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

About us Liora Alschuler alschuler.spinosa, consultants Co-chair HL7 Structured Documents TC Co-editor, CDA member, 2005, HL7 Board of Directors Roberto Ruggeri Senior Healthcare Strategist Microsoft Member of the ASTM CCR Technical group and TAG Member of the HL7 Structured Documents Committee 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 Charlie McCay Ramsey Systems, UK Also participating: Dr. Tom Sullivan, Massachusetts Medical Society; Bill Braithwaite, HL7 Thanks to Bob Dolin for help in coding clinical statements

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

Continuity of Care Record What is it? Core data set of the most relevant and timely facts about a patients 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.

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)

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….

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

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 wont have to search for relevant information Fewer repeat lab tests and other evaluations

The CCR Is Not… An EHR It is not a complete electronic health record of a patients 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

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 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) What is CDA?

CDA interoperable with EHR, V3 messaging clinical content through clinical statement

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

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 CCR CDA

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

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

Create derived MIF

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

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)

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

What to template? Sections Sub-sections Selected observations

Create table of CDA & template markup Document type code: LOINC Coding limited to template objectives Used CCRlocal where term equivalent not found

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]

MS Word XML authoring

Validation in MS Word XML

Save as CDA XML

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

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

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

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!

Thank you! Questions?