Clinical Document Architecture:Care Record Summaries

Liora Alschuleralschuler.spinosa

Co-chair, Structured Documents TCCo-editor, CDA

HL7 Board of Directors

Liora Alschuler liora@the-word-electric.com

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

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,…)

CDA

CDA: A Document Exchange Specification

This is a CDA and this and this and this and this and this and this

CDA Release 2: Text + Observation<Section> <code code="10153-2" 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>

2005.3.14 日本 HL7協会　第 18回 HL7セミナー

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

CDA Widely implemented outside 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

CDA Specification is generic

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

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

CDA Body: Machine Processible

Clinical statement Observation Procedure Organizer Supply Encounter Substance Administration Observation Media Region Of Interest Act Optional

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

Validating CDA document types

.xmlCRS

prose.xsd

XPath validation of Implementation Guide requirements

Validates against generic schema

<Section code=Plan>

.xPath, .xsl,

Schematron

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)

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

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

Clinical content invariant, regardless of level

Level 1: non-XML body

Level 1: XML, no codes

Level 2: XML, section codes

Let’s take a look…

Implementation Guides constrain coding

Not presentation Not narrative style

Identical required section coding

Different optional narrative coding

Two styles of presentation, one Implementation Guide

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

Current ballots & more…

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Clinical Language Understanding

Care Record SummaryImplementation Guides for CDA Release 2

April 13, 2005

Keith W. Boonekeith.boone@dictaphone.comDictaphone Corporation

Thank you!

Questions?