Joint ITU-WHO Workshop on
e-Health Standards and Interoperability
(Geneva, Switzerland, 26-27 April 2012)
HL7 CDA and its broad adoption
Catherine Chronaki
Affiliate Director, HL7 International
Board of Directors
chronaki@ics.forth.gr
Geneva, Switzerland, 26-27 April 2012
What is CDA?
CDA is a document markup standard for the
structure and semantics of an exchanged
"clinical document".
CDA embodies business critical characteristics
Persistence
Stewardship
Potential for authentication
Context
Wholeness
Human readability
A CDA document can
exist outside of a message
include text, images, sounds, multimedia content.
Major Components of a CDA Document
<ClinicalDocument>
...
<structuredBody>
<section>
<text>...</text>
<observation>...</observation>
<substanceAdministration>
<supply>...</supply>
</substanceAdministration>
<observation>
<externalObservation>
...
</externalObservation>
</observation>
</section>
<section>
<section>...</section>
</section>
</structuredBody>
</ClinicalDocument>
Header
Narrative Block
External
References
E
N
T
R
I
E
S
S
E
C
T
I
O
N
S
B
O
D
Y
D
O
C
U
M
E
N
T
What are CDA Characteristics?
Richly expressive and flexible
Encoded in Extensible Markup Language (XML).
Based upon HL7's Reference Information Model (RIM)
Enables data reuse
Patient summaries
Lab and pharmacy messages
Clinical research
Electronic prescriptions
Clinical Decision Support
Public Health
Quality assessment
Constrained by Templates, conformance profiles,
implementation guides to be fit for purpose
Standard EHR Interface
National /xborder Requirements
Local EHR
Clinical reuse
Decision support
Secondary use
CDA
Template
Library
Quality reporting
CDA
Implementation
Guide
What is the Key Value of CDA?
Incremental Interoperability means that an
implementer can begin with a simple CDA, and
then add structured data elements over time.
CDA R2 consists of a single CDA XML Schema,
and the “architecture” arises from the ability
to apply one or more “templates” which serve to
constrain the richness and flexibility of CDA.
Professional society recommendations, national
clinical practice guidelines, standardized data
sets can be expressed as CDA templates.
Trifolia workbench library freely available to
HL7 members: numerous types of reusable
templates that might be created in CDA.
Templated CDA
Many different kinds of documents
A bucket of reusable templates
Trifolia Workbench : CDA Template Library
There are many kinds
of templates that
might be created.
Particularly relevant
for documents are:
Document-level
templates constrain the
CDA header and
allowable sections
Section-level
templates constrain
the allowable entries
Entry-level
templates, define the
atomic clinical
statements within
document sections
greenCDA
XML
CDA
Template
Library
Data Entry
Form
CDA Instance
Validation
CDA
Implementation
Guide
Support for standards
development
Runtime API
Support for standards
implementation
Green CDA
The problem
An instance conforming to an
CDA Implementation Guide may
require knowledge multiple
specifications
CDA R2 base specification;
HL7 Version 3 data types
CDA templates defined in the IG;
CDA templates referenced by IG;
Terminology code lists
defined/referenced by IG;
Validation of an instance
conforming to a CDA IG may
require additional validation
W3C Schema validation;
Schematron validation;
Geneva, Switzerland, 26-27 April 2012
The solution
Create “authoring schema” to
simplify IG creation/ processing:
Clinically meaningful XML
element and attribute names;
100% transformable into
conformant CDA IG;
Hiding complexities of HL7 v3
GreenCDA schema modular and
easily reproducible
We call this strategy:
greenCDA
greenCDA schemas are
modular, corresponding to CDA
templates.
9
CDA Interoperability Roadmap
1.
2.
Get the data flowing, get the data flowing, get the data flowing.
Incrementally add structure, where valuable to do so.
Quality
Reporting
Decision
Support
Clinical
Applications
Meaningful
Use!
Coded Discrete
Data Elements
HL7 CDA
Structured
Documents
Narrative
Text
SNOMED CT
Disease,
DF-00000
Metabolic
Disease, D6Disorder of carbohydrate
00000
metabolism, D6-50000
Disorder of glucose
metabolism, D6-50100
Diabetes Mellitus,
DB-61000
Type 1,
DBNeonatal,
61010
DB75110
Carpenter
Syndrome, DB02324
Insulin dependant
type IA, DB-61020
Why CDA is so widely adopted?
Numerous implementations worldwide
Japan, Korea, France, Europe (epSOS,..), US, Canada, ..
CDA hits the “sweet spot”
CDA expresses clinical documents. A single standard for the entire EHR is
too broad. Multiple standards and/or messages for each EHR function
may be difficult to implement. CDA is “just right”.
Implementation experience – green CDA
CDA has been a normative standard since 2000, and has been balloted
through HL7's consensus process. CDA is widely implemented.
Gentle on-ramp to information exchange
CDA is straight-forward to implement, and provides a mechanism for
incremental semantic interoperability.
Improved patient care
CDA provides a mechanism for inserting evidence-based medicine into
the process of care (via templates)
CDA crosses institutional borders/Lower costs
CDA’s top down strategy let’s you implement once, and reuse many
times for new scenarios.
Extra slides
Geneva, Switzerland, 26-27 April 2012
12
Conclusions and
Recommendations
Templated CDA
Provides reusable building
blocks
Streamlines efforts:
Implement once,
deploy often.
Promotes modularity and
reusability across Igs
Offers “incremental
interoperability” is core
to CDA’s strategy : Begin
with simple CDA, and add
templates as they are
prioritized.
Geneva, Switzerland, 26-27 April 2012
Future of CDA
CDA Version 3
Rapid adoption of template
libraries
Template/ schema tooling
Vocabulary binding
International resources
ISO Standardization
Lessons from CDA adoption
Intuitive/ low entry
Free Trifolia library
Collaboration
Mobile health comes next with
Green CDA
13
Continuity of Care Document
•
•
•
•
•
•
•
•
Clinical history
Advance Directives
Support
Functional Status
Problems
Family History
Social History
Allergies
•
•
•
•
•
•
•
•
Medications
Medical Equipment
Immunizations
Vital Signs
Results
Procedures
Encounters
Plan of Care
CDA Guiding Principles
• Prioritizes documents generated by clinicians
involved in direct patient care.
• Minimizes the technical barriers needed for
implementation
• Promotes longevity of all information
• Enables exchange that is independent of the
underlying transfer or storage mechanism.
• Assures that policy-makers can control their own
information requirements without relying upon
extensions
HIT Standards, Terminologies, and
Profiles: a Strong Collaboration
Drive
Standards Development Organizations
HL7 International, ISO/TC 215 Health
Informatics, IHTSDO CEN/TC 251 Health
Informatics, CDISC, GS1, others
Terminologies
Regenstrief (LOINC)
EDQM
WHO (ICD)
Integration Profiles
www.jointinitiativecouncil.org
Integrating the Healthcare Enterprise (Content
profiles)
Continua Health Alliance (personal health devices
CDA Template Development*
TODAY
A thousand flowers
bloom
* After the Gartner Curve
Active
Harmonization
Gradual increase in templates
demanded by new use cases
Templated CDA
• Many different kinds of documents
• A library of reusable templates
A CDA document
using CCD templates plus others
A CDA document using CCD templates
New Section…
Discharge Diet
Surgical Finding
Mode of
Transport
Discharge
Diagnosis
Chief Complaint
Payer
Problems
Medications
Vital Signs
Social History
Family History
Allergies
CDA
....
Demographics
CCD
The Business Case for CDA
CDA is highly flexible and configurable – CDA support every type of
clinical document. A single standard for the entire EHR
may be too broad. Multiple standards and/or messages
for each EHR function may be difficult to implement.
CDA satisfies all such needs.
CDA Implementation experience is vast - CDA
has been a Normative Standard since
2000, and has been balloted through HL7's
consensus process. CDA is widely implemented.
CDA provides a gentle on-ramp to information exchange - CDA is
straight-forward to implement, and provides a mechanism for incremental
semantic interoperability.
CDA improves patient care - CDA provides a mechanism for inserting
evidence-based medicine directly into the process of care (via templates)
CDA lowers costs – Leveraging CDA provides “top down” strategy allowing
initial implementation to be reused many times for highly varying scenarios.
Requirements for Achieving Quality







Policy Alignment
Relevant Standards
Economic Incentives
Industry Collaboration
Public Health Support
Research Validation
Trust
Collaboration
If you want to go fast, go alone.
If you want to go far, go together.
- African Proverb
Quality Reporting Framework
Leveraging Open Source Quality Measures
popHealth: An open-source quality measure
eMeasure
QRDA
Category
II/III Reports
PQRI XML
Registry
Specification
QRDA
Category I
Instances
Quality Assessment using CDA Templates
Translating a Use Case to CDA
Understanding Templated CDA
Highly Configurable CDA Templates
30.05.2016
Content for Patient Summary ‘Minimum dataset’
Information/dataset
Contains
Patient Identification
Unique identification for the patient in that country.
Patient Personal information
Allergies
Full name.
Date of birth
Gender
Allergy description and agent
Medical Alerts
Other alerts not included in allergies
List of current problems
Problems/diagnosis that need treatment and/or follow up by a
Health Professional
Medication Summary
Current medications
Country
Name of Country of origin of the patient (country A)
Date of Creation
Data on which PS was generated
Date of last update
Data on which PS was updated
Author organization
At least an author organization (HCPO) shall be listed. In case
there is not HCPO identified at least a HCP shall be listed.
J. Thorp 2011
Example: Need for information in France
Hospital in
Dijon
(CHU Dijon)
?
• Maria Schmidt, a 25 year old Austrian student
shows up at the Emergency department at CHU
Dijon (Hospital in Dijon). The chief complaint is
abdominal pain occurring 3 to 4 hours after a meal
• An abdominal x-rays show signs of intestinal
occlusion. The overall clinical presentation is
inconclusive, with a diffuse abdominal pain and
not needing surgical intervention
• The physician considers keeping the patient under
observation only, or performing an exploratory
laparotomy
J. Thorp 2011
Request to the French NCP
• As the physican knows that epSOS can provide more
information, she searches for the patient.
• The search is directed towards the French National
Contact Point (NCP), which in turn will provide the
location of the student’s Patient Summary
French NCP
Request for information
CHU de
Dijon
J. Thorp 2011
Request from NCP France to NCP Austria
• The French NCP issues a request for information to the
Austrian NCP.
French NCP
Request for information
Austrian
NCP
J. Thorp 2011
Austrian Patient Summary – 1
1. The Austrian Patient Summary of the patient is located
2. The document is syntactically transformed into the epSOS
format, according to the specifications
xml - epSOS CDA
original
Transformation
National Connector and National Transformer
J. Thorp 2011
Austrian Patient Summary – 2
1. The original document is transformed into an epSOS document
2. The original document is also transformed into a pdf file
3. The pdf has the same header as the epSOS document (in order to
provide the link and the traceability between the two documents)
epSOS CDA
original pdf with the
same CDA header
CDA+ pdf
National Connector and National Transformer
J. Thorp 2011
Information from Austrian NCP to French NCP
• The Austrian NCP sends two documents to the French NCP:
• the transformed document (in epSOS format)
• the original document in a document (pdf) format
French NCP
Information returned
Austrian
NCP
J. Thorp 2011
Results available for the French physician
• The French physician receives the original document
as pdf in German as well as the transformed
document in the epSOS format.
Information returned
original pdf with the
same CDA header
French NCP
epSOS CDA
CHU de
Dijon
J. Thorp 2011
Austrian Patient summary is
understandable by the French physician
J. Thorp 2011
CDA: Towards Standard EHR Interface
Quality
Measure
EHR
system
Decision
Support
Comparative
Effectiveness
Clinical
Research Public
Health
CDA
Template
Library