CDA the Primacy of Information

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CDA the Primacy of Information Powered By Docstoc
					 HL7’s Clinical Document
 Architecture


           Liora Alschuler
                HIMSS
Dallas, Texas         February, 2005
About me
 Liora Alschuler
      alschuler.spinosa, consultants
      Co-chair HL7 Structured Documents TC
      Co-editor, CDA
      Member, 2005, HL7 Board of Directors
      Project manager for Operation Jumpstart, (initial
       design of CDA)
      past Chair, XML SIG
      liora@the-word-electric.com

 Also contributing: Bob Dolin, MD, Kaiser-Permanente;
  John Madden, MD, Duke University Medical Center
Clinical Document Architecture: CDA


 What is it?
 How does it allow you to:
     Do simple things simply
     Invest in information (doing complex things
      carefully)
What is CDA?
 ANSI/HL7 CDA r1-2000 (Release one)
    On CD, includes prose spec, RMIM, DTDs
 December 2004 ballot (Release two)
    Structured Documents Tech Cmte, zip file on
     HL7.org – PASSED, will be published shortly
 A specification for document exchange using
    XML,
    the HL7 Reference Information Model (RIM)
    Version 3 methodology
    and vocabulary (SNOMED, ICD, local,…)
CDA: A Document Exchange Specification

 This is a CDA
 and this
 and this
 and this
 and this
 and this
 and this
CDA: A Document Exchange Specification

 A CDA can be a
     Discharge Summary
     Referral (CCR is one such)
     Progress Note
     H&P
     Public health report
 … any content that carries a signature
CDA: XML


 XML is Extensible Markup Language
  (www.w3c.org)
 In XML, structure & format are conveyed by
  markup which is embedded into the
  information
Sample CDA
CDA = header + body
 CDA Header
    Metadata required for document discovery,
     management, retrieval
 CDA Body
    Clinical report
          Discharge Summary
          Referral
          Progress Note
          H&P
          Public health report
     … any content that carries a signature
CDA Header

 The header describes:
     The document itself (unique ID, document
      type classification, version)
     Participants (providers, authors, patients…)
     Document relationships (to orders, other
      documents…)
 Metadata sufficient for document
  management
CDA Body: two types of markup
 Human-readable “narrative block”, all that
  is required to reproduce the legal, clinical
  content
 Optional machine-readable CDA Entries,
  which drive automated processes
CDA Body: Human-readable
    paragraph
    list
    table
    caption
    link                                                 required
    content
    revise (delete/insert)
    subscript/superscript
    special characters (e.g., symbols, Greek letters) in
     Unicode
    emphasis
    line break
    renderMultiMedia (non-XML graphics, video…)
CDA Body: Machine Processible
    Clinical statement
         Observation
         Procedure
         Organizer
         Supply
         Encounter
         Substance Administration
         Observation Media
         Region Of Interest
         Act
                                     Optional
CDA Body: Why isn’t XML + SNOMED enough?




                   “hives”: SNOMED CT 247472004

                   “Dr. Dolin asserts that Henry Levin
                   manifests hives as a previously-diagnosed
                    allergic reaction to penicillin”
First: human readable
                  Allergy to penicillin

Next: series of   Observation:      RIM-defined
                           Prior dx: SNOMED

related           Hives
                           Allergy to penicillin: SNOMED


statements                 Prior dx: SNOMED
                           Hives: SNOMED
                  Hives is a manifestation of a reaction
                  to penicillin
                  Relationship:    RIM-defined
Then: supply context



                Who is the subject?
                Target:         RIM-defined
                Id:             local
How are these concepts, relationships
CDA RMIM
defined?




                 CDA Body,                       Extl
 CDA Header                        CDA Entries
                 Section, and                    Refs
                 Narrative Block
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
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
Low End Applications for CDA
 Persistant, accessible, human-readable
  documents
 Document requirements:
     CDA header
     Release One or Two body
          Narrative block
          Non-semantic markup (HTML-like)
 Document options:
    More complex markup can be inserted, to be
     used or ignored
Low End Investment in CDA
 Many forms of document creation technology
     Voice (dictation, transcription)
     eForm
     EHR (CDA is output as “report”)
        What is the simplest way to create a
        CDA document?

     Enter
     minimal
     metadata




                                                      Point to document body



See HL7.org NLM Project: freely available application (by 3/1)
 What you can do with simple CDA
 documents: the registry hub
                                                              4. Retrieve




                                           “what imaging
                                           reports are available
                                           from the last
1. Create documents     2. Register        episode?”         3. Discover

  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
A tip of the hat to…
Aluetietojärjestelmä
 40% of Finnish population covered including Helsinki
Investing in Information
 Simple documents
     retrieval, display
     metadata registry
 Two examples of higher-level investment:
     HIMSS 2004, Dr. John Madden, Duke
      University Medical Center, created a CDA
      pathology note that doubles as a tumor board
      report
     Also at Duke, the Starbrite “Single Source”
      Proof of Concept for clinical trials
        A single
data REPRESENTATION
         standard
   facilitates multiple
document PRESENTATION
       standards !
 Pathologist view:
CAP/ACoS standards
compliant, template-
  driven data entry
      Repository view:
HL7-CDA standard XML with
XQuery-ready, context-linked
    SNOMED encodings
South Hospital




            Clinician view:
         Traditional format,
       print/electronic delivery
        South Hospital




 Tumor registrar view:
Irrelevant items filtered,
     stage computed
      automatically
One CDA, many applications:
pathology

                 Display or print
                 (referring physician’s
                 view


Source CDA
                                   Archival CDA
(pathologist,                      XML
author’s view)

                 Tumor Board,
                 synopsis, meets
                 CAP reporting
                 guidelines
Investing in Information
 “Single Source”
     Create once
     Use many
     Reuse clinical data in clinical trials
 Duke Clinical Research Institute
     Proof of Concept
     Principals:
          Landen Bain, Rebecca Kush, Liora Alschuler
          Microsoft, primary technology partner
    The Challenge: Integrate Patient Care
    and Clinical Research Data

Patient Care World                 Clinical Research World



              Electronic
            Medical Record




                             The Void
Single Source vs Previous Solutions
 eSource & electronic data capture
     redundant with creation of clinic note
     require information reside in EMR/EHR
     proprietary data formats
 CDA & CDISC in “single-source”
     capture trial data, merge it into clinic note
      (re-use)
     work with current technology, workflow
     open, non-proprietary data formats
CDA in Starbrite Trial
                       Manual creation and re-entry of CRF

                 HIS
                                                              validation



                          
     lab, ADT,
                                                                           db
     meds,       LIS
     source
                          display    manual               re-key CRF
     documents
                                     entry to
                                    CRF

                                    CLINIC           CRO

                                                               Current
                 HIS
                                                               processes
                                                               (dual
     lab, ADT,
     meds,
     source
     documents
                 LIS
                         
                         display    dictate
                                                               source)

                                    chart note
                 

                       Redundant creation of chart note
CDA in Starbrite Trial

                    Merged workflow: electronic CRF
                    re-used in chart note
             HIS                    validation


 lab, ADT,
                   
                                        CDA/
             LIS                                 db
 meds,                                  ODM
 source            display   eCRF
 documents                                             Proposed
                                                      processes
                             dictate
                                                       (single
                             chart note                source)

                             CLINIC              ARO
One CDA, many applications: clinical
trials

                 Clinic note inserted
                 into patient chart             See demo here,
                                                Microsoft pod!


Source CDA
                                 Archival CDA
(principal                       XML
investigator,
author’s view)
                 Case report form
                 submission to
                 research database
Investing in Information
                           Disecting the curve
                           What is easy:
                              Header
                              Human-readable body
cost
                              Low degree of coding
                           What is hard:
                              Concensus on semantic
                               content requirements
        80/20
                              Model/vocabulary
                               interface
                     √
                benefit
Investing in Information
 Example of what is hard
     TermInfo 2004 conference
          NASA August 1-4, 2004, Houston, TX
          Notes posted to the summit’s web page:
           http://csd2.no-ip.net/Composition/ and
           www.terminfo.org
          New project within HL7
     Looked at issues raised by David Markwell
      (and previously identified by others)
Investing in information: what is hard?

 Issue 1: Code/value dichotomy
     abdominal tenderness is observed
          examination (code) / abdomen tender (value);
           abdominal examination / abdomen tender;
          abdominal palpitation / abdomen tender;
          abdominal tenderness / present, etc.
Investing in information: what is hard?

 Strong collaborative effort established to
  address issues
 Most syntatic issues addressed, full
  concentration on semantic interoperability
 Issues will be resolved, but will take time
  and experience
  Investing in Information: phased
  approach
 Lay groundwork
    CDA header metadata
    XML R1 or R2 CDA body

 Build
    Concensus on requirements
    Understanding of modeling process
    Vocabulary glossary

 Understand
    Relationship of vocabulary to model

 Introduce interoperable semantic content as
  requirements and business drivers dictate
CDA: doing simple things simply, &
more complex things slowly
 What can be done now
   Basic (Level One) CDA (R1 or R2) can be created with
    any degree of technical sophistication
      Document scanner+web form

      Transcription

      Electronic health record

 What can be done later
   Increase coding sophistication as business
    requirements dictate (return on investment and
    regulation)
 http://www.intersystems.com/mt_washington_vision.pdf
Thank you!
Questions?

				
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