A CDA Template for Continuity of Care

Liora Alschuler, Roberto Ruggeri

HIMSS 2005Acapulco partners: Charlie McCay, Ted Blizzard

About us Liora Alschuler

alschuler.spinosa, consultants Co-chair HL7 Structured Documents TC Co-editor, CDA member, 2005, HL7 Board of Directors liora@the-word-electric.com

Roberto Ruggeri Senior Healthcare Strategist Microsoft Member of the ASTM CCR Technical group and TAG Member of the HL7 Structured Documents Committee rruggeri@microsoft.com

Ted Blizzard Vice President of Information Technology for the Massachusetts Medical Society and New

England Journal of Medicine Member of the ASTM CCR Steering group and TAG Member of the HL7 Structured Documents Committee email:tblizzard@mms.org

Charlie McCay Ramsey Systems, UK charlie@ramseysystems.co.uk

Also participating: Dr. Tom Sullivan, Massachusetts Medical Society; Bill Braithwaite, HL7

Thanks to Bob Dolin for help in coding clinical statements

A CDA Template for Continuity of Care

What is CCR? What is CDA? Relationship of CCR to CDA CDA to CCR mapping CCR as CDA Conclusions Next Steps

Continuity of Care Record What is it? Core data set of the most relevant and timely

facts about a patient’s healthcare. Organized and transportable. Prepared by a practitioner at the conclusion of

a healthcare encounter. To enable the next practitioner to readily

access such information. May be prepared, displayed, and transmitted on

paper or electronically.

History of the CCR Originally the MA Patient Care Referral Form (PCRF)

Consortium of sponsoring organizations ASTM International Massachusetts Medical Society HIMSS American Academy of Family Physicians American Academy of Pediatrics American Medical Association Patient Safety Institute American Health Care Association National Association for the Support of LTC Additional sponsoring organizations pending

Featured at HIMSS, TEPR, and … HL7 ASTM MOU (CDA/CCR)

Sponsors represent:

ANSI-recognized standards development organization

Over 400,000 practitioners Over 13,000 IT professionals Over 12,000 institutions in the long-term care

community that provide care to over 1.5 million elderly and disabled

Patients, patient advocates, data sources, corporations, provider institutions….

The effort is positioned to be Patient-focused

Not about what the system says to do but about what patient information is most relevant

Provider-focusedPractitioners determine what information is

most relevant Content-focused

Emphasis is on what providers need to know to deliver good patient care

Why So Much Interest in the CCR? It is intended to be simple to implement, use and explain It is not a top-down approach

End-users, i.e., practitioners have participated in its design The originator determines the relevant content

It has support and leadership from organizations representing end-users, who are Involving, advising, and assisting their constituents in its adoption

It allows options for implementation Paper or electronic

It has potential to reduce inefficiencies and costs Practitioners won’t have to search for relevant information Fewer repeat lab tests and other evaluations

The CCR Is Not… An EHR

It is not a complete electronic health record of a patient’s lifelong health status and healthcare

It is not universally accessible It does not have a universal patient identifier

A progress note, discharge summary, or consultation It is not limited to information from a single encounter It is not free-text based

A loose dataset of health information It is a defined set of core data in specified XML code

An HL7 Version 3 specification for any clinical document.

A clinical document ... has the following characteristics: Persistence Stewardship Potential for authentication Context Wholeness Human readability

What is CDA?

CDA is defined by the RIM CDA RMIM is a constraint on the RIM

Classes “cloned” (replicated, renamed, constrained with vocabulary, datatypes)

What is CDA?

What is CDA? CDA interoperable with

EHR, V3 messaging clinical content through “clinical statement”

What is CDA?

CDA complimentary to medical records messages and orders

Message is the envelope CDA is the payload/contents/“letter”

CDA is persistent (WORM drive heuristic) Cannot be relied on for distribution & routing beyond

static contents of CDA header

CDA is a snapshot in time, under signature Is not, itself, a birth-to-death, aggregate record

Areas of overlap Can include contents of single referral Both use XML for document exchange

Areas of divergence Generality:

CDA is generic to all clinical documents CCR is specific to continuity, US realm

XML CCR XML handcrafted CDA XML derived from RIM using V3 principles

Persistence CDA persistent CCR contains transmission-specific information

Aggregation CDA a single unit, can be part of an aggregate record CCR can be single unit or can be the aggregate record

Conclusions Significant areas of overlap, although aspects of scope, approach differ HL7 sees continuity of care records as just another document type

CCR CDA

CDA– CCR Mapping

Mapping project fall, 2003 Included CDA, CCR, New Zealand Health Event

Summary, Australian Health Connect, requirements & participation from Germany, Japan

Roughly equivalent metadata

General vs. specific content

<Plan>

<Section><Section

code=Plan>

.xml

..xsd

.mif

..xsd

.mif

.xml

.xml

xslt

Plan

prose

rsMIFeditor

V3xsdGen

Template creation & validation: model-based (Acapulco flavor)

Create derived MIF

Template creation & validation: model-based (Acapulco flavor)

Advantages Exchange & validate

referral requirements Exchange & validate

at highest level of interoperability

Can constrain authoring

Disadvantages Tooling immature Still limited by xsd

Template Creation & validation (Dallas flavor) Objectives:

CDA CCR creation and validation in simple authoring environment with simple rule set

Method: Use prototype instance (CDA CCR) “Unwind” to authoring style XML (nonCDA CCR) Develop authoring environment in MS Word XML with

tagging, schema validation, styles and CCR rule validation

“Rewind” to normative CDA CCR (.xml)

Sample document:TemplatesSampleReferral.mms.doc

Provided by Tom Sullivan, MD, Mass. Med. Society; co-chair ASTM E31-28

What to “template”?• Sections• Sub-sections• Selected observations

Create table of CDA & template markupDocument type code: LOINC 34140-4

• Coding limited to template objectives

• Used “CCRlocal” where term equivalent not found

XML encode sample using generic CDA, CCRCDA.xml

• Hand-crafted,

• Narrative block complete

• Coding limited to template table

“Unwind” to authoring-style XML (nonCDA CCR) [unwind.xslt]

MS Word XML authoring

Validation in MS Word XML

Save as CDA XML

<Plan><Section

code=Plan>

.xml

.mif

.xml

Plan

prose

rsMIFeditor

Dallas flavor validation:

.xsd+xpath

XPath validation of document type requirements

Transform to generic CDA

Valids against generic schema

Conclusions: concept Concept: viable Must extend model to RIM-compliant expression of

full requirements

CCR documents

CCR referral documents

CCR GP referrals CCR pediatric referrals

CCR geriatric referrals

Reference Information Model

CDA + MRM RMIM

CCR Medical records CCR Orders

CCR EHR, Patient Care

Referrals DMIM

<Section><Section

code=Plan>

.xml

.mif

.mif

.xml

Plan

prose

rsMIFeditor

V3xsdGen

Next step for V3 tooling: 2-stage validation

.xsd+xpath

..xsd• Refine and extend V3 tooling and methodology

• MIF editor, schema editor to manage constraint of vocabulary, datatypes• Prototype two-stage (xsd+rules) derived from constrained model • Look at RelaxNG for single-step validation

Next Steps for CCR as CDADefine full scope of CCR information model

and explore its relationship to the RIM and derivative specifications (documents, messages, EHR)

Explore relationship to international referral requirements, methodology

Next Steps for CDADefine general method for specifying all types of clinical

documents: anesthesiology, imaging, pathology, history & physical, etc.

Do it!

Thank you!

Questions?