Testing a New CDA Development Strategy in a Standardized Infrastructure for Continuity of Care in

Chronic Kidney Disease Patients Alberto Moreno, Alicia Martínez, Francisco Núñez, Carlos Parra

IHIC Conference

28th September 2012

Research partly funded by the Instituto de Salud Carlos III within RETICS Innovation in

Healthcare Technology call (code RD09/0077/00025), Corporación Tecnológica de Andalucia

and REDSA S.A.

Haemodialysis Scenario

Hospital provides care for more than 500 Patients diagnosed with CKD

When the patients are stable they are transferred to 8 outsourced external HD centres

Although the hospital is responsible of the patient and also pays the patient treatment the evaluation of the patients once they are transferred is not exhaustive enough

The communication was previously paper based

Referral

Prescription

Lab results

External HD

Private Center

Haemodialysis Scenario

Patients transferred back to the hospital

The information is urgently required when:

• Their health condition become unstable

• When an organ is available for patients that are included in the transplant list

?

External HD

Private Center

Project Objectives

As research project we aim to develop and test new interoperability approaches in a real scenario.

Develop a platform for our Nephrology department able to provide the means for continuity of care in CKD patients.

Requirements

– Integrated with the regional architecture of the Andalusian Health Service

– Interoperable with external nephrology

systems based on defined specifications.

Integration with regional infrastructure

Nephrology platform is integrated with the Andalusian Public Health Regional SOA infrastructure through the following services:

• UDB. User Data Base. This is a central patient management system that includes their demographic data.

• OCAM. Operator Centralised Access Module. This system manages professional roles and passwords in order to allow other applications set different access levels.

• CCD. Centralised Clinical Data. This system is a registry that contains identifiers and pointers to clinical reports and general information about the patients (encounters, allergies, problems and treatments, etc.).

Interoperability with External Private Centres

Definition of specifications based on IHE profiles for coordinating document and patient management tasks within the different systems in an Affinity Domain.

- Cross-Enterprise Clinical Documents Share Profile (XDS.b)

- Patient Identifier Cross-referencing for MPI Profile (PIX)

.

Interoperability with External Private Centres

External HD

Private Center

External HD

Private Center External HD

Private Center

Health IT

Provider

External HD

Private Center

External HD

Private Center

Business

Model A

Business Model B

ESB

LIS

Nephrology Platform

OCAM

UDB

CCD

Services from

the regional

infrastructure

Documents shared with HD centers

• Referral CDA a patient summary and patient evolution through previous HD sessions.

• Prescription CDA. In this document the nephrology professionals specify the patient treatment plan including number of dialysis sessions, dialysis settings and medication list. This document guides nurses in preparation tasks of the sessions.

• Session CDA. This document contains the patient evolution through the session including vital sign evolution, weight, dialysis catheter, others accesses. Nurses must record patient vital sign every hour.

• Lab Results NP receives all the lab results from the Laboratory Information System (LIS) as HL7 v2.5 messages. Once the patient is transferred to an external private HD centre, NP sends notifications of all previous Lab Results from this patient to the system of the external HD centre which could request these documents at any time based on XDS profile.

Referral CDA

Prescription CDA

Sessions CDA

Lab results (HL7v2)

External HD

Private Center

CDA development

CDA Archetype (Template

in ADL format)

XML instance CDA instance

Legacy data schema (XSD)

XQuery Engine

LinkEHR Tool

Export Mappings

(XQuery format)

LinkEHR tool that is able to map information from any XML format to the most

common EHR standards such as CDA, HL7v2 and ISO13606. This tool

defines these mapping relationships as a XQuery file and this can be executed

by any XQuery engine.

Source Target

Interoperability with External Private Centres

External HD

Private Center

External HD

Private Center External HD

Private Center

Health IT

Provider

External HD

Private Center

External HD

Private Center

Business

Model A

Business Model B

ESB

LIS

Nephrology Platform

Xquery Engine

OCAM

UDB

CCD

Services from

the regional

infrastructure

Validated with Lantana CDA Validator

With the large amount of information required by

the clinicians, we tried to maximise the reusability

of the CDA structures

Generic CDA archetypes defined the constrains

and semantics required in the CDA model for a

local organisation or IT infrastructure specific

system

CDA development

Generic Header

CDA development

Generic Observation

CDA development

Generic SubstanceAdministration

CDA development Generic Organiser

CDA development

Secondly we defined specialised archetypes, which are conformant to the resultant

CDA and include the clinical concepts specified by our nephrology department.

Specialised Observation Specialised Header

CDA development

CDA Document CDAHeader Substance Administration

Organiser Observation

Referral 1 1 0 16

Prescription 1 1 29 121

Session 1 1 75 389

Successfully defined highly complex CDA structures and that are able to be

created from legacy data

Conclusions

• The platform piloted by the nephrology

department and the 8 external HD private

centres through an IT Health provider.

• Perform a cost-effectivity study about the

impact that this new infrastructure has on

clinical practice.

• The defined specifications have successfully

opened a market for different health and

technical providers.

Conclusions

• Promising results of using CDA templates,

provides better management and audit of the

semantic structures, aligned with CIMI

• These archetypes are expected to be the

source for a new implementation guide for

CDA in the nephrology domain which has

just started within the HL7 Spain

Technical Committee.

Thank you for your kind attention alberto.moreno.exts@juntadeandalucia.es