Clinical Document Architecture: Care Record Summaries Liora Alschuler alschuler.spinosa Co-chair,...
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Transcript of Clinical Document Architecture: Care Record Summaries Liora Alschuler alschuler.spinosa Co-chair,...
Clinical Document Architecture:Care Record Summaries
Liora Alschuleralschuler.spinosa
Co-chair, Structured Documents TCCo-editor, CDA
HL7 Board of Directors
Liora Alschuler [email protected]
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…
1
2
3
4
Clinical Language Understanding
Care Record SummaryImplementation Guides for CDA Release 2
April 13, 2005
Keith W. [email protected] Corporation
Thank you!
Questions?