Example of CDA limitations to interoperability: time intervals

The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. CDA is an ANSI-certified standard from Health Level Seven (HL7).  The CDA is highlighted as a flexible framework that can contain any type of clinical content.  Additionally, the details of the encoding of clinical data and associated aspects of that data are intentionally designed to be flexible.

That flexibility provides freedoms in various different systems' ability to export clinical data.  However, that same flexibility is an increasing barrier to the interoperability of data as systems need to import that same data.  My biggest pet peeve with the CDA and this problem is the flexibility that the CDA provides in the encoding of time intervals.

Based on clinical reason, the CDA provides the freedom to encode time intervals in eight (8) (VIII) different representations.

<low>
<width>
<high>
<low> <width>
<low> <high>
<center>
<center> <width>

This amount of flexibility in expressing something as simple as a time interval is an obstacle for any receiving system hoping to import and parse an HL7 CDA-based XML document without knowing the way that the generating system is going to express something as basic as a time interval. This permissive nature of the CDA's artifacts is common beyond this one basic example.

What is needed, and hopefully addressed in the emerging FHIR specification, is a more constrained approach to the foundational aspects of clinical data, such as how to encode time intervals.  To reach a point with more interoperability of healthcare data, analysis is needed of the presence of types of structured clinical data concepts and associated clinical codes used operationally.

I feel that the healthcare standards community ultimately needs to identify a strict and simple constrained set of ways of expressing clinical concepts that healthcare Standards Development Organizations (SDOs) like HL7 should use to constrain existing permissive and complex standards.  This could also be done to guide a stricter and simpler implementation to support interoperability via FHIR.

This could introduce significant and radical improvements in the interoperability of patient data in the US healthcare industry.  This will better enable disparate healthcare software systems to work together without requiring point-to-point coordination.  This could reduce, and eventually eliminate, these problems of point-to-point coordination that result in islands of automation.

This "loose coupler" approach will encourage HL7, or possibly new healthcare SDOs, to embrace a core set of strict and simple required attributes, over the current state of the practice using permissive and complex attributes.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. © Rob McCready, 2014.

Example QRDA Category 3 XML for Meaningful Use Stage 2 Clinical Quality Measure Reporting

I have been preparing to lead a summit in D.C. tomorrow to discuss versioning of the various Meaningful Use Clinical Quality Measure (CQM) standards.  During final preparation for the summit, I have been digging into the QRDA Category 3 XML specification.  As I detailed a few months ago, the QRDA Category 3 XML is used for reporting aggregate data for reporting CQMs.  The more that I go spelunking into the QRDA Category 3 standard, the more I understand the complexities associated with it.  I am hoping that providing an example QRDA Category 3 XML will be helpful to the broader community.

Detailed below is a (verbose) example QRDA Category 3 XML file for expressing the Meaningful Use Stage 2 Clinical Quality Measure for expressing the results for "NQF 0018 Controlling High Blood Pressure".  Assume that this CQM is being considered against a population of patients that would generate aggregate section results that would look like this:

• Initial Patient Population (IPP): 3
• Denominator: 3
• Numerator: 1
• Exceptions: 1
• Exclusions: 0

Additionally, Electronic Health Record (EHR) systems are required to report on the supplemental data for sex, ethnicity, race and payer.  So for this data set, assume that there are two males that meet the IPP and only one female.  Then, assume only one of the males meets the numerator requirement.  For simplicity, assume that we do not have any information on race, ethnicity, or payers… so assume "unknown" for all the patients on those dimensions.

Scrolling below, I enumerate a valid example QRDA Category 3 XML file and the sections used to report the aggregate results via CQM QRDA Category 3.  I highlighting the aggregate section results with a yellow background, and the supplemental data with a violet background.

Similar to the QRDA Category 1, it is really difficult to understand why there is so much XML bloat here.  For expressing the CQM results I enumerated after the third paragraph of this blog entry, it takes 679 lines of XML to express these results in the QRDA Category 3!  It is a real struggle to attempt to explain why so much verbose XML is needed to convey such little aggregate information.

With a more detailed understanding of the QRDA Category 3 specification, I think it is finally time to seriously question the ongoing use of the HL7 Clinical Document Architecture (CDA) and the HL7 Reference Implementation Model (RIM) for expressing any type of healthcare data in XML.  While I appreciate what the leaders at HL7 are attempting to do, the QRDA Category 3 XML bloat is probably the best (worst?) example I have seen to support use of a simpler and less complex standard that deviates from the CDA and RIM.

Steve Jobs quote that needs to be considered here “Simple can be harder than complex.  You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there, you can move mountains.”  See the evidence of the need for this type of change below:

<?xml version="1.0" encoding="utf-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
 xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.27.1.1"/>
<id root="9c9762c0-2ac3-0131-4e2f-0050560100a9"/>
<code code="55184-6" codeSystem="2.16.840.1.113883.6.1"
 codeSystemName="LOINC"
 displayName="QRDA Category 3 Summary Report"/>
<title>QRDA Category 3 Calculated Summary Report</title>
<effectiveTime value="20131108164909"/>
<confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
<languageCode code="en-US"/>
<versionNumber value="1"/>
<recordTarget>
  <patientRole>
    <id nullFlavor="NA"/>
  </patientRole>
</recordTarget>
<author>
  <time value="20131108164909"/>
  <assignedAuthor>
    <id extension="Foo" root="Bar"/>
    <assignedAuthoringDevice>
      <softwareName/>
    </assignedAuthoringDevice>
    <representedOrganization>
      <id root="root" extension="ext"/>
      <name/>
    </representedOrganization>
  </assignedAuthor>
</author>
<custodian>
  <assignedCustodian>
    <representedCustodianOrganization>
      <id root="root"/>
      <name>Some Custodian Name</name>
    </representedCustodianOrganization>
  </assignedCustodian>
</custodian>
<legalAuthenticator>
  <time value="20131108164909"/>
  <signatureCode code="S"/>
  <assignedEntity>
    <id root="root"/>
    <representedOrganization>
      <id root="root"/>
    </representedOrganization>
  </assignedEntity>
</legalAuthenticator>
<component>
  <structuredBody>
    <component>
      <section>
        <templateId root="2.16.840.1.113883.10.20.17.2.1"/>
        <templateId root="2.16.840.1.113883.10.20.27.2.2"/>
        <code code="55187-9" codeSystem="2.16.840.1.113883.6.1"/>
        <title>Reporting Parameters</title>
        <text>
          <list>
            <item>Reporting period Dec 31 2011 - 
                  Dec 31 2012</item>
          </list>
        </text>
        <entry typeCode="DRIV">
          <act classCode="ACT" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.17.3.8"/>
            <code code="252116004"
             codeSystem="2.16.840.1.113883.6.96"
             displayName="Observation Parameters"/>
            <effectiveTime>
              <low value="20111231120000"/>
              <high value="20121231120000"/>
            </effectiveTime>
          </act>
        </entry>
      </section>
    </component>
    <component>
      <section>
        <templateId root="2.16.840.1.113883.10.20.24.2.2"/>
        <templateId root="2.16.840.1.113883.10.20.27.2.1"/>
        <code code="55186-1" codeSystem="2.16.840.1.113883.6.1"/>
        <title>Measure Section</title>
        <text></text>
        <entry>
          <organizer classCode="CLUSTER" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
            <templateId root="2.16.840.1.113883.10.20.27.3.1"/>
            <statusCode code="completed"/>
            <reference typeCode="REFR">
              <externalDocument classCode="DOC" moodCode="EVN">
                <id root="40280381-3D61-56A7-013E-66BC02DA4DEE"/>
                <text>Controlling High Blood Pressure</text>
                <setId
                 root="ABDC37CC-BAC6-4156-9B91-D1BE2C8B7268"/>
                <versionNumber value="1"/>
              </externalDocument>
            </reference>
            <component>
              <observation classCode="OBS" moodCode="EVN">
                <templateId
                 root="2.16.840.1.113883.10.20.27.3.14"/>
                <code code="72510-1"
                 codeSystem="2.16.840.1.113883.6.1"
                 displayName="Performance Rate"
                 codeSystemName="2.16.840.1.113883.6.1"/>
                <statusCode code="completed"/>
                <value xsi:type="REAL" value="0.5"/>
                <reference typeCode="REFR">
                  <externalObservation classCode="OBS" 
                   moodCode="EVN">
                    <id 
                     root="5EE417A9-32DB-452F-BAA0-74C5831A4457"/>
                    <code code="NUMER" displayName="Numerator"
                     codeSystem="2.16.840.1.113883.5.1063"
                     codeSystemName="ObservationValue"/>
                  </externalObservation>
                </reference>
              </observation>
            </component>
            <component>
              <!-- DATA FOR IPP B936D6B5-151F-47FB-97D8-A5AB9AB00656 -->
              <observation classCode="OBS" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.27.3.5"/>
                <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                 displayName="Assertion" codeSystemName="ActCode"/>
                <statusCode code="completed"/>
                <value xsi:type="CD" code="IPP"
                 codeSystem="2.16.840.1.113883.5.1063"
                 codeSystemName="ObservationValue"/>
                <entryRelationship typeCode="SUBJ" inversionInd="true">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" displayName="rate aggregation"
                       codeSystem="2.16.840.1.113883.5.4"
                       codeSystemName="ActCode"/>
                      <value xsi:type="INT" value="3"/>
                      <methodCode code="COUNT" displayName="Count"
                       codeSystem="2.16.840.1.113883.5.84"
                       codeSystemName="ObservationMethod"/>
                  </observation>
                </entryRelationship>
                <!-- SEX Supplemental Data for IPP
                     B936D6B5-151F-47FB-97D8-A5AB9AB00656 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId
                root="2.16.840.1.113883.10.20.27.3.6"/>
                    <id nullFlavor="NA"/>
                    <code code="184100006"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" code="F"
                     codeSystem="2.16.840.1.113883.5.1"/>
                    <entryRelationship typeCode="SUBJ"
                     inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- SEX Supplemental Data Reporting for IPP
                     B936D6B5-151F-47FB-97D8-A5AB9AB00656 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.6"/>
                    <id nullFlavor="NA"/>
                    <code code="184100006"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" code="M"
                     codeSystem="2.16.840.1.113883.5.1"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="2"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- ETHNICITY Supplemental Data Reporting for IPP
                     B936D6B5-151F-47FB-97D8-A5AB9AB00656 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.7"/>
                    <id nullFlavor="NA"/>
                    <code code="364699009"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="3"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- RACE Supplemental Data Reporting for IPP
                     B936D6B5-151F-47FB-97D8-A5AB9AB00656 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.8"/>
                    <id nullFlavor="NA"/>
                    <code code="103579009"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="3"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- PAYER Supplemental Data Reporting for IPP
                     B936D6B5-151F-47FB-97D8-A5AB9AB00656 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.9"/>
                    <id nullFlavor="NA"/>
                    <code code="48768-6" codeSystem="2.16.840.1.113883.6.1"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="3"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <reference typeCode="REFR">
                  <externalObservation classCode="OBS" moodCode="EVN">
                    <id root="B936D6B5-151F-47FB-97D8-A5AB9AB00656"/>
                  </externalObservation>
                </reference>
              </observation>
            </component>
            <component>
              <!-- MEASURE DATA REPORTING FOR DENOM
                   2A53CBF0-510A-429D-814D-CBCA4DC0E2A8 -->
              <observation classCode="OBS" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.27.3.5"/>
                <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                 displayName="Assertion" codeSystemName="ActCode"/>
                <statusCode code="completed"/>
                <value xsi:type="CD" code="DENOM"
                 codeSystem="2.16.840.1.113883.5.1063"
                 codeSystemName="ObservationValue"/>
                <entryRelationship typeCode="SUBJ" inversionInd="true">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                    <code code="MSRAGG" displayName="rate aggregation"
                     codeSystem="2.16.840.1.113883.5.4"
                     codeSystemName="ActCode"/>
                    <value xsi:type="INT" value="3"/>
                    <methodCode code="COUNT" displayName="Count"
                     codeSystem="2.16.840.1.113883.5.84"
                     codeSystemName="ObservationMethod"/>
                  </observation>
                </entryRelationship>
                <!-- SEX Supplemental Data Reporting for DENOM
                     2A53CBF0-510A-429D-814D-CBCA4DC0E2A8 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.6"/>
                    <id nullFlavor="NA"/>
                    <code code="184100006"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" code="F"
                     codeSystem="2.16.840.1.113883.5.1"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- SEX Supplemental Data Reporting for DENOM
                     2A53CBF0-510A-429D-814D-CBCA4DC0E2A8 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.6"/>
                    <id nullFlavor="NA"/>
                    <code code="184100006"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" code="M"
                     codeSystem="2.16.840.1.113883.5.1"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="2"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- ETHNICITY Supplemental Data Reporting for DENOM
                     2A53CBF0-510A-429D-814D-CBCA4DC0E2A8 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.7"/>
                    <id nullFlavor="NA"/>
                    <code code="364699009"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="3"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- RACE Supplemental Data Reporting for DENOM
                     2A53CBF0-510A-429D-814D-CBCA4DC0E2A8 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.8"/>
                    <id nullFlavor="NA"/>
                    <code code="103579009"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="3"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- PAYER Supplemental Data for DENOM
                     2A53CBF0-510A-429D-814D-CBCA4DC0E2A8 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.9"/>
                    <id nullFlavor="NA"/>
                    <code code="48768-6" codeSystem="2.16.840.1.113883.6.1"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="3"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <reference typeCode="REFR">
                  <externalObservation classCode="OBS" moodCode="EVN">
                    <id root="2A53CBF0-510A-429D-814D-CBCA4DC0E2A8"/>
                  </externalObservation>
                </reference>
              </observation>
            </component>
            <component>
              <!-- MEASURE DATA FOR NUMER
                   5EE417A9-32DB-452F-BAA0-74C5831A4457 -->
              <observation classCode="OBS" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.27.3.5"/>
                <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                 displayName="Assertion" codeSystemName="ActCode"/>
                <statusCode code="completed"/>
                <value xsi:type="CD" code="NUMER"
                 codeSystem="2.16.840.1.113883.5.1063"
                 codeSystemName="ObservationValue"/>
                <entryRelationship typeCode="SUBJ" inversionInd="true">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                    <code code="MSRAGG" displayName="rate aggregation"
                     codeSystem="2.16.840.1.113883.5.4"
                     codeSystemName="ActCode"/>
                    <value xsi:type="INT" value="1"/>
                    <methodCode code="COUNT" displayName="Count"
                     codeSystem="2.16.840.1.113883.5.84"
                     codeSystemName="ObservationMethod"/>
                  </observation>
                </entryRelationship>
                <!-- SEX Supplemental Data for NUMER
                     5EE417A9-32DB-452F-BAA0-74C5831A4457 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.6"/>
                    <id nullFlavor="NA"/>
                    <code code="184100006"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" code="M"
                     codeSystem="2.16.840.1.113883.5.1"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- ETHNICITY Supplemental Data for NUMER
                     5EE417A9-32DB-452F-BAA0-74C5831A4457 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.7"/>
                    <id nullFlavor="NA"/>
                    <code code="364699009"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- RACE Supplemental Data for NUMER
                     5EE417A9-32DB-452F-BAA0-74C5831A4457 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.8"/>
                    <id nullFlavor="NA"/>
                    <code code="103579009"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- PAYER Supplemental Data for NUMER
                     5EE417A9-32DB-452F-BAA0-74C5831A4457 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.9"/>
                    <id nullFlavor="NA"/>
                    <code code="48768-6" codeSystem="2.16.840.1.113883.6.1"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <reference typeCode="REFR">
                    <externalObservation classCode="OBS" moodCode="EVN">
                        <id root="5EE417A9-32DB-452F-BAA0-74C5831A4457"/>
                    </externalObservation>
                </reference>
              </observation>
            </component>
            <component>
              <!-- MEASURE DATA REPORTING FOR DENEX
                   57F3D1D7-F9FA-437F-A2B9-406A1498E8C0 -->
              <observation classCode="OBS" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.27.3.5"/>
                <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                 displayName="Assertion" codeSystemName="ActCode"/>
                <statusCode code="completed"/>
                <value xsi:type="CD" code="DENEX"
                 codeSystem="2.16.840.1.113883.5.1063"
                 codeSystemName="ObservationValue"/>
                <entryRelationship typeCode="SUBJ" inversionInd="true">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                    <code code="MSRAGG" displayName="rate aggregation"
                     codeSystem="2.16.840.1.113883.5.4"
                     codeSystemName="ActCode"/>
                    <value xsi:type="INT" value="1"/>
                    <methodCode code="COUNT" displayName="Count"
                     codeSystem="2.16.840.1.113883.5.84"
                     codeSystemName="ObservationMethod"/>
                  </observation>
                </entryRelationship>
                <!-- SEX Supplemental Data Reporting for DENEX
                     57F3D1D7-F9FA-437F-A2B9-406A1498E8C0 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.6"/>
                    <id nullFlavor="NA"/>
                    <code code="184100006"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" code="F"
                     codeSystem="2.16.840.1.113883.5.1"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- ETHNICITY Supplemental Data Reporting for
                     DENEX 57F3D1D7-F9FA-437F-A2B9-406A1498E8C0 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.7"/>
                    <id nullFlavor="NA"/>
                    <code code="364699009"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- RACE Supplemental Data for DENEX
                     57F3D1D7-F9FA-437F-A2B9-406A1498E8C0 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">=
                    <templateId root="2.16.840.1.113883.10.20.27.3.8"/>
                    <id nullFlavor="NA"/>
                    <code code="103579009"
                     codeSystem="2.16.840.1.113883.6.96"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <!-- PAYER Supplemental Data for DENEX
                     57F3D1D7-F9FA-437F-A2B9-406A1498E8C0 -->
                <entryRelationship typeCode="COMP">
                  <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.27.3.9"/>
                    <id nullFlavor="NA"/>
                    <code code="48768-6" codeSystem="2.16.840.1.113883.6.1"/>
                    <statusCode code="completed"/>
                    <value xsi:type="CD" nullFlavor="UNK"/>
                    <entryRelationship typeCode="SUBJ" inversionInd="true">
                      <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                        <code code="MSRAGG" displayName="rate aggregation"
                         codeSystem="2.16.840.1.113883.5.4"
                         codeSystemName="ActCode"/>
                        <value xsi:type="INT" value="1"/>
                        <methodCode code="COUNT" displayName="Count"
                         codeSystem="2.16.840.1.113883.5.84"
                         codeSystemName="ObservationMethod"/>
                      </observation>
                    </entryRelationship>
                  </observation>
                </entryRelationship>
                <reference typeCode="REFR">
                  <externalObservation classCode="OBS" moodCode="EVN">
                    <id root="57F3D1D7-F9FA-437F-A2B9-406A1498E8C0"/>
                  </externalObservation>
                </reference>
              </observation>
            </component>
          </organizer>
        </entry>
      </section>
    </component>
  </structuredBody>
</component>
</ClinicalDocument> 

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. © Rob McCready, 2013.