alschuler.spinosa copyright 2001, Liora Alschuler HL7s CDA & the EHR TEPR Seattle Liora Alschuler May 13, 2002 alschuler.spinosa (dba) East Thetford, VT La Jolla, CA Structured Documents: What a few tags can do

alschuler.spinosa copyright 2001, Liora Alschuler 2 alschuler.spinosa : consulting practice with focus on application of XML and related standards to healthcare Liora Alschuler –Co-chair HL7 Structured Documents TC –Chair, HL7 Marketing Committee –past Chair, KEG (wrote HL7 Clinical Document Architecture) –coordinator, HL7 HIMSS Technical Demo –consultant, writer –author, ABCD… SGML: A Users Guide to Structured Information, 1995 John Spinosa –MD and Ph.D. from UC San Diego; trained in pathology at UCSD; hematopathology fellowship, staff member at Scripps La Jolla –Co-founder of XML TC –Member of the CAP informatics committee

alschuler.spinosa copyright 2001, Liora Alschuler 3 Outline –Information ecology –XML, a few tags at a time –Gating factors –Why this might work –Conclusions

alschuler.spinosa copyright 2001, Liora Alschuler 4 Information Ecology business drivers data technology business drivers technology

alschuler.spinosa copyright 2001, Liora Alschuler 5 Information Ecology Primary cause of poor information flow in healthcare: lack of usable and re- usable electronic data –85-95% of clinical data still paper based HIMSS Leadership Survey –99: 10-11% have implemented EHR –99: 25% planning to w/in one year –00: 10-11% have implemented EHR –00: 25% planning to w/in one year

alschuler.spinosa copyright 2001, Liora Alschuler 6 Bad ecology The impact: –IOM report: poor information leads to poor healthcare –cant control costs –some claims, all attachments, most admin/finan transactions still paper electronic :: paper 3 billion :: billion (Wit Capitol, 2000) Can track price of peaches in Alberta, but cant track status of claims

alschuler.spinosa copyright 2001, Liora Alschuler 7 XML and info ecology XML can break the electronic data log jam The big breakthrough is not in the CPRI The big change is in the –simple XML documents for ubiquitous access, integration and reuse –encoding of narrative, human language, for H2H and simple machine processing

alschuler.spinosa copyright 2001, Liora Alschuler 8 Tim Bray, June, 2001 What matters, what doesnt?

alschuler.spinosa copyright 2001, Liora Alschuler 9 Tim Bray, June, 2001

alschuler.spinosa copyright 2001, Liora Alschuler 10 #1 80/20 point Tim Bray, June, 2001

alschuler.spinosa copyright 2001, Liora Alschuler 11 XML for healthcare data where is the 80/20 point for healthcare information? it is not the full-blown computerized patient record (XML-encoded or not) Erica Drazen, VP First Consulting Group, in Healthcare Informatics: There are few organizations claiming complete CPR systems. As originally defined, a CPR is neither necessary nor sufficient on its own as a tool for improving care. To be useful, information needs to be available, first and foremost, and only then does it matter if it is coded to the extent that will support a CPR. Its doubtful that all the information in current records will ever be duplicated in electronic records, and it certainly will not all be coded.

alschuler.spinosa copyright 2001, Liora Alschuler 12 The 80/20 point for healthcare Setting new targets for information exchange –more like the Web –healthcare-specific Extensible Markup Language (XML) Clinical Document Architecture

alschuler.spinosa copyright 2001, Liora Alschuler 13 Clinical Document Architecture New specification (Nov. 2000) for healthcare documents Uses XML, like the Web, but vocabulary specific to medicine Lower, simpler objectives than previous exchange specifications –common format for transcription and EHR records –Human-readable on Web, PDA, cell,…

alschuler.spinosa copyright 2001, Liora Alschuler 14 CDA Lets take a look...

alschuler.spinosa copyright 2001, Liora Alschuler 15 the 80/20 sweet spot: XML, a few tags at a time Impressions RLL nodule suggestive of malignancy... Impressions RLL nodule suggestive of malignancy... Impressions RLL nodule suggestive of malignancy... any transcription system can produce this or this or this, with post- process coding, NLP, AI, KM or a better user interface

alschuler.spinosa copyright 2001, Liora Alschuler 16 BestPractice Hospital eMedicalFiles Epic IPNet MSBizTalk /CGE&Y Eclipsys Sentillion MercuryMD Innovision Sun Microsystems Mercator MDProductivity CSI FPT NeoTool SoftwareAG SNOMED GoodHealth Clinic Alpha Labs Beta Labs Virtual Health Record Gamma Registry Speedy Payer SmallDoc Office BeWell Hospital CCOWAttachmentsV3V2CDAADTOrdersResultsReportsVocabConsultBillContextVHRVocabVocab MSDashboard

alschuler.spinosa copyright 2001, Liora Alschuler 17 creating CDA documents –Mayo –transcription –EHR –query CDA: How to Create

alschuler.spinosa copyright 2001, Liora Alschuler 18 What can you do with a few tags? access/portability/exchange –query/locate by patient, provider, practioner, setting, encounter, date integration –multiple transcription systems –with EHR records re-use/derivative data –summaries –billing

alschuler.spinosa copyright 2001, Liora Alschuler 19 XML separates display format from structure and content, so you get one file, many displays What can you do with a few tags? provide universal access

alschuler.spinosa copyright 2001, Liora Alschuler 20 XML data is accessible Allergy List … Medications List automated table of contents creation, linked to content, through style sheet transformations

alschuler.spinosa copyright 2001, Liora Alschuler 21 One document, many views CDA: How to Display

alschuler.spinosa copyright 2001, Liora Alschuler 22 One document, many views Many documents, one view CDA: How to Display

alschuler.spinosa copyright 2001, Liora Alschuler 23 transcription What can you do with a few tags? integrate records from multiple applications standard XML CPR/EHR

alschuler.spinosa copyright 2001, Liora Alschuler 24

alschuler.spinosa copyright 2001, Liora Alschuler 25 BestPractice Hospital eMedicalFiles Epic IPNet MSBizTalk /CGE&Y Eclipsys Sentillion MercuryMD Innovision Sun Microsystems Mercator MDProductivity CSI FPT NeoTool SoftwareAG SNOMEDADTOrdersResultsReportsVocabConsultBill GoodHealth Clinic Alpha Labs Beta Labs Virtual Health Record Gamma Registry Speedy Payer SmallDoc Office BeWell Hospital CDAAttachmentsV2V2CDA V3 MSDashboard CCOWContextVHR

alschuler.spinosa copyright 2001, Liora Alschuler 26 CDA: How to Manage

alschuler.spinosa copyright 2001, Liora Alschuler 27 CDA::(v)EHR a single CDA is not an EHR a CDA is an episodic snapshot of care a single CDA can be EHR input a single CDA can be EHR output CDA documents can serve as a virtual EHR

alschuler.spinosa copyright 2001, Liora Alschuler 28 CDA::(v)EHR CDA is not an EHR –will not drive decision support –will not supply fine-grained clinical data to drive public health surveillance CDA Level One will be extended to Level Three supporting fine-grained clinical data CDA Level One provides a gentle on- ramp to gain wider interoperability

alschuler.spinosa copyright 2001, Liora Alschuler 29 Transcription: problem or solution? Remains number one interface for creation of clinical records Transcription: seen as cost factor to be minimized or eliminated XML can make transcription output: –usable and re-usable –portable –basis for richly encoded record, mixing narrative, controlled text and images

alschuler.spinosa copyright 2001, Liora Alschuler 30 Gating factors Provider demand Vendor suppy Standards

alschuler.spinosa copyright 2001, Liora Alschuler 31 Provider demand Currently, no strong demand for XML as deliverable Providers will create demand for clear quality/ROI goals: –access/portability/exchange –integration –re-use/derivative data Clinical information as enduring asset

alschuler.spinosa copyright 2001, Liora Alschuler 32 Vendor supply: Feb –MedQuist: XML internally for platform integration; tracking stds –Edix: XML control files, clinical report in ASCII, HTML, Word –HealthScribe: XML-based technology in development for transcriptionist use –CareFlow|Net: XML output available, one client using it –Lanier: air of inevitability, but no demand –Vianeta: startup, XML-based technology for transcriptionist use –[2/02: MDProductivity, speech-to-CDA]

alschuler.spinosa copyright 2001, Liora Alschuler 33 Standard XML HL7s Clinical Document Architecture ANSI/HL7 CDA R meets current requirements –will extend to specialized document types –will extend to granular data –will be vehicle for professional/industry groups to standardize their own practice

alschuler.spinosa copyright 2001, Liora Alschuler 34 Gating factors: summary Healthy information exchange: –technology not the barrier –waiting for provider demand –standards helpful, but pull will come from providers business drivers technology business drivers technology data

alschuler.spinosa copyright 2001, Liora Alschuler 35 This might work: Why? technical issues: not difficult many P2P models available 100% solutions have not worked 80/20 solutions gaining credibility Jim Klein, Gartner Group, on HL7s CDA, April, 2001 RU: HL7's Clinical Document Architecture (CDA) defines a new target for clinical information exchange that is substantially easier to hit than one based on standards for discrete data while delivering 80 percent of the value of the latter approach.

alschuler.spinosa copyright 2001, Liora Alschuler 36 This might work: Why? technical issues: not difficult many P2P models available 100% solutions have not worked 80/20 solutions gaining credibility can scale down The Bosworth/Bray Principle: simple interoperability wins supported by early adopters

alschuler.spinosa copyright 2001, Liora Alschuler 37 Conclusions XML bang-for-buck: transcription Incremental road to CPR/EHR starts with simple, electronic documents Impetus is providers Gradual approach that wins with physicians, scales down will change the industry

alschuler.spinosa copyright 2001, Liora Alschuler 38 Discussion More info: Structured Documents TC 1st CDA Conference: Oct. 7-9, 2002 Europe