Embed Size (px)
Citation preview
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Clinical Document Architecture
CDA::CCRand the Continuity of Care
Record
Clinical Document Architecture
CDA::CCRand the Continuity of Care
Record
MRI ConferenceAugust 2004, Boston
Liora Alschuler
2
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
• Liora Alschuler– alschuler.spinosa, consultants– Co-chair, HL7 Structured Documents
TC– Co-chair, HL7 Marketing Committee– Co-editor, CDA– Single Source, principal– Manager, 2004 HL7 HIMSS Technical
Demo– [email protected]
3
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Outline
• Introduction to the CDA– What is the CDA & What Does It Do?– Key Design Decisions– Implementing CDA
• CDA and CCR• Current & future
4
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
• Clinical Document Architecture
• ANSI/HL7 CDA R1.0-2000
• first certified XML spec for healthcare
• first balloted portion of HL7’s “V3”
• first RIM-based specification
• created & maintained by HL7 Structured Documents Technical Committee (SDTC)
CDA
5
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Short history of CDA• Jan. 1997: 1st meeting as HL7 SGML SIG• July 1997: Operation Jumpstart at Kona Mansion• Jan. 1998: Kona Editorial Group (KEG)• Sept. 1998: Presentation of (renamed & RIM-
based) Patient Record Architecture (PRA)• Jan. 2000: First committee level ballot passes• May 2000: Second committee level ballot
passes• Sept. 2000: Membership ballot passes
unanimously• Nov. 2000: ANSI/HL7 CDA R1.0-2000• July 2003: First committee ballot CDA Release 2• August 2004: Third committee ballot now open
6
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
rClinical Document
Architecture3M Health Information SystemsAkron General Medical CenterCare Data SystemsCareScience, Inc.Danica Biomedical ABElectronic Data Systems CorporationEpic Systems CorporationFigler ConsultingHealth Network VenturesHealtheon/WebMD CorporationHL7 AustraliaHL7 CanadaHL7 GermanyHL7 JapanHL7 United KingdomIDX Systems CorporationIntermountain Health CareKaiser PermanenteLabtest.com, Inc.Lanier Worldwide, Inc.LifeGard TechnologiesLos Alamos National LaboratoryMagnolia TechnologiesMayo Foundation
McKessonHBOCMedic Computer Systems, LLC Medical Center of Boston Intl Medical Informatics Project, UCSFMedical Manager Research & Development, Inc.MedicaLogic, Inc.Netfish Technologies, Inc.Oacis Healthcare Systems, Inc.Oracle CorporationPartners HealthCare System, Inc.PBM Micro, Inc.Per-Se Technologies, Inc.Pitt County Mem. Hospital /University SystemsQuadraMed CorporationQueensland HealthSaint Vincent Hospital and Health Centerscheduling.comShafarman ConsultingShared Medical Systems (SMS)St. Alphonsus Regional Medical CenterSUNY Stony BrookSutter Healththe BREENsThe Word ElectricU.S. Department of Veterans AffairsUniversity of California Arthur ASHE StudentUniversity of Chicago Hospitals & Health SystemsWashoe Medical Center
Release 1.0: 3 ballots; 108 votes; all negatives reconciled; unanimous final ballot
7
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
The HL7 Clinical Document Architecture
• priority is patient care, other applications facilitated
• minimize technical barriers to implementation
• promote longevity of clinical records• scoped by exchange, independent of
transfer or storage• enable policy-makers to control
information requirements
8
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
• The scope of the CDA is the standardization of clinical documents for exchange.
CDA: scope
9
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA: A Document Exchange Specification
• This is a CDA• and this• and this• and this• and this• and this• and this
10
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA: A Document Exchange Specification
• A CDA can be a– Discharge Summary– Referral– Progress Note– H&P– Public health report
• … any content that carries a signature
11
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Clinical Document Architecture on One Leg
• (Relatively) simple XML specification for exchange of clinical documents
• The rest is commentary
12
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Sample CDA: Ballot R1 2000
13
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Sample CDA: HIMSS 2004
14
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Why ?• Lack of usable and re-usable
electronic data: Numbers moving slowly upward, if at all
• Need to get information to the point of care, as-needed, when needed
• Need to leverage investment in information through re-use for decision support, claims, clinical trials…
15
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Applications of the CDA…or
What can you dowith a few tags?
• access/portability/exchange– query/locate by patient, provider, practioner,
setting, encounter, date– access distributed information through
common metadata
• integration– multiple transcription systems– with EHR records
• re-use/derivative data– summaries, reports– decision support
16
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
rThe CDA document
defined
(material in blue is quoted from theClinical Document Architecture Release 1.0)
(material in blue is quoted from theClinical Document Architecture Release 1.0)
CDA Release 2 (draft), section 2.1:
A clinical document ... has the following characteristics: Persistence Stewardship Potential for authentication Context Wholeness Human readability
“Context - Contents of a clinical document share a common context unless all or part of that context is overridden or nullified.”
17
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Other Key Aspects of CDA
• CDA documents are encoded in XML• CDA documents derive their meaning
from the HL7 Reference Information Model (RIM) and use the HL7 Version 3 data types
• The CDA specification is generic to all clinical content
• CDA documents can be constrained to meet the requirements of specific document types
18
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
• CDA documents are “human readable” =– This principle means that CDA documents
are human readable using: a) widely-available and commonly deployed
XML-aware browsers and print drivers and b) a generic CDA style sheet written in a
standard style sheet language.
• CDA documents are also “machine processable” to the degree that markup has been added– required markup provides initial
functionality– optional markup can augment processing
CDA::Readability
19
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
XML-encoded info <Section>
<code code="10123-x" codeSystem="LOINC">Allergies and Adverse Reactions</code>
<text>
<list>
<item><content>Penicillin - Hives</content></item> </list>
</text>
<component>
<Observation>
<code code="G-1001" codeSystem="SNOMED" displayName="Prior dx"/> <value xsi:type="CD" code="DF-10074" codeSystem="SNOMED"
displayName="Allergy to penicillin"/>
<pertinentInformation typeCode="MFST">
<Observation>
<code code="G-1001" codeSystem="SNOMED" displayName="Prior dx"/>
<value xsi:type="CD" code="D0-00165"
codeSystem="SNOMED" displayName="Hives"/>
</Observation>
CDA Release 2.0: Draft
human readable
machine processible
20
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
The CDA Document
• A CDA document is comprisedof a header, referred to as the “CDA Header",and a body referredto as the“CDA Level One Body".
Header
Body
21
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
The CDA Header: Purpose
• The CDA Header is constant across all CDA documents. Its purpose is to:– Enable clinical document exchange
across and within institutions– Facilitate clinical document management– Facilitate compilation of an individual
patient’s clinical documents into a lifetime electronic patient record(“uniquely identify a single patient”)
22
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA Level One Body
• The body consists of either nested containers (sections, paragraphs, lists, tables) or a non-XML blob
23
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA "structures"
CDA "entries"
A section can contain "structures", nested section's, and codes. CDA structures contain "entries".
24
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA: How to Create• creating CDA documents
– eForms– transcription– EHR– knowledge base– dynamic query– HL7 message conversion (V2 & V3)– DICOM Structured Report transform
25
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
• any way you like
CDA: How to Display
26
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
XML data is accessible
<section>Allergy List</section>
<para>…</para>
<para>…</para><section>Medications List</section>automated table of contents creation, linked to content, through style sheet transformations
27
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
• One document, many views• Many documents, one view
CDA: How to Display
28
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA::HIMSS demo 2004• Document creation:
– Epic– Microsoft InfoPath (2)– Dictaphone– Adobe– Microsoft BizTalk Server– GE
• Management/display: – NIST ebXML registry/repository (open source): model for NHII– Siemens– MS BizTalk, Sharepoint– Raining Data– Kryptiq– Digital Infuzion– CommerceNet– Simi
• Document types:– Clinical documentation: surgical note, imaging report, discharge summary– Claims attachments (HIPAA)– Continuity of Care/Referral (Massachusetts Medical Society)– Public health reporting (CA Dept of PH Botulism Case Report)– Tumor registry report (College of American Pathologists)– Structured Product Label (SPL)
29
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
• Continuity of Care scenario– Developed by physicians at Massachusetts
Medical Society, Duke University Medical Center, Northwestern (Chicago)
– Document types:• MMS/ASTM Continuity of Care (CCR) implemented
as a R2 CDA• R1 from dictation with voice recognition and NLP• R2 Pathology report• R2 Discharge Summary• R2 Imaging report transformed from DICOM SR
CDA::HIMSS demo 2004
30
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
One CDA, many applications: pathology
Source CDA
(pathologist, author’s view)
Display or print (referring physician’s view
Archival CDA XML
Tumor Board, synopsis, meets CAP reporting guidelines
31
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Relationship to HL7 messages
• CDA complements HL7 messaging specs
• A CDA document is a defined and complete information object that can exist outside of a messaging context
• A CDA document can be a MIME-encoded payload within an HL7 message
32
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
HL7 V3
<service_cd> <service_txt T="ED">
</service_txt></service_cd>
HL7 V2.x
MSH|...EVN|...PID|...PV1|...TXA|...OBX|1|ED|...
|...
CDA documents are encapsulated as MIME packages within HL7 messages
CDA
CDA
Relationship to HL7 messages
33
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
HL7’s Development FrameworkReference Information Model RMIM
Hierarchical Description<xs:element name="ClinicalDocument" type="CDA_MT000017.ClinicalDocument" />
- <xs:group name="CDA_MT000017">- <xs:sequence>
<xs:element name="ClinicalDocument" type="CDA_MT000017.ClinicalDocument" />
XML Schema
• subset of RIM• tighten constraints
• linearization• additional constraints
• algorithm
34
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Code Display Name Definition ADMPHYS admitting physician A physician who admitted a patient to a hospital or other care unit that is the context of this
service. ANEST anesthesist In a typical anesthesia setting an anesthesiologist or anesthesia resident in charge of the
anesthesia and life support, but only a witness to the surgical procedure itself. To clarify responsibilities anesthesia should always be represented as a separate service related to the surgery.
ANRS anesthesia nurse In a typical anesthesia setting the nurse principally assisting the anesthesiologist during the critical periods.
ATTPHYS attending physician A physician who is primarily responsible for a patient during the hospitalization, which is the context of the service.
DISPHYS discharging physician A physician who discharged a patient from a hospital or other care unit that is the context of this service.
FASST first assistant surgeon In a typical surgery setting the assistant facing the primary surgeon. The first assistant performs parts of the operation and assists in others (e.g., incision, approach, electrocoutering, ligatures, sutures.)
MDWF midwife A person (usually female) helping a woman deliver a baby. Responsibilities vary locally, ranging from a mere optional assistant to a full required participant, responsible for (normal) births and pre- and post-natal care for both mother and baby.
NASST nurse assistant In a typical surgery setting the non-sterile nurse handles material supply from the stock, forwards specimen to pathology, and helps with other non-sterile tasks (e.g., phone calls, etc.)
PCP primary care physician The healthcare provider that holds primary responsibility for the overall care of a patient. PRISURG primary surgeon In a typical surgery setting the primary performing surgeon. RNDPHYS rounding physician A physician who made rounds on a patient in a hospital or other care center. SASST second assistant surgeon In a typical surgery setting the assistant who primarily holds the hooks. SNRS scrub nurse In a typical surgery setting the nurse in charge of the instrumentation. TASST third assistant In a typical surgery setting there is rarely a third assistant (e.g., in some Hip operations the third
assistant postures the affected leg.)
Table 17. Vocabulary domain for <function_cd> (CWE) Table 17. Vocabulary domain for <function_cd> (CWE)
35
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Low End Applications for CDA
• Persistant, accessible, human-readable documents
• Requirements:– CDA header– Release One or Two body
• Narrative block• Non-semantic markup (HTML-like)
• Options:– More complex markup can be inserted, to
be used or ignored
36
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
What you can do with simple CDA documents: the registry
hub
“what imaging reports are available from the last episode?”1. Create documents 2. Register 3. Discover
4. Retrieve
• Ubiquitous access to distributed information– By class of document, patient, provider, encounter (CDA
header metadata)– Documents remain under local control– Document creation technology evolves under local control– Registry (hub) for access control, identifier xRef
37
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Investing in Information
• CDA XML can be simple• CDA XML can be complex• Simple encoding relatively inexpensive• Complex encoding costs more• You get what you pay for:
– like charging a battery, – the more detailed the encoding – the greater the potential for reuse
38
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA: Return on Investment
– Low end: Access to documents• “please send referral letter to…”• “please get me the discharge summary…”• “what imaging reports are available from the
last episode?”
– High end: Reuse• Send synopsis to tumor board• Attach to claim for automated adjudication of
payment• Extract data for clinical research
39
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Investing in Information
cost
benefit
√
80/20?
40
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Why do we need a CDA?A document specification that hits the 80/20 sweet spot:
Jim Klein, Gartner Group, on HL7’s CDA, April, 2001 RU:
“HL7's Clinical Document Architecture (CDA) defines a new target for clinical information exchange that is substantially easier to hit than one based on standards for discrete data while delivering 80 percent of the value of the latter approach.”
41
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
So, how does this relate to the CCR?
• History:– Meetings initiated one year ago– Massachusetts Medical Society taking
lead in coordination effort– Series of joint meetings,
teleconferences– Combined with international effort on
referrals (show spreadsheet)– Proof of concept at HIMSS 2004
42
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
ASTM/HL7 MOU• “ASTM has just adopted a standard set
of core data elements for a Continuity of Care Record (CCR) and is in the process of developing an implementation guide for same, and HL7 has adopted a standard for Clinical Document Architecture (CDA) and a standard for the functionality of an Electronic Health Record (EHR) system. Since both SDOs want implementations based on these standards to be semantically interoperable, we agree to cooperate in the process of harmonizing the definitions of the data elements and the methods for representing instances of the data elements in XML….
43
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
HL7/ASTM MOU
• “…We agree that compatibility will be enhanced by using the HL7 Reference Information Model (RIM) as a common basis for such harmonization and that the CCR standard, the EHR standard(s), the CDA standard, and the RIM are all open to appropriate modifications (with appropriate ballot cycles for approve of same for each SDO) to enable such harmonization.”
44
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
…but wait, there’s more• Mapping of data elements is good• We will establish a canonical method of
implementing CCR as a template layered on top of CDA
• Benefits: – Interoperability with HL7 Reference Information
Model– Compatibility with HIPAA, NHII document standard– Compatible with international approach to
interoperability– EHR compatibility– Drive decision support, advanced processing
applications– Public health, clinic trials tie-ins– Automated validation of specific, local requirements
45
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
HL7 Templates
• Constraints on HL7 specifications• What is a “constraint”?
– <section> called “ROS” must contain <section> on “vital signs”
– <document> called “H&P” must contain <section> called “ROS”
• CDA schema says “documents have sections”
• CCR template says: “CDA CCR documents have ASTM-specified required sections”
46
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
HL7 Templates
• A template can constrain:– sections of a CDA document– set of laboratory observation result
codes– coding scheme for a coded element– data type subcomponent
47
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
HL7 Templates
• Who creates HL7 Templates?– domain experts– standards groups (e.g., ASTM)– regulatory agencies
• Where are templates used?– within CDA documents– within HL7 V3 messages
48
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA CCR compatibility
• Questions that need resolution:– Levels of machine processibility,
reuse, interoperability– Levels of generality, constraint,
validation
49
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
<Section>
<code code="10123-x" codeSystem="LOINC">Allergies and Adverse Reactions</code>
<text>
<list>
<item><content>Penicillin - Hives</content></item> </list>
</text>
<component>
<Observation>
<code code="G-1001" codeSystem="SNOMED" displayName="Prior dx"/> <value xsi:type="CD" code="DF-10074" codeSystem="SNOMED"
displayName="Allergy to penicillin"/>
<pertinentInformation typeCode="MFST">
<Observation>
<code code="G-1001" codeSystem="SNOMED" displayName="Prior dx"/>
<value xsi:type="CD" code="D0-00165"
codeSystem="SNOMED" displayName="Hives"/>
</Observation>
CDA Release 2.0: Draft
required: human readable
optional: machine processible
CDA::CCR processibility
CCR: clin
ical c
onte
nt a
ll
optio
nal
50
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
• CDA: single-styesheet rendering favors simple exchange for point of care review
• CDA CCR: will integrate required semantics for additional machine processing, reuse, RIM-based interoperability, retaining single-stylesheet rendering
CDA::CCR processibility
51
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA::CCR compatibility
• Existing levels of generality– CDA is generic to any document type– CCR is specific to referral-type
scenarios, but general to requirements of any single implementation
• Ideal: CCR-compliant CDA with template for automated validation of local requirements
52
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA::CCR compatibility
• CDA schema + ASTM CCR template– Valid according to ASTM
implementation guide• CDA schema + ASTM CCR template
+ local template– Machine validation of full local
requirements– Interoperable with full spectrum of HL7
version 3, RIM-compliant messages & documents
53
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CCR—more specific than CDA
• CDA: sections not specified
• CCR: Specifies sections, all optional
• CDA+CCR template: fine-level constraints with validation
54
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
“Dr. Dolin asserts that Henry Levin manifests hives as a previously-diagnosed allergic reaction to penicillin”
“hives”: SNOMED CT 247472004
What does all this buy you?
55
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
First: human readable
56
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Next: series of related
statements
Allergy to penicillin
Observation: RIM-defined
Prior dx: SNOMED Allergy to penicillin: SNOMED
HivesPrior dx: SNOMED Hives: SNOMED
Hives is a manifestation of a reaction to penicillinRelationship: RIM-defined
57
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Getting from the RIMto CDA . .
58
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
59
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
ExtlRefsCDA EntriesCDA Header CDA Body,
Section, andNarrative Block
CDA RMIMHow are these concepts,
relationships defined?
60
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA: Major Implementations• PICNIC (European Union)• SCIPHOX (Germany)• HYGEIAnet/WebOnColl (Greece)• NHS South Staffordshire (United Kingdom)• Aluetietojärjestelmä (Finland)• Health Information Summaries (New Zealand)• Referrals (Australia)• MERIT-9 (Japan) • e-Claims Supporting Document Architecture (Canada)• Mayo Clinic (USA)• Buenos Aires HMO project (Argentina)• Dalhousie U, QEII Health Sci Ctr (Canada)• Plus projects in Italy, Russia, Ireland, Mexico, …
61
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
SCIPHOX, GermanyK
ai Heitm
ann
62
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Seamless Care and CDA, FinlandAluetietojärjestelmä
40% of Finnish population covered including Helsinki
63
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
CDA in the USA
• CDA Implementation: USA– Mayo Clinic (50,000 notes/week)– Kaiser– Columbia Presbyterian– VA – Duke Clinical Research Institute (Single
Source Proof of Concept: integrating patient records and clinical trial case report forms )
• Proposed for HIPAA Claims Attachments• Cited by DHHS as document standard
for NHII
64
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Vendors• Transcription: Dictaphone, MedQuist,
MD Productivity, Cquence Medical, any• EMR: IDX (Mayo), Epic Systems (Kaiser),
Siemens (HIMSS)• New:
– VertiSoft's QuickDelivery for clinical documents
– ChartIndex (a project at Stanford U. School of Medicine)
• In development: many (Mmodal, Guidant, SierraSystems…)
• Non-healthcare-specific: Microsoft InfoPath, Adobe Acrobat, Arbortext, Software AG, Oracle (any XML)
• Not a comprehensive list
65
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Current Activities
• Release 2: 2nd ballot successful– Updated to current RIM (2.02)– addition of CDA entries– separation of human-readable &
machine processible components
• 3rd Committee-level ballot: open now!– CDA functionality driven by articulated
user requirements– And implementation experience
66
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
International Conference on the CDA• Berlin, Germany,
October 7-9, 2002• 80+ participants• 20 countries• 22 presentations
– tutorials– 10 case studies– original research– CEN/GEHR alignment
http//www.hl7.de/cda2002
/progoverz.html
67
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Coming soon….
2nd International Conference on the Clinical Document Architecture
Acapulco, MexicoOctober 20-22, 2004
Hosted by HL7 Mexico in conjunction with the HL7 International Affiliates, HL7 Canada, HL7 Germany and the Structured Documents TC
68
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Getting involved
• Join HL7 & vote on current ballot• Listservs
– SDTC & Templates, see www.hl7.org
• CDA teleconferences: weekly or bi-weekly
• HL7 meeting schedule, see www.hl7.org
69
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Current references• CDA Release 2 Committee Level Ballot 3:
hl7.org, Structured Documents Technical Committee web page
• Regulatory Initiatives in HL7 Using XML and Structured Documents: http://www.hl7.org/Library/Committees/structure/Alschuler_DIA2003.zip
• First International Conference on the CDA -- abstracts: http://www.hl7.org/Library/Committees/structure/abstracts%2Epdf
• CDA in Context: http://www.hl7.org/Library/Committees/structure/CDA%5Fin%5Fcontext%5Fwithpics%2Ezip
70
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Selected References• Dolin RH, Alschuler L, Beebe C, Biron PV, Boyer S, Essin D, Kimber E, Lincoln T, Mattison JE. The HL7 Clinical
Document Architecture. J Am Med Inform Assoc. 2001;8:552-569.• http://www.medcom.dk/picnic• http://www.sciphox.org/• http://www.hygeianet.gr/Application_Domains/WebOnColl/weboncoll.html• Chronaki CE, Lelis P, Demou C, Tsiknakis M, Orphanoudakis SC. An HL7/CDA Framework for the Design and
Deployment of Telemedicine Services. Proceedings of EMBC 2001, 23rd Annual International Conference of the IEEE Engineering in Medicine and Biology Society, 25-28 Oct. 2001, Istanbul, Turkey.
• www.southstaffs-erdip.co.uk/reports/technical/architecture/EHR%20Technical%20Architecture3%20dec%2001.htm
• www.southstaffs-erdip.co.uk/technical/cda/Clinical%20Document%20Architecture.htm• www.makropilotti.fi/english• Paterson GI, Shepherd M, Wang X, Watters C, Zitner D. Using the XML-based Clinical Document Architecture
for Exchange of Structured Discharge Summaries. Proceedings of the 35th Hawaii International Conference on System Sciences - 2002, 0-7695-1435-9/02. IEEE Computer Society. [Available: http://dlib2.computer.org/conferen/hicss/1435/pdf/14350119b.pdf]
• Paterson GI, Wang X, Shepherd M, Watters C, Zitner D. Electronic Exchange of Structured Interim Discharge Summaries Using the XML-based Clinical Document Architecture, e-Health 2001: The Future of Health Care Proceedings. 26-29 May 2001, Toronto, Ontario. COACH Conference. CD-ROM. [Available: http://www.medicine.dal.ca/dmedinfo/ehealth2001f.ppt]
• www.nhsia.nhs.uk/gp2gp
71
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
rThank you!any questions?
Thank you!any questions?
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Continuity of Carevirtual tour
HL7-IHE DemonstrationHIMSS 2004
73
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Presented by
• John Madden, MD, PhD, Duke University Medical Center, Department of Pathology
• Liora Alschuler, HL7
74
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Continuity of CarePatient scenario
• John is a 70-year old man with a 100-pack-year smoking history
• He recently developed persistent cough with blood-streaked sputum
• He visits Dr. Sullivan, his Primary Care Provider (PCP)
• Dr. Sullivan sends John to a nearby radiology practice for a chest x-ray
75
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
AdobeBerdyCarefxCommerceNetDCRIDictaphoneDigital InfuzionEclipsysEpicGEHeartlabIBMINFINITTKodakKryptiqMicrosoftMisysMortaraNISTPhilipsRaining DataSentillionSiemensSNOMEDXIMIS Outpatient encounter and chest xray
Scheduled workflow; report stored as CDA
PCP
Continuity of CareImaging Integration, Tumor Reporting, Claims Processing
Repository
RIS
ServerWorkstation
Registry
ImagingHL7
StandardsaECG ArdenCCOW
CDA ODMLDMRIM
SDMSPLV2V3
IHE ProfilesCT
EUAPIX
PSARID
SWFPCP sends order to
radiology office
Radiology information systemqueries scheduling server
Imaging modality queries schedulingserver for demographics
Imaging system uploads completedimage to server
Server relays copy of imageto repository.
Repository forwards document information to registry.
76
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Continuity of CarePatient scenario
• Chest x-ray shows a 3 cm right upper lobe mass
• Radiologists communicate result to Dr. Sullivan the same day
• She refers John to Dr. Blade, a chest surgeon at the South Hospital Medical Center
77
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Patient referred for surgeryEMR & eForms CCR sent through brokers to hospital, surgery
PCP
Continuity of CareImaging Integration, Tumor Reporting, Claims Processing
EMRBroker
Hospital
Repository
eForms
Surgery
RIS
Server
Imaging
Workstation
Registry
Server/WSEMR
EMR
AdobeBerdyCarefxCommerceNetDCRIDictaphoneDigital InfuzionEclipsysEpicGEHeartlabIBMINFINITTKodakKryptiqMicrosoftMisysMortaraNISTPhilipsRaining DataSentillionSiemensSNOMEDXIMIS
HL7 Standards
aECG ArdenCCOW
CDA ODMLDMRIM
SDMSPLV2V3
IHE ProfilesCT
EUAPIX
PSARID
SWF
PCP enters referral requestvia eForms application
Broker forwards referral to South
Med Center and torepository/registry
Hospital EMR distributes referral
request and schedules patient
visit
Clinic queries community
radiology server for availability
of x-rays
78
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Continuity of CarePatient scenario
• Dr. Blade performs wedge resection of RUL with node sampling
• Specimen is examined by pathology; the diagnosis is large cell carcinoma with negative nodes
• Pathology report is sent to Dr. Blade, hospital Tumor Registry
• A copy is sent to the PCP, Dr. Sullivan
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
A singleA singledata data
REPRESENTATIONREPRESENTATION standard standard
facilitates multiplefacilitates multiple document document
PRESENTATIONPRESENTATION standards !standards !
80
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Pathologist view:Pathologist view:CAP/ACoS standards CAP/ACoS standards compliant, template-compliant, template-
driven data entrydriven data entry
81
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
Repository view:Repository view:HL7-CDA standard XML HL7-CDA standard XML
with XQuery-ready, with XQuery-ready, context-linked SNOMED context-linked SNOMED
encodingsencodings
82
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
South Hospital
Clinician view:Clinician view:Traditional format, Traditional format,
print/electronic print/electronic deliverydelivery
83
c o
py r ig
ht 2
00
4 L
ior a
Als c h
ul e
r
South Hospital
Tumor registrar view:Tumor registrar view:Irrelevant items Irrelevant items filtered, stage filtered, stage
computed computed automaticallyautomatically
