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Development, implementation, and initial evaluation of a foundational open interoperability standard for oncology treatment planning and summarization.

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Presentation on theme: "Development, implementation, and initial evaluation of a foundational open interoperability standard for oncology treatment planning and summarization."— Presentation transcript:

1 Development, implementation, and initial evaluation of a foundational open interoperability standard for oncology treatment planning and summarization Jeremy L. Warner, Suzanne E. Maddux, Kevin S. Hughes, John C. Krauss, Peter Paul Yu, Lawrence N. Shulman, Deborah K. Mayer, Mike Hogarth, Mark Shafarman, Allison Stover Fiscalini, Laura Esserman, Liora Alschuler, George Augustine Koromia, Zabrina Gonzaga, Edward P. Ambinder

2 Consider this Realistic Situation
A postmenopausal, diabetic woman has been diagnosed with early-stage invasive breast cancer She will require surgery, adjuvant (postoperative) chemotherapy, radiation treatment, and hormonal therapy She has an established relationship with a local primary care physician (PCP) and an endocrinologist She lives 150 km from a National Accreditation Program for Breast Centers (NAPBC) Center of Excellence The nearest infusion center for chemo is 50 km away None of her providers share an interoperable electronic health record (EHR)

3 A Tangled Web Patient Caregivers PCP Visiting Nurse Nursing Home
Surg Onc Med Onc PCP Nursing Home Rad Onc Visiting Nurse Without standards, communication pathways may be haphazard, incomplete, and nonsynchronous.

4 2013 Oncology Standards Summit

5 2013 Oncology Standards Summit

6 2013 Oncology Standards Summit

7 Initial Project Vision
2013 Oncology Standards Summit

8 2013 Oncology Standards Summit

9 ASCO’s Approach to HL7 Working with Lantana Consulting to develop HL7 CDA templates for ASCO’s Breast Cancer Adjuvant TPS Develop oncology-specific CDA templates CDA templates are re-usable, incremental, and extensible. C-CDA is referenced in MU Stage 2. Harmonize and re-use existing oncology profiles NCI templates CDC Implementation Guide for Healthcare Reporting to Central Cancer Registries Adapted from 2013 Oncology Standards Summit

10 Templated CDA . . . . Many different kinds of documents
A selection of reusable templates Medications Payer Social History Demographics Allergies Vital Signs Chief Complaint Discharge Diagnosis Problems CDA document using CCD templates CDA document using CCD templates plus others Mode of Transport New Section… Family History Surgical Finding Discharge Diet CDA CCD © CDA Academy, 2012

11 Consolidated CDA R1 (Cited in MU2)
CDA templates for common document types: Continuity of Care Document (CCD) plus Consultation Note Diagnostic Imaging Report Discharge Summary H & P Operative Note Procedure Note Progress Note Unstructured Document Benefits More comprehensive patient information than the CCD Continuity of care is improved © CDA Academy, 2012

12 Deconvoluting Patient PCP Med Onc Visiting Nurse Surg Onc Rad Onc
Secondary needs Surg Onc Med Onc PCP Nursing Home Rad Onc Visiting Nurse Standards enable reliable, complete, and replicable communication—with or without a central source of truth, such as a health information exchange

13 Hurricane Katrina, 2005 © Associated Press Public domain  ”…tens of thousands of records have been lost.” - Economist

14 Chemotherapy Treatment Plan and Summary Templates
Goal: to enable continuity of care even with the loss of medical records e.g. Katrina Paper-based documents used during the cancer work-up and treatment planning phase, treatment, and as a summary after completion of treatment Breast, Colon, Lung (SCLC/NSCLC), Lymphoma Curable breast cancer is a common but fairly complex scenario, selected for CDA DSTU1



17 80+ data elements Numeric (e.g. medical record number; OncotypeDX recurrence score) Dated (e.g. patient date of birth) Encodeable to an HL7-recognized terminology (e.g. Breast TNM node category  SNOMED-CT, US Realm) Encoded to an HL7 RIM Class (e.g. Practice site  Entity Class) Narrative representation

18 Warner et al. JAMIA 2015


20 eCOTPS New Template Example

21 First Implementation of eCOTPS: Health Story Project
2014 Oncology Standards Summit


23 2014 Oncology Standards Summit




27 Second Implementation of eCOTPS: Project INSPIRE
INSPIRE: INteroperability to Support Practice Improvement, Disease REgistries, and Care Coordination GOAL: Improve acquisition and exchange of patient data in high impact conditions in order to support longitudinal disease registries, care coordination, and practice improvement Adapted from 2014 Oncology Standards Summit

28 Athena-INSPIRE: Today and the Future
EHR 1 Our Goal (Future): ASCO/HL7 eCOTPS CAP eCC XML EHR 2 EHR ASCO/HL7 eCOTPS State Central Cancer Registry ASCO/HL7 eCOTPS Dynamic Form for Data Capture (XML-driven and questionnaire like with skip/branch, etc…. Rendered *within* EHR) ASCO/HL7 eCOTPS Health Information Home Today: Prototype Health Information Home (HIH) Cloud Web-app ASCO/HL7 eCOTPS HTML window rendering external web app Visual Force Web App EpicCare Epic Desktop Client Adapted from 2014 Oncology Standards Summit

29 The eCOTPS Mapping Project
Task: Map Athena checklist data elements using eCOTPS Challenges: Athena checklist elements are much more comprehensive than those specified in the eCOTPS and meant to be entered in real-time to facilitate care coordination Athena checklist data are often at a finer level of detail than is specified in the eCOTPS specification Use cases for the Health Information Home (HIH) also specify a finer level of detail Requires adding appropriate templates to the eCOTPS, and deciding on their location in the eCOTPS structures Adapted from 2014 Oncology Standards Summit

30 The Mapping Project: Issues I
Discovering the proper codes to represent the Athena concepts: using SNOMED, LOINC, PhinVads, and other terminology browsers Requires working with terminology standards organizations to create new codes, and/or using codes from several organizations not mentioned in the eCOTPS specification Often requires creating combinations of codes (and structures) to create a better mapping (using the CTS2 strategies for mapping codes to HL7 V3 structures) Creating, adapting and using the CDA templates required by the Athena use of the eCOTPS specification. Adapted from 2014 Oncology Standards Summit

31 The Mapping Project: Issues II
The eCOTPS needs to be sent multiple times to the HIH as a patient proceeds through their “cancer journey.” This means that additional administrative details (id’s, signatures, etc.) must be added to the eCOTPS. The current stage of the project deals primarily with the machine-readable, structured aspects of the eCOTPS. Human-readable representation details left for a second stage. Adapted from 2014 Oncology Standards Summit

32 Summary eCOTPS is the first oncology-specific CDA standard to achieve HL7 DSTU status Lessons learned during design and implementation have led to improvements in the draft standard eCOTPS is now in DSTU R2, with addition of Colon Cancer Adjuvant Treatment Plan & Summary template definitions Future roadmap includes adding other disease sites, survivorship, patient-reported outcomes, and balloting for normative status

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