HL7’s CDA & the EHR TEPR Seattle

1. Structured Documents: What a few tags can do HL7’s CDA & the EHRTEPRSeattle Liora Alschuler May 13, 2002 alschuler.spinosa (dba) East Thetford, VT La Jolla, CA liora@the-word-electric.com

2. alschuler.spinosa: consulting practice with focus on application of XML and related standards to healthcare • Liora Alschuler • Co-chair HL7 Structured Documents TC • Chair, HL7 Marketing Committee • past Chair, KEG (wrote HL7 Clinical Document Architecture) • coordinator, HL7 HIMSS Technical Demo • consultant, writer • author, ABCD… SGML: A User’s Guide to Structured Information, 1995 • John Spinosa • MD and Ph.D. from UC San Diego; trained in pathology at UCSD; hematopathology fellowship, staff member at Scripps La Jolla • Co-founder of XML TC • Member of the CAP informatics committee

3. Outline • Information ecology • XML, a few tags at a time • Gating factors • Why this might work • Conclusions

4. Information Ecology technology technology business drivers business drivers data

5. Information Ecology • Primary cause of poor information flow in healthcare: lack of usable and re-usable electronic data • 85-95% of clinical data still paper based • HIMSS Leadership Survey 99-00 • 99: 10-11% have implemented EHR • 99: 25% planning to w/in one year • 00: 10-11% have implemented EHR • 00: 25% planning to w/in one year

6. Bad ecology • The impact: • IOM report: poor information leads to poor healthcare • can’t control costs • some claims, all attachments, most admin/finan transactions still paper electronic :: paper 3 billion :: 25-30 billion (Wit Capitol, 2000) • Can track price of peaches in Alberta, but can’t track status of claims

7. XML and info ecology • XML can break the electronic data log jam • The big breakthrough is not in the CPRI • The big change is in the • simple XML documents for ubiquitous access, integration and reuse • encoding of narrative, human language, for H2H and simple machine processing

8. What matters, what doesn’t? Tim Bray, June, 2001

9. Tim Bray, June, 2001

10. Tim Bray, June, 2001  #1 80/20 point     

11. XML for healthcare data • where is the 80/20 point for healthcare information? • it is not the full-blown “computerized patient record” (XML-encoded or not) Erica Drazen, VP First Consulting Group, in Healthcare Informatics: There are few organizations claiming complete CPR systems. “As originally defined, a CPR is neither necessary nor sufficient on its own as a tool for improving care.” To be useful, information needs to be available, first and foremost, and only then does it matter if it is coded to the extent that will support a CPR. “It’s doubtful that all the information in current records will ever be duplicated in electronic records, and it certainly will not all be coded.”

12. The 80/20 point for healthcare • Setting new targets for information exchange • more like the Web • healthcare-specific • Extensible Markup Language (XML) • Clinical Document Architecture

13. Clinical Document Architecture • New specification (Nov. 2000) for healthcare documents • Uses XML, like the Web, but vocabulary specific to medicine • Lower, simpler objectives than previous exchange specifications • common format for transcription and EHR records • Human-readable on Web, PDA, cell,…

14. CDA • Let’s take a look...

15. the 80/20 sweet spot:XML, a few tags at a time any transcription system can produce this <section> <caption> Impressions </caption> <paragraph><content>RLL nodule suggestive of malignancy... <assessment> <caption> Impressions </caption> <paragraph><content>RLL nodule suggestive of malignancy... or this or this, with post-process coding, NLP, AI, KM or a better user interface <assessment> <caption> Impressions </caption> <paragraph><content> <concept> <nodule type=“RLL”/> <coded entry domain=“SNOMED” v=“123”/> RLL nodule </concept> suggestive of malignancy...

16. ADT Orders Results Reports Vocab Vocab Vocab Consult Context Bill VHR Beta Labs Gamma Registry Speedy Payer Alpha Labs CSI Mercator SNOMED NeoTool MDProductivity SmallDoc Office GoodHealth Clinic Virtual Health Record FPT eMedicalFiles IPNet BeWell Hospital SoftwareAG MercuryMD Epic MSBizTalk/CGE&Y Sun Microsystems BestPractice Hospital Innovision Eclipsys MSDashboard Sentillion V2 V3 CDA CCOW Attachments

17. CDA: How to Create • creating CDA documents • Mayo • transcription • EHR • query

18. What can you do with a few tags? • access/portability/exchange • query/locate by patient, provider, practioner, setting, encounter, date • integration • multiple transcription systems • with EHR records • re-use/derivative data • summaries • billing

19. What can you do with a few tags? XML separates display format from structure and content, so you get one file, many displays provide universal access

20. XML data is accessible <section>Allergy List</section> <para>…</para> <para>…</para> <section>Medications List</section> automated table of contents creation, linked to content, through style sheet transformations

21. CDA: How to Display • One document, many views

22. CDA: How to Display • One document, many views • Many documents, one view

23. What can you do with a few tags? integrate records from multiple applications  CPR/EHR  standard XML transcription

25. ADT Orders Results Reports Vocab Consult Context Bill VHR Beta Labs Gamma Registry Speedy Payer Alpha Labs CSI Mercator SNOMED NeoTool MDProductivity SmallDoc Office GoodHealth Clinic Virtual Health Record FPT eMedicalFiles IPNet BeWell Hospital SoftwareAG MercuryMD Epic MSBizTalk/CGE&Y Sun Microsystems BestPractice Hospital Innovision Eclipsys MSDashboard Sentillion V3 CCOW V2 V2 CDA CDA Attachments

26. CDA: How to Manage

27. CDA::(v)EHR • a single CDA is not an EHR • a CDA is an episodic snapshot of care • a single CDA can be EHR input • a single CDA can be EHR output • CDA documents can serve as a virtual EHR

28. CDA::(v)EHR • CDA is not an EHR • will not drive decision support • will not supply fine-grained clinical data to drive public health surveillance • CDA Level One will be extended to Level Three supporting fine-grained clinical data • CDA Level One provides a gentle on-ramp to gain wider interoperability

29. Transcription: problem or solution? • Remains number one interface for creation of clinical records • Transcription: seen as cost factor to be minimized or eliminated • XML can make transcription output: • usable and re-usable • portable • basis for richly encoded record, mixing narrative, controlled text and images

30. Gating factors • Provider demand • Vendor suppy • Standards

31. Provider demand • Currently, no strong demand for XML as deliverable • Providers will create demand for clear quality/ROI goals: • access/portability/exchange • integration • re-use/derivative data • Clinical information as enduring asset

32. Vendor supply: Feb. 2001 • MedQuist: XML internally for platform integration; tracking stds • Edix: XML control files, clinical report in ASCII, HTML, Word • HealthScribe: XML-based technology in development for transcriptionist use • CareFlow|Net: XML output available, one client using it • Lanier: “air of inevitability”, but no demand • Vianeta: startup, XML-based technology for transcriptionist use • [2/02: MDProductivity, speech-to-CDA]

33. Standard XML • HL7’s Clinical Document Architecture ANSI/HL7 CDA R1.0-2000 meets current requirements • will extend to specialized document types • will extend to granular data • will be vehicle for professional/industry groups to standardize their own practice

34. Gating factors: summary • Healthy information exchange: • technology not the barrier • waiting for provider demand • standards helpful, but pull will come from providers technology technology business drivers business drivers data

35. This might work: Why? • technical issues: not difficult • many P2P models available • 100% solutions have not worked • 80/20 solutions gaining credibility Jim Klein, Gartner Group, on HL7’s CDA, April, 2001 RU: “HL7's Clinical Document Architecture (CDA) defines a new target for clinical information exchange that is substantially easier to hit than one based on standards for discrete data while delivering 80 percent of the value of the latter approach.”

36. This might work: Why? • technical issues: not difficult • many P2P models available • 100% solutions have not worked • 80/20 solutions gaining credibility • can scale down • The Bosworth/Bray Principle: simple interoperability wins • supported by early adopters

37. Conclusions • XML bang-for-buck: transcription • Incremental road to CPR/EHR starts with simple, electronic documents • Impetus is providers • Gradual approach that wins with physicians, scales down will change the industry

38. Discussion More info: liora@the-word-electric.com www.HL7.org, Structured Documents TC 1st CDA Conference: Oct. 7-9, 2002 Europe