Presentation on theme: "HL7 CDA and its broad adoption"— Presentation transcript:
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 adoptionCatherine ChronakiAffiliate Director, HL7 International Board of DirectorsGeneva, 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 characteristicsPersistenceStewardshipPotential for authenticationContextWholenessHuman readabilityA CDA document canexist outside of a messageinclude 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:PersistenceStewardshipPotential for authenticationContextWholenessHuman readabilityA 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>DOCUMENTBODYHeaderSECTIONNarrative BlockENTRISExternalReferences
4 What are CDA Characteristics? Richly expressive and flexibleEncoded in Extensible Markup Language (XML).Based upon HL7's Reference Information Model (RIM)Enables data reusePatient summariesLab and pharmacy messagesClinical researchElectronic prescriptionsClinical Decision SupportPublic HealthQuality assessmentConstrained by Templates, conformance profiles, implementation guides to be fit for purposeDiscuss the consensus that has gone in to the RIM
5 Standard EHR Interface Local EHRNational /xborder RequirementsClinical reuseDecision supportSecondary useQuality reportingCDATemplateLibraryCDAImplementation 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 CDAMany different kinds of documentsA bucket of reusable templates
8 Trifolia Workbench : CDA Template Library greenCDAXMLThere are many kinds of templates that might be created. Particularly relevant for documents are:Document-level templates constrain the CDA header and allowable sectionsSection-level templates constrain the allowable entriesEntry-level templates, define the atomic clinical statements within document sectionsCDATemplateLibraryData Entry FormCDA Instance ValidationCDAImplementation GuideRuntime APISupport for standards developmentSupport 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 specificationsCDA R2 base specification;HL7 Version 3 data typesCDA 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 validationW3C 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 v3GreenCDA schema modular and easily reproducibleWe call this strategy: greenCDAgreenCDA 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 ReportingNarrativeTextHL7 CDA Structured DocumentsCoded Discrete Data ElementsDecision SupportMeaningful Use!Clinical ApplicationsSNOMED CTDisease, DF-00000Metabolic Disease, DDisorder of glucose metabolism, DDiabetes Mellitus, DB-61000Type 1, DB-61010Insulin dependant type IA, DB-61020Neonatal, DB75110Carpenter Syndrome, DB-02324Disorder of carbohydrate metabolism, D
11 Why CDA is so widely adopted? Numerous implementations worldwideJapan, 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 CDACDA 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 exchangeCDA is straight-forward to implement, and provides a mechanism for incremental semantic interoperability.Improved patient careCDA provides a mechanism for inserting evidence-based medicine into the process of care (via templates)CDA crosses institutional borders/Lower costsCDA’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 experienceCDA 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 exchangeCDA is straight-forward to implement, and provides a mechanism for incremental semantic interoperability.Improved patient careCDA provides a mechanism for inserting evidence-based medicine into the process of care (via templates)CDA crosses institutional bordersLower costsCDA’s top down strategy let’s you implement once, and reuse many times for new scenarios.
13 Conclusions and Recommendations Templated CDAFuture of CDAProvides reusable building blocksStreamlines efforts: Implement once, deploy often.Promotes modularity and reusability across IgsOffers “incremental interoperability” is core to CDA’s strategy : Begin with simple CDA, and add templates as they are prioritized.CDA Version 3Rapid adoption of template librariesTemplate/ schema toolingVocabulary bindingInternational resourcesISO StandardizationLessons from CDA adoptionIntuitive/ low entryFree Trifolia libraryCollaborationMobile health comes next with Green CDAGeneva, Switzerland, April 2012
14 Continuity of Care Document Clinical historyAdvance DirectivesSupportFunctional StatusProblemsFamily HistorySocial HistoryAllergiesMedicationsMedical EquipmentImmunizationsVital SignsResultsProceduresEncountersPlan of Care
15 CDA Guiding Principles Prioritizes documents generated by clinicians involved in direct patient care.Minimizes the technical barriers needed for implementationPromotes longevity of all informationEnables 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 OrganizationsHL7 International, ISO/TC 215 Health Informatics, IHTSDO CEN/TC 251 Health Informatics, CDISC, GS1, othersTerminologiesRegenstrief (LOINC)EDQMWHO (ICD)Integration ProfilesIntegrating the Healthcare Enterprise (Content profiles)Continua Health Alliance (personal health devicesGive input and receive direction to enhance the eHealth standardization process.
17 CDA Template Development* TODAYA thousand flowersbloomActiveHarmonizationGradual increase in templatesdemanded by new use cases* After the Gartner Curve
18 Templated CDA Many different kinds of documents A library of reusable templatesMedicationsPayerSocial HistoryDemographicsAllergiesVital SignsChief ComplaintDischarge DiagnosisProblemsA CDA document using CCD templatesA CDA documentusing CCD templates plus othersMode of TransportNew Section…Family HistorySurgical FindingDischarge DietCDACCD
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 AlignmentRelevant StandardsEconomic IncentivesIndustry CollaborationPublic Health SupportResearch ValidationTrust
21 If you want to go fast, go alone. If you want to go far, go together. CollaborationIf you want to go fast, go alone.If you want to go far, go together.- African Proverb
26 Understanding Templated CDA constrain / consistencycommunity librarymultiple contributorssmall, able to be assembled, able to use multiple in a documentoutput in an interoperable formatvetted by SMEsminimal disruption in clinical workflow
28 New name to communicate Patient Focus and avoid S.O.S distress signal
29 Content for Patient Summary ‘Minimum dataset’ Information/datasetContainsPatient IdentificationUnique identification for the patient in that country.Patient Personal informationFull name.Date of birthGenderAllergiesAllergy description and agentMedical AlertsOther alerts not included in allergiesList of current problemsProblems/diagnosis that need treatment and/or follow up by a Health ProfessionalMedication SummaryCurrent medicationsCountryName of Country of origin of the patient (country A)Date of CreationThis is the detailed content of the PS dataset.Data on which PS was generatedDate of last updateData on which PS was updatedAuthor organizationAt 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 mealAn abdominal x-rays show signs of intestinal occlusion. The overall clinical presentation is inconclusive, with a diffuse abdominal pain and not needing surgical interventionThe physician considers keeping the patient under observation only, or performing an exploratory laparotomyHospital 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 SummaryFrench NCPRequest for informationCHU de DijonJ. Thorp 2011
32 Request from NCP France to NCP Austria The French NCP issues a request for information to the Austrian NCP.French NCPAustrian NCPRequest for informationJ. Thorp 2011
33 Austrian Patient Summary – 1 The Austrian Patient Summary of the patient is locatedThe document is syntactically transformed into the epSOS format, according to the specificationsoriginalxml - epSOS CDATransformationNational Connector and National TransformerJ. Thorp 2011
34 Austrian Patient Summary – 2 The original document is transformed into an epSOS documentThe original document is also transformed into a pdf fileThe pdf has the same header as the epSOS document (in order to provide the link and the traceability between the two documents)epSOS CDAoriginal pdf with the same CDA headerCDA+ pdfNational Connector and National TransformerJ. 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) formatAustrian NCPFrench NCPInformation returnedJ. 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 returnedFrench NCPoriginal pdf with the same CDA headerepSOS CDACHU de DijonJ. Thorp 2011
37 Austrian Patient summary is understandable by the French physician J. Thorp 2011
38 CDA: Towards Standard EHR Interface Quality MeasureEHR systemDecision SupportCDATemplateLibraryComparativeEffectivenessClinical ResearchPublicHealth