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Geneva, Switzerland, 26-27 April 2012 HL7 CDA and its broad adoption Catherine Chronaki Affiliate Director, HL7 International Board of Directors

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Presentation on theme: "Geneva, Switzerland, 26-27 April 2012 HL7 CDA and its broad adoption Catherine Chronaki Affiliate Director, HL7 International Board of Directors"— Presentation transcript:

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

3 DOCUMENTDOCUMENT BODYBODY Header SECTIONSSECTIONS Narrative Block ENTRIESENTRIES External References Major Components of a CDA Document

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

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

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 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 Implementation Guide CDA Implementation Guide CDA Instance Validation Data Entry Form greenCDA XMLgreenCDA Runtime API Support for standards development Support for standards implementation CDA Template Library CDA Template Library

9 Green CDA The problem 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; The solution 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 20129

10 CDA Interoperability Roadmap Narrative Text HL7 CDA Structured Documents Coded Discrete Data Elements SNOMED CT Disease, DF Metabolic Disease, D Disorder of glucose metabolism, D Diabetes Mellitus, DB Type 1, DB Insulin dependant type IA, DB Neonatal, DB75110 Carpenter Syndrome, DB Disorder of carbohydrate metabolism, D Quality Reporting 1. Get the data flowing, get the data flowing, get the data flowing. 2. Incrementally add structure, where valuable to do so.

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.

12 Extra slides Geneva, Switzerland, April

13 Conclusions and Recommendations Templated 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. Future of CDA 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

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

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

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

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 2000, 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 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 QRDA Category I Instances PQRI XML Registry Specification QRDA Category II/III Reports eMeasure

24 Quality Assessment using CDA Templates

25 Translating a Use Case to CDA

26 Understanding Templated CDA

27 Highly Configurable CDA Templates

28

29 Information/datasetContains Patient IdentificationUnique identification for the patient in that country. Patient Personal informationFull name. Date of birth Gender AllergiesAllergy description and agent Medical AlertsOther alerts not included in allergies List of current problemsProblems/diagnosis that need treatment and/or follow up by a Health Professional Medication SummaryCurrent medications Date of CreationData on which PS was generated Date of last updateData on which PS was updated Author organizationAt least an author organization (HCPO) shall be listed. In case there is not HCPO identified at least a HCP shall be listed. Content for Patient Summary ‘Minimum dataset’ Country Name of Country of origin of the patient (country A) J. Thorp 2011

30 Example: Need for information in France Austrian 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 CHU de Dijon Request for information French NCP J. Thorp 2011

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

33 Austrian Patient Summary – 1 1.The Austrian Patient Summary of the patient is located 2.The document is syntactically transformed into the epSOS format, according to the specifications National Connector and National Transformer Transformation original xml - epSOS CDA J. Thorp 2011

34 Austrian Patient Summary – 2 National Connector and National Transformer epSOS CDA original pdf with the same CDA header 1.The original document is transformed into an epSOS document 2.The original document is also transformed into a pdf file 3.The pdf has the same header as the epSOS document (in order to provide the link and the traceability between the two documents) CDA+ pdf 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) pdf the original document in a document (pdf) format French NCP Austrian 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. CHU de Dijon French NCP Information returned epSOS CDA original pdf with the same CDA header J. Thorp 2011

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

38 CDA: Towards Standard EHR Interface Quality Measure Decision Support PublicHealthPublicHealth Clinical Research ComparativeEffectivenessComparativeEffectiveness CDATemplateLibraryCDATemplateLibrary EHR system


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