A CDA Template for Continuity of Care

1. A CDA Template for Continuity of Care Liora Alschuler, Roberto Ruggeri HIMSS 2005 Acapulco partners: Charlie McCay, Ted Blizzard

2. 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

3. 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

4. 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.

5. 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)

6. 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….

7. 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-focused • Practitioners determine what information is most relevant • Content-focused • Emphasis is on what providers need to know to deliver good patient care

8. 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

9. 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

10. What is CDA? 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

11. 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)

12. What is CDA? • CDA interoperable with EHR, V3 messaging clinical content through “clinical statement”

13. 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

14. ? CCR CDA • 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

15. 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

16. Template creation & validation: model-based (Acapulco flavor) .mif √ ..xsd .xml .xml <Section code=Plan> <Section> rsMIFeditor V3xsdGen xslt .mif prose ..xsd .xml Plan <Plan> √

17. Create derived MIF

18. 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

19. 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)

20. Sample document:TemplatesSampleReferral.mms.doc Provided by Tom Sullivan, MD, Mass. Med. Society; co-chair ASTM E31-28

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

22. Create table of CDA & template markup Document type code: LOINC 34140-4 • Coding limited to template objectives • Used “CCRlocal” where term equivalent not found

23. 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]

24. MS Word XML authoring

25. Validation in MS Word XML

26. Save as CDA XML

27. Dallas flavor validation: .mif √ .xsd+xpath .xml .xml <Section code=Plan> <Plan> rsMIFeditor Valids against generic schema Transform to generic CDA √ prose XPath validation of document type requirements Plan

28. Conclusions: concept • Concept: viable • Must extend model to RIM-compliant expression of full requirements Reference Information Model CDA + MRM RMIM ? Referrals DMIM CCR Medical records CCR documents CCR Orders CCR referral documents CCR EHR, Patient Care CCR GP referrals CCR pediatric referrals CCR geriatric referrals

29. Next step for V3 tooling: 2-stage validation .mif √ .xsd+xpath .xml .xml <Section code=Plan> <Section> rsMIFeditor V3xsdGen √ .mif prose ..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 Plan

30. Next Steps for CCR as CDA • Define 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 CDA • Define general method for specifying all types of clinical documents: anesthesiology, imaging, pathology, history & physical, etc. • Do it!

31. Thank you! Questions?