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A CDA Template for Continuity of Care
Liora Alschuler, Roberto Ruggeri
HIMSS 2005Acapulco partners: Charlie McCay, Ted Blizzard
About us Liora Alschuler
alschuler.spinosa, consultants Co-chair HL7 Structured Documents TC Co-editor, CDA member, 2005, HL7 Board of Directors [email protected]
Roberto Ruggeri Senior Healthcare Strategist Microsoft Member of the ASTM CCR Technical group and TAG Member of the HL7 Structured Documents Committee [email protected]
Ted Blizzard Vice President of Information Technology for the Massachusetts Medical Society and New
England Journal of Medicine Member of the ASTM CCR Steering group and TAG Member of the HL7 Structured Documents Committee email:[email protected]
Charlie McCay Ramsey Systems, UK [email protected]
Also participating: Dr. Tom Sullivan, Massachusetts Medical Society; Bill Braithwaite, HL7
Thanks to Bob Dolin for help in coding clinical statements
A CDA Template for Continuity of Care
What is CCR? What is CDA? Relationship of CCR to CDA CDA to CCR mapping CCR as CDA Conclusions Next Steps
Continuity of Care Record What is it? Core data set of the most relevant and timely
facts about a patient’s healthcare. Organized and transportable. Prepared by a practitioner at the conclusion of
a healthcare encounter. To enable the next practitioner to readily
access such information. May be prepared, displayed, and transmitted on
paper or electronically.
History of the CCR Originally the MA Patient Care Referral Form (PCRF)
Consortium of sponsoring organizations ASTM International Massachusetts Medical Society HIMSS American Academy of Family Physicians American Academy of Pediatrics American Medical Association Patient Safety Institute American Health Care Association National Association for the Support of LTC Additional sponsoring organizations pending
Featured at HIMSS, TEPR, and … HL7 ASTM MOU (CDA/CCR)
Sponsors represent:
ANSI-recognized standards development organization
Over 400,000 practitioners Over 13,000 IT professionals Over 12,000 institutions in the long-term care
community that provide care to over 1.5 million elderly and disabled
Patients, patient advocates, data sources, corporations, provider institutions….
The effort is positioned to be Patient-focused
Not about what the system says to do but about what patient information is most relevant
Provider-focusedPractitioners determine what information is
most relevant Content-focused
Emphasis is on what providers need to know to deliver good patient care
Why So Much Interest in the CCR? It is intended to be simple to implement, use and explain It is not a top-down approach
End-users, i.e., practitioners have participated in its design The originator determines the relevant content
It has support and leadership from organizations representing end-users, who are Involving, advising, and assisting their constituents in its adoption
It allows options for implementation Paper or electronic
It has potential to reduce inefficiencies and costs Practitioners won’t have to search for relevant information Fewer repeat lab tests and other evaluations
The CCR Is Not… An EHR
It is not a complete electronic health record of a patient’s lifelong health status and healthcare
It is not universally accessible It does not have a universal patient identifier
A progress note, discharge summary, or consultation It is not limited to information from a single encounter It is not free-text based
A loose dataset of health information It is a defined set of core data in specified XML code
An HL7 Version 3 specification for any clinical document.
A clinical document ... has the following characteristics: Persistence Stewardship Potential for authentication Context Wholeness Human readability
What is CDA?
CDA is defined by the RIM CDA RMIM is a constraint on the RIM
Classes “cloned” (replicated, renamed, constrained with vocabulary, datatypes)
What is CDA?
What is CDA? CDA interoperable with
EHR, V3 messaging clinical content through “clinical statement”
What is CDA?
CDA complimentary to medical records messages and orders
Message is the envelope CDA is the payload/contents/“letter”
CDA is persistent (WORM drive heuristic) Cannot be relied on for distribution & routing beyond
static contents of CDA header
CDA is a snapshot in time, under signature Is not, itself, a birth-to-death, aggregate record
Areas of overlap Can include contents of single referral Both use XML for document exchange
Areas of divergence Generality:
CDA is generic to all clinical documents CCR is specific to continuity, US realm
XML CCR XML handcrafted CDA XML derived from RIM using V3 principles
Persistence CDA persistent CCR contains transmission-specific information
Aggregation CDA a single unit, can be part of an aggregate record CCR can be single unit or can be the aggregate record
Conclusions Significant areas of overlap, although aspects of scope, approach differ HL7 sees continuity of care records as just another document type
CCR CDA
CDA– CCR Mapping
Mapping project fall, 2003 Included CDA, CCR, New Zealand Health Event
Summary, Australian Health Connect, requirements & participation from Germany, Japan
Roughly equivalent metadata
General vs. specific content
<Plan>
<Section><Section
code=Plan>
.xml
..xsd
.mif
..xsd
.mif
.xml
.xml
xslt
Plan
prose
rsMIFeditor
V3xsdGen
Template creation & validation: model-based (Acapulco flavor)
Create derived MIF
Template creation & validation: model-based (Acapulco flavor)
Advantages Exchange & validate
referral requirements Exchange & validate
at highest level of interoperability
Can constrain authoring
Disadvantages Tooling immature Still limited by xsd
Template Creation & validation (Dallas flavor) Objectives:
CDA CCR creation and validation in simple authoring environment with simple rule set
Method: Use prototype instance (CDA CCR) “Unwind” to authoring style XML (nonCDA CCR) Develop authoring environment in MS Word XML with
tagging, schema validation, styles and CCR rule validation
“Rewind” to normative CDA CCR (.xml)
Sample document:TemplatesSampleReferral.mms.doc
Provided by Tom Sullivan, MD, Mass. Med. Society; co-chair ASTM E31-28
What to “template”?• Sections• Sub-sections• Selected observations
Create table of CDA & template markupDocument type code: LOINC 34140-4
• Coding limited to template objectives
• Used “CCRlocal” where term equivalent not found
XML encode sample using generic CDA, CCRCDA.xml
• Hand-crafted,
• Narrative block complete
• Coding limited to template table
“Unwind” to authoring-style XML (nonCDA CCR) [unwind.xslt]
MS Word XML authoring
Validation in MS Word XML
Save as CDA XML
<Plan><Section
code=Plan>
.xml
.mif
.xml
Plan
prose
rsMIFeditor
Dallas flavor validation:
.xsd+xpath
XPath validation of document type requirements
Transform to generic CDA
Valids against generic schema
Conclusions: concept Concept: viable Must extend model to RIM-compliant expression of
full requirements
CCR documents
CCR referral documents
CCR GP referrals CCR pediatric referrals
CCR geriatric referrals
Reference Information Model
CDA + MRM RMIM
CCR Medical records CCR Orders
CCR EHR, Patient Care
Referrals DMIM
<Section><Section
code=Plan>
.xml
.mif
.mif
.xml
Plan
prose
rsMIFeditor
V3xsdGen
Next step for V3 tooling: 2-stage validation
.xsd+xpath
..xsd• Refine and extend V3 tooling and methodology
• MIF editor, schema editor to manage constraint of vocabulary, datatypes• Prototype two-stage (xsd+rules) derived from constrained model • Look at RelaxNG for single-step validation
Next Steps for CCR as CDADefine full scope of CCR information model
and explore its relationship to the RIM and derivative specifications (documents, messages, EHR)
Explore relationship to international referral requirements, methodology
Next Steps for CDADefine general method for specifying all types of clinical
documents: anesthesiology, imaging, pathology, history & physical, etc.
Do it!
Thank you!
Questions?