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