1. Clinical Document Architecture: Care Record Summaries
Liora Alschuler
alschuler.spinosa
Co-chair, Structured Documents TC
Co-editor, CDA
HL7 Board of Directors
Liora Alschuler

2. Health Level Seven (HL7.org)
Standards Development Organization
Developing standards for interoperability
Patient care
Public health
Clinical trials
Reimbursement
HIPAA DSMO
20 years, 2000 members
26 international affiliates
“A model community”: building standards to a single information model

3. CDA Clinical Document Architecture ANSI/HL7 CDA R1.0-2000
CDA R2.0 to be published shortly
created & maintained by HL7 Structured Documents Technical Committee (SDTC)
A specification for document exchange using
XML,
the HL7 Reference Information Model (RIM)
Version 3 methodology
and vocabulary (SNOMED, ICD, local,…)

4. CDA: A Document Exchange Specification
This is a CDA
and this

5. CDA Release 2: Text + Observation
<Section>
<code code=" " codeSystem="LOINC“> Past Medical History </code>
<text>Patiënt met een voorgeschiedenis astma en hoge bloeddruk Nu opgenomen in het ziekenhuis met een osteoartritis, rechter knie
</text>
<component1>
<contextConductionInd value="TRUE"/>
<Observation classCode=“COND”>
<code code=”G-1001” codeSystem=”SNOMED” displayName=”Prior dx”/>
<value code=”D1-201A8” codeSystem=”SNOMED” displayName=”Osteoarthritis”>
<originalText><reference value=”#a3”/></originalText>
</value>
<targetSiteCode code=”T-15720” codeSystem=”SNOMED”
displayName=”knee”>
<qualifier>
<name code=”G-C220” codeSystem=”SNOMED”
displayName=”with laterality”/>
<value code=”G-A100” codeSystem=”SNOMED” displayName=”right”/>
</qualifier>
</targetSiteCode>
</Observation>
</component1>
</Section>

6. 日本HL7協会情報教育担当リーダー 東芝住電医療情報システムズ（株） 村上 英
CDA R2の概要と適用検討例
日本HL7協会情報教育担当リーダー
東芝住電医療情報システムズ（株）
村上　英
日本HL7協会　第18回HL7セミナー

7. CDA Widely implemented outside the US In the US
most common application is transfer of care (Germany, Greece, Finland, Japan, Korea, Canada, Argentina)
CDA transfer of care pilot in British Columbia (see CDA Implementation Guide for Vancouver Island Health Authority on SDTC web page)
In the US
CDA considered for HIPAA Claims Attachments (as payload in X12 message)
Mayo: ramping up to 50,000 notes/week: investment in information as capital asset
Columbia-Presbyterian: text and fielded data entry with natural language processing and controlled vocabulary
Tricare Management Activity (DoD TMA) will implement CDA attachments supporting referrals management

8. CDA Specification is generic Human-readable “narrative block”
Any document type
Any clinical content
Human-readable “narrative block”
Defines legal content
Displays with simple style sheet
Required
Machine-readable “clinical statements”
Drives automated extraction, decision support….
Uses HL7 RIM, controlled vocabulary
Optional

9. CDA Body: Human-readable
paragraph
list
table
caption
link
content
revise (delete/insert)
subscript/superscript
special characters (e.g., symbols, Greek letters) in Unicode
emphasis
line break
renderMultiMedia (non-XML graphics, video…)
required

10. CDA Body: Machine Processible
Clinical statement
Observation
Procedure
Organizer
Supply
Encounter
Substance Administration
Observation Media
Region Of Interest
Act
Optional

11. Creating CDA Document Types
Add constraints to generic specification
Designed for a community of users
Scope: US
Clinical applications: transfer of care
Can be further specialized for closer communities
Scope: Massachusetts
Clinical application: pediatric
Document coded to requirements of the document type
Still valid against generic schema and specification

12. Validating CDA document types
.xPath, .xsl,
Schematron
prose √
.xsd
CRS
.xml
Validates against generic schema
<Section
code=Plan> √
XPath validation of Implementation Guide requirements

13. CDA & Incremental Semantic Interoperability
Patients transfer between providers with vastly different IT capabilities
Need to support information requirements at point of care
Full EMR adoption… not predictable based on past adoption curves
Assume gradually rising, but still heterogeneous levels of sophistication
Data formats (imaging, text, XML)
Coded data (metadata, basic structure, simple results reporting, complex clinical statements)

14. CDA & Incremental Semantic Interoperability
Level 1: standardizes just the metadata (header) required for management
Query, retrieve, file, track
Full clinical content, but no coding requirements
Target authoring: any (including imaging, fax)
Level 2: Level 1 + standard structures (section, list, table titles)
Clinical domain-specific
Supports basic extraction, summary
Target authoring: dictation, electronic text with template or minimal consistent structure

15. CDA & Incremental Semantic Interoperability
Level 1: just the metadata (header)
Level 2: Level 1 + structures
Level 3: Level 2 + clinical statements (coded for machine processing)
Expressive to full extent of Reference Information Model and vocabulary
Target authoring: EMR, forms entry, natural language processing
Many actual levels between these benchmarks
A document can always exceed the required level of encoding

16. Clinical content invariant, regardless of level
Same clinical content
Level 1: XML, no codes
Level 1: non-XML body
Level 2: XML, section codes
only the codes change

17. Let’s take a look…

18. Implementation Guides constrain coding
Identical required section coding
Not presentation
Not narrative style
Different optional narrative coding
Two styles of presentation, one Implementation Guide

19. Implementation Guides constrain coding
Not presentation
Not narrative style
Can impose uniform presentation, style
but just for presentation
the coding drives machine processing
Distinction becomes more significant with Level 3

20. Current ballots & more…3 1 4 2

21. Care Record Summary Implementation Guides for CDA Release 2
April 13, 2005
Keith W. Boone
Dictaphone Corporation

22. Thank you!
Questions?