PHC Ind Emr Co Stand V1 201 en PDF

Canadian Institute for Health
Information Primary Health Care

Indicators Electronic Medical
Preliminary Provincial and Territorial Government
Records Content Standards
Health Expenditure Estimates
Version 1.1
1974–1975 to 2004–2005
N a t Pi ro i nma al r H
y e Ha el ta hl t h
E x Cp ae rn ed i I t nu f r oe r mD aa tt iaobna s e
Production of this report is made possible by financial contributions from Health Canada
and provincial and territorial governments. The views expressed herein do not necessarily
represent the views of Health Canada or any provincial or territorial government.
The contents of this publication may be reproduced in whole or in part, provided the
intended use is for non-commercial purposes and full acknowledgement
is given to the Canadian Institute for Health Information.
Canadian Institute for Health Information

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ISBN 978-1-55465-509-0 (PDF)
© 2009 Canadian Institute for Health Information
How to cite this document:

Canadian Institute for Health Information, Canadian Institute for Health Information Primary Health Care Indicators
Electronic Medical Record Content Standards, Version 1.1 (Ottawa, Ont.: CIHI, 2009).
Cette publication est aussi disponible en français sous le titre Normes de l’Institut canadien d'information sur la
santé relatives au contenu du dossier médical électronique en lien avec les indicateurs de soins de santé
primaires, version 1.0.
ISBN 978-1-55465-470-3 (PDF)
Canadian Institute for Health Information Primary Health Care Indicators
Electronic Medical Record Content Standards,
Version 1.1
Table of Contents
Acknowledgements .................................................................................................iii
About the Canadian Institute for Health Information ..................................................... v
Executive Summary ................................................................................................ vii
1. Background and Introduction............................................................................... 1
2. Intent for Use ................................................................................................... 3
3. Benefits of Use ................................................................................................. 5
4. Development Process....................................................................................... 13
5. CIHI PHC Indicators EMR Data Set..................................................................... 15
6. Next Steps ..................................................................................................... 43
7. Glossary of Terms ........................................................................................... 45
8. Appendices..................................................................................................... 47
Appendix A: Observation History and Current Encounter Health Issues Picklist ........ 47
Appendix B: Family Health History Picklist .......................................................... 51
Appendix C: Observation Interventions Picklist .................................................... 54
Appendix D: Current Encounter Interventions Picklist ........................................... 60
Appendix E: Observation History Allergy Types Picklist......................................... 62
Appendix F: Ordering Diagnostic Imaging Codes Picklist ....................................... 64
Appendix G: Medication Picklist ........................................................................ 67
Appendix H: Lab Test Ordering Codes Picklist ..................................................... 72
Appendix I: Provider Role Type Picklist ............................................................... 77
Appendix J: Provider Expertise Picklist ............................................................... 79
Appendix K: Service Recipient Ethnicity Picklist ................................................... 82
Appendix L: Service Recipient Primary Language Picklist....................................... 83
Appendix M: Current Encounter Influenza and Pneumococcal Vaccine “Not Given”
Reason Picklist ............................................................................. 84
Appendix N: CIHI PHC Indicator Mapping............................................................ 85
References............................................................................................................ 91
Electronic Medical Record Content Standards, Version 1.1
Acknowledgements
The Canadian Institute for Health Information (CIHI) would like to acknowledge and thank
the many individuals and organizations that contributed to the development of this product.
In particular, CIHI would like to acknowledge and express its appreciation to the members
of the external content standards working group, who provided invaluable guidance in
developing the CIHI Primary Health Care (PHC) Indicators Electronic Medical Record (EMR)
Content Standards. The members of the working group were:
• Ms. Claire Bernatchez, Senior • Ms. Gayle Lamont, Health Information
Program Manager, Health Information Coordinator, Prince Edward Island
Management, Federal Healthcare Department of Health
Partnership, Ontario • Dr. Marion Lyver, Physician, Managing
• Ms. Heather E. N. Cooper, Health Director, Healthy Futures, Ontario
Information Standards Coordinator, • Ms. Sheila Miller, Director, Planning and
Alberta Health and Wellness Evaluation, Department of Health and
• Mr. Tom Fogg, Director of Strategy Community Services, Newfoundland
and Planning, Manitoba eHealth and Labrador
• Mr. Felix Fridman, Team Lead, • Ms. Lisa Napier, Program Manager,
Standards Infrastructure and Program Primary Health Care Information
Support, Physician Office System Management, Nova Scotia Department
Program (POSP), Alberta of Health
• Ms. Beverly Greene, Consultant, • Ms. Ethine Reichert, Clinical Consultant
Primary Health Care, New Brunswick for Primary Health Care Project,
Department of Health Saskatchewan Ministry of Health
• Dr. Roger Hamilton, Physician, • Ms. Marion Relf, Director, Primary Health
Nova Scotia Care Initiatives, Alberta Health Services
• Dr. Liisa Jaakkimainen, Family • Dr. Ray Simkus, Physician, Brookswood
Physician; Scientist, Institute for Family Practice Biomedical Informatics,
Clinical Evaluative Sciences British Columbia
• Mr. Mark Kickham, Health
Information Specialist, Prince Edward
Island Department of Health
CIHI 2009 iii

The project team responsible for developing the CIHI PHC Indicators EMR Content
Standards included:
• Ms. Kunval Chaudhery, PHC Content Support and Data Quality Verification
• Ms. Paula Freedman, Standards Subject Matter Expert
• Ms. Shabnam Ismaily, Classification Subject Matter Expert
• Ms. Judith MacPhail, PHC Subject Matter Expert
• Ms. Cristina Mihelic, Standards Subject Matter Expert
• Ms. Shaheena Mukhi, PHC Project and Content Lead
• Ms. Christine Proietti, Information Technology Subject Matter Expert
• Ms. Maria Sanchez, PHC Content and Data Quality Verification
• Ms. Huma Sindhu, PHC Content and Data Quality Verification
• Ms. Patricia Sullivan-Taylor, PHC Subject Matter Expert, Reviewer and Editor
• Mr. Greg Webster, Reviewer and Editor
CIHI would also like to recognize Canada Health Infoway’s standards collaborative
working groups 2 and 3 for their initial input and their reviews in various phases of the
project. The assistance offered by individuals and organizations—including Ms. Linda Miller,
Deputy Minister, Alberta Health and Wellness; the Centre for Practical Health Informatics
Committee of the Group Health Centres, Sault Ste. Marie, Ontario; and those within the
health regions, provinces and territories—who provided input to the CIHI PHC Indicators
EMR Content Standards is gratefully acknowledged.
This product could not have been completed without the generous support and assistance
of many other CIHI staff members, including classifications, information technology and
services, CIHI standards working group, layout and design, translation, communications
and distribution, who provided ongoing support to the core team.
iv CIHI 2009
About the Canadian Institute for

Health Information
The Canadian Institute for Health Information (CIHI) is one of Canada’s premiere sources of
high-quality, reliable and timely health information.
Canada’s federal, provincial and territorial governments created CIHI as an independent,

not-for-profit organization dedicated to forging a common approach to Canadian health
information. CIHI is a focal point for collaboration among major health players—from
provincial governments, regional health authorities and hospitals to the federal government,
researchers and associations representing health care professionals.
Taking Health Information Further

CIHI provides Canadians with essential statistics and analyses about their health and their
health care system. CIHI is a source of information for those seeking answers to critical
questions around the performance of the Canadian health system, the delivery of health
care and the status of Canadians’ health.
CIHI collects and analyzes information on health and health care in Canada and makes it
publicly available. CIHI’s data and reports inform health policies, support the effective
delivery of health services and raise awareness among Canadians of the factors that
contribute to good health.
Specifically, CIHI:
• Identifies and promotes national health indicators;
• Coordinates and promotes the development and maintenance of national health
information standards;
• Develops and manages databases and registries: health care services, health human
resources and health spending;
• Examines what factors determine good health (Canadian Population Health Initiative);
• Conducts analyses and special studies and participates in research;
• Publishes reports and disseminates health information; and
• Coordinates and conducts education sessions and conferences.
Governance
A strong and active 16-member board of directors, whose membership strikes a balance
among the health sectors and regions in Canada, governs CIHI. The board provides strategic
guidance to both CIHI and the Health Statistics Division at Statistics Canada. In addition, the
board maintains strong links with the Conference of Deputy Ministers of Health.
For more information, visit our website at www.cihi.ca.
CIHI 2009 v
Executive Summary
Primary health care (PHC) has been described as the foundation of Canada’s health care
system and is the most common type of health care experienced by Canadians. Ninety-four
percent of Canadians 15 and older use first contact services each year,1 and Canada’s first
ministers agreed that PHC is one of the priority areas for improvement.2 However, despite
the importance of PHC in the overall management of Canadians’ health and the health
system, it is an area lacking comparable, standardized data to support system-level
analysis to better understand and inform delivery. With the increasing use of electronic
medical record (EMR) applications in PHC settings across Canada, the use of common EMR
content standards in PHC is necessary to have relevant and standardized data to support
decision-making related to key elements of care such as access, quality and outcomes.
Primary health care is, for most people, the first point of contact with the health care
system, often through a family physician. It is where short-term health issues are resolved,
where the majority of chronic health conditions are managed, where health promotion and
education efforts are undertaken and where patients in need of more specialized services
are connected with care. Dietitians, nurses, occupational therapists, physiotherapists,
pharmacists, psychologists, social workers and other health care workers also deliver
PHC services.3
To close the PHC information gap related to clinical quality of care indicators and in
response to provincial and territorial requests, CIHI led the PHC Indicators EMR Content
Standards Project and developed the CIHI PHC Indicators EMR Data Set for use in EMR
applications. This data set includes data elements related to patients, providers, encounters
and outcomes of care and will support consistent, comparable data capture for 12 CIHI
PHC clinical quality of care indicators in the areas of prevention, patient safety, quality and
outcomes. This product is meant to support the needs of the provinces and territories as
they develop requests for proposals to short-list EMR vendors or refine requirements with
existing vendors over time. This standardized data set can also be used for other purposes.
For example, implementing the CIHI PHC Indicators EMR Data Set in existing chronic
disease registries (collaboratives) would support the capture of standardized data in the
areas of diabetes, coronary artery disease, hypertension and depression and would enable
jurisdictions to better understand their performance.
The two main goals of the PHC Indicators EMR Content Standards Project are:
• To lead the coordination and development of common content standards that can be
used to increase the availability of the clinical and administrative data required for
calculating and reporting on a subset of 12 PHC clinical quality of care indicators.
• To promote the adoption and uptake of the CIHI PHC Indicators EMR Data Set for use
in EMRs by a wide range of stakeholders, including provinces and territories, PHC
providers, the College of Family Physicians of Canada, Canada Health Infoway,
provincial health quality councils and the EMR vendor community.
CIHI 2009 vii

Table 1 lists the 12 CIHI clinical quality of care indicators that could be calculated using
the CIHI PHC Indicators EMR Data Set.
Table 1 CIHI PHC Indicators Available Through the CIHI PHC Indicators EMR Data Set
Primary and Secondary Prevention
• Health risk screening
• Cervical cancer screening
• Influenza immunization, 65+
• Pneumococcal immunization, 65+
• Screening for modifiable risk factors in adults with coronary artery disease
• Screening for modifiable risk factors in adults with hypertension
• Screening for modifiable risk factors in adults with diabetes
Patient Safety
• Antidepressant monitoring
Outcomes
• Glycemic control for diabetes
• Blood pressure control for hypertension
• Treatment of dyslipidemia
• Treatment of depression
The PHC Indicators EMR Data Set was established in consultation with experts from across
Canada, including clinicians, federal, provincial and territorial representatives, PHC
researchers and standards experts. Where possible, the elements are aligned to pan-
Canadian and international standards. This standardized data set will allow consistent data
capture that will improve understanding and ability to report on PHC utilization and access,
chronic disease prevention and management, health promotion, medication usage, patient
safety, quality of care practices and outcomes.
The CIHI PHC Indicators EMR Data Set can be used by PHC providers to:
• Support chronic disease prevention and management;
• Identify select patient populations within a practice and determine the proportion
receiving treatment according to select clinical practice guidelines (CPGs) and resulting
outcomes of care;
• Inform care management and patient self-management program planning;
• Support population health analysis at the provider level; and
• Monitor PHC performance in the areas of prevention, patient safety, quality and
outcomes and promote an understanding of socio-demographic variations and unique
population needs to support program planning.
viii CIHI 2009

The CIHI PHC Indicators EMR Data Set can be used by provinces, territories and others to:
• Strengthen the requirements for PHC-based EMRs; and
• Increase the collection of standardized information about chronic disease prevention
and management from PHC settings and existing collaboratives in the areas of diabetes,
coronary artery diseases, hypertension and depression.
Early in 2009, CIHI will work with interested PHC providers and jurisdictions across
Canada to pilot test the CIHI PHC Indicators EMR Data Set. Pilot testing will inform future
versions of these standards. CIHI will also work with the jurisdictions and other key
stakeholders to support the uptake and adoption of these standards into PHC-based EMRs
across Canada.
The remainder of this document describes more fully the complete CIHI PHC Indicators
EMR Data Set and the mapping of the data elements to the 12 pan-Canadian PHC quality
of care indicators.
CIHI 2009 ix
1. Background and Introduction

Primary health care (PHC) is the most common type of health care experienced by
Canadians. Ninety-four percent of Canadians 15 and older use first contact services
each year,1 and Canada’s first ministers agreed that PHC is one of the priority areas for
improvement. Primary health care includes those providers and settings that resolve
short-term, acute health issues and where prevention and management of chronic health
conditions generally occur.2 However, despite the importance of PHC in the overall
management of Canadians’ health, it is an area lacking standardized and comparable
information with which to support local and system-level analysis required to better
understand the factors affecting PHC quality and outcomes.
In 2005, CIHI received funding from the Primary Health Care Transition Fund and partnered
with a broad range of PHC experts across Canada to develop an agreed-upon set of pan-
Canadian indicators that could be used to measure PHC at multiple levels within jurisdictions
across Canada. These 105 indicators were published in the two-volume report, Pan-Canadian
Primary Health Care Indicators in 20064, 5 with an accompanying report that recommended
options for enhancing the infrastructure required to collect the necessary data in order to
report on the PHC indicators. CIHI built on this work in 2007 by exploring the feasibility
of various options to collect more data on PHC, including expanded data collection
through surveys.
In fall 2007, CIHI launched a PHC information program focused on establishing new pan-
Canadian data streams for populating and reporting on the PHC indicators to improve the
understanding of PHC across the country and inform health policy and decision-making at
a variety of levels. Through the PHC Indicators EMR Content Standards Project, CIHI led
the development of the CIHI PHC Indicators EMR Data Set to support the collection of
comparable PHC information where the most likely data source is an EMR. As such, these
standards are intended to enhance the PHC data collection infrastructure.
Several provinces have completed procurement processes to approve PHC-based EMR

vendors. These activities reflect the interest in EMR standards among both jurisdictions and
PHC providers. Over the past year, Canada Health Infoway facilitated work to promote a
pan-Canadian set of physician office system requirements that addresses functional and
technical standards for EMRs.
Currently, EMRs are fully implemented in fewer than 30%6 of Canadian PHC practices.
There are initiatives under way in Canada to speed the adoption of EMRs and collect
patient-specific information in PHC settings. However, the data collected in EMRs are often
not standardized or structured and, therefore, are not comparable for analysis. This limits
the extent to which data captured in EMRs may be used to monitor, evaluate and improve
the quality of care delivered in PHC settings. As a result, the time is right to adopt PHC data
content standards and improve the PHC collection infrastructure in Canada.
The CIHI PHC Indicators EMR Content Standards leverage the work completed to date by
providing further detail on the data content required for PHC indicator reporting and by
aligning with existing pan-Canadian standards, such as those for the Interoperable
CIHI 2009 1
Electronic Health Record (iEHR) and International Organization for Standardization (ISO),
where appropriate. Furthermore, in collaboration with PHC providers, researchers,
standards experts and health system managers, CIHI strengthened the data collection
infrastructure by providing these standardized data elements, identified as important for
data collection, analysis and population of 12 PHC clinical quality of care indicators. This
document includes the CIHI PHC Indicators EMR Data Set (Section 5) along with many
details, including the CIHI PHC indicator mapping (Appendix N). This product is meant to
support the needs of provinces, territories, PHC providers and others in their efforts to
improve standardized data collection in the areas of chronic disease prevention and
management through PHC-based EMRs in Canada.
2 CIHI 2009
2. Intent for Use

The CIHI PHC Indicators EMR Data Set and the 12 PHC clinical quality of care indicators
presented (Section 5) were established in consultation with experts across Canada,
including clinicians, federal, provincial and territorial representatives, PHC researchers and
standards experts.
The CIHI PHC Indicators EMR Data Set supports standardized and consistent data
collection for data elements related to select priority chronic diseases. These data
standards are intended for use by a range of stakeholders interested in strengthening
the data available in EMRs.
The CIHI PHC Indicators EMR Data Set can be used by PHC providers to:
• Support chronic disease prevention and management;
• Identify select patient populations within a practice and determine the proportion
receiving treatment according to select clinical practice guidelines (CPGs) and resulting
outcomes of care;
• Inform care management and patient self-management program planning;
• Support population health analysis at the provider level; and
• Monitor PHC performance in the areas of prevention, patient safety, quality and
outcomes and promote an understanding of socio-demographic variations and unique
population needs to support program planning.
The CIHI PHC Indicators EMR Data Set can be used by provinces, territories and others to:
• Strengthen the requirements for PHC-based EMRs; and
• Increase the collection of standardized information about chronic disease prevention
and management from PHC settings and existing collaboratives in the areas of diabetes,
coronary artery diseases, hypertension and depression.
CIHI 2009 3
3. Benefits of Use
The benefits of adopting the CIHI PHC Indicators EMR Data Set are extensive in supporting
chronic disease prevention, management and monitoring at the provider, practice, regional
and pan-Canadian levels.
The CIHI PHC Indicators EMR Data Set:

• Provides common content standards in the form of 112 data elements to report on
12 PHC clinical quality of care indicators, principally in the areas of prevention, quality,
outcomes, access and patient safety;
• Responds to the need for standardized data in PHC and promotes improved data
collection where most Canadians receive care;
• Engages key stakeholders, including provinces, territories, PHC providers and EMR
vendors, in aligning efforts to capture comparable chronic disease prevention and
management information;
• Ensures that common PHC data could be collected through EMRs across the
country; and
• Promotes discussion on standards of care, potentially leading to improved PHC delivery.
The use of the CIHI PHC Indicators EMR Data Set at various levels (local, regional,
national) will improve the relevance and comparability of PHC data captured at the point of
care using EMRs and will:
• Enable monitoring and evaluation of PHC to understand and improve overall
performance of the health system locally (within a provider practice) and nationally;
• Provide structured data capture so that providers can more easily create disease
registries within their practices and assess whether their patient populations are
receiving recommended care;
• Permit development of provider feedback reports in order to improve the quality and
continuity of patient care, particularly for patients with chronic diseases;
• Support reporting of the current status of PHC in Canada and identify areas for
improvement; and
• Provide data to support ongoing health planning and policy development.
Throughout this project CIHI collaborated with standards experts, initiatives and
stakeholders from across Canada, which in some cases resulted in better alignment of
the visions for EMRs and increased interest in a common approach to data collection
and reporting.
CIHI 2009 5
Table 2 illustrates specific data needs of each target audience and the benefits the CIHI PHC Indicators EMR Data Set
will provide.
Table 2 Needs for and Benefits of EMR Content Standards for Target Audiences
Benefits of EMR Content Standards—
Audience Needs for EMR Content Standards
CIHI PHC Indicators EMR Data Set
All • Lack comparable data capture to support care • Improve availability of standardized and comparable
record for PHC patients with chronic conditions PHC clinical data from EMRs
• Limited ability by providers to generate disease • Increase availability of the clinical administrative data
registry for specific patient populations; limited required for calculating and reporting on a subset of
ability to produce standard reports 12 PHC clinical quality of care indicators with a focus
• Lack of ability to assess if patients are receiving on chronic conditions
recommended care and insufficient data to • Support efficient data capture to improve the ability to
efficiently monitor and inform patient care monitor and inform patient care at the provider,
• Limited information on access and outcomes of practice, regional or national level
care related to various delivery models (for • Support data collection that will:
example, solo versus family health team) – Improve and support patient care management
• Focus needed on evaluating primary care renewal (provider feedback reports)
efforts and collecting standardized, comparable – Enable monitoring and evaluation of PHC:
information across the country to aid understanding o Locally (comparative reports within a practice
and guide improvement efforts or region); and
• Lack of baseline information in PHC for measuring o Nationally to understand and improve overall
performance over time performance and better inform how various
elements of PHC (such as outcomes, access,
continuity) relate to different models of care
delivery (solo versus family health team)
• Data can be used to inform and direct quality
improvement in PHC at many levels
6 CIHI 2009

Federal and • Unable to assess incidence and prevalence of • Improve chronic condition identification, prevention
Provincial chronic conditions in PHC across Canada and management in PHC settings
Ministries of • Unable to assess adherence to recommended care • Support the transition or portability of a subset
Health according to the nationally agreed-upon CPGs of clinical quality PHC data to electronic health
• Early stages of shared care records, lack of record (EHR)
consensus nationally on data to include in shared • Support the development of PHC paths that are
care records evidence-based and focus on primary and secondary
• Unable to monitor and evaluate PHC renewal prevention as well as outcomes achieved
efforts, and identify better practices • Improve understanding of PHC elements, specifically
• Limited data to inform chronic condition prevention access, quality, coordination of care, continuity,
and management and to aid comparisons inter- models and outcomes
provincially and nationally • Promote discussion on standards of care to improve
• Unable to assess which PHC models of care practice, inform whether clinically recommended care
provide the best care and value for money results in better outcomes in various models
• Lack of baseline information in PHC for measuring • Provide standardized comparable data to report on
performance over time health system changes and support resource planning
• Focus needed on EMR clinical quality measures (for • Develop partnerships and strategic alliances (locally
example, for patients with diabetes, have they with providers and nationally)
received clinically recommended care and reached • Ability to capture standardized, comparable
target best practice outcomes?) information available across jurisdictions (regardless of
EMR vendor) to support comparable monitoring and
reporting for quality improvement at all levels
• Support linkages to population health
CIHI 2009 7

Health Region • Unable to assess incidence and prevalence of • Improve chronic condition identification, prevention
Managers chronic conditions in PHC across Canada and management in PHC settings
• Unable to assess adherence to recommended care • Support the transition or portability of a subset of
according to the nationally agreed-upon CPGs clinical quality PHC data to EHRs
• Lack of information to support planning and • Promote discussion and data capture on standards of
monitoring of chronic disease prevention and care for chronic disease prevention and management
management • Provide standardized comparable data to report on
• Unable to assess which PHC models of care health system changes and support resource planning
provide the best outcomes for specific patient • Facilitate the development of partnerships and
populations strategic alliances, as well as provide opportunities for
• Significant information gaps about PHC in Canada chronic condition collaboratives
• Focus needed on EMR clinical quality measures (for • Ability to capture standardized, comparable
example, for patients with hypertension, have they information available across jurisdictions (regardless of
received clinically recommended care and reached EMR vendor) to support comparable monitoring and
target best practice outcomes?) reporting for quality improvement at all levels
• Improve ability to capture data that will support
understanding of which models of care result in
better outcomes
• Support linkages to population health analysis
and reporting
Public Health • Limited information on chronic disease prevention • Promote discussion on standards of care for chronic
and Community and management disease prevention and management (risk factors, care
Health Centres • Limited information on public health practices, etc.)
• Unable to assess which PHC models of care • Support linkages to population health analysis
provide the best outcomes and value and reporting
• Focus needed on EMR clinical quality measures (for • Improve ability to support data portability (from one
example, for patients with hypertension, have they vendor to another)
received clinically recommended care and reached • Improve ability to capture data that will support
target best practice outcomes?) understanding of which models of care result in
better outcomes
• Provide standardized comparable data to report on
health system changes and support resource planning
8 CIHI 2009

PHC Providers • Lack standardized, comparable way to measure and • Promote discussion on standards of care
and understand PHC in Canada • Support data capture to enable chronic disease
Associations • Limited data to fully support chronic disease registry use at the provider level (for example,
prevention and management improved patient follow-up)
• Unable to assess which PHC models of care • Improve clinical decision-making tools at the point of
provide the best outcomes care and ultimately lead to better health outcomes
• Focus needed on EMR clinical quality measures (for for patients
example, for patients with hypertension, have they • Improve ability to support data portability (from one
received clinically recommended care and are blood vendor to another)
pressure outcomes achieved?) • Support data collection to generate provider feedback
• Limited ability to evaluate own practice patterns reports locally, with potential for national reporting
with that of comparative populations locally or • Promote refinement of indicators and data required for
nationally to understand and improve patient care PHC system planning and management
EMR Vendors • Focus needed on the development of a system that • Support data capture once at the point of care that
will meet the current requirements and will provide can be used for multiple purposes in the EMR, EHR
the best strategic fit for future EHR development and health system planning and management across
• Need for pan-Canadian EMR standards to Canada
promote re-use • Improve ability to support data portability (from one
• Desire for alignment of content standards with vendor to another and potentially to EHR)
relevant EHR or iEHR standards • Improve viability of product to providers, system
planners and funders
CIHI 2009 9

Researchers • Unable to assess which PHC models of care • Facilitate increased research with new PHC data set
provide the best outcomes and value • Provide data to inform CPGs for primary health care
• Limited data on PHC in Canada using primary health care data
• CPGs applied in PHC settings are frequently based • Inform future research and data requirements
on secondary or tertiary care settings due to lack of • Facilitate the development of partnerships and
PHC data strategic alliances, as well as provide opportunities for
• Limited information on chronic disease prevention chronic condition collaboratives
and management • Support data capture and linkages to population health
• Focus needed on EMR clinical quality measures (for analysis and reporting
example, for patients with hypertension, have they • Improve ability to capture data that will support
received clinically recommended care and are blood understanding of which models of care result in better
pressure outcomes achieved?) outcomes to enable research to explore good practices
and evolving models
Patients • Lack of understanding as to whether patients • Develop reports and programs that will facilitate
receive high-quality, recommended care communication between provider and patient
• Lack of data locally (for example, chronic disease • Collect standardized accessible data that are
registries within a practice) to support patients and understandable and comparable across PHC settings,
PHC providers in delivering evidence-based care thereby ensuring continuity of care
• Lack of information to support prevention, • Improve data to support prevention, planning and
planning and management of chronic conditions management of chronic conditions and clinical
(ability to show trends in blood pressure, A1c, decision-making at the point of care, which may
cholesterol values compared to target) to ultimately lead to better engagement and health
encourage self-management outcomes for patients
• Support self-care management
10 CIHI 2009

CIHI • CIHI mandate to report on PHC in Canada • Leverage and align with work of other functional and
to stakeholders technical standards in various stages of development
• Significant information gaps related to clinical or implementation across Canada
quality of care in PHC • Data capture locally that may be collected and
• Focus needed on EMR clinical quality measures (for reported centrally via a CIHI voluntary PHC database
example, for patients with chronic conditions, have that:
they received clinically recommended care and – Supports providers, regional health managers, as
reached target outcomes?) well as provinces and territories in their efforts to
enhance the relevance and comparability of PHC
data available through EMRs
– Enables the production of regional, provincial and
national reports to inform the health of Canadians
– Facilitates analysis and reporting on population
health outcomes
– Informs the understanding of the impact of various
models of care on elements of PHC (for example,
access, outcomes)
– Develop partnerships and strategic alliances to
identify and promote national PHC indicators (for
example, with Canada Health Infoway, Statistics
Canada, Public Health Agency of Canada)
• Enhance data holdings to take health information
further and support reporting across the care
continuum
CIHI 2009 11
4. Development Process
In late 2007, development of the CIHI PHC Indicators EMR Content Standards was
accelerated in an effort to support the needs of the provinces and territories as they
developed requests for proposals to short-list EMR vendors. As well, two provinces were
implementing quality improvement projects using a subset of the PHC indicators, hence the
increasing urgency to develop the CIHI PHC Indicators EMR Data Set to ensure that the
data and indicators would be comparable within and across provincial boundaries (for
example, blood pressure values for patients with a hypertension diagnosis, A1c values for
diabetes patients). When developing these standards, efforts were made to align with
existing national and international content standards and national initiatives under way,
including the physician office system requirements facilitated by Canada Health Infoway.
The four goals of the development process for the PHC Indicators EMR Content Standards
Project were to:
1. Lead the coordination and development of the CIHI PHC Indicators EMR Data Set and
underlying content standards that can be used to increase the availability of the clinical
and administrative data required for calculating and reporting on a subset of 12 PHC
clinical quality of care indicators;
2. Promote the adoption of CIHI PHC Indicators EMR Content Standards and ensure that
all provinces and territories are aware of these standards and the benefits of uptake
and implementation;
3. Develop and implement a communication strategy and plan to ensure engagement of
key stakeholders and to support uptake of the PHC Indicators EMR Content Standards in
order to improve the comparability of PHC data that can be obtained from EMRs; and
4. Work with external organizations such as the College of Family Physicians of Canada,
Canada Health Infoway, the Western Health Information Collaborative and others (such
as quality councils) to inform the refinement of these standards and the CIHI PHC
Indicators EMR Data Set.
The PHC Indicators EMR Content Standards Project comprises five phases:
Phase 1: Planning and Information Needs Assessment.
Phase 2: Requirements Definition and Gap Analysis.
Phase 3: CIHI PHC Indicators EMR Data Set Refinement.
Phase 4: CIHI PHC Indicators EMR Content Standards Dissemination.
Phase 5: Uptake, Promotion and Pilot Testing.
Phase 1: Planning and Information Needs Assessment

Phase 1 of the project involved the development and approval of the project charter to
outline the scope, objectives and participants involved. After outlining these goals and
objectives, developing and implementing a communications strategy and plan helped
ensure early engagement of key stakeholders to support future uptake of the CIHI PHC
Indicators EMR Content Standards. Another key element of the project was to conduct an
environmental scan and complete consultations with most provinces and territories and
external organizations such as the College of Family Physicians of Canada, provincial and
CIHI 2009 13
territorial chief information officers, Canada Health Infoway, the Western Health
Information Collaborative, provincial and territorial EMR physician office system
initiatives (such as Ontario MD) and provincial and territorial chronic disease management
collaboratives. Consultations were enhanced with the establishment of an external content
standards working group to provide strategic direction and to assist with the CIHI PHC
Indicators EMR Data Set validation and alignment. The preliminary list of data elements,
otherwise known as the CIHI PHC Indicators EMR Data Set, was developed and mapped, in
the form of an indicator mapping document, to the subset of clinical quality of care
indicators. This preliminary list was shared with provincial and territorial chief information
officers in January 2008.
Phase 2: Requirements Definition and Gap Analysis

Phase 2 of the project resulted in the development and validation of a business
requirements document, an evidence-based review and gap analysis using information from
the environmental scan and meetings with key informants, including an information EMR
vendor forum. Phase 2 also saw the implementation of the communication plan and
continued consultation with provinces and territories, clinicians and vendors. The working
group convened three times via teleconference during the first half of 2008. The evidence-
based review was conducted to ensure the changes in CPGs were reflected in the indicators
and CIHI PHC Indicators EMR Data Set. A gap analysis with other chronic disease and PHC
data sets in Canada and internationally was conducted to inform refinement of the CIHI
PHC Indicators EMR Data Set. The information from the consultation, gap analysis and
evidence-based review resulted in additional consultation with jurisdictions and standards
experts and further validation of the CIHI PHC Indicators EMR Data Set.
Phase 3: CIHI PHC Indicators EMR Data Set Refinement

Phase 3 of the project addressed the refinement of the CIHI PHC Indicators EMR Data Set
based on the feedback received from the working group and additional environmental
scanning. The working group and others (for example, a physician consultant to CIHI)
reviewed the CIHI PHC Indicators EMR Data Set and indicator mapping and provided
feedback that was incorporated into the final product. Additional input to ensure alignment
with pan-Canadian EHR and iEHR standards as well as ISO standards was validated as data
element definitions were finalized.
Phase 4: CIHI PHC Indicators EMR Content Standards Dissemination

Phase 4 focused on disseminating the CIHI PHC Indicators EMR Content Standards to key
stakeholders, including federal and provincial ministries of health, health region managers,
PHC providers and associations, EMR vendors, researchers, public health and community
health centres and the public. Collaboration with the provinces and territories occurred
through key business and information technology contacts.
Phase 5: Uptake, Promotion and Pilot Testing

Phase 5 will focus on maximizing the uptake and implementation of the standards
into PHC-based EMRs across Canada. It will also include pilot testing the standards to
inform subsequent versions. Both of these activities will involve a broad range of
stakeholder consultation.
14 CIHI 2009
5. CIHI PHC Indicators EMR Data Set

The CIHI PHC Indicators EMR Data Set provides EMR content standards that can be used
to support the consistent collection of more comprehensive and comparable PHC
information at the point of care. The content standards are aligned to pan-Canadian and
international standards.
As a starting point, the CIHI PHC Indicators EMR Data Set will support the population of
12 PHC clinical quality of care indicators for reporting on chronic disease prevention,
management and monitoring at the provider, clinical practice, regional and pan-Canadian
levels. A mapping of the CIHI PHC Indicators EMR Data Set to the 12 CIHI PHC indicators
is provided in Appendix N.
Table 3 lists the 12 CIHI clinical quality of care indicators that could be calculated using
the CIHI PHC Indicators EMR Data Set.
Table 3 CIHI PHC Indicators Available Through the CIHI PHC Indicators EMR Data Set
Primary and Secondary Prevention
• Health risk screening (indicator number 13)
• Cervical cancer screening (indicator number 50)
• Influenza immunization, 65+ (indicator number 41)
• Pneumococcal immunization, 65+ (indicator number 42)
• Screening for modifiable risk factors in adults with coronary artery disease
(indicator number 55)
• Screening for modifiable risk factors in adults with hypertension (indicator number 56)
• Screening for modifiable risk factors in adults with diabetes (indicator number 57)
Patient Safety
• Antidepressant monitoring (indicator number 63)
Outcomes
• Glycemic control for diabetes (indicator number 39)
• Blood pressure control for hypertension (indicator number 40)
• Treatment of dyslipidemia (indicator number 61)
• Treatment of depression (indicator number 64)
A list of the 77 data elements in the CIHI PHC Indicators EMR Data Set, which are required
for reporting on the 12 PHC clinical quality of care indicators, can be found in Table 4.
Supplementary variables that support additional capacity for analysis and reporting can be
found in Table 5. The complete listing of the CIHI PHC Indicators EMR Data Set is
presented in Table 6.
CIHI 2009 15
Table 4 provides a list of the PHC data elements, established in consultation with PHC field
experts across Canada, required for reporting on the 12 clinical quality of care indicators.
Table 4 Required PHC Data Elements for Reporting on the 12 PHC Clinical Quality
of Care Indicators
Service Recipient Demographics
• Service Recipient Birthdate • Service Recipient Identifier • Service Recipient Province/
• Service Recipient Gender Number Territory of Residence
• Service Recipient Identifier • Service Recipient Postal Code
Type of Residence
• Service Recipient Identifier
Issuer
Health History and Encounter Information
• Encounter Date • Observation History • Antidepressant Treatment
• Date of Initial Encounter With – Allergy Type Follow-Up and Indicator
PHC Provider – Health Issue(s) and • Current Encounter
• Current Encounter Service Diagnosed Date – Health Issue(s)
Recipient – Lab Test Code(s), Performed – Intervention(s)
– Diastolic and Systolic Blood Date and Value – End-of-Life Indicator
Pressure Values – Medication(s) Prescribed, – Lab Test Date Ordered,
– Height Value Dose, Frequency and Code(s), Value and
– Hip and Waist Circumference Strength Performed Date
Values – Diastolic and Systolic Blood – Medication(s) Prescribed,
– Weight Value Pressure Values and Date Dose, Frequency, Strength
– Medication(s) Non-Adherence – Intervention(s) and Date and Repeat
Indicator – End-of-Life Indicator • Referred To Encounter
– Medication(s) “not given – End-of-Life Date Occurred Indicator
reason”
Prevention
• Current Encounter • Observation History (Past • Current Encounter Service
– Influenza Vaccine Indicator Medical History) Recipient (Screening Indicators)
– Pneumococcal Vaccine – Influenza Immunization Date – Depression
Indicator – Influenza Immunization – Eating Habits
– Intervention Lifestyle Advice Indicator – Physical Activity
Indicator – Pneumococcal Immunization – Smoker
– Papanicolaou Test (Pap) Date – Unintentional Falls
Screening Indicator – Pneumococcal Immunization – Unmanaged Psychosocial
Indicator Stress
– Unsafe Drinking
– Unsafe Drug Use
– Unsafe Sexual Practice
Provider and Service Delivery Information
• Provider Expertise and • Service Delivery Location (SDL) • Referred To Provider
Role Type – Identifier Number Identifier Number, Expertise
• Provider Identifier Number, – Type and Role Type
Type and Issuer – Postal Code
16 CIHI 2009
Table 5 depicts supplementary data elements, recommended by the expert working group,
to support additional capacity for analysis and reporting (for example, ethnicity, payor
source, wait times).
Table 5 Supplementary PHC Data Elements for Analysis and Reporting

• Current Encounter: • Current Encounter: • Service Recipient
– Influenza Vaccine “Not – Depression Screening Tool – Ethnicity
Given” Reason – Unsafe Drug Use – Primary Language
– Pneumococcal Vaccine “Not Screening Tool – Homeless Indicator
Given” Reason – Unsafe Drinking Screening Tool – Rostered Indicator
• Service Delivery Location Name – Unsafe Sexual Practice – Estimated Birthdate
• Estimated Date of Initial Screening Tool • Observation History
Encounter With PHC Provider – Unmanaged Psychosocial – Prescribed Medication Form
Indicator Stress Screening Tool and Route
• Observation History Estimated • Provider Name – Health Issue Estimated
Pneumococcal Immunization • Encounter Booking Date Diagnosed Date Indicator
Date Indicator • Encounter Mode of Visit – Estimated Intervention Date
• Diagnostic Imaging (DI) • Encounter Payor Source Indicator
– Code • Current Encounter Prescribed – Estimated End-of-Life Date
– Booking Date Medication Form Indicator
– Performed Date • Current Encounter Prescribed – Systolic Blood Pressure
– Result Medication Route Estimated Value Date
• Observation Family Health History Indicator
• Observation History Estimated Lab – Diastolic Blood Pressure
Test(s) Performed Date Indicator Estimated Value Date
• Observation History Estimated Indicator
Influenza Immunization Date
Indicator
Given the evolution of e-health initiatives under way across Canada, the data elements
were aligned to existing standards, where possible, recognizing that some of this work is
evolving at a different pace in each province and territory.
Table 6 outlines the CIHI PHC Indicators EMR Data Set and is organized into six columns.
The columns are:
• Item Number—A numerical listing to track the data elements.
• High-Level Concept/Sub-Concept—The high-level concepts are Service Recipient,
Provider, Service Delivery Location, Encounter, Observation—History, Observation—
Current, Laboratory, Diagnostic Imaging, Intervention and Medication.
• Data Element Name—This describes the name assigned to each data and label element.
• Data Element Description—This describes the information that the data element is
expected to collect.
• Potential Representation—The format in which each data element is expected to
be collected.
• Reporting of PHC Quality of Care Indicator Number—A list of specific PHC indicators
(referenced in Table 3) that each data element will support. The asterisk in the table
represents the number of the CIHI PHC indicator from the original list of 105 indicators.
Complete definitions can be found in appendix N.
CIHI 2009 17
Table 6 CIHI PHC Indicators EMR Data Set

High-Level Reporting of PHC
Item Data Element Data Element
Concept/ Potential Representation Quality of Care
Number Name Description
Sub-Concept Indicator Number*
Service Recipient
1 Service Service A value used to • Character, Code (20) 13, 63, 64, 50,
Recipient Recipient uniquely identify a • This data element aligns with the concepts contained 41, 42, 55, 56,
Identifier service recipient. within most pan-Canadian EHR standards, CIHI Data 57, 39, 40, 61
Number Dictionary and CIHI Reference Data Model Project. May be
jurisdictionally decided (for example, provincial client
registry identification number).
2 Service Service A descriptor of the • Character, Code 13, 63, 64, 50,
Recipient Recipient service recipient’s type • A few examples for the selection list may include: 41, 42, 55, 56,
Identifier Type of identifier (for – Jurisdictional health card number 57, 39, 40, 61
example, health card – Federal number for Department of Veterans
number) represented in Affairs Canada
Service Recipient – Federal number for Department of National Defence
Identifier Number. – Non-Canadian
– Not applicable (only to be used in conjunction with
Service Recipient Homeless Indicator)
• This data element concept is aligned with Pan-Canadian
Client Registry, CIHI Data Dictionary and CIHI Reference
Data Model Project.
3 Service Service A code representing the • Character, Code 13, 63, 64, 50,
Recipient Recipient organization (including • Selection options may include: 41, 42, 55, 56,
Identifier Issuer authority and – Ontario Ministry of Health and Long-Term Care 57, 39, 40, 61
jurisdiction) responsible – Alberta Health and Wellness
for assigning the – Federal number for Department of Veterans
identifier number to the Affairs Canada
service recipient. – Federal number for Department of National Defence
– Non-Canadian issuing authority
– Not applicable (only to be used in conjunction with
Service Recipient Homeless Indicator)
• This data element concept is aligned with Pan-Canadian
Client Registry, CIHI Data Dictionary and CIHI Reference
Data Model Project.
18 CIHI 2009

4 Service Service Homelessness refers to • Character, Code, C (Y, N, 8 [not applicable]) N/A
Recipient Recipient the condition and • This value domain aligns to HL7 data standard, CIHI Data
Homeless societal category of Dictionary and CIHI Reference Data Model Project.
Indicator people who lack
housing, live in
transitional housing or
spend most nights in a
supervised public or
private facility providing
temporary living
quarters or in a public
or private place not
designed for regular
sleeping
accommodation for
human beings.
5 Service Service The year, month and • Date, YYYYMMDD 13, 63, 64, 50,
Recipient/ Recipient day on which the • This definition aligns with the CIHI Data Dictionary, CIHI 41, 42, 55, 56,
Demographics Birthdate service recipient was Reference Data Model Project, Client Registry and HL7 57, 39, 40, 61
born. data standard.
• The value domain of date aligns to HL7 data standard,
CIHI Data Dictionary and CIHI Reference Data
Model Project.
6 Service Service Indicates whether or • Character, Code, C (Y, N, 9 [unknown]) N/A
Recipient/ Recipient not the service • This data element concept aligns with the ISO standard
Demographics Estimated recipient’s date of birth Subjects of Care.
Birthdate is estimated. • This value domain aligns to HL7 data standard, CIHI Data
Indicator Dictionary and CIHI Reference Data Model Project.
7 Service Service A reported sexual • Character, Code, C (M, F, U [undifferentiated], 13, 63, 64, 50,
Recipient/ Recipient category of the service 9 [unknown]) 41, 42, 55, 56,
Demographics Gender recipient at a given • This data element aligns with the CIHI Data Dictionary, 57, 39, 40, 61
point in time used for CIHI Reference Data Model Project, HL7 standards, Client
administrative purposes. Registry and ISO standard Subjects of Care.
CIHI 2009 19

8 Service Service A person’s ethnic origin • Character, Code N/A
Recipient/ Recipient is the ethnic or cultural • Selection options may include:
Demographics Ethnicity group(s) to which his or – Aboriginal origins
her ancestors belonged. – French origins
Therefore, the ethnic – British Isles origins
origin refers to a • Please refer to Appendix K for an expanded list of Service
person’s “roots” and Recipient Ethnicity.
should not be confused • Representation form aligns to Statistics Canada
with his or her 2001 census.
citizenship or
nationality.
9 Service Service The language the • Character, Code, CCC N/A
Recipient/ Recipient service recipient is • Selection options may include:
Demographics Primary fluent in and uses in – American Sign Language
Language everyday conversation. – Gitksan
– Cantonese
– Aboriginal language not elsewhere specified
• Please refer to Appendix L for an expanded list of Service
Recipient Primary Language.
• This data element aligns with the CIHI Data Dictionary and
CIHI Reference Data Model Project for languages specific
to CIHI business and ISO language codes.
10 Service Service Indicates whether or • Character, Code, C (Y, N, 9 [unknown]) N/A
Recipient/ Recipient not the service recipient • This value domain aligns to HL7 data standard, CIHI Data
Patient Profile Rostered is a registered/rostered Dictionary and CIHI Reference Data Model Project.
Indicator patient in the PHC
practice/clinic.
11 Service Service The province or territory • Character, Code, CC 13, 63, 64, 50,
Recipient/ Recipient associated with the • Selection options may include: 41, 42, 55, 56,
Address Province/ service recipient’s – AB 57, 39, 40, 61
Territory of residential address. – ON
Residence – SK
– 97 (not collected)
– 98 (not applicable)
• This concept aligns with EHR standards, CIHI Data
Dictionary, CIHI Reference Data Model Project and Canada
Post for representation of provinces and territories.
20 CIHI 2009

12 Service Service The postal code • Character, Code, ANANAN 13, 63, 64, 50,
Recipient/ Recipient Postal associated with the • This data element aligns with HL7, EHR Pan-Canadian 41, 42, 55, 56,
Address Code of service recipient’s Standards, CIHI Data Dictionary, CIHI Reference Data 57, 39, 40, 61
Residence residential address. Model Project and Canada Post.
Provider
13 Provider Provider Name A descriptor of the Free text C (100) N/A
provider’s name.
14 Provider Provider A value assigned by an • Character, Code (length to be jurisdictionally determined) 13, 63, 64, 50,
Identifier organization, including • Selection options may include: 41, 42, 55, 56,
Number authority and – Licensing number from the College of Family Physicians 57, 39, 40, 61
jurisdiction, used to of Canada
uniquely identify a – Billing number issued by jurisdictions
provider within a • This data element aligns with Pan-Canadian EHR
specified context (as Standards (Provider Registry), CIHI Data Dictionary and
described in Provider CIHI Reference Data Model Project.
Identifier Type).
15 Provider Provider A descriptor of the • Character, Code, CCC 13, 63, 64, 50,
Identifier Type provider’s type of • Selection options may include: 41, 42, 55, 56,
identifier represented in – 005 provincial or territorial provider registration number 57, 39, 40, 61
Provider Identifier (college registration number)
Number. – 030 provider billing number
• This concept also exists within the Pan-Canadian
Provider Registry.
• The data element and the value domain are aligned
with CIHI Data Dictionary and CIHI Reference Data
Model Project.
16 Provider Provider A code representing the • Character, Code, C (9) 13, 63, 64, 50,
Identifier Issuer organization (including • This concept also exists within the Pan-Canadian 41, 42, 55, 56,
authority and Provider Registry. 57, 39, 40, 61
jurisdiction) responsible • This data element aligns with CIHI Organization
for assigning the Index, CIHI Data Dictionary and CIHI Reference Data
identifier number to the Model Project.
provider.
CIHI 2009 21

17 Provider Provider Role A provider’s primary • Character, Code, CCC 13, 63, 64, 50,
Type function/role within the • Selection options may include: 41, 42, 55, 56,
health care system. – 100 medical doctor 57, 39, 40, 61
– 095 licensed practical nurse (registered practical nurse)
– 250 physiotherapist
– 060 dietitian
– 340 social worker
• Please refer to Appendix I for an expanded list of Provider
Role Type.
• This data element aligns to CIHI Data Dictionary, CIHI
Reference Data Model Project and Pan-Canadian Provider
Registry standard.
18 Provider Provider Skill or knowledge in a • Character, Code, CCC 13, 63, 64, 50,
Expertise particular area or field. • Selection options may include: 41, 42, 55, 56,
Providers may claim – 040 cardiovascular surgery 57, 39, 40, 61
expertise in a particular – 165 hematology
area if they completed – 460 urology
specific training for that – 095 endocrinology and metabolism
area. The expertise may – 430 registered nurse practitioner
or may not be licensed • Please refer to Appendix J for an expanded list of
by a governing or Provider Expertise.
regulating body. • This data element aligns to CIHI Data Dictionary, CIHI
Reference Data Model Project and Pan-Canadian Provider
Registry standard.
Service Delivery Location
19 Service Service Delivery Used to uniquely • Assigned code by CIHI 13, 63, 64, 50,
Delivery Location (SDL) identify a PHC • This concept is PHC-specific; no pan-Canadian EHR 41, 42, 55, 56,
Location (SDL) Identifier practice (SDL). standard exists. Potential for future alignment to SDL 57, 39, 40, 61
Number registry. SDL registry is not established in any jurisdiction;
therefore, number and format could initially come from
CIHI Organizational Index.
22 CIHI 2009

20 Service SDL Type Where PHC-related • Character, Code, CCC 13, 63, 64, 50,
Delivery services were delivered • Selection options may include: 41, 42, 55, 56,
Location (SDL) by the provider to the – PHC clinic or practice 57, 39, 40, 61
service recipient. – Home
– Assisted living (includes retirement home, group home,
supportive housing)
– Residential care (includes long-term care facilities,
nursing homes)
• This concept is PHC-specific; no pan-Canadian EHR
standard exists. Potential for future alignment to SDL
registry. SDL registry is not established in any jurisdiction;
therefore, number and format could initially come from
CIHI Organizational Index.
21 Service SDL Postal Code The postal code of the • Character, Code, ANANAN 13, 63, 64, 50,
Delivery PHC practice (SDL) • This data element aligns to Canada Post for format 41, 42, 55, 56,
Location (SDL) where provision of care and content. 57, 39, 40, 61
to service recipient
(patient), for the
encounter, is delivered.
22 Service SDL Name The name of the PHC • Free text C (100) N/A
Delivery practice (SDL) where • This concept is PHC-specific; no pan-Canadian EHR
Location (SDL) provision of care to the standard exists. Potential for future alignment to SDL
service recipient registry. SDL registry is not established in any jurisdiction.
(patient), for the It will be determined by each provider who will submit
encounter, is delivered. data to CIHI.
Encounter
23 Encounter/ Date of Initial The date of the very • Date, YYYYMMDD 13, 63, 64, 50,
History Encounter With first visit, when the • The value domain of date aligns to HL7 data 41, 42, 55, 56,
PHC Provider service recipient standard, CIHI Data Dictionary and CIHI Reference 57, 39, 40, 61
(patient) was initially Data Model Project.
assessed by the health
provider.
CIHI 2009 23

24 Encounter/ Estimated Date Indicates whether or • Character, Code, C (Y, N, 9 [unknown]) N/A
History of Initial not the date of the very • This value domain aligns to HL7 data standard, CIHI Data
Encounter With first visit, when the Dictionary and CIHI Reference Data Model Project.
PHC Provider service recipient
Indicator (patient) was initially
assessed by the health
provider or PHC
organization as captured
by Date of Initial
Encounter With PHC
Provider, is estimated.
25 Encounter Encounter Mode A description of the • Character, Code, CCC N/A
of Visit type of contact • Selection options may include:
between the provider – Face-to-face
and the service recipient – Telephone
for a registered – Video conference
encounter or visit. – Email
26 Encounter Encounter The date that the • Date, YYYYMMDD N/A

Booking Date service recipient’s • This value domain aligns to HL7 data standard, CIHI Data
(patient) encounter was Dictionary and CIHI Reference Data Model Project.
booked in the PHC
provider’s scheduling
system.
27 Encounter Encounter Date The actual date that the • Date, YYYYMMDD 13, 63, 64, 50,
encounter occurred • The value domain of date aligns to HL7 data standard, 41, 42, 55, 56,
(service recipient was CIHI Data Dictionary and CIHI Reference Data 57, 39, 40, 61
seen by health Model Project.
provider).
24 CIHI 2009

28 Encounter Encounter Payor The source of payment • Character, Code, CC N/A
Source for the encounter. • Selection options may include:
– Patient (self-pay)
– Provincial or territorial insurance
– Workers’ compensation
– Federal government funds—Department of
Veterans Affairs
– Other
– Unknown
– Not collected
– Not applicable
• This data element aligns to the CIHI Data Dictionary, CIHI
Reference Data Model Project standard and NeCST.
29 Encounter/ Referred To The identifier number of • Character, Code (length to be jurisdictionally determined) 63, 64
Referred To Provider the health provider to • Licensing number from the College of Family Physicians of
Identifier whom the service Canada and/or billing number issued by jurisdictions
Number recipient is referred. • This data element aligns with Pan-Canadian EHR
Standards (Provider Registry), CIHI Data Dictionary and
CIHI Reference Data Model Project.
30 Encounter/ Referred To The role type of the • Character, Code, CCC 63, 64
Referred To Provider Role provider to whom the • Selection options may include:
Type service recipient was – 100 medical doctor
referred. – 095 licensed practical nurse (registered practical nurse)
– 250 physiotherapist
– 060 dietitian
– 340 social worker
• Please refer to Appendix I for an expanded list of Provider
Role Type.
• The concept of referral exists in the iEHR.
• The value domain of Provider Role Type aligns to CIHI
Data Dictionary, CIHI Reference Data Model Project and
Pan-Canadian Provider Registry Standard.
CIHI 2009 25

31 Encounter/ Referred To The expertise of the • Character, Code, CCC 63, 64
Referred To Provider provider to whom the • Selection options may include:
Expertise service recipient was – 040 cardiovascular surgery
referred. – 165 hematology
– 460 urology
– 095 endocrinology and metabolism
– 430 registered nurse practitioner
• Please refer to Appendix J for an expanded list of
Provider Expertise.
• The concept of referral exists in the iEHR.
• The value domain of Provider Expertise aligns with CIHI
Data Dictionary, CIHI Reference Data Model Project and
Pan-Canadian Provider Registry Standard.
32 Encounter/ Referred To Indicates whether or • Character, Code, C (Y, N, 8 [not applicable], 9 [unknown]) 63, 64
Referred To Encounter not the referred to • The concept of referral exists in the iEHR.
Occurred encounter occurred. • This value domain aligns to HL7 data standard, CIHI Data
Indicator Dictionary and CIHI Reference Data Model Project.
33 Encounter Antidepressant Indicates whether or • Character, Code, C (Y, N, 8 [not applicable]) 63
Treatment not the health provider • The concept aligns to PHC context.
Follow-Up followed up with the • This value domain aligns to HL7 data standard, CIHI Data
Indicator service recipient for Dictionary and CIHI Reference Data Model Project.
antidepressant
treatment prescribed
during an encounter
that occurred within the
previous two weeks.
26 CIHI 2009

Observation—History (that is, made during or associated with a past PHC encounter within the last three years)
34 Observation/ Observation A past health issue(s), • Character, Code, CCCC 13, 63, 64, 50,
History/Health History Health which may include • Selection options may include: 41, 42, 55, 56,
Issue(s) Issue(s) resolved issue(s) and/or – 125.1 coronary artery disease (CAD) atherosclerotic 57, 39, 40, 61
managed chronic heart disease
disease(s). – E 10 diabetes type I
– E 11 diabetes type II
– F 32.9 depression, depressive episode, unspecified
• Please refer to Appendix A for an expanded list of
Observation History Health Issues.
• This concept aligns to Health Condition Record in the
iEHR, ICD-10-CA/CCI and EHR health conditions or
observations which may use SNOMED.
• This value domain aligns to ICPC2 and CIHI ICD-10-CA.
35 Observation/ Observation The date the • Date, YYYYMMDD 13, 63, 64, 50,
History/Health History Health Observation History • The value domain of date aligns to HL7 data standard, 41, 42, 55, 56,
Issue(s) Issue Diagnosed Health Issue(s) was CIHI Data Dictionary and CIHI Reference Data 57, 39, 40, 61
Date diagnosed. Model Project.
36 Observation/ Observation Indicates whether or • Character, Code, C (Y, N, 9 [unknown]) N/A

History/Health History Health not the date that the • This value domain aligns to HL7 data standard, CIHI Data
Issue(s) Issue Estimated service recipient was Dictionary and CIHI Reference Data Model Project.
Diagnosed Date diagnosed with the past
Indicator health issue as captured
by Observation History
Health Issue Diagnosed
Date is estimated.
37 Observation/ Observation A past intervention(s) • Character, Code, CCCCC 13, 63, 64, 50,
History/ History of that may include • Please refer to Appendix C for an expanded list of 41, 42, 55, 56,
Intervention Intervention(s) medical/surgical, Observation Interventions. 57, 39, 40, 61
diagnostic, cognitive • This concept aligns with iEHR Professional Services and
and psychosocial CIHI CCI Classification (and where possible, LOINC).
(includes behavioral)
therapy.
CIHI 2009 27

38 Observation/ Observation The date the • Date, YYYYMMDD 13, 63, 64, 50,
History/ History of observation history • The value domain of date aligns to HL7 data 41, 42, 55, 56,
Intervention Intervention intervention was standard, CIHI Data Dictionary and CIHI Reference Data 57, 39, 40, 61
Date performed. Model Project.
39 Observation/ Observation Indicates whether or • Character, Code, C (Y, N, 9 [unknown]) N/A
History/ History not the date that the • This value domain aligns to HL7 data standard, CIHI Data
Intervention Estimated service recipient Dictionary and CIHI Reference Data Model Project.
Intervention received a past
Date Indicator intervention as captured
of Intervention Date is
estimated.
40 Observation Observation Indicates whether or • Character, Code, C (Y, N, 9 [unknown]) 13, 63, 64, 50,
History History End-of- not the service recipient • The concept is PHC-specific. 41, 42, 55, 56,
Life Indicator has been determined by • This value domain aligns to HL7 data standard, CIHI Data 57, 39, 40, 61
a health provider to be Dictionary and CIHI Reference Data Model Project.
at the end of life.
41 Observation Observation Date when end-of-life • Date, YYYYMMDD 13, 63, 64, 50,
History History End-of- indicator for service • The value domain of date aligns to HL7 data standard, 41, 42, 55, 56,
Life Date recipient was CIHI Data Dictionary and CIHI Reference Data 57, 39, 40, 61
determined. Model Project.
42 Observation Observation Indicates whether or • Character, Code, C (Y, N, 9 [unknown]) N/A
History History not the date that the • This value domain aligns to HL7 data standard, CIHI Data
Estimated End- service recipient was Dictionary and CIHI Reference Data Model Project.
of-Life Date determined to be at the
Indicator end of life, as captured
End-of-Life Date, is
estimated.
43 Observation Observation Record of the medical • Character, Code, CCCC N/A
History Family Health history of a group of • Please refer to Appendix B for an expanded list of Family
History persons sharing Health History.
common ancestry. • The concept aligns with observation in the EHR using
SNOMED.
• This value domain aligns with ICD-10-CA.
28 CIHI 2009

44 Observation Observation Service recipient’s • BP measurement standard, CCC 55, 56, 57, 40
History History of previously measured • The standard unit of measurement is mmHg; the concept
Systolic Blood systolic blood pressure aligns with LOINC.
Pressure Value value (in mmHg).
45 Observation Observation The date of the service • Date, YYYYMMDD 55, 56, 57, 40
History History of recipient’s previously • The value domain of date aligns to HL7 data standard,
Systolic Blood measured systolic blood CIHI Data Dictionary and CIHI Reference Data
Pressure Value pressure value (in Model Project.
Date mmHg).
History History of not the date that the • This value domain aligns to HL7 data standard, CIHI Data
Systolic Blood service recipient’s Dictionary and CIHI Reference Data Model Project.
Pressure systolic blood pressure
Estimated Value value was measured, as
Date Indicator captured by
Observation History of
Systolic Blood Pressure
Value Date, is
estimated.
47 Observation Observation Service recipient’s • BP measurement standard, CCC 55, 56, 57, 40
History History of previously measured • The standard unit of measurement is mmHg; the concept
Diastolic Blood diastolic blood pressure aligns with LOINC.
Pressure Value value (in mmHg).
48 Observation Observation The date of the service • Date, YYYYMMDD 55, 56, 57, 40
History History of recipient’s previously • The value domain of date aligns to HL7 data standard,
Diastolic Blood measured diastolic CIHI Data Dictionary and CIHI Reference Data
Pressure Value blood pressure value (in Model Project.
Date mmHg).
CIHI 2009 29

History History of not the date that the • This value domain aligns to HL7 data standard, CIHI Data
Diastolic Blood service recipient’s Dictionary and CIHI Reference Data Model Project.
Pressure diastolic blood pressure
Estimated Value value was measured, as
Diastolic Blood Pressure
Value Date, is
estimated.
50 Observation Observation A lab test code value • Character, Code, C (6 to 8) 50, 55, 56, 57,
History History Lab Test that identifies the type • Selection options may include: 39, 61
Code(s) of lab test performed. – A1c
– Albumin–creatinine ratio
– Fasting blood sugar value
– Full fasting lipid profile (LDL)
• Please refer to Appendix H for an expanded list of Lab
Test Ordering Codes.
• The concept aligns with the lab domain (pan-Canadian
EHR specifications) in the use of LOINC for representation
as a lab code.
51 Observation Observation Identifies the results of • Character, Code, C (6 to 8) 50, 55, 56, 57,
History History Lab the observation history • The concept aligns with the lab domain (pan-Canadian 39, 61
Test(s) Value lab test performed. EHR specifications) in the use of LOINC for representation
as a lab code.
52 Observation Observation Identifies the date that • Date, YYYYMMDD 50, 55, 56, 57,
History History Lab the observation history • The value domain of date aligns to HL7 data standard, 39, 61
Test(s) lab test was performed. CIHI Data Dictionary and CIHI Reference Data
Performed Date Model Project.
Estimated Lab observation history lab Dictionary and CIHI Reference Data Model Project.
Test(s) test was performed, as
Performed Date captured by
Indicator Observation History Lab
Test(s) Performed Date,
is estimated.
30 CIHI 2009

54 Observation Observation Indicates whether the • Character, Code, C (Y, N, 9 [unknown]) 41
History History of service recipient • The concept is PHC-specific.
Influenza received the influenza • This value domain aligns to HL7 data standard, CIHI Data
Immunization vaccine. Dictionary and CIHI Reference Data Model Project.
Indicator
55 Observation Observation The date of the service • Date, YYYYMMDD 41
History History of recipient’s observation • The value domain of date aligns to HL7 data standard,
Influenza history influenza CIHI Data Dictionary and CIHI Reference Data
Immunization immunization. Model Project.
Date
Estimated observation history Dictionary and CIHI Reference Data Model Project.
Influenza influenza immunization
Immunization was administered, as
Influenza Immunization
Date, is estimated.
57 Observation Observation Indicates whether the • Character, Code, C (Y, N, 9 [unknown]) 42
History History of service recipient • The concept is PHC-specific.
Pneumococcal received the • This value domain aligns to HL7 data standard, CIHI Data
Immunization pneumococcal vaccine. Dictionary and CIHI Reference Data Model Project.
Indicator
58 Observation Observation The date of the service • Date, YYYYMMDD 42
History History of recipient’s observation • The value domain of date aligns to HL7 data standard,
Pneumococcal history of CIHI Data Dictionary and CIHI Reference Data
Immunization pneumococcal Model Project.
Date immunization.
CIHI 2009 31

Estimated observation history Dictionary and CIHI Reference Data Model Project.
Pneumococcal pneumococcal
Immunization immunization was
Date Indicator administered, as
captured by
Pneumococcal
Immunization Date, is
estimated.
60 Observation Observation The medication(s) • Character, Code 61, 63, 64
History History prescribed to the • Please refer to Appendix G for an expanded list of
Medication(s) service recipient. medications.
Prescribed • This concept aligns to ATC.
61 Observation Observation The physical • Selection may include: N/A
History History configuration, – Capsules
Prescribed presentation or state of – Tablets
Medication Form matter of any given • This concept aligns to HL7 messaging and ATC.
drug product.
62 Observation Observation The measured portion • Selection options may include: 61, 63, 64
History History of a drug taken at any – 500 mg
Prescribed one time reported as a – 0.25 mcg
Medication Dose metric unit. • This concept aligns to HL7 messaging and ATC.
63 Observation Observation The number of • Selection options may include: 61, 63, 64
History History occurrences within a – Twice daily
Prescribed given time period that a – Every six hours
Medication dose of a drug is – Once weekly
Frequency administered. – Once monthly
• This concept aligns to HL7 messaging and ATC.
32 CIHI 2009

64 Observation Observation Indicates the part of the • Selection options may include: N/A
History History body on which, through – Oral
Prescribed which or into which a – Topical
Medication drug product is to be – Intramuscular
Route introduced. A drug – Rectal
product can have more – Intravenous
than one route of – Intraarticular
administration. • This concept aligns to HL7 messaging and ATC.
65 Observation Observation This refers to the • Selection options may include: 61, 63, 64
History History amount of the active – Gram
Prescribed (medicinal) ingredient(s) – Millilitre
Medication contained in a product. – Milligram
Strength • This concept aligns to CIHI Data Dictionary,
CIHI Reference Data Model Project and ATC.
66 Observation Observation Indicates the type of • Character, Code, C (3 to 5) 41, 42, 61, 63, 64
History History Allergy allergy service • Selection options may include:
Type recipients have that – Food
may make them – Medication
susceptible to – Environmental factors
physiological reactions. • Please refer to Appendix E for an expanded list of
Observation History Allergy Types.
• The concept is PHC-specific; the value domain is aligned
to CCI and LOINC.
CIHI 2009 33

Current Encounter (that is, made during or associated with the current PHC encounter; all current observations are to be dated or associated with a
current encounter date)
67 Current Current The observation by a • Character, Code, C (3 to 5) 13, 63, 64, 50,
Encounter/ Encounter provider of a service • Selection options may include: 41, 42, 55, 56,
Health Issue Health Issue(s) recipient’s diagnosis or – 125.1 coronary artery disease (CAD) atherosclerotic 57, 39, 40, 61
administrative reason heart disease
for encounter. – E 10 diabetes type I
– E 11 diabetes type II
– F 32.9 depression, depressive episode, unspecified
• Please refer to Appendix A for an expanded list of Current
Encounter Health Issues.
• This concept aligns to Health Condition Record in the
iEHR, ICD-10-CA/CCI and EHR health conditions or
observations which may use SNOMED.
• This value domain aligns to ICPC2 and CIHI ICD-10-CA.
68 Current Current Service recipient’s • Centimetres, CCC 13, 55, 56, 57
Encounter Encounter height (in centimetres) • The standard unit of measurement is centimetres; the
Service measured during the concept aligns to LOINC standard.
Recipient Height current encounter.
Value
69 Current Current Service recipient’s • Kilograms, CCC 13, 55, 56, 57
Encounter Encounter weight (in kilograms) • The standard unit of measurement is kilograms; the
Service measured during the concept aligns to LOINC standard.
Recipient Weight current encounter.
Value
70 Current Current Service recipient’s hip • Centimetres, CCC 55, 56, 57, 13
Encounter Encounter circumference (in • The standard unit of measurement is centimetres; the
Service centimetres) measured concept aligns to LOINC standard.
Recipient Hip during the current
Circumference encounter.
Value
71 Current Current Service recipient’s waist • Centimetres, CCC 55, 56, 57, 13
Encounter Encounter circumference (in • The standard unit of measurement is centimetres; the
Service centimetres) measured concept aligns to LOINC standard.
Recipient Waist during the current
Circumference encounter.
Value
34 CIHI 2009

72 Current Current Service recipient’s • BP measurement standard, CCC 55, 56, 57, 40
Encounter Encounter systolic blood pressure • The standard unit of measurement is mmHg; the concept
Service value (in mmHg) aligns to LOINC standard.
Recipient measured during the
Systolic BP current encounter.
Value
73 Current Current Service recipient’s • BP measurement standard, CCC 55, 56, 57, 40
Encounter Encounter diastolic blood pressure • The standard unit of measurement is mmHg; the concept
Service value (in mmHg) aligns to LOINC standard.
Recipient measured during the
Diastolic BP current encounter.
Value
74 Current Current Indicates whether the • Character, Code, C (Y, N, 9 [unknown]) 13
Encounter Encounter service recipient is a • The concept is PHC-specific.
Service current user of tobacco • This value domain aligns to HL7 data standard, CIHI Data
Recipient products. Dictionary and CIHI Reference Data Model Project.
Smoker
Indicator
Encounter Encounter service recipient’s • The concept is PHC-specific.
Service diet/nutrition status is • This value domain aligns to HL7 data standard, CIHI Data
Recipient Eating assessed during the Dictionary and CIHI Reference Data Model Project.
Habits Screening current encounter.
Indicator
76 Current Current Identifies whether the • Character, Code, C (Y, N, 9 [unknown]) 13
Service physical activity status • This value domain aligns to HL7 data standard, CIHI Data
Recipient is assessed during the Dictionary and CIHI Reference Data Model Project.
Physical Activity current encounter.
Screening
Indicator
Service unsafe sexual practice • This value domain aligns to HL7 data standard, CIHI Data
Recipient Unsafe is assessed during the Dictionary and CIHI Reference Data Model Project.
Sexual Practice current encounter.
Screening
Indicator
CIHI 2009 35

78 Current Current Identifies the screening • Character, Code N/A
Encounter Encounter tool that is used to • The concept is PHC-specific.
Unsafe Sexual assess the service
Practice recipient’s involvement
Screening Tool in unsafe sexual
practices.
79 Current Current Indicates whether the • Character, Code, C (Y, N, 9 [unknown]) 13, 63, 64
Encounter Encounter service recipient is • The concept is PHC-specific.
Service assessed for his or her • This value domain aligns to HL7 data standard, CIHI Data
Recipient inability to manage Dictionary and CIHI Reference Data Model Project.
Unmanaged psychosocial stress
Psychosocial during the current
Stress Screening encounter.
Indicator
80 Current Current Identifies the screening • Character, Code (Perceived Stress Scale [PSS], N/A
Encounter Encounter tool that is selected and Perceived Stress Questionnaire [PSQ], other, unknown,
Unmanaged used to assess if the not applicable)
Psychosocial service recipient • The concept is PHC-specific.
Stress Screening exhibits unmanaged
Tool psychosocial stress or
symptoms associated
with biochemical
imbalances.
Service assessed for acute or • This value domain aligns to HL7 data standard, CIHI Data
Recipient Unsafe chronic dependence on Dictionary and CIHI Reference Data Model Project.
Drug Use drug use (legal or illicit)
Screening during the time of
Indicator current encounter.
82 Current Current Identifies the screening • Character, Code (CRAFFT, ASSIST, CAGE-AID, DAST, N/A
Encounter Encounter tool used to assess the other, unknown, not applicable)
Unsafe Drug service recipient’s acute • The concept is PHC-specific.
Use Screening or chronic dependence
Tool on drug use (legal or
illicit) at the time of
current encounter.
36 CIHI 2009

Service assessed for • This value domain aligns to HL7 data standard, CIHI Data
Recipient unintentional falls Dictionary and CIHI Reference Data Model Project.
Unintentional during the current
Falls Screening encounter.
Indicator
84 Current Current Indicates whether or • Character, Code, C (Y, N, 9 [unknown]) 50
Encounter Encounter not a Pap smear was • The concept is PHC-specific.
Papanicolaou performed in the last • This value domain aligns to HL7 data standard, CIHI Data
Test (Pap) three years. Dictionary and CIHI Reference Data Model Project.
Smear Screening
Indicator
Service assessed for unsafe • This value domain aligns to HL7 data standard, CIHI Data
Recipient Unsafe drinking. Dictionary and CIHI Reference Data Model Project.
Drinking
Screening
Indicator
86 Current Current Identifies the screening • Character, Code (CAGE, AUDIT, MAST, other, not N/A
Encounter Encounter tool that is used to applicable, unknown)
Unsafe Drinking assess the service • The concept is PHC-specific.
Screening Tool recipient’s unsafe
drinking during the
current encounter.
87 Current Current Indicates whether the • Character, Code, C (Y, N, 9 [unknown]) 13, 63, 64
Service assessed for depression • This value domain aligns to HL7 data standard, CIHI Data
Recipient during the current Dictionary and CIHI Reference Data Model Project.
Depression encounter.
Screening
Indicator
CIHI 2009 37

88 Current Current Identifies the screening • Character, Code (PHQ-9, Kessley Psychological Distress N/A
Encounter Encounter tool that is used to Scale [K10], Hospital Anxiety and Depression Scale
Depression assess if the service [HADS], other, unknown, not applicable)
Screening Tool recipient exhibits • The concept is PHC-specific.
symptoms of
depression.
Laboratory
89 Lab Current The type of lab test • Character, Code, C (6 to 8) 50, 55, 56, 57,
Encounter Lab ordered by the health • Selection options may include: 39, 61
Test Code(s) provider during the – A1c
current encounter. – Albumin–creatinine ratio
– Fasting blood sugar value
– Full fasting lipid profile (LDL)
• Please refer to Appendix H for an expanded list of Lab
Test Ordering Codes.
• The concept aligns with the lab domain (pan-Canadian
EHR specifications) in the use of LOINC of representation
as a lab code.
90 Lab Current The date when a lab • Date, YYYYMMDD 50, 55, 56, 57,
Encounter Lab test is ordered for the • The concept aligns with the lab domain (pan-Canadian 39, 61
Test Date service recipient. EHR specifications) in the use of LOINC of representation
Ordered as a lab code.
Model Project.
91 Lab Current Identifies the date that • Date, YYYYMMDD 50, 55, 56, 57,
Encounter Lab the lab test is • The concept aligns with the lab domain (pan-Canadian 39, 61
Test Performed performed. EHR specifications) in the use of LOINC of representation
Date as a lab code.
Model Project.
92 Lab Current Identifies the results of • Character, Code, C (6 to 8) 50, 55, 56, 57,
Encounter Lab the lab result report for • The concept aligns with the lab domain (pan-Canadian 39, 61
Test(s) Value the performed lab test. EHR specifications) in the use of LOINC of representation
as a lab code.
38 CIHI 2009

Diagnostic Imaging
93 DI DI Code Identifies the type of • Character, Code, C (6) N/A
diagnostic imaging • Selection options may include:
ordered for the service – X-ray (chest, arm, leg, etc.)
recipient by the health – CT scan (brain, body, kidney, etc.)
provider during the – ECG
current encounter. – MRI
• Please refer to Appendix F for an expanded list of Ordering
Diagnostic Imaging Codes.
• This value domain and concept aligns to pan-Canadian
standards in CCI/LOINC.
94 DI DI Booking Date The date that the • Date, YYYYMMDD N/A
diagnostic imaging • The concept is PHC-specific.
appointment is booked • This value domain aligns to HL7 data standard, CIHI Data
in the provider’s Dictionary and CIHI Reference Data Model Project.
scheduling system.
95 DI DI Performed Identifies the date of • Date, YYYYMMDD N/A
Date the performed • The concept aligns to LOINC.
diagnostic imaging. • This value domain aligns to HL7 data standard, CIHI Data
Dictionary and CIHI Reference Data Model Project.
96 DI DI Result Identifies result • Character, Code N/A
associated with the • The concept aligns to LOINC.
diagnostic imaging
performed.
Intervention
97 Intervention Current Indicates whether the • Character, Code, C (Y, N, 9 [unknown]) 61
Encounter service recipient is • The concept is PHC-specific.
Intervention offered lifestyle advice • This value domain aligns to HL7 data standard, CIHI Data
Lifestyle Advice for dyslipidemia. Dictionary and CIHI Reference Data Model Project.
Indicator
98 Intervention Current Describes the • Character, Code, C (5) 13, 63, 64, 50,
Encounter interventions performed • Please refer to Appendix D for an example list 41, 42, 55, 56,
Intervention(s) by the provider for the of interventions. 57, 39, 40, 61
service recipient during • This concept aligns with iEHR Professional Services and
the current encounter. CIHI CCI Classification (and where applicable, to LOINC).
• This value domain aligns to CCI.
CIHI 2009 39

99 Intervention Current Indicates whether the • Character, Code, C (Y, N, 9 [unknown]) 13, 63, 64, 50,
Encounter End- service recipient is • The concept is PHC-specific. 41, 42, 55, 56,
of-Life Indicator determined by a health • This value domain aligns to HL7 data standard, CIHI Data 57, 39, 40, 61
provider to be at the Dictionary and CIHI Reference Data Model Project.
end of life at the time of
encounter.
Medication
100 Medication Current Identifies whether the • Character, Code, C (Y, N, 9 [unknown]) 41
Influenza offered an influenza • This value domain aligns to HL7 data standard, CIHI Data
Vaccine vaccine during the Dictionary and CIHI Reference Data Model Project.
101 Medication Current Identifies the reason • Character, Code N/A
Encounter why the influenza • Selection options may include:
Influenza vaccine that is offered – Anaphylactic hypersensitivity to egg and
Vaccine “Not to the service recipient egg-related antigens
Given” Reason during the current – Contraindication
encounter is not given. – Declined
– Deferred
– Religious reasons
• Please refer to Appendix M for an expanded list of “not
given” reasons.
• The concept is PHC-specific.
102 Medication Current Identifies whether the • Character, Code, C (Y, N, 9 [unknown]) 42
Pneumococcal offered a pneumococcal • This value domain aligns to HL7 data standard, CIHI Data
Vaccine vaccine during the Dictionary and CIHI Reference Data Model Project.
40 CIHI 2009

103 Medication Current Identifies the reason • Character, Code N/A
Encounter why the pneumococcal • Selection options may include:
Pneumococcal vaccine that is offered – Anaphylactic hypersensitivity to egg and egg-related
Vaccine “Not to the service recipient antigens
Given” Reason during the current – Contraindication
encounter is not given. – Declined
– Deferred
• Please refer to Appendix M for an expanded list of “not
given” reasons.
104 Medication Current The medication(s) • Character, Code 61, 63, 64
Encounter prescribed to the • Please refer to Appendix G for an expanded list of
Medication(s) service recipient during medications. ATC classification system is proposed for
Prescribed the current encounter collection of medication names.
by the health provider. • This concept aligns to ATC.
105 Medication Current The physical • Selections may include: N/A
Encounter configuration, – Capsules
Prescribed presentation or state of – Tablets
Medication Form matter of any given • This concept aligns to HL7 messaging and ATC.
drug product.
106 Medication Current The measured portion • Selection options may include: 61, 63, 64
Encounter of a drug taken at any – 500 mg
Prescribed one time reported as a – 0.25 mcg
Medication Dose metric unit. • This concept aligns to HL7 messaging and ATC.
107 Medication Current The number of • Selection options may include: 61, 63, 64
Encounter occurrences within a – Twice daily
Prescribed given time period that a – Every six hours
Medication dose of a drug is – Once weekly
Frequency administered. – Once monthly
• This concept aligns to HL7 messaging and ATC.
CIHI 2009 41

108 Medication Current Indicates the part of the • Selection options may include: N/A
Encounter body on which, through – Oral
Prescribed which or into which a – Topical
Medication drug product is to be – Intramuscular
Route introduced. A drug – Rectal
product can have more – Intravenous
than one route of – Intraarticular
administration. • This concept aligns to HL7 messaging and ATC.
109 Medication Current This refers to the • Selection options may include: 61, 63, 64
Encounter amount of the active – Gram
Prescribed (medicinal) ingredient(s) – Millilitre
Medication contained in a product. – Milligram
Strength • This concept aligns to CIHI Data Dictionary,
CIHI Reference Data Model Project and ATC.
110 Medication Current The value indicates the • Character, Code 61, 63, 64
Encounter number of times the
Prescribed prescription can be used
Medication to refill the prescribed
Repeat medication.
111 Medication Current Indicates service • Character, Code, C (Y, N, 8 [not applicable], 9 [unknown]) 61, 63, 64
Encounter recipient non-adherence • The concept is PHC-specific.
Service Recipient to the prescribed • This value domain aligns to HL7 data standard, CIHI Data
Medication(s) medication(s). Dictionary and CIHI Reference Data Model Project.
Non-Adherence
Indicator
112 Medication Current Identifies the reason • Character, Code 61, 63, 64
Encounter why the medication • Selection options may include:
Service prescribed to the – Anaphylactic hypersensitivity to egg and
Recipient service recipient during egg-related antigens
Medication “Not the current encounter is – Contraindication
Given” Reason not given. – Declined
– Deferred
Note
* The number represents the CIHI PHC indicator from the original list of 105 indicators. Complete definitions can be found in Appendix N.
42 CIHI 2009
6. Next Steps
This is the first version of the CIHI PHC Indicators EMR Content Standards. Updated versions
will be released periodically. These standards will be shared with stakeholders and efforts
made to support their adoption and uptake through meetings with jurisdictions, standards
collaborative working groups, vendor forums, PHC organizations and providers. It will be
necessary to continue to update these standards based on information gathered through pilot
testing and implementation, indicator refinement and as clinical guidelines change. As a
greater number of PHC providers across Canada utilize EMRs, their data needs and
workflows will become clearer. This will inform updates to the CIHI PHC Indicators EMR
Content Standards. The evolution of e-health projects, provincial registries and care delivery
practices will also necessitate changes to the standards over time. The development of the
CIHI PHC Reporting System Prototype will also provide an opportunity for pilot testing the
CIHI PHC Indicators EMR Content Standards and inform future iterations.
CIHI PHC Reporting System Prototype

The CIHI PHC Indicators EMR Content Standards also provide a starting data set for the
PHC Prototype that is currently in the planning stage, with Phase 1 to be completed in
2009. The purpose of this pan-Canadian system is to set up the infrastructure to collect
comparable PHC data about the most common chronic conditions in Canada, such as
diabetes, depression, hypertension and coronary artery disease.
This pilot project will inform the feasibility and level of effort needed to capture selected
elements of EMR data to report on clinical quality indicators. Furthermore, this pilot project
will inform additional data elements for consideration in future iterations of the CIHI PHC
Indicators EMR Content Standards.
Communications and Outreach

CIHI will continue to communicate with external organizations and promote the CIHI PHC
Indicators EMR Content Standards in an attempt to educate potential stakeholders on the
merits of pan-Canadian content standards, as well as to identify and establish future
collaborations with organizations whose work closely aligns with CIHI’s. This is an iterative
process and must be done with a range of stakeholders. Periodic vendor forums with EMR
vendors facilitated by the Canadian Healthcare Information Technology Trade Association
will occur to share results and updates to the CIHI PHC Indicators EMR Content Standards
and solicit input.
This product will also be shared at international levels where it can be compared with other
initiatives in an attempt to refine and improve future releases.
Contacts
For more information, please contact the CIHI Primary Health Care Information program
area by sending an email message to phc@cihi.ca.
CIHI 2009 43
7. Glossary of Terms
Concept Name
Definition
or Term
Character A data type name used to store alphanumeric text, such as letters, numbers,
spaces, symbols and punctuation. Source: Microsoft Developer Network
(MSDN) Library, Centre Visual Fox Pro.
Code A system of valid symbols that substitute for specified values.
Source: ISO 11179 documentation Part 3.
Concept An abstract or generic idea, thought or notion generalized from
particular instances.
Data Dictionary Refers to the Canadian Institute for Health Information Data Dictionary.
Source: http://secure.cihi.ca/ddexternal/welcome.do?lng=E.
Data Element Unit of data for which the definition, identification, representation and
permissible values are specified by means of a set of attributes. Source:
Microsoft Developer Network (MSDN) Library, Centre Visual Fox Pro.
Electronic Health An electronic health record (commonly known as an EHR) is a secure
Records (EHRs) and private lifetime record of an individual’s health and care history,
available electronically to authorized health care providers. Source: Canada
Health Infoway.
Electronic Medical The electronic medical record (EMR) is provider-centric, focuses on medical
Records (EMRs) or physician-specific information and is configured to reflect the needs of
individual physicians or groups of physicians who are directly caring for a
patient. The EMR is a record of each and every patient encounter and will
detail encounter information. This is also the system where patient results,
(such as laboratory, diagnostic imaging and other reports ordered by a
provider) are delivered to that provider’s electronic in-box (that is, this
information is pushed to the provider, negating the need for the provider to
go out and seek it). Source: College of Family Physicians of Canada.
Encounter A health care service or health care–related service registered interaction
between a service recipient and a provider. An encounter occurs over a
continuous period of time that is represented by a start and end date or a
date only. Examples include inpatient admission, family doctor visit,
telehealth call or ER visit. Source: CIHI Data Dictionary and CIHI Reference
Data Model Project.
Ethnicity A person’s ethnic origin is the ethnic or cultural group(s) to which his or her
ancestors belonged. Therefore, the ethnic origin refers to a person’s “roots”
and should not be confused with his or her citizenship or nationality.
Source: Statistics Canada Census, 2001.
Expertise Provider expertise is skill or knowledge in a particular area or field. The
provider may claim expertise in a particular area if he or she completed
specific training for that area. The expertise may or may not be licensed by a
governing or regulating body. Source: CIHI Data Dictionary and CIHI
Reference Data Model Project.
Health Issue The observation by a provider of a service recipient’s diagnosis or
administrative reason for encounter. Examples: diabetes, lower arm
fracture or throat pain. Source: CIHI Data Dictionary and CIHI Reference
Data Model Project.
CIHI 2009 45
Concept Name
Definition
or Term
Indicator The indicator (Yes or No) shows the existence or non-existence of
something of interest. Source: Microsoft Developer Network (MSDN) Library,
Centre Visual Fox Pro.
Interoperable The interoperable Electronic Health Record Program will implement solutions
Electronic Health that support the creation of an EHR that links clinics, hospitals, pharmacies
Records (iEHRs) and other points of care. Establishing an interoperable EHR allows clinicians
to view and update an integrated patient-centric health record that includes
demographic, diagnostic imaging, drug, laboratory, infectious disease,
immunization and other relevant health information anywhere, any time.
Source: Canada Health Infoway.
International ISO is the world’s largest developer and publisher of international standards.
Organization for ISO is a network of the national standards institutes of 157 countries (one
Standardization member per country) with a central secretariat in Geneva, Switzerland, that
(ISO) coordinates the system. Source: www.iso.org.
Intervention A diagnostic, therapeutic, cognitive or other health care–related service
performed by a provider for an intended curative, maintenance or
preventive outcome. Source: CIHI Data Dictionary and CIHI Reference
Data Model Project.
Observation The act of obtaining, affirming and recording information associated with a
service recipient’s physical, cognitive, emotional and/or social state and well-
being as well as any applicable medical history. Source: CIHI Data Dictionary
and CIHI Reference Data Model Project.
Provider A person qualified to deliver health care–related services or goods. Note:
Each provider acts in a Provider Role Type. Source: CIHI Data Dictionary and
CIHI Reference Data Model Project.
Provider Role Type A provider’s primary function/role within the health care system.
Source: CIHI Data Dictionary and CIHI Reference Data Model Project.
Service Delivery A location where health-related services were provided by a provider to a
Location (SDL) service recipient. Source: CIHI Data Dictionary and CIHI Reference Data
Model Project.
Service Recipient A person that received or is receiving health care–related services or goods.
This term is used interchangeably with “patient” and “client” throughout
this document. Source: CIHI Data Dictionary and CIHI Reference Data
Model Project.
Value Domain Set of permissible values. Source: Microsoft Developer Network (MSDN)
Library, Centre Visual Fox Pro.
46 CIHI 2009
8. Appendices
The following 14 appendices (A through N) provide an expanded view of the picklists
supplied by CIHI for select data elements in the CIHI PHC Indicators EMR Data Set.
Appendix A: Observation History and Current Encounter

Health Issues Picklist
Item Diagnosis/Health ICD-10-CA ICD-10-CA Code (Version 2007)
Number Condition Picklist Code Description
1. Abnormal Weight Gain R63.5 Abnormal weight gain
2. Acute Coronary Syndrome I24.9 Acute ischemic heart
disease, unspecified
3. Addison’s Disease E27.1 Primary adrenocortical insufficiency
4. Adiposity E65 Localized adiposity
5. AIDS B24 Human immunodeficiency virus
[HIV] disease
6. Albuminuria R80 Isolated proteinuria
7. Alzheimer’s Disease G30 Alzheimer’s disease
8. Anemia D64.9 Anaemia, unspecified
9. Angina I20 Angina pectoris
10. Anxiety F41.9 Anxiety disorder, unspecified
11. Asthma J45 Asthma
12. Asymptomatic HIV Infection Z21 Asymptomatic human
Status immunodeficiency virus [HIV]
infection status
13. Atrial Fibrillation I48.0 Atrial fibrillation
14. Atrophy of Thyroid (Acquired) E03.4 Atrophy of thyroid (acquired)
15. Autoimmune Thyroid Disease E06.3 Autoimmune thyroiditis
16. Bradycardia R00.1 Bradycardia, unspecified
17. Cancer: Bladder C67 Malignant neoplasm of bladder
18. Cancer: Brain C71 Malignant neoplasm of brain
19. Cancer: Breast C50 Malignant neoplasm of breast
20. Cancer: Cervix C53 Malignant neoplasm of cervix uteri
21. Cancer: Colon C18 Malignant neoplasm of colon
22. Cancer: Esophagus C15 Malignant neoplasm of oesophagus
23. Cancer: Hodgkin’s Lymphoma C81 Hodgkin’s disease
24. Cancer: Kidney C64 Malignant neoplasm of kidney, except
renal pelvis
25. Cancer: Larynx C32 Malignant neoplasm of larynx
26. Cancer: Leukemia C95 Leukaemia of unspecified cell type
27. Cancer: Liver C22 Malignant neoplasm of liver and
intrahepatic bile ducts
28. Cancer: Lung C34 Malignant neoplasm of bronchus
and lung
29. Cancer: Melanoma C43 Malignant melanoma of skin
30. Cancer: Multiple Myeloma C90 Multiple myeloma and malignant
plasma cell neoplasms
CIHI 2009 47

31. Cancer: Non-Hodgkin’s C85 Other and unspecified types of non-
Lymphoma Hodgkin’s lymphoma
32. Cancer: Oral Cavity C06 Malignant neoplasm of other and
unspecified parts of mouth
33. Cancer: Ovary C56 Malignant neoplasm of ovary
34. Cancer: Pancreas C25 Malignant neoplasm of pancreas
35. Cancer: Prostate C61 Malignant neoplasm of prostate
36. Cancer: Rectum C20 Malignant neoplasm of rectum
37. Cancer: Stomach C16 Malignant neoplasm of stomach
38. Cancer: Testis C62 Malignant neoplasm of testis
39. Cancer: Thyroid C73 Malignant neoplasm of thyroid gland
40. Cancer: Uterus C55 Malignant neoplasm of uterus,
part unspecified
41. Cancer: Malignancy of C80 Malignant neoplasm without
Unspecified Site specification of site
42. Cerebrovascular Disease I67 Other cerebrovascular diseases
43. Chronic Obstructive Pulmonary J44 Other chronic obstructive
Disease (COPD) pulmonary disease
44. Coagulopathy D68.9 Coagulation defect, unspecified
45. Convulsions R56 Convulsions, not elsewhere classified
46. Coronary Artery Disease I25.1 Atherosclerotic heart disease
47. Dementia: Alzheimer’s F00.9 Dementia in Alzheimer’s
disease, unspecified
48. Dementia: Multi-Infarct F01.1 Multi-infarct dementia
49. Dementia: Vascular F01.9 Vascular dementia, unspecified
50. Dementia: Unspecified F03 Unspecified dementia
51. Dependence: Renal Dialysis Z99.2 Dependence on renal dialysis
52. Dependence: Walker Z99.8 Dependence on other enabling
machines and devices
53. Dependence: Wheelchair Z99.3 Dependence on wheelchair
54. Depression: Unspecified F32.9 Depressive episode, unspecified
55. Depression: Post-Partum F53 Mental and behavioural disorders
associated with the puerperium, not
elsewhere classified
56. Diabetes: Type 1 E10 Type 1 diabetes mellitus
57. Diabetes: Type 2 E11 Type 2 diabetes mellitus
58. Diabetes: Type Unspecified E14 Unspecified diabetes mellitus
59. Disorder of Thyroid E07.9 Disorder of thyroid, unspecified
60. Dissection of Aorta I71.0 Dissection of aorta [any part]
61. Dysthymia F34.1 Dysthymia
62. Eating Disorder: Anorexia F50.0 Anorexia nervosa
63. Eating Disorder: Bulimia F50.2 Bulimia nervosa
64. Eating Disorder: Unspecified F50.9 Eating disorder, unspecified
65. Edema R60 Oedema, not elsewhere classified
66. Electrolyte Imbalance E87.8 Other disorders of electrolyte and fluid
balance, not elsewhere classified
67. Emphysema J43 Emphysema
48 CIHI 2009

68. Epilepsy G40 Epilepsy
69. Excessive Eating R63.2 Polyphagia
70. Exposure to HIV Z20.6 Contact with and exposure to human
immunodeficiency virus [HIV]
71. Exposure to Second-Hand Smoke Z58.7 Exposure to tobacco smoke
72. Fibromyalgia M79.7 Fibromyalgia
73. Fluid Overload E87.7 Fluid overload
74. Heart Failure: Congestive (CHF) I50.0 Congestive heart failure
75. Heart Failure: Left Ventricular I50.1 Left ventricular failure
76. Heart Failure: Unspecified I50.9 Heart failure, unspecified
77. Hemophilia D66 Hereditary factor VIII deficiency
78. HIV: Asymptomatic Human Z21 Asymptomatic human
Immunodeficiency Virus (HIV) immunodeficiency virus [HIV] infection
Infection Status status
79. HIV: Acquired Immunodeficiency B24 Human immunodeficiency virus [HIV]
Syndrome (AIDS) NOS disease
80. HIV: Exposure to HIV Z20.6 Contact with and exposure to human
immunodeficiency virus [HIV]
81. HIV: Non-Conclusive Serologic R75 Laboratory evidence of human
Evidence of HIV immunodeficiency virus [HIV]
82. Hyperaldosteronism E26.9 Hyperaldosteronism, unspecified
83. Hyperchylomicronemia E78.3 Hyperchylomicronaemia
84. Hyperglycemia R73.9 Hyperglycaemia, unspecified
85. Hyperlipidemia E78.5 Hyperlipidaemia, unspecified
86. Hypernatremia E87.0 Hyperosmolality and hypernatraemia
87. Hypertension: Benign I10.0 Benign hypertension
88. Hypertension: Malignant I10.1 Malignant hypertension
89. Hypertension: Secondary I15 Secondary hypertension
90. Hypertensive Encephalopathy I67.4 Hypertensive encephalopathy
91. Hypertensive Heart Disease I11 Hypertensive heart disease
92. Hypertensive Renal Disease I12 Hypertensive renal disease
93. Hyponatremia E87.1 Hypo-osmolality and hyponatraemia
94. Insomnia (Non-Organic) F51.0 Nonorganic insomnia
95. Intracerebral Hemorrhage I61 Intracerebral haemorrhage
96. Lipoprotein Deficiency E78.6 Lipoprotein deficiency
97. Myalgia M79.1 Myalgia
98. Myocardial Infarction: Old I25.2 Old myocardial infarction
99. Nephropathy N28.9 Disorder of kidney and ureter,
unspecified
100. Neuropathy G62.9 Polyneuropathy, unspecified
101. Non-Conclusive Serologic R75 Laboratory evidence of human
Evidence of HIV immunodeficiency virus [HIV]
102. Obesity: Morbid E66.8 Other obesity
103. Obesity: Unspecified E66.9 Obesity, unspecified
104. Obsessive–Compulsive Disorder F42 Obsessive-compulsive disorder
(OCD)
105. Osteoarthritis: Hip M16.9 Coxarthrosis [arthrosis of hip]
CIHI 2009 49

106. Osteoarthritis: Knee M17.9 Gonarthrosis [arthrosis of knee]
107. Osteoarthritis: Multiple Joint M15.9 Polyarthrosis
Sites (Includes Hip, Knee, Foot,
Hand, Elbow, Shoulder, Spine)
108. Osteoarthritis: Other Site M19 Other arthrosis
(Not Including Hip, Knee,
Carpometacarpal Joint or Spine)
109. Osteoarthritis: Spine M47.8 Other spondylosis
110. Paraplegia G82.2 Paraplegia, unspecified
111. Peripheral Vascular Disease I70.2 Atherosclerosis of arteries of
(PVD) extremities
112. Pneumonia J18 Pneumonia, organism unspecified
113. Personal History of Tobacco Use Z86.42 Personal history of tobacco use
114. Psychosis F29 Unspecified nonorganic psychosis
115. Post-Traumatic Stress Disorder F43.1 Post-traumatic stress disorder
(PTSD)
116. Pulmonary Heart Disease I27.9 Other pulmonary heart disease
117. Renal Dialysis Status: For Z99.2 Dependence on renal dialysis
Chronic Kidney Disease
118. Retinopathy H35.0 Background retinopathy and retinal
vascular changes
119. Rheumatoid Arthritis M06.9 Rheumatoid arthritis, unspecified
120. Seasonal Affective Disorder F33.9 Recurrent depressive disorder,
(SAD) unspecified
121. Stroke or Cerebrovascular I64 Stroke, not specified as haemorrhage
Accident (CVA) or infarction
122. Subarachnoid Hemorrhage I60 Subarachnoid haemorrhage
123. Tachycardia R00.0 Tachycardia, unspecified
124. Thrombocytopenia D69.6 Thrombocytopenia, unspecified
125. Thrombocytosis D47.3 Essential (haemorrhagic)
thrombocythaemia
Source
International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada
(ICD-10-CA), 2007, Canadian Institute for Health Information.
50 CIHI 2009
Appendix B: Family Health History Picklist

Item ICD-10-CA Code ICD-10-CA Code (Version 2007)
Family History Picklist
Number (Version 2007) Description
1. Alcohol Abuse Z81.1 Family history of alcohol abuse
2. Arthritis: Osteoarthritis Z82.61* Family history of arthritis and other
diseases of the musculoskeletal system
and connective tissue—osteoarthritis
3. Arthritis: Rheumatoid Z82.60* Family history of arthritis and other
and connective tissue
4. Arthritis: Unspecified Z82.69* Family history of arthritis and other
and connective tissue—arthritis,
unspecified
5. Asthma Z82.52* Family history of asthma and other
chronic lower respiratory diseases—
asthma
6. Cancer: Bladder Z80.51* Family history of malignant neoplasm
of urinary tract—bladder
7. Cancer: Brain Z80.82* Family history of malignant neoplasm
of other organs or systems—brain
8. Cancer: Breast Z80.3 Family history of malignant neoplasm
of breast
9. Cancer: Cervix Z80.480* Family history of malignant neoplasm
of other genital organs—cervix
10. Cancer: Esophagus Z80.00* Family history of malignant neoplasm
of digestive organs—oesophagus
11. Hodgkin’s Disease Z80.70* Family history of other malignant
neoplasms of lymphoid—Hodgkin’s
Disease
12. Cancer: Small Intestine Z80.02* Family history of malignant neoplasm
of digestive organs—small intestine
13. Cancer: Kidney Z80.50* Family history of malignant neoplasm
of urinary tract—kidney
14. Cancer: Large Intestine Z80.03* Family history of malignant neoplasm
of digestive organs—large intestine
Excludes: rectum
15. Cancer: Larynx Z80.20* Family history of malignant neoplasm
of other respiratory and intrathoracic
organs—larynx
16. Leukemia Z80.6 Family history of leukemia
17. Cancer: Liver Z80.05* Family history of malignant neoplasm
of digestive organs—liver
18. Cancer: Lung Z80.10* Family history of malignant neoplasm
of trachea, bronchus and lung—lung
19. Melanoma Z80.81* Family history of malignant neoplasm
of other organs or systems—melanoma
CIHI 2009 51

20. Multiple Myeloma Z80.72* Family history of other malignant
neoplasms of lymphoid—Multiple
Myeloma
21. Neoplasm of Digestive Z80.09* Family history of other malignant
Organs, Site Unspecified neoplasms of digestive organs—
unspecified site
22. Non-Hodgkin’s Lymphoma Z80.71* Family history of other malignant
neoplasms of lymphoid—Non-
Hodgkin’s Lymphoma
23. Cancer: Oral Cavity Z80.80* Family history of malignant neoplasm
of other organs or systems—oral cavity
24. Cancer: Ovary Z80.40 Family history of malignant neoplasm
of ovary
25. Cancer: Pancreas Z80.06* Family history of malignant neoplasm
of digestive organs—pancreas
26. Cancer: Prostate Z80.41 Family history of malignant neoplasm
of prostate
27. Cancer: Rectum Z80.04* Family history of malignant neoplasm
of digestive organs—rectum
28. Cancer: Small Intestine Z80.02* Family history of malignant neoplasm
of digestive organs—small intestine
29. Cancer: Stomach Z80.01* Family history of malignant neoplasm
of digestive organs—stomach
30. Cancer: Testis Z80.482* Family history of malignant neoplasm
of other genital organs—testis
31. Cancer: Thyroid Z80.83* Family history of malignant neoplasm
of other organs or systems—thyroid
32. Cancer: Uterus Z80.481* Family history of malignant neoplasm
of other genital organs—uterus
33. Cancer: Unspecified Site Z80.9 Cancer: Malignancy of unspecified site
34. Chronic Obstructive Z82.51* Family history of asthma and other
Pulmonary Disease (COPD) chronic lower respiratory diseases—
COPD
35. Coronary Artery Disease Z82.4 Family history of ischaemic heart
(CAD) disease and other diseases of the
circulatory system
36. Depression Z81.8 Family history of other mental and
behavioural disorders
37. Diabetes Z83.3 Family history of diabetes mellitus
38. Emphysema Z82.50* Family history of asthma and other
chronic lower respiratory diseases—
emphysema
39. Epilepsy Z82.0 Family history of epilepsy and other
diseases of the nervous system
40. Hypertension Z82.4 Family history of ischaemic heart
disease and other diseases of the
circulatory system
52 CIHI 2009

41. Ischemic Heart Disease Z82.4 Family history of ischaemic heart
disease and other diseases of the
circulatory system
42. Mental and Behavioural Z81.8 Family history of other mental and
Disorders behavioural disorders
43. Psychoactive Substance Z81.3 Family history of other psychoactive
Abuse substance abuse
44. Second-Hand Smoke Z58.7 Exposure to tobacco smoke
45. Stroke Z82.3 Family history of stroke
46. Tobacco Use Z81.2 Family history of tobacco abuse
Note
* All the ICD-10-CA (version 2007) codes that have an asterisk will be found in ICD-10-CA v. 2012.
Source
CIHI 2009 53
Appendix C: Observation Interventions Picklist

Item CCI Code
Past Intervention Picklist CCI Code (Version 2007) Description
Number (Version 2007)
1. • Adjustment of Appliance 1.HZ.38 Management of external appliance,
of Heart heart NEC
• Removal of Appliance
of Heart
2. • Amputation of Forefoot 1.WJ.93 Amputation, tarsometatarsal joints,
metatarsal bones and
metatarsophalangeal joints [forefoot]
3. • Amputation of Hindfoot or 1.WE.93 Amputation, tarsal bones and
Midfoot intertarsal joints [hindfoot, midfoot]
4. • Amputation of Phalanx 1.WL.93 Amputation, phalanx of foot
of Foot
5. • Amputation of the Apex of 1.HR.87 Excision partial, interventricular
the Ventricle and Portions septum
of the Ventricular Septum
Along With Closure of the
Resultant Defect
6. • Amputation of Toe 1.WM.93 Amputation, interphalangeal joints
of toe
7. • Arteriothrombectomy of 1.KG.57 Extraction, arteries of leg NEC
Lower Limb Arteries
• Declotting (Graft)
• Endarterectomy
• Removal of Atheromatous
Plaque, Lower Limb
Arteries
• With or Without Dilation
8. • Atherectomy, Coronary 1.IJ.57 Extraction, coronary
Artery arteries
• Endarterectomy, Coronary
Artery
• Removal of Atheromatous
Plaque, Coronary Artery
• Removal, Atheromatous
Plaque From Previously
Grafted Coronary Artery
(Code Revision Using
Status Attribute)
• With or Without Dilation of
Artery (For Example,
Balloon Angioplasty)
9. • Attachment of Appliance, 1.HZ.37 Installation of external
Heart appliance, heart NEC
10. • Behaviour Therapy 6.AA.30 Therapy, mental health
(Psychodynamic)
11. • Below Knee Amputation 1.VQ.93 Amputation, tibia and fibula
12. • Biopsy of the Heart 2.HZ.71 Biopsy, heart
54 CIHI 2009
Item CCI Code

13. • Bypass Arteries of Leg 1.KG.76 Bypass, arteries of leg NEC
14. • Cardiac Catheterization 3.IP.10 X-ray, heart with coronary arteries
15. • Cardiac Resynchronization 1.HZ.53 Implantation of internal device,
Therapy—Defibrillator heart NEC
(CRT-D, Using Three Leads)
• Cardiac Resynchronization
Therapy—Pacemaker
(CRT-P, Using Three Leads)
• Insertion, Automatic
Implantable Cardioverter—
Defibrillator (AICD, Using
Two Leads)
• Insertion, Heart
Biventricular Pacemaker
16. • Cardiac Support (for CHF) 1.HZ.34 Compression, heart NEC
• Encirclage, Heart
(Preventing Further
Enlargement)
• Wrap (Dacron), Heart
17. • Cardiopulmonary 1.HZ.30 Resuscitation, heart NEC
Resuscitation (CPR)
• External Cardiac Massage
18. • Cardioversion (External), 1.HZ.09 Stimulation, heart NEC
Atrial
• Conversion, Cardiac (Sinus)
Rhythm
• Defibrillation, Heart
19. • Chest Therapy (for Sputum 1.GZ.12 Therapy, respiratory system NEC
Induction)
20. • Computerized Tomography 3.IP.20 Computerized tomography [CT],
(CT) Heart heart with coronary arteries
21. • Construction or 1.HR.84 Construction or reconstruction,
Reconstruction of interventricular septum
Interventricular Septum
22. • Coronary Artery Bypass 1.IJ.76 Bypass, coronary arteries
Graft (CABG)
23. • Correction of Ventricular 1.HR.80 Repair, interventricular septum
Septal Defect
24. • Counselling: Addictions 6.AA.10 Counselling, mental health
25. • Counselling for Alcohol 7.SP.10.VA Counselling, promoting health and
Abuse preventing disease for alcohol abuse
26. • Counselling for Conception 7.SP.10.VC Counselling, promoting health and
preventing disease for conception
27. • Counselling for Drug Abuse 7.SP.10.VB Counselling, promoting health and
preventing disease for drug abuse
28. • Counselling for Nutrition 7.SP.10.VD Counselling, promoting health and
preventing disease for nutrition
(maintaining balanced/corrective diet)
CIHI 2009 55
Item CCI Code

29. • Counselling for Organ 7.SP.10.VX Counselling, promoting health and
Donation preventing disease practice for
organ donation
30. • Counselling for Other 7.SP.10.ZZ Counselling, promoting health and
Reason NEC preventing disease practice for other
reason NEC
31. • Counselling for Safe 7.SP.10.VE Counselling, promoting health and
Environment preventing disease for safe
environment (home, work)
32. • Counselling for Safe 7.SP.10.VF Counselling, promoting health and
Recreation preventing disease for safe
recreation (leisure activity,
playground, sports)
33. • Counselling for Safe Sexual 7.SP.10.VG Counselling, promoting health and
Practice (Includes preventing disease practice for safe
Contraception) sexual practice (includes:
contraception)
34. • Counselling for Safe 7.SP.10.VH Counselling, promoting health and
Vehicle (Bicycle, Boat, Car) preventing disease practice for safe
vehicle (bicycle, boat, car)
35. • Counselling for Smoking 7.SP.10.VK Counselling, promoting health and
preventing disease practice for
smoking
36. • Counselling for 6.DA.10 Counselling, interpersonal
Interpersonal Relationships relationships
37. • Counselling for Mediation 6.DA.07 Facilitation, interpersonal
relationships
38. • Cryocardioplegia (to Induce 1.HZ.35 Pharmacotherapy (local), heart NEC
Arrest of Contractures
During Surgery)
• Injection (of Agent), Heart
• Injection, Myocardium
• Injection, Pericardium
• Instillation, Heart NEC
39. • Declotting of Jugular Vein 1.JQ.57 Extraction, jugular veins
• With or Without Dilation
• Thrombectomy
40. • Dilation, Arteries of Leg 1.KG.50 Dilation, arteries of leg NEC
NEC
41. • Diversion, Blood Flow From 1.HP.76 Bypass, ventricle
Right Ventricle
42. • Electroconvulsive Therapy 1.AN.09 Stimulation, brain
(ECT)
56 CIHI 2009
Item CCI Code

43. • Excision of Aneurysm of 1.HX.87 Excision partial, structures adjacent
Sinus of Valsalva to valves
• Excision of Aortic
Subvalvular (Fibrous) Ring
• Excision of Subaortic
Fibromuscular Ridge
• Excision of Supravalvar
Mitral Ring
• Excision of Vascular Ring
• Expansion of Aortic Ostium
• Fenestration of Chordae
• Resection of Chordae
Tendinae
44. • Excision Total of Mitral 1.HU.90 Excision total with reconstruction,
Valve With Reconstruction mitral valve
45. • Excision Total of Pulmonary 1.HT.89 Excision total, pulmonary valve
46. • Exercise Stress Test 2.HZ.08 Test, heart

47. • Extracranial 1.JX.87 Excision partial, other vessels of
Aneurysmectomy head, neck and spine NEC
48. • Extracranial Angioplasty 1.JX.50 Dilation, other vessels of head, neck
and spine NEC
49. • Implantation of Radioactive 1.IJ.26 Brachytherapy, coronary arteries
Material, Coronary Arteries
• Intravascular
Brachytherapy, Coronary
Artery
50. • Insertion of Access Device 1.JQ.53 Implantation of internal device,
for Short-Term Dialysis, jugular veins
Jugular Veins
51. • Interpersonal Therapy 6.DA.30 Therapy, interpersonal relationships
52. • Intravascular Sonotherapy 1.IJ.54 Management of internal device,
(Alone) for Treatment of In- coronary arteries
Stent Stenosis
• Therapeutic Ultrasound
(Alone) for Treatment of In-
Stent Stenosis
53. • Kidney Transplant 1.PC.85 Transplant, kidney
54. • Lens Extraction (for 1.CL.89 Excision total, lens
Cataract)
55. • Magnetic Resonance 3.IP.40 Magnetic resonance imaging [MRI],
Imaging (MRI): Heart heart with coronary arteries
56. • Mammogram 3.YM.10 X-ray, breast
57. • Microbiology Swab 2.ZZ.13 Specimen collection (for diagnostic
(Any Site) testing), total body
CIHI 2009 57
Item CCI Code

58. • Nebulizer 1.GZ.35 Pharmacotherapy (local), respiratory
system NEC
59. • Nuclear Imaging Study: 3.IP.70 Diagnostic nuclear (imaging) study,
Heart heart with coronary arteries
• MUGA Scan
60. • Pap Smear (Endocervical) 2.RN.71 Biopsy, cervix
61. • Pap Smear (Endometrial) 2.RM.71 Biopsy, uterus and surrounding
structures
62. • Partial Excision of Jugular 1.JQ.87 Excision partial, jugular veins
Veins (For Example,
Thrombectomy)
63. • Partial Excision of Veins of 1.JU.87 Excision partial, veins of arm NEC
the Arm (For Example,
Thrombectomy)
64. • Percutaneous Coronary 1.IJ.50 Dilation, coronary arteries
Artery Angioplasty (PTCA)
65. • Pulmonary Function Test 2.GZ.21 Capacity measurement, respiratory
(PFT) system
66. • Removal of Device From 1.IJ.55 Removal of device, coronary arteries
Coronary Arteries
67. • Removal of Foreign Body 1.HZ.56 Removal of foreign body, heart NEC
Lying Entirely Within (Any)
Heart Chamber
68. • Removal of Pacemaker and 1.HZ.55 Removal of device, heart NEC
Leads (Any Device, Any
Approach)
69. • Renal Dialysis 1.PZ.21 Dialysis, urinary system NEC
70. • Repair of Aortic Valve 1.HV.80 Repair, aortic valve
71. • Repair of Coronary Arteries 1.IJ.80 Repair, coronary arteries
72. • Repair of Jugular Veins 1.JQ.80 Repair, jugular veins
73. • Repair of Mitral Valve 1.HU.80 Repair, mitral valve
74. • Repair of Other Vessels of 1.JX.80 Repair, other vessels of head, neck
Head, Neck and Spine and spine NEC
75. • Repair of Pulmonary Valve 1.HT.80 Repair, pulmonary valve
76. • Repair of the Atrium 1.HM.80 Repair, atrium

77. • Repair of Tricuspid Valve 1.HS.80 Repair, tricuspid valve
78. • Repair of Unroofed 1.IK.80 Repair, coronary veins
Coronary Sinus
79. • Repair Retinal Detachment 1.CN.59 Destruction, retina
• Repair Retinal Tear
80. • Repair, Pulmonary Vein 1.IN.80 Repair, pulmonary vein
81. • Replacement of 1.HV.90 Excision total with reconstruction,
Aortic Valve aortic valve
82. • Replacement of 1.HT.90 Excision total with reconstruction,
Pulmonary Valve pulmonary valve
58 CIHI 2009
Item CCI Code

83. • Replacement of 1.HS.90 Excision total with reconstruction,
Tricuspid Valve tricuspid valve
84. • Teletherapy of 1.IJ.27 Radiation, coronary arteries
Coronary Arteries
• Therapy, Radiation
(Radiotherapy),
Coronary Arteries
85. • Thrombectomy of Atrium 1.HM.57 Extraction, atrium
86. • Thrombectomy of 1.IK.57 Extraction, coronary veins
Coronary Veins
87. • Transplant of Heart With 1.HY.85 Transplant, heart with lung(s)
Lung(s)
88. • Ultrasound of 3.IJ.30 Ultrasound, coronary arteries
Coronary Arteries
89. • Unroofing of Coronary 1.IK.87 Excision partial, coronary veins
Sinus
90. • Vaccination Against 8.IN.70 Immunization (to prevent) influenza
Influenza
91. • Vaccination Against 8.BR.70 Immunization (to prevent)
streptococcal pneumoniae streptococcal pneumococcal bacteria
Note
NEC: not elsewhere classified.
Source
Canadian Classification of Health Interventions (CCI), 2007, Canadian Institute for Health Information.
CIHI 2009 59
Appendix D: Current Encounter Interventions Picklist

Item Current Encounter CCI Code CCI Code (Version 2007)
Number Interventions Picklist (Version 2007) Description
1. Behaviour Therapy 6.AA.30 Therapy, mental health
(Psychodynamic)
2. Chest Therapy (for Sputum 1.GZ.12 Therapy, respiratory system NEC
Induction)
3. Computed Tomography (CT) 3.IP.20 Computerized tomography [CT],
of Heart heart with coronary arteries
4. Counselling for Addictions 6.AA.10 Counselling, mental health
(For Example, Alcohol, Drugs,
Gambling, Sex)
5. Counselling for Alcohol Abuse 7.SP.10.VA Counselling, promoting health and
preventing disease for alcohol abuse
6. Counselling for Conception 7.SP.10.VC Counselling, promoting health and
preventing disease for conception
7. Counselling for Drug Abuse 7.SP.10.VB Counselling, promoting health and
preventing disease for drug abuse
8. Counselling for Interpersonal 6.DA.10 Counselling, interpersonal
Relationships relationships
9. Counselling for Mediation 6.DA.07 Facilitation, interpersonal
relationships
10. Counselling for Nutrition 7.SP.10.VD Counselling, promoting health and
(Maintaining Balanced/ preventing disease for nutrition
Corrective Diet) (maintaining balanced/corrective
diet)
11. Counselling for Organ 7.SP.10.VX Counselling, promoting health and
Donation preventing disease for organ
donation
12. Counselling for Other Reason 7.SP.10.ZZ Counselling, promoting health and
preventing disease for other
reason NEC
13. Counselling for Safe 7.SP.10.VE Counselling, promoting health and
Environment (Home, Work) preventing disease for safe
environment (home, work)
14. Counselling for Safe 7.SP.10.VF Counselling, promoting health and
Recreation (Leisure Activity, preventing disease for safe
Playground, Sports) recreation (leisure activity,
playground, sports)
15. Counselling for Safe Sexual 7.SP.10.VG Counselling, promoting health and
Practice (Includes preventing disease for safe sexual
Contraception) practice (includes: contraception)
16. Counselling for Safe Vehicle 7.SP.10.VH Counselling, promoting health and
(Bicycle, Boat, Car) preventing disease for safe vehicle
(bicycle, boat, car)
17. Counselling for Smoking 7.SP.10.VK Counselling, promoting health and
Cessation preventing disease for smoking
60 CIHI 2009
Item Current Encounter CCI Code CCI Code (Version 2007)

Number Interventions Picklist (Version 2007) Description
18. Diagnostic Nuclear (Imaging) 3.IP.70 Diagnostic nuclear (imaging) study,
Study of the Heart With heart with coronary arteries
Coronary Arteries
19. Dialysis (for Acute Renal 1.PZ.21 Dialysis, urinary system, NEC
Failure)
20. Magnetic Resonance Imaging 3.IP.40 Magnetic resonance imaging [MRI],
(MRI): Heart heart with coronary arteries
21. Nebulizer 1.GZ.35 Pharmacotherapy (local), respiratory
system NEC
22. Pap Smear (Endometrial) 2.RM.71 Biopsy, uterus and surrounding
structures
23. Pap Smear Cervical (Cervix) 2.RN.71 Biopsy, cervix
24. Ultrasound of Coronary 3.IJ.30 Ultrasound, coronary arteries
Arteries
25. Ultrasound of the Heart 3.HZ.30 Ultrasound, heart NEC
26. Vaccination Against Influenza 8.IN.70 Immunization (to prevent) influenza
27. Vaccination Against 8.BR.70 Immunization (to prevent)
streptococcal pneumoniae streptococcal pneumococcal
bacteria
Note
Source
CIHI 2009 61
Appendix E: Observation History Allergy Types Picklist

Item ICD-10-CA Code
Types of Allergy ICD-10-CA Code Description
1. Drugs and Biological Z88.0 Personal history of allergy to
Substances Allergy: penicillin
Penicillin
2. Drugs and Biological Z88.1 Personal history of allergy to other
Substances Allergy: antibiotic agents
Other Antibiotic Agents
(For Example, Gentamicin,
Neomycin)
Substances Allergy: sulfonamides
Sulfonamides
Substances Allergy: anti-infective agents
Other Anti-Infective Agents
Substances Allergy: anaesthetic agent
Anesthetic Agent
Substances Allergy: narcotic agent
Narcotic Agent
Substances Allergy: analgesic agent
Analgesic Agent
8. Drugs and Biological Z88.7 Personal history of allergy to serum
Substances Allergy: and vaccine
Serum and Vaccine
(Includes Chicken Protein
Formaldehyde,
Hemagglutinin, Thimerosal)
Substances Allergy: drugs, medicaments and biological
Multiple Drug Allergies substances
Substances Allergy: unspecified drugs, medicaments and
Unspecified Drugs, biological substances
Medicaments and Biological
Substances
11. Environmental Allergy: J30.0 Vasomotor rhinitis
Airborne Substances—
Rhinitis
12. Environmental Allergy: J30.3 Other allergic rhinitis
Animal Dander, Animal Hair
Dandruff Perennial allergic rhinitis
14. Environmental Allergy: L23 Allergic contact dermatitis
Dermatitis
62 CIHI 2009
Item ICD-10-CA Code

Types of Allergy ICD-10-CA Code Description
Dust
Feathers, Kapok Perennial allergic rhinitis
17. Environmental Allergy: J30.1 Allergic rhinitis due to pollen
Grass, Hay Fever, Pollen,
Ragweed, Tree
18. Food Allergy: T78.10* Food allergy: Peanuts
Peanuts
19. Food Allergy: T78.11* Food allergy: Shell fish (crustaceans)
Shellfish (Crustaceans)
20. Food Allergy: T78.12* Food allergy:
Other Fish other fish
Fruits and Vegetables fruits and vegetables
Tree Nuts and Seeds tree nuts & seeds
Food Additives food additives
Milk and Dairy Products milk and dairy products
Eggs eggs
Other Food Products—Those other food products—those not
Not Listed Above listed above
Unspecified Food Products unspecified food products
Note
* All the ICD-10-CA (version 2007) codes that have an asterisk will be found in ICD-10-CA v. 2012.
Source
CIHI 2009 63
Appendix F: Ordering Diagnostic Imaging Codes Picklist

LOINC DI Ordering Codes will be inserted with the next release of this document; these
codes are currently unavailable
Item CCI Intervention Code

X-Ray Site CCI Code Description
1. Abdomen 3.OT.10 X-ray, abdominal cavity
2. Arm 3.TZ.10 X-ray, arm
3. Bladder 3.PM.10 X-ray, bladder NEC
4. Bones: Clavicle 3.SM.10 X-ray, clavicle
5. Bones: Facial Bones 3.EI.10 X-ray, facial bone structure
6. Bones: Femur 3.VC.10 X-ray, femur
7. Bones: Finger 3.UJ.10 X-ray, phalanx of hand
8. Bones: Foot 3.WG.10 X-ray, foot
9. Bones: Hand 3.UZ.10 X-ray, hand with wrist
10. Bones: Humerus 3.TK.10 X-ray, humerus
11. Bones: Pelvis 3.SQ.10 X-ray, pelvis
12. Bones: Radius and Ulna 3.TV.10 X-ray, radius and ulna
13. Bones: Ribs 3.SL.10 X-ray, ribs
14. Bones: Sacrum and Coccyx 3.SF.10 X-ray, sacrum and coccyx
15. Bones: Scapula 3.SN.10 X-ray, scapula
16. Bones: Skull 3.EA.10 X-ray, cranium
17. Bones: Spine 3.SC.10 X-ray, spinal vertebrae
18. Bones: Sternum 3.SK.10 X-ray, sternum
19. Bones: Tibia and Fibula 3.VQ.10 X-ray, tibia and fibula
20. Brain 3.AN.10 X-ray, brain
21. Breast: Mammogram 3.YM.10 X-ray, breast
22. Chest 3.GY.10 X-ray, thoracic cavity NEC
23. Joint: Ankle 3.WA.10 X-ray, ankle joint
24. Joint: Hip 3.VA.10 X-ray, hip joint
25. Joint: Knee 3.VG.10 X-ray, knee joint
26. Joint: Shoulder 3.TB.10 X-ray, acrominoclavicular and
sternoclavicular joints
Note
Source
64 CIHI 2009
Item Computerized CCI Ordering Code

CCI Code Description
Number Tomography (CT) Site (Version 2007)
1. Abdomen 3.OT.20 Computerized tomography [CT],
abdominal cavity
2. Brain 3.AN.20 Computerized tomography [CT], brain
3. Breast 3.YM.20 Computerized tomography [CT], breast
4. Chest 3.GY.20 Computerized tomography [CT], thoracic
cavity
5. Head 3.ER.20 Computerized tomography [CT], head NEC
6. Kidney 3.PC.20 Computerized tomography [CT], kidney
7. Lung 3.GT.20 Computerized tomography [CT], lung NEC
8. Prostate 3.QT.20 Computerized tomography [CT], prostate
9. Sinuses: Nasal 3.EY.20 Computerized tomography [CT], paranasal
sinuses
10. Spinal Vertebrae 3.SC.20 Computerized tomography [CT], spinal
vertebrae
Note
Source
Item Magnetic Resonance CCI Code

CCI Code Description
Number Imaging (MRI) Site (Version 2007)
1. Abdomen 3.OT.40 Magnetic resonance imaging [MRI],
abdominal cavity
2. Brain 3.AN.40 Magnetic resonance imaging [MRI], brain
3. Breast 3.YM.40 Magnetic resonance imaging [MRI], breast
4. Chest 3.GY.40 Magnetic resonance imaging [MRI],
thoracic cavity NEC
5. Head 3.ER.40 Magnetic resonance imaging [MRI], head
NEC
6. Kidney 3.PC.40 Magnetic resonance imaging [MRI], kidney
7. Prostate 3.QT.40 Magnetic resonance imaging [MRI],
prostate
8. Sinus 3.ER.40 Magnetic resonance imaging [MRI], sinus
9. Spinal Vertebrae 3.SC.40 Magnetic resonance imaging [MRI], spinal
vertebrae
10. Total Body 3.ZZ.40 Magnetic resonance imaging [MRI],
total body
11. Heart 3.IP.40 Magnetic resonance imaging [MRI], heart
with coronary arteries
Note
Source
CIHI 2009 65
Item CCI Code

Ultrasound Site CCI Code Description
1. Abdomen and Pelvic Cavity 3.OT.30 Ultrasound, abdominal cavity
(Organs/Structures Within)
2. Abdominal Veins 3.KQ.30 Ultrasound, abdominal veins NEC
3. Aorta 3.ID.30 Ultrasound, aorta NEC
4. Arm and Hand (With Wrist) 3.TZ.30 Ultrasound, arm NEC
5. Artery With Vein 3.KY.30 Ultrasound, artery with vein
6. Artery 3.KV.30 Ultrasound, artery NEC
7. Brain 3.AN.30 Ultrasound, brain
8. Breast 3.YM.30 Ultrasound, breast
9. Bronchial Vessel 3.JY.30 Ultrasound, thoracic vessels NEC
10. Cerebellar Vessel 3.JX.30 Ultrasound, other vessels of head, neck
and spine NEC
11. Cerebral Vessel 3.JX.30 Ultrasound, other vessels of head, neck
and spine NEC
12. Chest 3.GY.30 Ultrasound, thoracic cavity NEC
13. Coronary Arteries 3.IJ.30 Ultrasound, coronary arteries
14. Elbow 3.TM.30 Ultrasound, elbow joint
15. Eye 3.CA.30 Ultrasound, orbit (of eye)
16. Head 3.ER.30 Ultrasound, head NEC
17. Head and Neck Vessel NEC 3.JX.30 Ultrasound, other vessels of head, neck
and spine NEC
18. Heart 3.HZ.30 Ultrasound, heart NEC
19. Hepatic Vessel 3.KE.30 Ultrasound, abdominal arteries NEC
20. Hip Joint 3.VA.30 Ultrasound, hip joint
21. Intercostal Vessel 3.JY.30 Ultrasound, thoracic vessels NEC
22. Intracranial Vessel 3.JW.30 Ultrasound, intracranial vessels
23. Jugular Veins 3.JQ.30 Ultrasound, jugular veins
24. Kidney 3.PC.30 Ultrasound, kidney
25. Knee Joint 3.VG.30 Ultrasound, knee joint
26. Leg (Dopplergram) 3.KG.30 Ultrasound, arteries of leg NEC
27. Leg Veins 3.KR.30 Ultrasound, veins of leg NEC
28. Liver With Spleen 3.OC.30 Ultrasound, liver with spleen
29. Liver (Only) 3.OA.30 Ultrasound, liver
30. Pelvic Veins 3.KT.30 Ultrasound, vessels of pelvis, perineum
and gluteal region
31. Portal Veins 3.KQ.30 Ultrasound, abdominal veins NEC
32. Pulmonary Veins 3.JY.30 Ultrasound, thoracic vessels NEC
33. Renal Veins 3.KQ.30 Ultrasound, abdominal veins NEC
34. Shoulder Joint 3.TA.30 Ultrasound, shoulder joint
35. Soft Tissue of Head and Neck 3.EQ.30 Ultrasound, soft tissue of head and neck
36. Soft Tissue of Neck 3.FY.30 Ultrasound, soft tissue of neck
37. Suprarenal Veins 3.KQ.30 Ultrasound, abdominal veins NEC
38. Thoracic Cavity 3.GY.30 Ultrasound, thoracic cavity NEC
39. Thyroid Gland 3.FU.30 Ultrasound, thyroid gland
Note
Source
66 CIHI 2009
Appendix G: Medication Picklist

The table below provides a preliminary list of medications that are primarily relevant to
PHC chronic diseases of interest such as diabetes, depression, coronary artery disease
and hypertension.
ATC coding classification system will be used at the back end to capture medication
names (ATC code—with seven field size in length) prescribed electronically. Additionally,
relevant medication data elements such as route, strength, dose, form, frequency and
repeat will be collected.
Item
Value Label—Preliminary List of Medications
Number
1. ABCIXIMAB
2. ACARBOSE
3. ACEBUTOLOL
4. ACENOCOUMAROL
5. ACETYLSALICYLIC ACID
6. ALISKIREN
7. ALTEPLASE
8. AMILORIDE
9. AMITRIPTYLINE
10. AMITRIPTYLINE AND PSYCHOLEPTICS
11. AMLODIPINE
12. ANISTREPLASE
13. ANTITHROMBIN
14. ARGATROBAN
15. ATENOLOL
16. ATENOLOL AND OTHER DIURETICS
17. ATORVASTATIN
18. ATORVASTATIN AND AMLODIPINE
19. BENAZEPRIL
20. BEZAFIBRATE
21. BISOPROLOL
22. BUMETANIDE
24. CANDESARTAN
23. CANDESARTAN AND DIURETICS
25. CAPTOPRIL
26. CARVEDILOL
27. CHLORPROPAMIDE
28. CHLORTALIDONE
29. CHOLESTYRAMINE
30. CILAZAPRIL
CIHI 2009 67
Item
Number
31. CILAZAPRIL AND DIURETICS
32. CITALOPRAM
33. CLOMIPRAMINE
34. CLOPIDOGREL
35. COLESTIPOL
36. COMBINATIONS
37. DALTEPARIN
38. DANAPAROID
39. DESIPRAMINE
40. DILTIAZEM
41. DIPYRIDAMOLE
42. DOXEPIN
43. DROTRECOGIN ALFA
44. DULOXETINE
45. ENALAPRIL
46. ENALAPRIL AND DIURETICS
47. ENOXAPARIN
48. EPOPROSTENOL
49. EPROSARTAN
50. EPROSARTAN AND DIURETICS
51. EPTIFIBATIDE
52. ESCITALOPRAM
53. ESMOLOL
54. ETACRYNIC ACID
55. EZETIMIBE
56. FELODIPINE
57. FENOFIBRATE
58. FLUOXETINE
59. FLUVASTATIN
60. FLUVOXAMINE
61. FONDAPARINUX
62. FOSINOPRIL
63. FUROSEMIDE
64. GEMFIBROZIL
65. GLIBENCLAMIDE
66. GLICLAZIDE
67. GLIMEPIRIDE
68. GLIMEPIRIDE AND ROSIGLITAZONE
69. GLYCERYL TRINITRATE
68 CIHI 2009
Item
Number
70. HEMOPHILUS INFLUENZAE B, COMBINATIONS WITH TOXOIDS
71. HEPARIN
72. HEPARIN, COMBINATIONS
73. HYDROCHLOROTHIAZIDE
74. HYDROCHLOROTHIAZIDE AND POTASSIUM-SPARING AGENTS
75. IMIPRAMINE
76. INDAPAMIDE
77. INSULIN (HUMAN)
78. INSULIN (HUMAN)
79. INSULIN (HUMAN)
80. INSULIN (PORK)
81. INSULIN (PORK)
82. INSULIN ASPART
83. INSULIN ASPART
84. INSULIN DETEMIR
85. INSULIN GLARGINE
86. INSULIN LISPRO
87. INSULIN LISPRO
88. IRBESARTAN
89. IRBESARTAN AND DIURETICS
90. LABETALOL
91. LEPIRUDIN
92. LISINOPRIL
93. LISINOPRIL AND DIURETICS
94. LOSARTAN
95. LOSARTAN AND DIURETICS
96. LOVASTATIN
97. LOVASTATIN AND NICOTINIC ACID
98. MAPROTILINE
99. METFORMIN
100. METFORMIN AND ROSIGLITAZONE
101. METHYLDOPA (LEVOROTATORY) AND DIURETICS
102. METOLAZONE
103. METOPROLOL
104. MIRTAZAPINE
105. MOCLOBEMIDE
106. NADOLOL
107. NADROPARIN
108. NATEGLINIDE
CIHI 2009 69
Item
Number
109. NICOTINIC ACID
110. NIFEDIPINE
111. NIMODIPINE
112. NORTRIPTYLINE
113. OXPRENOLOL
114. PAROXETINE
115. PERINDOPRIL
116. PERINDOPRIL AND DIURETICS
117. PHENELZINE
118. PINDOLOL
119. PINDOLOL AND OTHER DIURETICS
120. PIOGLITAZONE
121. PNEUMOCOCCAL VACCINES
122. PNEUMOCOCCUS, PURIFIED POLYSACC.ANTIGEN CONJUGATED
123. PRAVASTATIN
124. PROBUCOL
125. PROPRANOLOL
126. QUINAPRIL
127. QUINAPRIL AND DIURETICS
128. RAMIPRIL
129. RAMIPRIL AND DIURETICS
130. RAMIPRIL AND FELODIPINE
131. REPAGLINIDE
132. RETEPLASE
133. ROSIGLITAZONE
134. ROSUVASTATIN
135. SERTRALINE
136. SIMVASTATIN
137. SITAGLIPTIN
138. SOTALOL
139. SPIRONOLACTONE
140. STREPTOKINASE
141. TELMISARTAN
142. TELMISARTAN AND DIURETICS
143. TICLOPIDINE
144. TIMOLOL
145. TINZAPARIN
146. TIROFIBAN
147. TOLBUTAMIDE
70 CIHI 2009
Item
Number
148. TRANDOLAPRIL
149. TRANDOLAPRIL AND VERAPAMIL
150. TRANYLCYPROMINE
151. TRAZODONE
152. TREPROSTINIL
153. TRIMIPRAMINE
154. TRYPTOPHAN
155. VALSARTAN
156. VALSARTAN AND DIURETICS
157. VENLAFAXINE
158. VERAPAMIL
159. WARFARIN
160. XANTHINE DERIVATIVES
Source
National Prescription Drug Utilization Information System Database, September 2008, Canadian Institute for
Health Information.
CIHI 2009 71
Appendix H: Lab Test Ordering Codes Picklist

Primary Health
Pan-Canadian
Item Care (PHC) Pan-Canadian LOINC
Component Alternate LOINC Code‡
Number Clinical Data Display Name† Component‡
Name†
Element*
1. Hemoglobin Hemoglobin Free Hemoglobin Free Hemoglobin.free 14134-1
Deprecated
Hgb Free Ser-mCnc
Hemoglobin 35183-3
Hgb Plas-msCnc
Hemoglobin; Hemoglobin 30313-1
Arterial Blood Hgb BldA-mCnc
Hemoglobin Hemoglobin 30350-3
Hgb BldV-mCnc
Hgb BldMV-mCnc
Venous Cord Hgb BldCoV-mCnc
Blood
Arterial Cord Hgb BldCoA-mCnc
Blood
2. Total Cholesterol Cholesterol Cholesterol Cholesterol 14647-2
Cholest
SerPl-sCnc
3. HDL Cholesterol Cholesterol.in 2085-9
HDL HDLc
SerPl-mCnc
Cholesterol In Cholesterol In 14646-4
HDL HDL HDLc
SerPl-sCnc
Cholesterol In Cholesterol In Cholesterol.in 26017-4
HDL 3 HDL 3 HDL 3 HDL3c
SerPl-sCnc
9833-5
HDL3c
SerPl-mCnc
4. LDL Cholesterol Cholesterol In Cholesterol In Cholesterol.in 22748-8
LDL LDL LDL LDLc
SerPl-sCnc
18262-6
LDLc
SerPl Direct Assay-
mCnc
2089-1
LDLc
SerPl-mCnc
LDL LDL LDLc
SerPl-sCnc
Cholesterol.in 2091-7
VLDL VLDLc
SerPl-mCnc
72 CIHI 2009
Primary Health
Pan-Canadian
Name†
Element*
VLDL VLDL VLDLc
SerPl-sCnc
5. TC:HDL Cholesterol/Chole Cholesterol/Chole Cholesterol.total/ 32309-7
Cholesterol Ratio sterol In HDL sterol In HDL Cholesterol.in Cholest/HDLc
HDL SerPl-sRto
6. Triglycerides Tryglyceride 2571-8
Trigl
SerPl-mCnc
7. Serum Creatinine Creatinine Creatinine Creatinine 14682-9
Creat
SerPl-sCnc
8. Albumin– Albumin/ 13705-9
Creatinine Ratio Creatinine Albumin/creat
(ACR) 24H Ur-mRto
Albumin– Albumin– 14585-4
Creatinine Creatinine Albumin/creat
Ur-sRto
14958-3
Microalbumin/creat
24H rate Ur
Creatinine Creatinine Microalbumin/creat
Ur-rto
9. Albumin– Albumin– Albumin– Albumin/ 30001-2
Creatinine Ratio Creatinine Creatinine Creatinine Microalbumin/creat
(ACR) Ur Test Str
Creatinine Creatinine Albumin/creat
Ur-Rto
9318-7
Albumin/creat
Ur-mRto
14959-1
Microalbumin/creat
Ur-mRto
10. Creatinine Creatinine Creatinine Creatinine 14683-7
Clearance Creat
Ur-sCnc
Creatinine Creatinine 14684-5
Creat
24H Ur-sRate
Creatinine; Creatinine 15051-6
Dialysis Fluid Creat
Diaf-sCnc
20624-3
Creat
24H Ur-mCnc
2160-0
Creat
SerPl-mCnc
CIHI 2009 73
Primary Health
Pan-Canadian
Name†
Element*
2161-8
Creat
Ur-mCnc
11. Creatinine Creatinine 2162-6
Clearance Creat
24H Ur-mRate
Creat
24H Ur-sCnc
5919-6
Creat
Dial fld-mCnc
Creat
SerPl-sCnc
12. 24-Hour Urinary Protein Protein Protein 2889-4
Protein Prot
24H Ur-mCnc
Protein Protein 21482-5
Prot
24H Ur-mCnc
13. Serum Potassium Potassium Potassium Potassium 2823-3
Potassium
SerPl-sCnc
14. Serum Sodium Sodium Sodium Sodium 2951-2
Sodium
SerPl-sCnc
15. Transferrin Iron/Iron binding 2505-6
Saturation capacity.total Iron/TIBC
SerPl-mRto
16. Serum Calcium Calcium Calcium Calcium 2000-8
Calcium
SerPl-sCnc
Calcium Calcium 2004-0
Calcium
Ur-sCnc
Calcium Calcium 25362-5
Calcium
24H Ur-sCnc
18488-7
Calcium
24H Ur-mCnc
Calcium Ionized Calcium Ionized Calcium.ionized 12180-6
Ca-I
SerPl ISE-sCnc
Calcium Ionized Calcium Ionized 1995-0
Ca-I
SerPl-sCnc
Calcium Ionized Calcium Ionized Calcium.ionized^^ 19072-8
Adjusted To pH Adjusted To pH adjusted to pH Ca-I adj pH7.4
7.4 7.4 7.4 SerPl-sCnc
74 CIHI 2009
Primary Health
Pan-Canadian
Name†
Element*
17. Serum Calcium Calcium Calcium Calcium^^ 29265-6
Corrected For Corrected For Corrected for Calcium Album cor
Albumin Albumin Albumin SerPl-sCnc
Calcium Calcium Calcium^^ 18281-6
Corrected For Corrected For corrected for Calcium TP cor
Total Protein Total Protein total protein SerPl-sCnc
18. Serum Phosphate Phosphate Phosphate 14879-1
Phosphorus Phosphate
SerPl-sCnc
19. Intact Parathyroid Parathyrin.intact^ 38158-2
Hormone (iPTH) baseline PTH-Intact BS
SerPl-mCnc
Parathyroid Parathyroid Parathyrin.intact 14866-8
Hormone [PTH] Hormone [PTH] PTH-Intact
Intact Intact SerPl-sCnc
20. Serum Albumin Albumin Albumin Albumin 1753-3
Alb
Ur Ql
14956-7
Microalbumin
24H rate Ur
14957-5
Microalbumin
Ur Qn
30003-8
Microalbumin
24H Cnc Ur
1751-7
Albumin
SerPl-mCnc
2862-1
Albumin
SerPl Elph-mCnc
21. Alanine Alanine Alanine Alanine 1742-6
Aminotransferase Aminotransferase Aminotransferase aminotransferase ALT SerPl-cCnc
(ALT)
CIHI 2009 75
Primary Health
Pan-Canadian
Name†
Element*
22. Creatine Kinase Creatine Kinase Creatine Kinase Creatine kinase 2157-6
(CK) CK
SerPl-cCnc
Creatine Kinase Creatine Kinase Creatine 2152-7
BB BB Kinase.BB CK BB
SerPl Elph-cCnc
BB/Total Creatine BB/Total Creatine Kinase.BB/ CK BB Fr
Kinase Kinase Creatine SerPl
kinase.total
MB MB kinase.MB CK MB
SerPl-mCnc
6773-6
Deprecated CK MB
SerPl EIA-cCnc
Creatine Creatine Kinase MB 2154-3
Kinase MB CK MB
SerPl Elph-cCnc
Creatine Creatine Kinase Creatine 20569-0
Kinase MB/Total Creatine kinase.MB/ CK MB Fr
MB/Total Kinase Creatine SerPl
Creatine kinase.total
Kinase
Creatine Creatine Kinase MM Creatine 2155-0
Kinase MM kinase.MM CK MM
SerPl Elph-cCnc
23. A1c Hemoglobin Hemoglobin A1/ Hemoglobin A1/ 4547-6
A1/Total Total Hemoglobin Hemoglobin.Total Hgb A1 Fr
Hemoglobin Bld
17856-6
Hgb A1c Fr
Bld HPLC
Hemoglobin Hemoglobin Hemoglobin 17855-8
A1c/Total A1c/Total A1c/Hemoglobin. Hgb A1c Fr
Hemoglobin Hemoglobin TotalCalculated Bld Calc
Hemoglobin Hemoglobin A1/ Hemoglobin A1c/ 4547-6
A1/Total Total Hemoglobin Hemoglobin.Total Hgb A1 Fr
Hemoglobin Bld
A1c/Total A1c/Total Hgb A1c Fr
Hemoglobin Hemoglobin Bld Elph
A1c/Total A1c/Total Hgb A1c Fr
Hemoglobin Hemoglobin Bld
Notes
* Data element relevant to CIHI PHC quality of care indicators.
† Pan-Canadian Laboratory Observation Code Database Standard, [online], cited from
<http://forums.infoway-inforoute.ca/PCS/Pan%20Canadian%20Laboratory%20Observation%20Code
%20Database/?14@410.QqjWasM9iL4.15@>.
‡ RELMA The Regenstrief LOINC Mapping Assistant, Version 3.23 Build 4, 2007. LOINC laboratory ordering
codes were derived from LOINC application 2007, version 3.23. The terms of use of LOINC codes permit use
of its codes without payment of license fees or royalties <http://loinc.org/terms-of-use>.
76 CIHI 2009
Appendix I: Provider Role Type Picklist

Item
Value Value Label
Number
1. 005 Alternative Healer
2. 010 Audiologist
3. 015 Cast Technician
4. 020 Chiropodist
5. 025 Chiropractor
6. 030 Dentist
7. 035 Dental Hygienist
8. 040 Dental Assistant
9. 045 Dental Mechanic
10. 050 Dental Surgeon
11. 055 Dentistry Unspecified
12. 060 Dietitian
13. 065 Electrocardiogram (ECG) Technician
14. 070 Emergency Medical Responder
15. 075 Endodontist
16. 080 Home Support/Home Care Personnel
17. 085 Kinesiologist
18. 090 Language Interpreter
19. 095 Licensed Practical Nurse (Registered Practical Nurse)
20. 100 Medical Doctor (See Provider Expertise for Specialty)
21. 105 Medical Laboratory Technologist
22. 110 Medical Radiation Technologist
23. 115 Massage Therapist
24. 120 Naturopath
25. 125 Nurse Aide/Health Care Aide/Orderly
26. 130 Nurse Practitioner (See Provider Expertise)
27. 135 Nurse, Unspecified
28. 140 Nutritionist
29. 145 Occupational Therapist
30. 150 Occupational Therapist Assistant
31. 155 Ophthalmologic Technician
32. 160 Optometrist
33. 165 Oral Pathologist
34. 170 Oral Radiologist
35. 175 Oral Surgeon
36. 180 Orthotist
37. 185 Orthodontist
38. 190 Orthoptician/Prosthetician
39. 195 Osteopath
40. 200 Paramedic
41. 205 Pastor/Clergy
42. 210 Pediatric Dentist
43. 215 Pediatric Oral Surgeon
44. 220 Pedodontist
45. 225 Periodontist
CIHI 2009 77
Item
Value Value Label
Number
46. 230 Pharmacist
47. 235 Pharmacist Assistant
48. 240 Physicist in Medicine
49. 245 Physiotherapist Assistant
50. 250 Physiotherapist
51. 255 Podiatrist
52. 260 Podiatry/Chiropody in General
53. 265 Prosthetist
54. 270 Psychologist
55. 275 Psychotherapist
56. 280 Radiotherapist
57. 285 Recreation Therapist
58. 290 Registered Acupuncturist
59. 295 Rehabilitation Counsellor
60. 300 Rehabilitation Disciplines, Unspecified
61. 305 Rehabilitation Engineer
62. 310 Rehabilitation Therapist
63. 315 Respiratory Therapist
64. 320 Registered Midwife
65. 325 Registered Nurse (Registered Nurse Practitioner, see Provider Expertise)
66. 330 Registered Psychiatric Nurse
67. 335 Speech Language Pathologist
68. 340 Social Worker
69. 345 Technician Group
70. 350 Therapist Group
71. 355 Therapy Assistant
72. 360 Vocational Rehabilitation Counsellor
73. 365 Licensed/Regulated Health Disciplines, Unspecified
74. 370 Other Licensed/Regulated Health Disciplines
75. 375 Unlicensed/Unregulated Personnel, Unspecified
76. 380 Other Unlicensed/Unregulated Health Personnel
Source
Canadian Institute for Health Information, CIHI Data Dictionary, [online], cited from
<http://secure.cihi.ca/ddexternal/welcome.do?lng=E>.
78 CIHI 2009
Appendix J: Provider Expertise Picklist

Item
Value Value Label
Number
1. 005 Anatomical Pathology
2. 010 Anesthesia
3. 015 Bacteriology
4. 020 Biochemistry
5. 025 Cardiac Surgery
6. 030 Cardiology
7. 035 Cardiothoracic Surgery
8. 040 Cardiovascular Surgery
9. 045 Cardiovascular Thoracic Surgery
10. 050 Clinical Immunology and Allergy
11. 055 Clinical Pharmacology
12. 060 Colorectal Surgery
13. 065 Community Medicine/Public Health
14. 070 Critical Care Medicine
15. 075 Dermatology
16. 080 Diagnostic Radiology
17. 085 Electroencephalography (EEG)
18. 090 Emergency Medicine
19. 095 Endocrinology and Metabolism
20. 100 Family Practitioner/General Practitioner
21. 105 Forensic Pathology
22. 110 Gastroenterology
23. 115 General Internal Medicine
24. 120 General Pathology
25. 125 General Surgery
26. 130 General Surgical Oncology
27. 135 Genetics
28. 140 Geriatric Medicine
29. 145 Gynecology
30. 150 Gynecologic Oncology
31. 155 Gynecologic Reproductive Endocrinology and Infertility
32. 160 Hematological Pathology
33. 165 Hematology
34. 170 Infectious Diseases/Tropical Diseases
35. 175 Internal Medicine
36. 180 Maternal–Fetal Medicine
37. 185 Medical Biochemistry
38. 190 Medical Genetics
39. 195 Medical Microbiology
40. 200 Medical Oncology
41. 205 Microbiology
42. 210 Neonatal–Perinatal Medicine
43. 215 Nephrology
44. 220 Neurology
45. 225 Neuropathology
CIHI 2009 79
Item
Value Value Label
Number
46. 230 Neuroradiology
47. 235 Neurosurgery
48. 240 Nuclear Medicine
49. 245 Obstetrics
50. 250 Obstetrics and Gynecology
51. 255 Oncology
52. 260 Ophthalmology
53. 265 Orthopedic Surgery
54. 270 Otolaryngology
55. 275 Pediatric Anesthesia
56. 280 Pediatric Cardiac Surgery
57. 285 Pediatric Cardiology
58. 290 Pediatric Cardiothoracic Surgery
59. 295 Pediatric Dermatology
60. 300 Pediatric Emergency Medicine
61. 305 Pediatric Endocrinology and Metabolism
62. 310 Pediatric Gastro-Enterology
63. 315 Pediatric General Surgery
64. 320 Pediatric Hematology
65. 325 Pediatric Immunology and Allergy
66. 330 Pediatric Nephrology
67. 335 Pediatric Neurology
68. 340 Pediatric Neurosurgery
69. 345 Pediatric Ophthalmology
70. 350 Pediatric Orthopedic Surgery
71. 355 Pediatric Otolaryngology
72. 360 Pediatric Plastic Surgery
73. 365 Pediatric Psychiatry
74. 370 Pediatric Respirology
75. 375 Pediatric Rheumatology
76. 380 Pediatric Thoracic Surgery
77. 385 Pediatric Urology
78. 390 Pediatric Vascular Surgery
79. 395 Pediatrics
80. 400 Pediatric Radiology
81. 405 Physical Medicine and Rehabilitation
82. 410 Plastic Surgery
83. 415 Psychiatry
84. 420 Psychiatry and Neuropsychiatry
85. 425 Radiation Oncology
86. 430 Registered Nurse Practitioner (Expertise of Registered Nurse Provider Role Type)
87. 435 Respirology/Respiratory Medicine
88. 440 Rheumatology
89. 445 Therapeutic Radiology
90. 450 Thoracic Surgery
91. 455 Transfusion Medicine
92. 460 Urology
80 CIHI 2009
Item
Value Value Label
Number
93. 465 Vascular Surgery
94. 470 Unclassified Physician
95. 997 Not Collected
96. 998 Not Applicable
97. 999 Unknown
Source
Canadian Institute for Health Information, CIHI Data Dictionary, [online], cited from
<http://secure.cihi.ca/ddexternal/welcome.do?lng=E>.
CIHI 2009 81
Appendix K: Service Recipient Ethnicity Picklist

In the Statistics Canada 2006 census, ethnic categories and subcategories used to classify
individual ethnic origins were as follows:
Item
Value Label
Number
1. British Isles origins
2. French origins
3. Aboriginal origins
4. Other North American origins
5. Caribbean origins
6. Latin, Central and South American origins
7. European origins
8. Western European origins
9. Northern European origins
10. Scandinavian origins
11. Eastern European origins
12. Other Eastern European origins
13. Southern European origins
14. Balkan origins
15. Other European origins
16. African origins
17. Arab origins
18. Maghrebi origins
19. West Asian origins
20. South Asian origins
21. East and Southeast Asian origins
22. Oceania origins
Source
2006 Census, Statistics Canada <www12.statcan.ca/english/census06/data/topics/
RetrieveProductTable.cfm?TPL=RETR&ALEVEL=3&APATH=3&CATNO=97-562-XCB2006006&
DETAIL=0&DIM=&DS=99&FL=0&FREE=0&GAL=0&GC=99&GK=NA&GRP=1&IPS
=97-562XCB2006006&METH=0&ORDER=1&PID=92333&PTYPE=88971&RL=0&S=1&ShowAll
=No&StartRow=1&SUB=801&Temporal=2006&Theme=80&VID=0&VNAMEE=&VNAMEF>.
82 CIHI 2009
Appendix L: Service Recipient Primary Language Picklist

Item
Value Value Label
Number
The value domain used for language English
1.
is ISO 632-2 alpha-3 code
The value domain used for language French
2.
is ISO 632-2 alpha-3 code
3. qaa American sign language
4. qab French sign language
5. qca Quebec sign language
6. qad Algonquin
7. qae Attikamek
8. qaf Carrier
9. qaq Chilcontin
10. qah Dene
11. qai Gitksan
12. qaj Han
13. qak Malecite
14. qal Mantagnais-Naskapi
15. qam Nishga
16. qan Nootka
17. qao North Slave (Hare)
18. qap Northern Tutchone
19. qaq Oji-Cree
20. qar Shuswap
21. qas South Slave
22. qat Southern Tutchone
23. qau Thompson (Ntlakapamux)
24. qav Cantonese
25. qaw Hakka
26. qax Mandarin
27. qay Aboriginal language not elsewhere specified
28. qtx Other language not elsewhere specified
Reserved for Canadian official language—
29. qty
both English and French
30. qtz Reserved
Not Collected—mandatory for optional data element
31. 7
when not collected
32. 8 Not applicable
33. 9 Unknown
Note
The entire list of languages can be accessed through ISO standards. CIHI locally defined language codes that
are applicable to CIHI businesses.
CIHI 2009 83
Appendix M: Current Encounter Influenza and Pneumococcal

Vaccine “Not Given” Reason Picklist
Item
Value Label
Number
1. Anaphylactic Hypersensitivity to Egg and Egg-Related Antigens
2. Contraindication—Allergy to Vaccine Component
3. Contraindication—Severely Immuno-Compromised
4. Contraindication—Pregnancy
5. Declined
6. Deferred
7. History of Adverse Event (For Example, Guillain Barre)
8. Previously Received
9. Recent Administration of Blood Product Containing Antibodies
10. Recent Administration of Live Virus Vaccine
11. Religious Reasons
12. Severe Bleeding Disorder
Source
PHC-specific context.
84 CIHI 2009
Appendix N: CIHI PHC Indicator Mapping

The following pages outline mapping of the required data elements to the 12 pan-Canadian
PHC clinical quality of care indicators. Below, the 12 PHC clinical quality of care indicators
are first defined and identified by their unique assigned number and their descriptor,
followed by a list of data elements required for reporting purpose. These indicators are
broken down into four categories: primary prevention, secondary prevention, patient safety
and outcome.
Data Elements Required for Reporting on All PHC Indicators:

Service Recipient
• Service Recipient Identifier Number
• Service Recipient Identifier Type
• Service Recipient Identifier Issuer
• Service Recipient Birthdate
• Service Recipient Gender
• Service Recipient Province/Territory of Residence
• Service Recipient Postal Code of Residence
Provider
• Provider Identifier Number
• Provider Identifier Type
• Provider Identifier Issuer
• Provider Role Type
• Provider Expertise
Service Delivery Location (SDL)
• SDL Identifier Number
• SDL Type
• SDL Postal Code
Current Encounter
• Current Encounter Health Issue(s)
• Current Encounter Intervention(s)
• Current Encounter End-of-Life Indicator
Observation History
• Observation History Health Issue(s)
• Observation History Health Issue Diagnosed Date
• Observation History of Intervention(s)
• Observation History of Intervention Date
• Observation History End-of-Life Indicator
• Observation History End-of-Life Date
Encounter
• Date of Initial Encounter With PHC Provider
• Encounter Date
CIHI 2009 85
Alignment of Data Elements to PHC Indicators

Primary Prevention
#13: Health Risk Screening in PHC

Definition: Percent of PHC clients or patients, 12 and older, who were screened by their
PHC provider for the following common health risks over the past 12 months:
• Tobacco use • Unsafe drug use
• Physical inactivity • Unsafe alcohol drinking
• Overweight status • Unsafe sexual practices
• Unhealthy eating habits • Unmanaged psychosocial stress
• Unintentional injuries: home risk factors • Depression
#41: Influenza immunization, 65+

Definition: Percent of PHC clients/patients, 65 and older, who received an influenza
immunization within the past 12 months
#42: Pneumococcal immunization, 65+

Definition: Percent of PHC clients/patients, 65 and older, who received a
pneumococcal immunization
#50: Cervical cancer screening

Definition: Percent of womeni PHC clients/patients, age 18 to 69, who received
Papanicolaou smear within the past three years
i. Women who have had hysterectomies are excluded.
86 CIHI 2009
List of Data Elements Required for Reporting

on PHC Indicators #13, #41, #42 and #50
Primary Prevention
• Current Encounter (in this context, • Current Encounter Service Recipient

current encounter refers to the – Smoker Indicator
administration of these vaccines) – Eating Habits Screening Indicator
– Influenza Vaccine Indicator – Physical Activity Screening Indicator
– Pneumococcal Vaccine Indicator – Unsafe Sexual Practice Screening
– Lab Test Code(s) Indicator
– Lab Test(s) Value – Unintentional Falls Screening
– Lab Test(s) Date Ordered Indicator
– Lab Test(s) Performed Date – Unmanaged Psychosocial Stress
• Observation History of: Screening Indicator
– Depression Screening Indicator
– Influenza Immunization Indicator
– Current Encounter Unsafe Drug Use
– Pneumococcal Immunization Indicator
Screening Tool
– Influenza Immunization Date
– Current Encounter Service Recipient
– Pneumococcal Immunization Date
– Unsafe Drinking Screening Indicator
– Lab Test Code(s)
– Current Encounter Papanicolaou Test
– Lab Test(s) Value
(Pap) Smear Screening Indicator
– Lab Test(s) Performed Date
• Current Encounter Service Recipient
• Observation History Allergy Type
– Height Value
– Weight Value
– Hip Circumference Value
– Waist Circumference Value
CIHI 2009 87

Secondary Prevention
#55: Screening for modifiable risk factors in adults with CAD

Definition: Percent of PHC clients/patients, 18 and older, with coronary artery disease
(CAD) who received annual testing, within the past 12 months
#56: Screening for modifiable risk factors in adults with hypertension

Definition: Percent of PHC clients/patients, 18 and older, with hypertension who received
annual testing, within the past 12 months
#57: Screening for modifiable risk factors in adults with diabetes

Definition: Percent of PHC clients/patients, 18 and older, with diabetes mellitus who
received annual testing, within the past 12 months
The list below includes the interventions relevant to #55, #56 and #57:
• Fasting blood sugar (FBS);
• Full fasting lipid profile screening;
• Serum creatinine (test to detect renal dysfunction);
• Blood pressure value(s);
• Obesity/overweight screening;
• Hemoglobin A1c testing (A1c); and
• Albumin–creatinine ratio, microalbuminuria (nephropathy screening).

on PHC Indicators #55, #56 and #57
Secondary Prevention
• Current Encounter Health Issue(s) • Observation History Lab Test

• Current Encounter Lab Test – Code
– Code – Performed Date
– Date Ordered – Value
– Value • Observation History of:
– Performed Date – Systolic Blood Pressure Value
• Current Encounter Service Recipient – Systolic Blood Pressure Value Date
– Height Value • Observation History of:
– Weight Value – Diastolic Blood Pressure Value
– Waist Circumference Value – Diastolic Blood Pressure Value Date
– Hip Circumference Value
– Systolic Blood Pressure Value
– Diastolic Blood Pressure Value
88 CIHI 2009

Patient Safety
#63: Antidepressant monitoring

Definition: Percent of PHC clients/patients with depression who are taking antidepressant
drug treatment under the supervision of a PHC provider, and who had follow-up contact by
a PHC provider for review within two weeks of initiating antidepressant drug treatment
Data Elements Required for Reporting on PHC Indicator #63
• Current Encounter Medication(s) • Current Encounter Service Recipient

– Prescribed Depression Screening Indicator
– Dose • Antidepressant Treatment Follow-Up
– Frequency Indicator
– Strength • Observation History Medication(s)
– Repeat
– Prescribed
– Dose
Medication Non-Adherence Indicator
– Frequency
• Current Encounter Service Recipient – Strength
Medication “Not Given” Reason • Observation History Allergy Type
• Current Encounter Service Recipient • Referred To Encounter Occurred
Unmanaged Psychosocial Stress Indicator
Screening Indicator
• Referred To Provider
– Identifier Number
– Role Type
– Expertise

Outcome
#39: Glycemic control for diabetics

Definition: Percent of PHC clients/patients, 18 and older, with diabetes mellitus in whom
the last A1c was 7.0% or less (or equivalent test/reference range depending on local
laboratory) in the last 15 months
#40: Blood pressure control for hypertension

Definition: Percent of PHC clients/patients, 18 and older, with hypertension for duration of
at least one year, who have blood pressure measurement control (less than 140/90 mmHg)
within the past 12 months
CIHI 2009 89
#61: Treatment of dyslipidemia

Definition: Percent of PHC clients/patients, 18 and older, with established coronary artery
disease (CAD) and elevated LDL-C (greater than 2.0 mmol/L) who were offered lifestyle
advice and/or lipid lowering medication
#64: Treatment of depression

Definition: Percent of PHC clients/patients, 18 and older, with depression who were
offered treatment (pharmacological and/or non-pharmacological) or referral to a mental
health provider

on PHC Indicators # 39, #40, #61 and #64
Outcome
• Current Encounter Service Recipient • Current Encounter Intervention(s)

– Systolic Blood Pressure Value Lifestyle Advice Indicator
– Diastolic Blood Pressure Value • Current Encounter Service Recipient
• Observation History of: Medication Non-Adherence Indicator
– Systolic Blood Pressure Value • Current Encounter Service Recipient
– Systolic Blood Pressure Value Date Medication “Not Given” Reason
• Observation History of: • Current Encounter Service Recipient
– Diastolic Blood Pressure Value Depression Screening Indicator
– Diastolic Blood Pressure Value Date • Antidepressant Treatment Follow-Up
• Referred To Provider Indicator
– ID • Current Encounter Service Recipient
– Role Type Unmanaged Psychosocial Stress
– Expertise Screening Indicator
• Referred To Encounter Occurred Indicator
• Observation History Allergy Type
• Current Encounter Medication(s)
• Current Encounter Lab Test
– Prescribed
– Code
– Dose
– Date Ordered
– Frequency
– Value
– Strength
– Performed Date
– Repeat
• Observation History Lab Test
• Observation History Medication(s)
– Code
– Prescribed
– Performed Date
– Dose
– Value
– Frequency
– Strength
90 CIHI 2009
References
1. C. Sanmartin et al., Access to Health Care Services in Canada 2001 (Ottawa, Ont.:
Statistics Canada, 2001): catalogue number 82-575-XIE2002001.
2. Health Council of Canada, Health Care Renewal in Canada: Accelerating Change

(Toronto, Ont.: Health Council of Canada, 2005).
3. D. Watson et al., A Results-Based Logic Model for Primary Health Care: Laying an
Evidence-Based Foundation to Guide Performance Measurement (Vancouver, B.C.:
Centre for Health Services and Policy Research, 2004): p. 1.
4. Canadian Institute for Health Information, Pan-Canadian Primary Health Care Indicators,
Report 1, Volume 1 (Ottawa, Ont.: CIHI, 2006).
5. Canadian Institute for Health Information, Pan-Canadian Primary Health Care Indicators,
Report 1, Volume 2 (Ottawa, Ont.: CIHI, 2006).
6. C. Shoen et al., International Health Policy Survey of Primary Care Physicians

(New York, New York: The Commonwealth Fund, 2006).
CIHI 2009 91
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CIHI 2009 iii

About the Canadian Institute for

Canada’s federal, provincial and territorial governments created CIHI as an independent,

Taking Health Information Further

For more information, visit our website at www.cihi.ca.

CIHI 2009 vii

viii CIHI 2009

1. Background and Introduction

Several provinces have completed procurement processes to approve PHC-based EMR

2. Intent for Use

The CIHI PHC Indicators EMR Data Set:

Benefits of EMR Content Standards—

Benefits of EMR Content Standards—

Benefits of EMR Content Standards—

Benefits of EMR Content Standards—

Benefits of EMR Content Standards—

Phase 1: Planning and Information Needs Assessment

Phase 2: Requirements Definition and Gap Analysis

Phase 3: CIHI PHC Indicators EMR Data Set Refinement

Phase 4: CIHI PHC Indicators EMR Content Standards Dissemination

Phase 5: Uptake, Promotion and Pilot Testing

5. CIHI PHC Indicators EMR Data Set

Table 5 Supplementary PHC Data Elements for Analysis and Reporting

Table 6 CIHI PHC Indicators EMR Data Set

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

26 Encounter Encounter The date that the • Date, YYYYMMDD N/A

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

36 Observation/ Observation Indicates whether or • Character, Code, C (Y, N, 9 [unknown]) N/A

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

High-Level Reporting of PHC

CIHI PHC Reporting System Prototype

Communications and Outreach

Appendix A: Observation History and Current Encounter

Item Diagnosis/Health ICD-10-CA ICD-10-CA Code (Version 2007)

Item Diagnosis/Health ICD-10-CA ICD-10-CA Code (Version 2007)

Item Diagnosis/Health ICD-10-CA ICD-10-CA Code (Version 2007)

Appendix B: Family Health History Picklist