A CDA Template for
Continuity of Care
Liora Alschuler, Roberto Ruggeri
HIMSS 2005
Acapulco partners: Charlie McCay, Ted Blizzard
About us
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Liora Alschuler
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Roberto Ruggeri
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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
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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
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alschuler.spinosa, consultants
Co-chair HL7 Structured Documents TC
Co-editor, CDA
member, 2005, HL7 Board of Directors
liora@the-word-electric.com
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
A CDA Template for Continuity of Care
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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 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.
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History of the CCR
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Originally the MA Patient Care Referral Form (PCRF)
Consortium of sponsoring organizations
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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:
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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
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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?
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It is intended to be simple to implement, use and explain
It is not a top-down approach
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End-users, i.e., practitioners have participated in its design
 The originator determines the relevant content
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It has support and leadership from organizations
representing end-users, who are
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It allows options for implementation
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Involving, advising, and assisting their constituents in its adoption
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
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The CCR Is Not…
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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
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A progress note, discharge summary, or
consultation
 It
 It
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is not limited to information from a single encounter
is not free-text based
A loose dataset of health information
 It
is a defined set of core data in specified XML code
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
What is CDA?
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CDA is defined by the RIM
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CDA RMIM is a constraint on the RIM
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Classes “cloned” (replicated, renamed, constrained with
vocabulary, datatypes)
What is CDA?
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CDA interoperable with
EHR, V3 messaging
clinical content through
“clinical statement”
What is CDA?
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CDA complimentary to medical records messages
and orders
Message is the envelope
 CDA is the payload/contents/“letter”
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CDA is persistent (WORM drive heuristic)
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Cannot be relied on for distribution & routing beyond
static contents of CDA header
CDA is a snapshot in time, under signature
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Is not, itself, a birth-to-death, aggregate record
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Areas of overlap
CCR
CDA
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Can include contents of single referral
 Both use XML for document exchange
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Areas of divergence
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Generality:
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XML
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CDA persistent
CCR contains transmission-specific information
Aggregation
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CCR XML handcrafted
CDA XML derived from RIM using V3 principles
Persistence
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CDA is generic to all clinical documents
CCR is specific to continuity, US realm
CDA a single unit, can be part of an aggregate record
CCR can be single unit or can be the aggregate record
Conclusions
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Significant areas of overlap, although aspects of scope, approach differ
HL7 sees continuity of care records as just another document type
CDA– CCR Mapping
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Mapping project fall, 2003
Roughly
equivalent 
metadata
Included CDA, CCR, New Zealand
General vs.Health
specific Event
content
Summary, Australian Health Connect,
requirements & participation from Germany,
Japan
Template creation & validation:
model-based (Acapulco flavor)
.mif
..xsd
.xml
<Section>
.xml
<Section
code=Plan>
rsMIFeditor
.mif
prose
Plan
xslt
V3xsdGen
..xsd
.xml
<Plan>
Create derived MIF
Template creation & validation:
model-based (Acapulco flavor)
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Advantages
 Exchange
& validate
referral requirements
 Exchange & validate
at highest level of
interoperability
 Can constrain
authoring
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Disadvantages
 Tooling
immature
 Still limited by xsd
Template Creation & validation
(Dallas flavor)
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Objectives:
 CDA CCR
creation and validation in simple authoring
environment with simple rule set
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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 34140-4
• 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
Dallas flavor validation:
.mif
.xsd+xpath
.xml
.xml
<Section
code=Plan>
<Plan>
rsMIFeditor
prose
Plan
Transform to
generic CDA
XPath
validation of
document type
requirements
Valids against
generic schema
Conclusions: concept
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Concept: viable
Must extend model to RIM-compliant expression of
full requirements
Reference Information Model
CDA + MRM RMIM
CCR documents
Referrals
DMIM
CCR Medical
records
CCR Orders
CCR referral documents
CCR GP referrals
CCR pediatric referrals
CCR geriatric referrals
CCR EHR,
Patient Care
Next step for V3 tooling:
2-stage validation
.mif
.xsd+xpath
.xml
<Section>
.xml
<Section
code=Plan>
rsMIFeditor
prose
Plan
.mif
V3xsdGen
..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
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?