c9a66"/>
261<code code="PQRI-113" codeSystem="2.16.840.1.113883.3.249.12" displayName="Colorectal Cancer Screening"/>
262<text>Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening</text>
263<statusCode code="completed"/>
264</act>
265</entry>
266<entry typeCode="DRIV">
267<act classCode="ACT" moodCode="DEF">
268<id root="3944fd29-865c-11df-a4ee-0800200c9a66"/>
269<code code="PQRI-124" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Electronic Health Records (EHR)"/>
270<text>Documents whether provider has adopted and is using health information technology. To qualify, the provider must havea adopted and be using a certified/qualified electronic health record (EHR)</text>
271<statusCode code="completed"/>
272</act>
273</entry>
274<entry typeCode="DRIV">
275<act classCode="ACT" moodCode="DEF">
276<id root="3944fd30-865c-11df-a4ee-0800200c9a66"/>
277<code code="eRx" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Medication Electronic Prescribing Measure"/>
278<text>Documents whether provider has adopted and is using ePrescribing</text>
279<statusCode code="completed"/>
280</act>
281</entry>
282<component>
283<section>
284<code code="55187-9" codeSystem="2.16.840.1.113883.6.1"/>
285<title>Reporting Parameters</title>
286<text>
287<list>
288<item>Reporting Period Jan 1, 2010 to Dec 31, 2010</item>
289</list>
290</text>
291<entry>
292<act classCode="ACT" moodCode="EVN">
293<code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters"/>
294<effectiveTime>
295<low value="20100101"/>
296<high value="20101231"/>
297</effectiveTime>
298</act>
299</entry>
300</section>
301</component>
302<component>
303<section>
304<templateId root="2.16.840.1.113883.10.20.1.13"/>
305<code code="48764-5" codeSystem="2.16.840.1.113883.6.1"/>
306<title>Purpose</title>
307<text>CEND PHR</text>
308</section>
309</component>
310<component>
311<section>
312<templateId root="2.16.840.1.113883.3.88.11.83.103" assigningAuthorityName="HITSP/C83"/>
313<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6" assigningAuthorityName="IHE PCC"/>
314<templateId root="2.16.840.1.113883.10.20.1.11" assigningAuthorityName="HL7 CCD"/>
315<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
316<title>Problems</title>
317<text>
318<table>
319<tbody>
320<tr>
321<th>Type</th>
322<th>Date</th>
323<th>Code</th>
324<th>Description</th>
325<th>Status</th>
326<th>Source</th>
327</tr>
328<tr>
329<td>Problem</td>
330<td>
331<table>
332<tbody>
333<tr xmlns="">
334<td>Oct 13, 2010</td>
335</tr>
336</tbody>
337</table>
338</td>
339<td>250.02 (ICD9CM)
340 </td>
341<td ID="PROBLEM1">Diabetes Mellitus without mention of Complication, type II or unspecified type,</td>
342<td>Active</td>
343<td>NANCY ANTHRACITE </td>
344</tr>
345<tr>
346<td>Problem</td>
347<td>
348<table>
349<tbody>
350<tr xmlns="">
351<td>Oct 4, 2010</td>
352</tr>
353</tbody>
354</table>
355</td>
356<td>250.00 (ICD9CM)
357 </td>
358<td ID="PROBLEM2">Diabetes Mellitus</td>
359<td>Active</td>
360<td>MATTHEW M KING </td>
361</tr>
362</tbody>
363</table>
364</text>
365<entry typeCode="DRIV">
366<act classCode="ACT" moodCode="EVN">
367<templateId root="2.16.840.1.113883.10.20.1.27"/>
368<id root="PROBLEM1" extension="CCRObjectID"/>
369<code nullFlavor="NA"/>
370<performer typeCode="PRF">
371<assignedEntity>
372<id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
373<addr use="WP">
374<streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
375<city>ALBANY</city>
376<state>NY</state>
377<postalCode>12180</postalCode>
378</addr>
379<telecom/>
380<assignedPerson>
381<name>
382<given>NANCY</given>
383<family>ANTHRACITE</family>
384</name>
385</assignedPerson>
386</assignedEntity>
387</performer>
388<entryRelationship typeCode="SUBJ">
389<observation classCode="OBS" moodCode="EVN">
390<templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
391<id root="PROBLEM1" extension="CCRObjectID"/>
392<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
393<text>
394<reference value="#PROBLEM1"/>
395</text>
396<statusCode code="completed"/>
397<effectiveTime>
398<low value="20101013"/>
399<high nullFlavor="UNK"/>
400</effectiveTime>
401<value displayName="Diabetes Mellitus without mention of Complication, type II or unspecified type," code="250.02" codeSystemName="ICD9CM" codeSystem=""/>
402<entryRelationship typeCode="REFR">
403<observation classCode="OBS" moodCode="EVN">
404<templateId root="2.16.840.1.113883.10.20.1.50"/>
405<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
406<statusCode code="completed"/>
407<value>
408<originalText>Active</originalText>
409</value>
410</observation>
411</entryRelationship>
412</observation>
413</entryRelationship>
414</act>
415</entry>
416<entry typeCode="DRIV">
417<act classCode="ACT" moodCode="EVN">
418<templateId root="2.16.840.1.113883.10.20.1.27"/>
419<id root="PROBLEM2" extension="CCRObjectID"/>
420<code nullFlavor="NA"/>
421<performer typeCode="PRF">
422<assignedEntity>
423<id extension="ACTORPROVIDER_10000000183" root="CCRActorID"/>
424<addr use="WP">
425<streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
426<city>ALBANY</city>
427<state>NY</state>
428<postalCode>12180</postalCode>
429</addr>
430<telecom/>
431<assignedPerson>
432<name>
433<given>MATTHEW</given>
434<given>M</given>
435<family>KING</family>
436</name>
437</assignedPerson>
438</assignedEntity>
439</performer>
440<entryRelationship typeCode="SUBJ">
441<observation classCode="OBS" moodCode="EVN">
442<templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
443<id root="PROBLEM2" extension="CCRObjectID"/>
444<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
445<text>
446<reference value="#PROBLEM2"/>
447</text>
448<statusCode code="completed"/>
449<effectiveTime>
450<low value="2010104"/>
451<high nullFlavor="UNK"/>
452</effectiveTime>
453<value displayName="Diabetes Mellitus" code="250.00" codeSystemName="ICD9CM" codeSystem=""/>
454<entryRelationship typeCode="REFR">
455<observation classCode="OBS" moodCode="EVN">
456<templateId root="2.16.840.1.113883.10.20.1.50"/>
457<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
458<statusCode code="completed"/>
459<value>
460<originalText>Active</originalText>
461</value>
462</observation>
463</entryRelationship>
464</observation>
465</entryRelationship>
466</act>
467</entry>
468</section>
469</component>
470<component>
471<section>
472<templateId root="2.16.840.1.113883.10.20.1.12"/>
473<code code="47519-4" codeSystem="2.16.840.1.113883.6.1"/>
474<title>Procedures</title>
475<text>
476<table>
477<tbody>
478<tr>
479<th>Type</th>
480<th>Date</th>
481<th>Code</th>
482<th>Description</th>
483<th>Location</th>
484<th>Substance</th>
485<th>Method</th>
486<th>Position</th>
487<th>Site</th>
488<th>Status</th>
489<th>Source</th>
490</tr>
491<tr id="PROCEDURE_4141_10">
492<td/>
493<table>
494<tbody>
495<tr xmlns="">
496<td>Procedure Date:
497 </td>
498<td>Oct 14, 2010</td>
499</tr>
500</tbody>
501</table>
502<td>99242 (CPT-4)
503 </td>
504<td>INTERMEDIATE (30min)</td>
505<td/>
506<td/>
507<td/>
508<td/>
509<td/>
510<td>Completed</td>
511<td>NANCY ANTHRACITE </td>
512</tr>
513<tr id="PROCEDURE_4092_7">
514<td/>
515<table>
516<tbody>
517<tr xmlns="">
518<td>Procedure Date:
519 </td>
520<td>Oct 4, 2010</td>
521</tr>
522</tbody>
523</table>
524<td>99213 (CPT-4)
525 </td>
526<td>Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213)</td>
527<td/>
528<td/>
529<td/>
530<td/>
531<td/>
532<td>Completed</td>
533<td>MATTHEW M KING </td>
534</tr>
535</tbody>
536</table>
537</text>
538<entry typeCode="DRIV">
539<procedure classCode="PROC" moodCode="EVN">
540<templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
541<templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
542<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
543<id root="PROCEDURE_4141_10" extension="CCRObjectID"/>
544<code displayName="INTERMEDIATE (30min)" code="99242" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
545<text>
546<reference value="#PROCEDURE_4141_10"/>
547</text>
548<statusCode code="completed"/>
549<effectiveTime>
550<low value="20101014"/>
551<high nullFlavor="UNK"/>
552</effectiveTime>
553</procedure>
554</entry>
555<entry typeCode="DRIV">
556<procedure classCode="PROC" moodCode="EVN">
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597<td/>
598<td/>
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600<td>***NEW PATIENT*** INTERMEDIATE (30min)</td>
601<td/>
602<td>NANCY ANTHRACITE </td>
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607<td/>
608<td/>
609<td/>
610<td> Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213)</td>
611<td/>
612<td>MATTHEW M KING </td>
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617<td/>
618<td/>
619<td/>
620<td> Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213)</td>
621<td/>
622<td>MATTHEW M KING </td>
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