1 / 46

HL7’s Clinical Document Architecture

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

lam
Download Presentation

HL7’s Clinical Document Architecture

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. HL7’s Clinical Document Architecture Liora Alschuler HIMSS Dallas, Texas February, 2005

  2. 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

  3. Clinical Document Architecture: CDA • What is it? • How does it allow you to: • Do simple things simply • Invest in information (doing complex things carefully)

  4. 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,…)

  5. CDA: A Document Exchange Specification • This is a CDA • and this • and this • and this • and this • and this • and this

  6. 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

  7. CDA: XML • XML is Extensible Markup Language (www.w3c.org) • In XML, structure & format are conveyed by markup which is embedded into the information

  8. Sample CDA

  9. 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

  10. 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

  11. CDA Body: two types of markup • Human-readable “narrative block”, all that is required to reproduce the legal, clinical content • Optionalmachine-readable CDA Entries, which drive automated processes

  12. CDA Body: Human-readable • paragraph • list • table • caption • link • content • revise (delete/insert) • subscript/superscript • special characters (e.g., symbols, Greek letters) in Unicode • emphasis • line break • renderMultiMedia (non-XML graphics, video…) required

  13. CDA Body: Machine Processible • Clinical statement • Observation • Procedure • Organizer • Supply • Encounter • Substance Administration • Observation Media • Region Of Interest • Act Optional

  14. 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” =

  15. First: human readable

  16. Allergy to penicillin Observation: RIM-defined Prior dx: SNOMED Allergy to penicillin: SNOMED Hives Prior dx: SNOMED Hives: SNOMED Hives is a manifestation of a reaction to penicillin Relationship: RIM-defined Next: series of related statements

  17. Then: supply context Who is the subject? Target: RIM-defined Id: local

  18. CDA Body, Section, and Narrative Block CDA Header CDA Entries CDA RMIM How are these concepts, relationships defined? Extl Refs

  19. 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

  20. 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

  21. 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

  22. Low End Investment in CDA • Many forms of document creation technology • Voice (dictation, transcription) • eForm • EHR (CDA is output as “report”)

  23. 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)

  24. What you can do with simple CDA documents: the registry hub • 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 4. Retrieve “what imaging reports are available from the last episode?” 1. Create documents 2. Register 3. Discover

  25. A tip of the hat to…Aluetietojärjestelmä 40% of Finnish population covered including Helsinki

  26. 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

  27. A singledata REPRESENTATIONstandard facilitates multiple document PRESENTATIONstandards !

  28. Pathologist view: CAP/ACoS standards compliant, template-driven data entry

  29. Repository view: HL7-CDA standard XML with XQuery-ready, context-linked SNOMED encodings

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

  31. South Hospital Tumor registrar view: Irrelevant items filtered, stage computed automatically

  32. One CDA, many applications: pathology Display or print (referring physician’s view Source CDA (pathologist, author’s view) Archival CDA XML Tumor Board, synopsis, meets CAP reporting guidelines

  33. 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

  34. Electronic Medical Record The Challenge: Integrate Patient Care and Clinical Research Data Patient Care World Clinical Research World The Void

  35. 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

  36. CDA in Starbrite Trial Manual creation and re-entry of CRF HIS validation  lab, ADT, meds, source documents db LIS display manual entry to CRF re-key CRF  CLINIC CRO Current processes (dual source) HIS  lab, ADT, meds, source documents LIS display dictate chart note  Redundant creation of chart note

  37. CDA in Starbrite Trial Merged workflow: electronic CRF re-used in chart note HIS validation  lab, ADT, meds, source documents CDA/ ODM LIS db display eCRF Proposed processes (single source)  dictate chart note CLINIC ARO

  38. One CDA, many applications: clinical trials Clinic note inserted into patient chart See demo here, Microsoft pod! Source CDA (principal investigator, author’s view) Archival CDA XML Case report form submission to research database

  39. Investing in Information • Disecting the curve • What is easy: • Header • Human-readable body • Low degree of coding • What is hard: • Concensus on semantic content requirements • Model/vocabulary interface cost x 80/20 √ benefit

  40. 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)

  41. 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.

  42. 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

  43. 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

  44. 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

  45. Thank you! Questions?

More Related