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Using the XML-Based Clinical Document Architecture for

Exchange of Structured Discharge Summaries

Grace I. Paterson, Michael Shepherd, Xiaoli Wang, Carolyn Watters, and David Zitner

DALHOUSIE University

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Overview

Health Level Seven (HL7) and XMLClinical Document Architecture (CDA)Levels within the CDAVocabulary DomainsImplementationClinical/Admin Information ExchangeCurrent Status

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Health Level Seven (HL7)

HL7 is an ANSI-accredited Standards Development Organization

Domain is clinical and administrative data Focus is the interchange of health care dataLevel 7 refers to the highest level,

applications, of the communications model for Open Systems Interconnection

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HL7 Mission

Clinical InteroperabilityInteroperability

:ability of two of more systems or components to exchange informationexchange information and to use the use the informationinformation that has been exchanged.

[Source: IEEE Standard Computer Dictionary: A Compilation of IEEE Standard Computer Glossaries, IEEE, 1990]

Functional Interoperability

SemanticInteroperability

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HL7 and SGML/XML

Initial release of HL7 Version 3 slated for December 2001 will use only XML encoding

Two groups in HL7 SGML/XMLXML as an alternative syntax for messagesStructured Documents Technical Committee

An architecture for structured documents defines relationships between documents and document specifications in terms of specialization and inheritance – a Clinical Document Architecture

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Clinical Document Architecture (CDA)

Kona Proposal drafted in 1996 (Kona Mansion)Clinical Document Architecture (CDA) is a

specification for exchanging clinical documents using eXtensible Markup Language (XML)

Leverages the use of XML, the HL7 Reference Information Model and coded vocabularies to specify the structure and semantics

Machine and Human-readable documentsApproved as an ANSI standard November 2000

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A CDA Document

A CDA document is a defined and complete information object

Can exist outside of a messaging context and/or can be a payload within an HL7 message

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Clinical Documents in QEII

Currently each page of paper chart reviewed to produce Discharge Summary and AbstractDemographic informationLength of StayDiagnoses and Procedures

Most of this information is produced by clinicians

Huge potential cost savings if the summary could be captured concurrent with care and used for discharge communication

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Discharge Summary –Hospital Communication to Family Doctor

QEII Department of Medicine Structured Discharge SummaryHeader Information (Participants and Roles –

Patient, Sender, Recipient)Most Responsible DiagnosisComorbidities/Cardiac Risk FactorsCourse in Hospital and ConclusionsPertinent Investigations/Lab ResultsFurther steps and scheduling

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Referral Communications

From Family Physician to HospitalPatient Information

Reason for referralSymptoms and DurationInvestigations and ResultsDiagnosis and TreatmentPrescribed Medications

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Features of DoctorPortal

Adding a discharge or referralFinding a discharge or referralEditing a discharge or referralQuerying a discharge or referralListing all discharges and referrals

assigned to a given doctor

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Query the Database

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Levels within the CDA

Level One is the root Most general specification (low-hanging fruit) Defined and complete information object – web

implementation of paper documents to startRIM classes are used in the CDA HeaderTerms from controlled vocabularies in body

Level Two will be a specialization of Level One Level Three: Clinical content can be marked up

to the extent that it is modeled in the HL7 RIM

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Level One CDA Document

Composed of CDA Header and CDA Body

Purpose of the CDA Header is to enable clinical document exchange across and within institutions

Coded entries uses HL7 Version 3 Data Types

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HL7 Version 3 Data Types

XML Element Names map to Data Types_cd vocabulary domain has coding strength

CNE coded, no extensionsCWE coded, with extensions (allows local codes)Make use of published authoritative sources of code values

_tmr document time stamp _id identifier_nbr number

Vocabulary domains may be HL7-defined concepts or recognized coding schemes such as SNOMED, READ, ICD10, Medcin

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Captions, Coded Captions, and Registered Vocabularies

<section> <caption>Most Responsible Diagnosis</caption> <section> <caption>Unstable Angina <caption_cd V=“I20.0”

S=“2.16.840.1.113883.6.3”/> </caption> <paragraph> <content>Y</content> </paragraph> </section>

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Level One Document Instance

<?xml version="1.0"?>

<!DOCTYPE levelone PUBLIC "-//HL7//DTD CDA Level One 1.0//EN" "dischargesummary.dtd">

<levelone>

<clinical_document_header>

…

</ clinical_document_header>

<body confidentiality= “CONF1”>…

</body>

</levelone>

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Level One: CDA Header

1. Document information includes <id>, <set id>, <version_nbr>, <document_type_cd>, <confidentiality_cd>, <document_relationship>

2. Encounter data describe the setting in which the documented encounter occurred and includes <patient_encounter>, <practice _setting_cd>, <encounter_tmr>, <service_location>, <addr>.

3. Provider includes the persons who participated in the services being documented

4. Patient includes the patient and other significant participants (such as family members)

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Level One: CDA Body

Nested containers in Level One body: sections, paragraphs, list and tables.

Minimal amount of markup and minimal constraint for this markup

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Doctor Portal Implementation

The portal has three features:1. Ability to add, edit, find, and query discharge

summaries2. Ability to add, edit, find, and query referral forms3. Ability to list all discharges and referrals assigned

to a specific doctor Javascript and HTML implement the interface

and interact with the user as information is entered into the form

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ces HTML

JAVAServlet

SAX Parser

XML DBAPI

dbXMLDatabase

Validates XMLHandles requests & responses

Performs dbXML Operations

Web interface

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Database Platform

dbXML is an open source Native XML Database stores and indexes compressed XML documents in

order to provide that data to a client application with very little server-side processing overhead

provides functionality that is unique to XML data, which can't easily be reproduced by relational databases

http://www.dbxml.org/ for Users Manual

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Clinical/Administration Information Exchange

CDA is sufficient backbone for communication between Information Systems in Physician Offices and Hospital

Canadian hospitals abstract each patient record for Canadian Institute for Health Information

Information should support clinical, administration, education and research

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Current Status

Working demonstration systemPlanned implementations for 2002

HealthInfoRx™: Lifelong Learning for Chronic Disease PatientsCDA will be used for physician to physician

referral/discharge communications for patients in Inflammatory Bowel Disease Clinic (Level Two)

Concurrent Review DocumentData collection January 2002 using XML systemTest of implementation in a District (Level Three)

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Thank You

Questions?

Further Information:www.medicine.dal.ca/dmedinfo

Grace.paterson@dal.ca

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Acknowledgements

Dr. Michael Shepherd, Computer Science, Dalhousie Dr. Carolyn Watters, Computer Science, Dalhousie Dr. David Zitner, Director, Medical Informatics, Dalhousie Dr. John Ginn, Medical Informatics, Dalhousie Kathy MacNeil, Director, Patient Information Services, QEII

Health Sciences Centre Patient Care Record Committee, Capital Health District

Authority Mary Eileen Wall, Clinical Informatics Coordinator, QEII

Health Sciences Centre Sandra Cascadden, Director of IT Services, QEII Health

Sciences Centre Dr. Elizabeth Cowden, Head, Department of Medicine, QEII Ron Soper, Computer Science CO-OP Student