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Using the XML-Based Clinical Document Architecture for Exchange of Structured Discharge Summaries

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. Overview. Health Level Seven (HL7) and XML Clinical Document Architecture (CDA)

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Using the XML-Based Clinical Document Architecture for Exchange of Structured Discharge Summaries

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  1. 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 DALHOUSIEUniversity

  2. Overview • Health Level Seven (HL7) and XML • Clinical Document Architecture (CDA) • Levels within the CDA • Vocabulary Domains • Implementation • Clinical/Admin Information Exchange • Current Status

  3. 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 data • Level 7 refers to the highest level, applications, of the communications model for Open Systems Interconnection

  4. HL7 Mission • Clinical Interoperability • Interoperability :ability of two of more systems or components to exchange information and to use the information that has been exchanged. [Source: IEEE Standard Computer Dictionary: A Compilation of IEEE Standard Computer Glossaries, IEEE, 1990] Functional Interoperability Semantic Interoperability

  5. HL7 and SGML/XML • Initial release of HL7 Version 3 slated for December 2001 will use only XML encoding • Two groups in HL7 SGML/XML • XML as an alternative syntax for messages • Structured 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

  6. 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 documents • Approved as an ANSI standard November 2000

  7. 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

  8. Clinical Documents in QEII • Currently each page of paper chart reviewed to produce Discharge Summary and Abstract • Demographic information • Length of Stay • Diagnoses 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

  9. Discharge Summary –Hospital Communication to Family Doctor • QEII Department of Medicine Structured Discharge Summary • Header Information (Participants and Roles – Patient, Sender, Recipient) • Most Responsible Diagnosis • Comorbidities/Cardiac Risk Factors • Course in Hospital and Conclusions • Pertinent Investigations/Lab Results • Further steps and scheduling

  10. Referral Communications • From Family Physician to Hospital • Patient Information • Reason for referral • Symptoms and Duration • Investigations and Results • Diagnosis and Treatment • Prescribed Medications

  11. Features of DoctorPortal • Adding a discharge or referral • Finding a discharge or referral • Editing a discharge or referral • Querying a discharge or referral • Listing all discharges and referrals assigned to a given doctor

  12. Query the Database

  13. 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 start • RIM classes are used in the CDA Header • Terms 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

  14. 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

  15. HL7 Version 3 Data Types • XML Element Names map to Data Types • _cd vocabulary domain has coding strength • CNE coded, no extensions • CWE 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

  16. 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>

  17. 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>

  18. 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)

  19. 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

  20. Doctor Portal Implementation • The portal has three features: 1. Ability to add, edit, find, and query discharge summaries 2. Ability to add, edit, find, and query referral forms 3. 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

  21. HTML Web interface JAVA Servlet SAX Parser Validates XML Handles requests & responses XML DB API dbXML Database Performs dbXML Operations

  22. 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

  23. 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

  24. Current Status • Working demonstration system • Planned implementations for 2002 • HealthInfoRx™: Lifelong Learning for Chronic Disease Patients • CDA will be used for physician to physician referral/discharge communications for patients in Inflammatory Bowel Disease Clinic (Level Two) • Concurrent Review Document • Data collection January 2002 using XML system • Test of implementation in a District (Level Three)

  25. Thank You Questions? Further Information: www.medicine.dal.ca/dmedinfo Grace.paterson@dal.ca

  26. 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

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