The ASTM/HL7 Continuity of Care Document. HIMSS 2008 Liora Alschuler
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1 The ASTM/HL7 Continuity of Care Document HIMSS 2008 Liora Alschuler 1
2 Liora Alschuler Consultant in healthcare IT 1997-present Founded consulting firm in 2005 Background in electronic text, industry analyst with Seybold Publications, xml.com Author, ABCD... SGML: A Manager s Guide to Structured Information, 1995 Volunteer standards work Health Level Seven Board of Directors ( ) Co-chair Structured Documents Technical Committee Co-editor Clinical Document Architecture (CDA) Co-editor, Continuity of Care Document (CCD), H&P, Consult, Op Note liora@alschulerassociates.com 2 Alschuler Associates, LLC 2008
3 Alschuler Associates, LLC Standards-based solutions for vendors, providers, standards developers CDA Implementations: Military Health System Enterprise-wide documents, files, images (DFIEA) Centers for Disease Control and Prevention Implementation Guide for Healthcare Associated infection Reports for the National Healthcare Safety Network North American Association of Central Cancer Registries Implementation Guide for cancer abstracts Department of Health and Human Services Supporting the Health IT Standards Panel (HITSP); Health Information Standards for Privacy and Confidentiality (HISPC); Assistant Secretary for Planning and Evaluation, prototype of the Minimum Data Set (MDS) CDA4CDT Co-founder & Project Management Private, commercial clients: Fortune 100 and startups 3 Alschuler Associates, LLC 2008
4 Health Level Seven (HL7) Non-profit ANSI Standards Development Organization 20 years old members individual, corporate 30 affiliates US affiliate in near future A model community : building standards to a single information model 4 Alschuler Associates, LLC 2008
5 Version 2.x Version 3 HL7 Standards Messages CDA: Clinical Document Architecture Others EHR Functional Model CCOW: Clinical Context Object Working Group (= Desktop Integration) Arden Syntax (Decision Support) 5 5 Alschuler Associates, LLC 2008
6 CDA: Clinical Document An HL7 Version 3 specification ANSI/HL7 CDA R ANSI/HL7 CDA R Created & maintained by HL7 Structured Documents Technical Committee (SDTC) A specification for document exchange using Extensible Markup Language (XML) the HL7 Reference Information Model (RIM) Version 3 methodology and vocabulary (SNOMED, ICD, local, ) Architecture 6 Alschuler Associates, LLC 2008
7 CDA Release 2, section 2.1: The CDA Defined A clinical document... has the following characteristics: Persistence Stewardship Potential for authentication Context Wholeness Human readability therefore, CDA documents are not: data fragments, unless signed birth-to-death aggregate records electronic health records 7 Alschuler Associates, LLC 2008
8 CDA = Header + Body CDA Header Metadata required for document discovery, management, retrieval CDA Body Clinical report Discharge Summary Care Record Summary Progress Note H&P Public health report any content that carries a signature 8 Alschuler Associates, LLC 2008
9 CDA Body: human-readable Any type of clinical document Discharge Summary Care Record Summary Progress Note H&P Public health report potential for signature Format: non-xml...tif, PDF, HTML, Format: XML Paragraph List Table Caption Link Content Presentation required 9 Alschuler Associates, LLC 2008
10 CDA XML Body: processible Clinical statement: Model-based computable semantics Observation Procedure Organizer Supply Encounter Substance Administration Observation Media Region Of Interest Act Optional 10 Alschuler Associates, LLC 2008
11 HL7 s CDA Clinical Document Architecture ANSI/HL7 R1-2000, R edocuments for Interoperability Key component for local, regional, national electronic health records Gentle on-ramp to information exchange Everyone uses documents EMR compatible, no EMR required All types of clinical documents Consult Discharge Radiology Path CDA Health chart Summary 11 Alschuler Associates, LLC 2008
12 ASTM s CCR 12 Alschuler Associates, LLC 2008
13 CDA & CCR CCR Paper or electronic, but always XML if electronic XML: per annex or other XML representation made possible through joint efforts of ASTM and other Standards Development Organizations... This specified XML coding provides flexibility that will allow users to prepare, transmit, and view the CCR in multiple ways, for example, in a browser, as an element in a Health Level 7 (HL7) message or CDA compliant document, Alschuler Associates, LLC 2008
14 ASTM CCR vs. HL7 CDA Conflicting? Overlapping? What if you could have both!#*?i!! What if you could have your data elements And send them in a common exchange framework? 14 Alschuler Associates, LLC 2008
15 ASTM CCR + HL7 CDA = CCD CDA is designed to support professional society recommendations, national clinical practice guidelines, standardized data sets, etc. From the perspective of CDA, the ASTM CCR is a standardized data set that can be used to constrain CDA specifically for summary documents. The resulting specification, known as the Continuity of Care Document (CCD), is being developed as a collaborative effort between ASTM and HL7. 15 Alschuler Associates, LLC 2008
16 Continuity of Care Document CCD maps the CCR elements into a CDA representation. CCR data element Results Result DateTime Type: Values include: Hematology, Chemistry, Serology, Virology, Toxicology, Microbiology, Imaging - X-ray, Ultrasound, CT, MRI, Angiography, Cardiac Echo, Nuclear Medicine, Pathology, Procedure Description Status Procedure Test CDA R2 correspondence Section Observation Observation.effectiveTime Draw values from observation.code (e.g. by looking at the LOINC class for a LOINC code). Observation.code Observation.statusCode Observation.methodCode; Procedure Observation 16 Alschuler Associates, LLC 2008
17 CCD Sample 17 Alschuler Associates, LLC 2008
18 Continuity of Care Document Project will develop basis for automated translation <Results> <Result> <CCRDataObjectID> </CCRDataObjectID> <DateTime> <Type> <Text>Assessment Time</Text> </Type> <ExactDateTime> T14:30Z </ExactDateTime> </DateTime> <Type> <Text>Hematology</Text> </Type> <Description> <Text>CBC WO DIFFERENTIAL</Text> <Code> <Value> </Value> <CodingSystem> SNOMED CT </CodingSystem> </Code> </Description> <Status> <Text>Final Results</Text> <section> <code code=" " codesystem=" " codesystemname="loinc"/> <title>results</title> <text> CBC (04/07/2000): HGB 13.2; WBC 6.7; PLT 123* </text> <entry typecode="driv"> <observation classcode="obs" moodcode="evn"> <id root=" " extension="1"/ <code code=" " codesystem=" " codesystemname="snomed CT" displayname="cbc WO DIFFERENTIAL"/> <statuscode code="completed"/> <effectivetime value=" "/> 18 Alschuler Associates, LLC 2008
19 CCR CDA correspondence <observation classcode="obs" moodcode="evn"> <id root=" " extension="1"/> <code code=" " codesystem=" " codesystemname="snomed CT" displayname="cbc WO DIFFERENTIAL"/> Same Context: CDA: observation, code, code system CCR: description, code, value, coding system CDA: optional unique ID; code system ID; mood Different approaches to human-readable text There are differences, but an implementation guide can support interoperability <Description> <Text>CBC WO DIFFERENTIAL</Text> <Code><Value> </Value> <CodingSystem>SNOMED CT</CodingSystem></Code> </Description> 19 Alschuler Associates, LLC 2008
20 Continuity of Care Document Did this come out of the blue? There is a history of collaboration Many people have participated in both efforts Presentation on CDA for continuity of care at ASTM CCR meeting, August, 2003 Memorandum of Understanding, 2004 Acapulco demo: CDA for CCR, October, 2004 HL7 partnered with Massachusetts Medical Society, Microsoft, Ramsey Systems (UK) Initial HL7 Care Record Summary ballot, April, 2005: Limited to CDA header, no detailed section coding Anticipated: Development of detailed (CDA Level 3) Implementation Guides for continuity of care (CCR) in collaboration with the ASTM E31 under the 2004 Memorandum of Understanding HL7 ballot on CCR, Spring 2005: incorporated changes required for bi-directional exchange and semantic interoperability 20 Alschuler Associates, LLC 2008
21 Continuity of Care Document ASTM is dedicated and privileged to work in collaboration with HL7 on the expression of ASTM's Continuity of Care Record content within HL7's CDA XML syntax and the seamless transformation of clinical and administrative data between the two standards. Rick Peters, MD, E Alschuler Associates, LLC 2008
22 CDA & CCR: differences Snapshot in time Simple rendering Legal part of record Model based Shared data types Extensibility Additional types Incremental Semantics CDA Yes Yes Yes Yes Yes Defined Yes Yes CCR Yes No Maybe No No Undef. No No 22 Alschuler Associates, LLC 2008
23 CDA: for the full patient record HL7-balloted Implementation Guides: Continuity of Care Document (CCD) ASTM complete History & Physical (H&P) CDA4CDT complete* Consult Note CDA4CDT complete* Healthcare Associated Infection CDC/NHSN complete* Operative Note CDA4CDT May 08** Diagnostic Imaging Reports DICOM May 08** Personal Health Monitor Report Continua May 08** PHR2PHR Summary AHIP/BCBSA May 08** Quality Reporting Document Arch QRDA Sept 08** others in development: anesthesiology, anatomic pathology, lab, long term care, pediatrics * = will be published shortly ** = first ballot constrain or reuse CCD templates 23 Alschuler Associates, LLC 2008
24 CDA: for the full patient record US Dept. of Health & Human Services: Health Information Technology Standards Panel (HITSP) Summary, Meds, Lab Quality, ED 2008 HIPAA Claims Attachments HL7/X12 NPRM/complete Minimum Data Set (MDS) HHS proof of concept 08 Pilots/Prototypes: North American Association of Central Cancer Registries (NAACCR) NAACCR summer 08 Quality Reporting Document Architecture (QRDA) summer 08 Alliance for Pediatric Quality, Children's Hospital Corporation of America, HL7 Pediatric Data Standards SIG DICOM SR 2 CDA Transformation Guide DICOM summer 08 Integrating the Healthcare Enterprise IHE HIMSS 08 7 Patient Care Coordination profiles using CCD constrain or reuse CCD templates 24 Alschuler Associates, LLC 2008
25 Continuity of Care Document Benefits Industry concensus on summary document contents and requirements through ASTM ballots (2004, 2005) Industry concensus on document exchange framework through HL7 ballots ( ) Summaries for continuity of care Interoperable with full range of document types Interoperable with HL7 V3 messages, all RIMbased specifications (public health reporting, clinical trials, structured product labels and more) 25 Alschuler Associates, LLC 2008
26 More Information at HIMSS: Wednesday, 3:15, HERE: What s New with CDA? Wednesday, 5:30, HERE: The CCD in National and International Activities CDA Release 2.0 Normative Edition, CCD: JAMIA Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV, Shabo A. HL7 Clinical Document Architecture, Release 2. J Am Med Inform Assoc. 2006;13: XML Schematron these slides will be posted by... 3/7/08 Quick Start Guides CDA Validator CDA Gallery liora@alschulerassociates.com 26 Alschuler Associates, LLC 2008
27 Thank you! Questions? 27 Alschuler Associates, LLC 2008
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