Direct Use Cases

Direct messaging can be utilized in many different use cases, however the most typical use cases involve sending transitions of care and referrals electronically.

In these use cases a CCDA XML document is exchanged, as is the required format under ONC's certification program for EHRs.

To render the CCDA XML as a human readable document (so that it can be read it more easily), there are a number of publicly available XML stylesheets that can be used to do this. First examine the file references or URLs that are typically at the very top of the XML file to see if they are absent or pointing to an unreachable URL, either of which may cause problems. Something like <?xml-stylesheet type="text/xsl" href="../stylesheet/CDA.xsl"?> should appear near the top of the XML file when you right-click on it (if viewing in a browser) and select "view source" or "view page source". If no stylesheet is referenced at all, your browser will default to showing the raw XML data.

You may need to find a suitable stylesheet for the XML, if one is not provided by the sender, and assist with modifying the XML in an appropriate file location, in order to view it rendered successfully. phiMail Web is able to leverage a stylesheet we host if the stylesheet reference is listed as href="CDA.xsl", a commonly used path. When XDM Zip files are received by phiMail Web, in addition to the usual link for attachment access an XDM viewing link is also added; invoking this option automatically unzips and displays XML from within the zip file right in phiMail Web.

Another thing to try is using a different browser to display the message (either IE or Chrome). phiMail Web displays exactly what was sent and if no stylesheet is available, phiMail Web does not add one.

If you are trying to parse the CCDA XML data elements for use by your system, the following documentation may assist you in understanding the XML format used by certified EHR systems to send clinical data; this list is taken directly from ONC's certification requirements:

170.205(a)(4)Standard. HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm), Draft Standard for Trial Use, Volume 1 - Introductory Material, Release 2.1 and HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm), Draft Standard for Trial Use, Volume 2 - Templates and Supporting Material, Release 2.1 (incorporated by reference in § 170.299).

HL7 publishes associated schema documents.

ONC also publishes a companion guide that may be helpful to review: https://www.healthit.gov/test-method/transitions-care

A suitable stylesheet for the XML may need to be located, if one is not provided by the sender. Using a self-selected style sheet also means modifying the XML in an appropriate file location within a secure environment, in order to view the XML rendered successfully.

If your use case involves sending large messages or adding patient metadata that is not inside a CCDA document, please contact us for additional information about phiMail Web Plus or Direct Messaging with Context Metadata.

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