1. HL7 CDA and its broad adoption
Joint ITU-WHO Workshop on e-Health Standards and Interoperability (Geneva, Switzerland, April 2012)
HL7 CDA and its broad adoption
Catherine Chronaki
Affiliate Director, HL7 International Board of Directors
Geneva, Switzerland, April 2012

2. What is CDA?
CDA is a document markup standard for the structure and semantics of an exchanged "clinical document".
CDA embodies business critical characteristics
Persistence
Stewardship
Potential for authentication
Context
Wholeness
Human readability
A CDA document can
exist outside of a message
include text, images, sounds, multimedia content.
The CDA is a document markup standard for the structure and semantics of an exchanged "clinical document".
A clinical document is a documentation of observations and other services with the following characteristics:
Persistence
Stewardship
Potential for authentication
Context
Wholeness
Human readability
A CDA document is a defined and complete information object that can exist outside of a message, and can include text, images, sounds, and other multimedia content

3. Major Components of a CDA Document
<ClinicalDocument>
...
<structuredBody>
<section>
<text>...</text>
<observation>...</observation>
<substanceAdministration>
<supply>...</supply>
</substanceAdministration>
<observation>
<externalObservation>
</externalObservation>
</observation>
</section>
<section>...</section>
</structuredBody>
</ClinicalDocument> D O C U M E N T B O D Y
Header S E C T I O N
Narrative Block E N T R I S
External
References

4. What are CDA Characteristics?
Richly expressive and flexible
Encoded in Extensible Markup Language (XML).
Based upon HL7's Reference Information Model (RIM)
Enables data reuse
Patient summaries
Lab and pharmacy messages
Clinical research
Electronic prescriptions
Clinical Decision Support
Public Health
Quality assessment
Constrained by Templates, conformance profiles, implementation guides to be fit for purpose
Discuss the consensus that has gone in to the RIM

5. Standard EHR Interface
Local EHR
National /xborder Requirements
Clinical reuse
Decision support
Secondary use
Quality reporting
CDA
Template
Library
CDA
Implementation Guide

6. What is the Key Value of CDA?
Incremental Interoperability means that an implementer can begin with a simple CDA, and then add structured data elements over time.
CDA R2 consists of a single CDA XML Schema, and the “architecture” arises from the ability to apply one or more “templates” which serve to constrain the richness and flexibility of CDA.
Professional society recommendations, national clinical practice guidelines, standardized data sets can be expressed as CDA templates.
Trifolia workbench library freely available to HL7 members: numerous types of reusable templates that might be created in CDA.

7. Templated CDA
Many different kinds of documents
A bucket of reusable templates

8. Trifolia Workbench : CDA Template Library
greenCDA
XML
There are many kinds of templates that might be created. Particularly relevant for documents are:
Document-level templates constrain the CDA header and allowable sections
Section-level templates constrain the allowable entries
Entry-level templates, define the atomic clinical statements within document sections
CDA
Template
Library
Data Entry Form
CDA Instance Validation
CDA
Implementation Guide
Runtime API
Support for standards development
Support for standards implementation

9. Green CDA The problem The solution We call this strategy: greenCDA
An instance conforming to an CDA Implementation Guide may require knowledge multiple specifications
CDA R2 base specification;
HL7 Version 3 data types
CDA templates defined in the IG;
CDA templates referenced by IG;
Terminology code lists defined/referenced by IG;
Validation of an instance conforming to a CDA IG may require additional validation
W3C Schema validation;
Schematron validation;
Create “authoring schema” to simplify IG creation/ processing:
Clinically meaningful XML element and attribute names;
100% transformable into conformant CDA IG;
Hiding complexities of HL7 v3
GreenCDA schema modular and easily reproducible
We call this strategy: greenCDA
greenCDA schemas are modular, corresponding to CDA templates.
Geneva, Switzerland, April 2012

10. CDA Interoperability Roadmap
Get the data flowing, get the data flowing, get the data flowing.
Incrementally add structure, where valuable to do so.
Quality Reporting
Narrative
Text
HL7 CDA Structured Documents
Coded Discrete Data Elements
Decision Support
Meaningful Use!
Clinical Applications
SNOMED CT
Disease, DF-00000
Metabolic Disease, D
Disorder of glucose metabolism, D
Diabetes Mellitus, DB-61000
Type 1, DB-61010
Insulin dependant type IA, DB-61020
Neonatal, DB75110
Carpenter Syndrome, DB-02324
Disorder of carbohydrate metabolism, D

11. Why CDA is so widely adopted?
Numerous implementations worldwide
Japan, Korea, France, Europe (epSOS,..), US, Canada, ..
CDA hits the “sweet spot”
CDA expresses clinical documents. A single standard for the entire EHR is too broad. Multiple standards and/or messages for each EHR function may be difficult to implement. CDA is “just right”.
Implementation experience – green CDA
CDA has been a normative standard since 2000, and has been balloted through HL7's consensus process. CDA is widely implemented.
Gentle on-ramp to information exchange
CDA is straight-forward to implement, and provides a mechanism for incremental semantic interoperability.
Improved patient care
CDA provides a mechanism for inserting evidence-based medicine into the process of care (via templates)
CDA crosses institutional borders/Lower costs
CDA’s top down strategy let’s you implement once, and reuse many times for new scenarios.
CDA hits the “sweet spot”
CDA expresses clinical documents. A single standard for the entire EHR is too broad. Multiple standards and/or messages for each EHR function may be difficult to implement. CDA is “just right”.
Implementation experience
CDA has been a normative standard since 2000, and has been balloted through HL7's consensus process. CDA is widely implemented.
Gentle on-ramp to information exchange
CDA is straight-forward to implement, and provides a mechanism for incremental semantic interoperability.
Improved patient care
CDA provides a mechanism for inserting evidence-based medicine into the process of care (via templates)
CDA crosses institutional borders
Lower costs
CDA’s top down strategy let’s you implement once, and reuse many times for new scenarios.

12. Extra slides
Geneva, Switzerland, April 2012

13. Conclusions and Recommendations
Templated CDA
Future of CDA
Provides reusable building blocks
Streamlines efforts: Implement once, deploy often.
Promotes modularity and reusability across Igs
Offers “incremental interoperability” is core to CDA’s strategy : Begin with simple CDA, and add templates as they are prioritized.
CDA Version 3
Rapid adoption of template libraries
Template/ schema tooling
Vocabulary binding
International resources
ISO Standardization
Lessons from CDA adoption
Intuitive/ low entry
Free Trifolia library
Collaboration
Mobile health comes next with Green CDA
Geneva, Switzerland, April 2012

14. Continuity of Care Document
Clinical history
Advance Directives
Support
Functional Status
Problems
Family History
Social History
Allergies
Medications
Medical Equipment
Immunizations
Vital Signs
Results
Procedures
Encounters
Plan of Care

15. CDA Guiding Principles
Prioritizes documents generated by clinicians involved in direct patient care.
Minimizes the technical barriers needed for implementation
Promotes longevity of all information
Enables exchange that is independent of the underlying transfer or storage mechanism.
Assures that policy-makers can control their own information requirements without relying upon extensions

16. HIT Standards, Terminologies, and Profiles: a Strong Collaboration Drive
Standards Development Organizations
HL7 International, ISO/TC 215 Health Informatics, IHTSDO CEN/TC 251 Health Informatics, CDISC, GS1, others
Terminologies
Regenstrief (LOINC)
EDQM
WHO (ICD)
Integration Profiles
Integrating the Healthcare Enterprise (Content profiles)
Continua Health Alliance (personal health devices
Give input and receive direction to enhance the eHealth standardization process.

17. CDA Template Development*
TODAY
A thousand flowers
bloom
Active
Harmonization
Gradual increase in templates
demanded by new use cases
* After the Gartner Curve

18. Templated CDA Many different kinds of documents
A library of reusable templates
Medications
Payer
Social History
Demographics
Allergies
Vital Signs
Chief Complaint
Discharge Diagnosis
Problems
A CDA document using CCD templates
A CDA document
using CCD templates plus others
Mode of Transport
New Section…
Family History
Surgical Finding
Discharge Diet
CDA
CCD

19. The Business Case for CDA
CDA is highly flexible and configurable – CDA support every type of clinical document. A single standard for the entire EHR may be too broad. Multiple standards and/or messages for each EHR function may be difficult to implement. CDA satisfies all such needs.
CDA Implementation experience is vast - CDA has been a Normative Standard since , and has been balloted through HL7's consensus process. CDA is widely implemented.
CDA provides a gentle on-ramp to information exchange - CDA is straight-forward to implement, and provides a mechanism for incremental semantic interoperability.
CDA improves patient care - CDA provides a mechanism for inserting evidence-based medicine directly into the process of care (via templates)
CDA lowers costs – Leveraging CDA provides “top down” strategy allowing initial implementation to be reused many times for highly varying scenarios.

20. Requirements for Achieving Quality
Policy Alignment
Relevant Standards
Economic Incentives
Industry Collaboration
Public Health Support
Research Validation
Trust

21. If you want to go fast, go alone. If you want to go far, go together.
Collaboration
If you want to go fast, go alone.
If you want to go far, go together.
- African Proverb

22. Quality Reporting Framework

23. Leveraging Open Source Quality Measures
popHealth: An open-source quality measure
eMeasure
QRDA Category II/III Reports
PQRI XML Registry Specification
QRDA Category I Instances

24. Quality Assessment using CDA Templates

25. Translating a Use Case to CDA

26. Understanding Templated CDA
constrain / consistency
community library
multiple contributors
small, able to be assembled, able to use multiple in a document
output in an interoperable format
vetted by SMEs
minimal disruption in clinical workflow

27. Highly Configurable CDA Templates

28.
New name to communicate Patient Focus and avoid S.O.S distress signal

29. Content for Patient Summary ‘Minimum dataset’
Information/dataset
Contains
Patient Identification
Unique identification for the patient in that country.
Patient Personal information
Full name.
Date of birth
Gender
Allergies
Allergy description and agent
Medical Alerts
Other alerts not included in allergies
List of current problems
Problems/diagnosis that need treatment and/or follow up by a Health Professional
Medication Summary
Current medications
Country
Name of Country of origin of the patient (country A)
Date of Creation
This is the detailed content of the PS dataset.
Data on which PS was generated
Date of last update
Data on which PS was updated
Author organization
At least an author organization (HCPO) shall be listed. In case there is not HCPO identified at least a HCP shall be listed.
J. Thorp 2011

30. Example: Need for information in France
Maria Schmidt, a 25 year old Austrian student shows up at the Emergency department at CHU Dijon (Hospital in Dijon). The chief complaint is abdominal pain occurring 3 to 4 hours after a meal
An abdominal x-rays show signs of intestinal occlusion. The overall clinical presentation is inconclusive, with a diffuse abdominal pain and not needing surgical intervention
The physician considers keeping the patient under observation only, or performing an exploratory laparotomy
Hospital in Dijon
(CHU Dijon) ?
J. Thorp 2011

31. Request to the French NCP
As the physican knows that epSOS can provide more information, she searches for the patient.
The search is directed towards the French National Contact Point (NCP), which in turn will provide the location of the student’s Patient Summary
French NCP
Request for information
CHU de Dijon
J. Thorp 2011

32. Request from NCP France to NCP Austria
The French NCP issues a request for information to the Austrian NCP.
French NCP
Austrian NCP
Request for information
J. Thorp 2011

33. Austrian Patient Summary – 1
The Austrian Patient Summary of the patient is located
The document is syntactically transformed into the epSOS format, according to the specifications
original
xml - epSOS CDA
Transformation
National Connector and National Transformer
J. Thorp 2011

34. Austrian Patient Summary – 2
The original document is transformed into an epSOS document
The original document is also transformed into a pdf file
The pdf has the same header as the epSOS document (in order to provide the link and the traceability between the two documents)
epSOS CDA
original pdf with the same CDA header
CDA+ pdf
National Connector and National Transformer
J. Thorp 2011

35. Information from Austrian NCP to French NCP
The Austrian NCP sends two documents to the French NCP:
the transformed document (in epSOS format)
the original document in a document (pdf) format
Austrian NCP
French NCP
Information returned
J. Thorp 2011

36. Results available for the French physician
The French physician receives the original document as pdf in German as well as the transformed document in the epSOS format.
Information returned
French NCP
original pdf with the same CDA header
epSOS CDA
CHU de Dijon
J. Thorp 2011

37. Austrian Patient summary is understandable by the French physician
J. Thorp 2011

38. CDA: Towards Standard EHR Interface
Quality Measure
EHR system
Decision Support
CDA
Template
Library
Comparative
Effectiveness
Clinical Research
Public
Health