Consolidated CDA Basics. Lisa R. Nelson, Lantana Consulting Group

Transcription

1 Consolidated CDA Basics Lisa R. Nelson, Lantana Consulting Group

2 Learning objectives 1. Explain why Consolidated CDA is relevant to Health Story Project (5) 2. Gain familiarity with the structure of a CDA document (15) 3. Appreciate the evolution of the Consolidated CDA (C-CDA) standard (20) 4. Discover reference sources for information about CDA and C-CDA (5) 5. Address questions about C-CDA (15)

3 Why is C-CDA important to Health Story?

4 CDA Design Principles 1. Persistence A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements (NOTE: There is a distinct scope of persistence for a clinical document, independent of the persistence of any XML-encoded CDA document instance). 2. Stewardship A clinical document is maintained by an organization entrusted with its care. 3. Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated. 4. Context - A clinical document establishes the default context for its contents. 5. Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document. 6. Human readability A clinical document is human readable.

5 Why is C-CDA important to Health Story?

6 Stakeholder objectives Patients Clinicians Payers Health Information Managers Researchers, Analysts Vendors OBJECTIVES Quality Ethics Legal DRs RNs Patients Families Researchers PH Administers Payers HIMs Vendors Regulators Contribute Your Point Of View HIMSS Health Story Project

7 What does a CDA document look like? Document Header Sections Entries Entry-parts [1..1] [1..1] [1..*] [0..*] [0..*] Alternate option: unstructured body

8 What does a CDA document look like?

9 What does a CDA document look like? Machine Processable xml File Style-sheet Transformed Human Readable Document

10 Human readable text and Machine readable entries

11 Human readable text and Machine readable entries

12 Human readable text and Machine readable entries Referential registration aligns human and machine readable information

13 HL7 Clinical Document Architecture Standard (HL7 CDA) The evolution of CDA Developed by Health Level Seven (HL7) to leverage HL7 v CDA got started 2000 Release 1 (HL7 CDA R1) 2005 Release 2 (HL7 CDA R2) 2006 Continuity of Care Record (ASTM CCR) 2007 Clinical Care Document (HL7 CCD) 2008 Additional Health Story Implementation Guides IHE Medical Summary and other document types HITSP C CDA R2 named in Meaningful Use Stage 1 (MU1) 2012 Consolidated-CDA (C-CDA R1) named in MU CDA R3 (postponed) 2014 CDA R2.1 project started 2014 C-CDA R2 to be published (November 2014) Constraints on CDA R2 Based on CCR, IHE Medical Summary, HITSP C-32, 8 Health Story Docs Consensus-based Consolidated

14 Past HL7 CDA R1 HL7 CDA R2 HL7 Continuity of Care Document (CCD) v1.0 Health Story Implementation Guides HITSP C-32 IHE Medical Document (XDS-MS) Consolidated CDA (C-CDA) R1.0

15 Present Consolidated CDA (C-CDA) R1.1 9 Document templates 1. CCD 2. Consultation Note 3. Diagnostic Imaging Report 4. Discharge Summary 5. H&P 6. Operative Note 7. Procedure Note 8. Progress Note 9. Unstructured Document 1 Header template 74 Section templates 90 Entry templates Clinician Generated Documents Near Future Consolidated CDA (C-CDA) R Document templates 1. CCD 2. Consultation Note 3. Diagnostic Imaging Report 4. Discharge Summary 5. H&P 6. Operative Note 7. Procedure Note 8. Progress Note 9. Unstructured Document 10. Care Plan 11. Referral Note 12. Transfer Summary & 2 Header templates 81 Section templates 119 Entry templates Clinician Generated Documents Patient Generated Documents

16 Reusable Reusable information representation patterns

17 ble Reusable data representation patterns

18 C-CDA Map to Meaningful Use Summary Types e

19 Other C-CDA-based documents Patient Care Antepartum Summaries Labor and Delivery Summaries Pt Plan of Care Advance Directives Quality, Research, and Public Health Cancer Registry Reporting Birth and Fetal Death Reporting Newborn Hearing Screening Newborn Hearing Plan of Care Public Health Case Reports National Hospital Care Surveys Health Questionnaires & Responses Questionnaire Response Laboratory Laboratory Report EP Report Registry Submission Anatomic Pathology Report to Public Health Anatomic Pathology Report Radiology Imaging Report Cardiology Cardiac Imaging Report Catheterization Report Patient Care Devices Personal Health Monitoring Record

20 C-CDA R2.0 Care Plan Goals Section (NEW) Health Concerns Section (NEW) Health Status Evaluations and Outcomes Section (NEW) Interventions Section (V2) Referral Note Opportunity for close loop communication Transfer Summary Greater Continuity of care

21 Future CDA R2.1 Incremental improvement of CDA R2 CDA on FHIR Minimizes disruption for existing implementations Document is a Composition Resource Basic constructs for document, header, sections, entries C-CDA on FHIR Profiles constraining FHIR Resources the way C-CDA Entry Templates constrain CDA FHIR & CDA Calder: Mountains and Clouds Fast Healthcare Implementation Resources (FHIR) Composition Resource Document Mobile Data Stabile Data Section Section Human readable text Reference Entry Human readable text Profiles Templates Resources Clinical Statements

22 Challenges Issue Risk of not maintaining enough focus, insufficient velocity of updates under rising demand Demonstration projects and pilots seem divergent and incompatible when used beyond display-only While CDA has the ability to organize collections of relevant data for sharing and re-use, it is not appropriate or sufficient for initial data capture Mitigation HIMSS Interoperability & Standards Practices Task Force C-CDA Specification Review Subgroup HL7 is mindful of the requirements, continuously reviews the needs, has issued assurance of timely updates Provide additional guidance to close the gap between guidance and implementation. Continue to develop other tools which will support the collection of data and population of persistent documents CDA Doc FHIR Content Creator share Content Consumer FHIR

23 Resources HL7 standards: IHE standards: Examples: Education: HL7, Lantana Academy, Books: The CDA Book. Keith Boone (Springer, 2011). Meaningful Use Companion Guide: Tooling: e Trifolia: MDHT: Art Décor: Value Sets: VSAC: PHINVADS:

24 Questions?