HL7 CDA Around The World: Many Patient Summaries One
HL7 Standards in the global eHealth Ecosystem: What’s new?HL7 CDA Around the World:Many Patient Summaries one StandardCatherine ndedunderFP7-610756
HL7 Leads HIT Standards development since 1987Mission: build the best most widely used HIT standardsHistory:Since 1987 HL7 grows exponentially - demand outstrips capacity, HL7 v3, HL7CDA, 40 WGs, 50 standards products in use; HL7 is supported by over 35national/regional Affiliates and members in over 55 countries1997:2004:2009:2010:2012:2013:19872first national affiliate on board/ IHIC conferenceHL7 CDA is adoptedHL7 International, USA on the International CouncilHL7 International Foundation in Europe established25 years youth celebration with FHIR, HL7 AsiaHL7 makes standards available under free license199720042009201020122013
OverviewPatient Summaries around the world in HL7 CDAPatient Summaries in CDAEuropeAsia-PacificAmericasEU: European Patient Summary GuidelineCross border care in the European UnionAcross the Atlantic with Trillium BridgeTrillium Bridge: Some early findingsThe problem with standardsConclusions / outlook3
HL7 CDA in GermanySlides Curtesy of: Kai HeitmannPast Chair HL7 Germany
Sciphox (sky-fox) Project (DE) Introduction of CDA in the year 2000 inGermany, as a cooperation between generalpractitioners and hospitals Lead later in 2005 to the first CDA R2Discharge Letter definition– With 15 vendors involved– Large show case, implementations Was input to similar definitions in Austria(national infrastructure ELGA) and Switzerlandaround 2008-2010
German Discharge LetterGenesis, influence, cooperation2005Courtesy of AlexanderMense, Stefan Sabutsch,Bernd Blobel, modified2014
ART-DECOR Tool DECOR– Data Elements, Codes, OIDs and Rules ART– Advanced Requirement ToolingInternet: art-decor.org
HL7 CDA legacy:patient summaries in FinlandSlides Curtesy of: Prof. Juha MykkänenChair HL7 Finland
HL7 Finland in context Finland: 5,5M population, steep aging curve Health care system: public health care organized by 320 municipalities and joint boards onthree levels: reform decision in 2014 five major regions as organizersof health and social services, municipalities as service providers private and third sector: occupational health services, private clinicsand hospitals eHealth in Finland 100% EPR penetration in public services, long-term development ofeHealth systems and services, from local to regional and national-level “at a world-level benchmark in eHealth” (EHTEL review 2013) New national eHealth strategy preparation underway:interoperability as a central part of infrastructure strategyHL7 Finland (est.1995): long history in HL7 messages and IGs, activetechnical committees, integrated IHE and personal health SIGs, etc.One of the very first implementation of HL7 CDA (2004-5)
HL7 CDA in Finland CDA R1 was used in regional information systems for information sharing CDA R2 was selected for national eHealth infrastructure ( 2005) Kanta services: National EPR archive, ePrescription centre, national code server, etc. Transport using HL7 v3 Medical Records Messages (in future: also IHE infrastructure) CDA R2 localized implementation guides in Finland for: ePrescription (prescriptions, dispensations) EPR core dataset patient summary, providers, diagnoses and concerns, procedures, examinations,results, service events, aids, blood group, functional status, medical certificates, queuing, followups, goals, risks, nursing core dataset including summaries lab, medication, imaging reference and report, referral and discharge, scanned documents, dentalrecords Use of CDA in national ePrescription IGs made it easier to study, understandand comply with the international ePrescription specifications According to epSOS experience from the National Insurance Institute (Kela)
HL7 CDA legacy in ELGA:patient summaries in AustriaInformation Curtesy of Dr StefanSabutsch, Chair HL7 Austria
HL7 CDA in ELGAThe ELGA GmbH is responsible for defining nation-wide HL7 CDAImplementation Guides in Austria.The process of creating HL7 CDA Implementation Guides was intense:3 years of harmonization work in working groupsInclusive process including Austrian stakeholdersResulted in nation-wide harmonized and detailed technicalspecifications and Implementation GuidesDischarge Summary (Physician)Discharge Summary (Nurse)Laboratory reportRadiology reportAll documents are availablefrom http://www.elga.gv.at/index.php?id 28(German language only).12
Global IHE Implementation Guidesin the Austrian contextUse of International standards is a fundamentalrequirement for ELGAIHE profiles are adapted to Austrian demandsWhy was it impossible to adopt as is the IHEspecifications?Austrian constraints demanded changing parts of templatesworking group experts considered better alternatives.What type of changes?stricter or relaxed options of CDA Level 3 entries based onvalue-sets for code-listsNew content template that matched perfectlythe Austrian needs.13
ELGA discharge summariesPhysician and Nursing discharge summary partsseparate CDA documents and Implementation Guides (IGs)relevant information is responsibity of Physician or Nurseboth accessible in ELGA by both parties.Austrian Health Record (ELGA) includes documents that followthe ELGA Implementation Guides.Organizations must upgrade the information systems toconform to ELGA IGs to connect to ELGAThree ELGA Interoperability Levels (EIS)to enable quick & easy connection of providers, min data qualityThe ELGA legislation act mention that in the future the AustrianMoH will enforce interoperability levels through ordinances.14
ELGA Interoperability levels (EIS)EIS “Basic” / “Structured” minimum requirementcoded information for document registry, access control system.medical content may be unstructured data, e.g. embedded PDF object.CDA documents conform to the Common Implementation Guide (IG) andCDA Header-constraints in Specialized IGsEIS “STRUCTURED” indicates that the human readable content ofan embedded PDF meets the requirements of Specialized IGsEIS “Enhanced” further to EIS “Basic/Stractured”documents have to additionally follow the CDA Body constraints ofSpecialized IGUnstructured content is not allowed in this level.CDA Body is generally structured in CDA 2 sections, may contain CDA L3elementsEIS “Full support” further to EIS “Enhanced”CDA documents conform to CDA Body constraints of Specialized IGsAdditional CDA Level 3 entries are required in most of the sections.15
Patient summaries in ELGAELGA to serve as platform for Patient summaryPatient Summary could be automatically created out ofexisting documents in ELGAdischarge summarylab radiology reportRequirements for ELGA patient summariesall ELGA documents in EIS “full support”more documents types to a complete patient summary.If these basic prerequisites are not fulfilled, anautomatically generated patient summary remains wishfulthinking 16
HL7 CDA & Patient summariesin the NetherlandsSlides Curtesy: Kai Heitmann,Past Chair HL7 GermanyInformation on Patientsummaries Curtesy of Dr MichielSpringer, NICTIZ
Colon Cancer Screening (NL)2Colonoscopy Pathology31PopulationScreeningData ExchangeColonoscopyPathologyvia HL7 CDADocumentsQuality insurance anddata center4Treatment orSurveillance
Screening Data set RIVM (National Institute for Public Health andthe Environment) specifies set of data for– Screening process– Data warehousing– Monitoring (quality, financial, etc.) Cooperation between Medical Specialists andIT-Professionals result:– dataset in ART-DECOR CDA documentspecifications for the exchange of information
Definition of a dataset
Dutch Discharge summary project8 University Medical Centers (UMCs) and Nictiz definepatient summary for patient referralsoutreach to 90 general hospitals in the countryextend to sectors like mental health and nursing homesPatient Summary in HL7 CCR/CCD, v1.0, Apr 2013.37 clinical templates or building blocksDCM methodology (light) SMOMED and LOINCDocumentation in English is available.4 of the 8 UMCs build new EHRs, and will add capability ofexchanging CDA patientsummaries.Refinement and maintenance procedure (summer 2014)Handle 90 change requestsAdd templates specific to nursing, quality reporting.C-CDA referral document.21
CDA life in New ZealandSlides Curtesy of Dr AlastairKenworthyMoH New Zealandithealthboard.health.nz/standards
Our three pillars of interoperability in NZClinical datarepositoriesmodelled onXDSCCR,SNOMED andopenEHRbased contentmodelCDA forclinicaldocuments
Where CDA life in NZcame from
NZ will use CDA at all pointson the circle of care
NZ is rapidly movingfrom HL7 v2 transport toRESTful web services
Summer of CDANZ has developed a core set ofCDA document types 10043 CDA Common Templates\10041.1 Discharge Summaries10047 Clinical Assessments10052 Ambulance ePRF10030 PrescriptionsGP2GP27
10052.1NZ is still busilydeveloping CDA basedAmbulance CareSummarystandardsData Set10052.2 CDA Templates forAmbulance Care SummarySNOMED coded clinicalimpressions and procedures forambulance ePRFIn development
Patient Summaries in KoreaSlides Curtesy of Prof. Il Kon Kim
Medical information exchange forWorker’s Compensation HospitalMetadatapatient infoCDADocument ofreferral/reply/CRSWorker’s althcareserviceCDA includingStandard termpaymentInformationexchange serviceCCD forRehabilitationAnd CRS MetadataIndustrial AccidentSpecial Hospitalspatientsmartactivity trackingRequest smartcare ulti-SensorActivity sensorSmartCare ServiceRef. ezCareTech, Korea
Project TeamFundProject AdministratorSubproject AdministratorConsulting Group
Care Record Summary Sections/EntriesHeaderBodyData ElementLOINCNameCodeItem / EntryDocumentInformationTemplateid / ID / Code / EffectiveTimeRecordTargetName/ Gendercode / Telecom /Birthtime/ address/ ID /AuthorInformationTime / ID / Address / Telecom / AssignedPersonCustodianID / Name / Address / TelecomTemplateIDEncounter Section46240-8Encounters Activities2.16.840.1.113883.10.20.22.2.22Problem Section11450-4Problem ConcernAct/Problem ionsSection10160-0Medication Activity / Medication Information /Medication Supply Order2.16.840.1.113883.10.20.22.2.1.1Results Section30954-2Result Organizer / Result ationsSection11369-6Immunization Activity /Immunization Medication Information2.16.840.1.113883.10.20.22.2.2Allergies Section48765-2Allergy Problem Act / Allergy Observation /Reaction sSection47519-4Procedures Activity Act / Indication2.16.840.1.113883.10.20.22.2.7.1Plan of CareSection18776-5Instruction / Plan of Activity Act / Plan of ActivityEncounter / Plan of Care Activity Observation /Plan of Care Activity Procedure / Plan of Care ActivitySubstance Administration / Plan of Care Activity Supply2.16.840.1.113883.10.20.22.2.10Vital Sign(Optional) Section8716-3Vital Signs OrganizerVital Signs Observation2.16.840.1.113883.10.20.22.2.4Ref. IHIS & Ucaresoft, Korea
Patient Summaries in JapanInformation Curtesy ofMassaki Hirai
Patient Summaries in JapanHL7 CDA has been adopted in JapanHL7 Japan work on summary standard using CDA.no paper base summary standard in Japan.Many researchers have tried to develop thestandard but they are not yet success.Current approach is that the standard is usingnarrative part and automatically generatedcontents.34
Patient Summaries in the EU
European Patient SummaryGuideline (based on epSOS)
Patient summaries in the USA
US Meaningful Use: ConsolidatedCDA/CCD§ 170.205 Content exchange standards andimplementation specifications forexchanging electronic health information.170.205(a Consolidated CDA (C-CDA):)(3)Standardized representation ofthe Consult Note, DiagnosticImaging Report, DischargeSummary, History and Physical,Operative Note, Procedure Note,Progress Note, and Continuity ofCare Document (CCD).170.205(h)CDA Guide for Quality ReportingDocument Architecture, Category I170.205(i)CDA Guide for Reporting to CentralCancer Registries170.205(k)CDA Guide for Quality ReportingDocument Architecture, Category III(QRDA-III)38
HL7 CDA content exchange standardsunder Meaningful Use Stage II§ 170.205 Content exchange standards and implementation specifications forexchanging electronic health 05(k)39Consolidated CDA (C-CDA): Standardized representation of the ConsultNote, Diagnostic Imaging Report, Discharge Summary, History and Physical,Operative Note, Procedure Note, Progress Note, and Continuity of CareDocument (CCD).CDA Guide for Quality Reporting Document Architecture, Category I (QRDAI): Standardized representation of quality data for an individual patient. Datain a QRDA-I report can be consumed by a calculation engine to determine ifthe patient met the numerator or denominator criteria for a given qualitymeasure.CDA Guide for Reporting to Central Cancer Registries: Standardized cancerregistry reporting format.CDA Guide for Quality Reporting Document Architecture, Category III(QRDA-III): Standardized representation of aggregate quality data (e.g.number of patients meeting the numerator criteria for a given qualitymeasure).
Blue Button HL7 C-CDA SectionsHeaderAllergies, Adverse Reactions, AlertsEncountersImmunizationsMedicationsCare PlanDischarge MedicationsReason for ReferralProblem ListProceduresFunctional & Cognitive StatusResultsSocial HistoryVital SignsDischarge Instructions40DescriptionPatient information demographicsIncludes status and severity of each.Surgeries, ED visits, etc.Immunizations and vaccinesAs prescribed by the providerPlanned activities and encountersPart of hospital discharge summaryWritten reason for referralConcerns, complaints, and observationsHistory of proceduresList of impairmentsIncludes laboratory testsObservations like smoking, drinking, etc.Includes height, weight, blood pressure, etcWritten discharge instructions
Trillium Bridge ProjectWhat:Pragmatic Feasibility study on the exchange of Patient Summariesacross the AtlanticHow:Comparing, analyzing, and mapping patient summaries starting withMeaningful Use 2 C-CDA/CCD and EU patient summaries (epSOS)When:From: July 2013 to February 2015Who:A stellar consortium comprising EU member state ministries,provider networks, industry, associations, SDOs41
Trillium Bridge Use CasesOne Value proposition:When patient needs unplanned care overseas, a EHR summary fit for thepurpose of safe and efficient health care is available.After the health care encounter, patient receives encounter report in aformat and language that can be understood back home.Two use cases:Provider mediated (citizen controlled, provider initiated)Patient mediated (citizen initiated, citizen controlled)Blazing the transatlantic path – constraints and assumptionsTranslation of narrative unstructured content (not in scope)Incorporate patient summary elements in EHR or PHR (not in scope)Preconditions: citizen empowermentEU Citizens have access to their EU Patient Summary (e.g. epSOS PAC, HECR)US Citizens have access to their Clinical Summary inC-CDA/ CCD42
Milestones to successWe arehereTesting theBridge:43 Testing ToolsBuilding the Data SetsBridge: Validation Aligning Structure Reports& Terminology Trust AgreementsSelecting InteroperabilityGrounds:assets Pilot Use Cases BusinessArchitecture Gap AnalysisPolicy Alignment: Organizational, Legal,Regulatory Interoperability Feasibility Analysis Cross-vendor integration Incentives Standardization Innovative Business models eIdentification, Security and privacy Education Clinical Research
Comparing EHR Summaries:EU Patient Summary vs US Clinical SummariesSame base Standard (HL7 CDA)Different philosophy: capture vs continuity of careDifferent IGs: C-CDA/CCD (US realm) vs epSOS IGDifferent technical approach: Open vs Closed Template44
Gap Analysis: Clinical Comparison (Body)epSOS/EU PatientSummary GuidelineSectionEU PSGuidelineepSOS gyMedical Alert emRROProceduresO (R only duresO (R only forinpatients)(other alerts not included inallergies)VaccinationsList of resolved, closed orinactive problemsSurgical Procedures prior tothe past six monthsList of current problems /diagnosesMedical Devices andimplantsMajor Surgical Procedures45in the past six months
Gap Analysis: Clinical Comparison (Body)epSOS/EU Patient SummaryGuidelineTreatmentRecommendationsAutonomy / InvalidityList of current medicinesSocial History ObservationsEU PSGuidelineRepSOS PS CCDOPlan of CareORROORFunctional StatusMedicationsSocial HistoryOROPregnancy history (Expected Odate of delivery)OOPhysical findings (VitalSigns Observations)Diagnostic tests (Bloodgroup)N/AN/AN/A46N/AOOPregnancyObservation of theSocial HistoryVital SignsOOOResults SectionRAdvance DirectivesFamily HistoryPayerEncountersOOOO
Gap Analysis: Sample Sections &TerminologiesCoded Section (CCDA/CCD)C-CDA Code SystemepSOS Value Set NameepSOSterminologyAllergy/Adverse Event Type SNOMED CTepSOSAdverseEventType/epSOSReactionAllergySNOMED CTMedication Clinical DrugName Value SetRxNORMepSOSActiveIngredientATCVaccine Admin Value SetCDC Vaccine Code (CVX) epSOSVaccineProblemSNOMED CTepSOSIllnessesandDisorder ICD-10sMedical EquipmentN/AepSOSMEdicalDevicesMedication Route i EDQMonSNOMED CTSNOMED CTUnitsofMeasureCaseSensitiv UCUMeepSOSUnitsUCUMVital SignepSOSBloodPressureLOINC47LOINC
Trillium Bridge: achievements/workaheadCompleted Gap analysisIn collaboration with S&I WG EHR Interoperability work streamReleased Deliverable D2.2: Comparing Patient Summaries in theEU and US: Gap Analysis and Pilot Use Case DefinitionIdentified interoperability AssetsEstablished the basis for a terminology service to offerinteroperability assetsPlan to provide prototype CTS-2 serviceInform and support standardization effortsRefine assets, complete the puzzle48
Interoperability assets online49
EU/US MoU Roadmap:expected outcomes & Trillum BridgeDevelopment of use cases/user storiesPerform Vocabulary AnalysisPerform Infrastructure AlignmentPerform Healthcare provider Mediated Exchange analysisSemantic and syntactic mapping of scenario relatedhealth dataPilotsA global standard or IGfor patient summaries?50
Trillium Demo.at the EU/USMarketplace in Boston October 20-21European HL7affiliatemembership 957orgs (2011)I hope you had the opportunity to seethe demo of Martha and Paolo crossingthe Trillium Bridge with their patientsummary.Stay tuned for Boston.51CZECHREPUBLICBOSNIA &HERZEGOVINAROMANIACROATIATURKEYemail: Euoffice@HL7.orgList: Europe@HL7.orgWeb site: www.HL7.eu
Many patient summaries, one standardProliferation of templates or building blocks frequentlyincompatible to convey the same clinical contentAttempts to construct the patient summary automaticallyDifferent coding systems and value setsSDOs have different financial models and there are overlaps andcompetition (sometimes unconstructive)National programs use standards creatively to meet local needsSharing experience and knowledge advances interoperability –standards are not to be used in a vacuumCosts of interoperability hiking!Education is the way to improve interoperability52
What the eHealth market needs HL7 CDA is a powerful tool for incremental interoperabilityEndorsed and adopted by several governmentsConstrained with Templates and Implementation GuidesDeveloped independently a cost to interoperabilityeHealth market calls for agile processes and toolsInteroperability to lower costsplug-n-play interoperability assetsIntelligent user interfacesHow do countries and economic blocks deal with patient summaries?What can you do to help?53
Parting Thoughts eHealth standards are the safety net that strengthens the fabricof the global eHealth infrastructure.Interoperability at affordable costBuilt once used anytime and anywhereWorking across cultures and bordersHealth IT is enabling safe informed health careKey to new market opportunitiesMilestone in the path to a healthier worldCulture of collaboration, creativity, and understanding for the eHealthecosystem.Deploy or Die!54Joi Ito, Head MIT Media Lab
HL7 Finland (est.1995): long history in HL7 messages and IGs, active technical committees, integrated IHE and personal health SIGs, etc. One of the very first implementation of HL7 CDA (2004-5) . an embedded PDF meets the requirements of Specialized IGs
HL7 C-CDA v1.1 MU 2014 HL7 C-CDA v2.0 HL7 C-CDA v2.1 MU 2015 2011 Edition/Stage 1 MU 2014 Edition/Stage 2 MU: – HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, DSTU Release 1.1 (US Realm) Draft Standard for Trial Use – HL7 Implementat
standardized input and output documents conforming an HL7-CDA wrapper. We define the HL7-CDA restrictions in a HL7-CDA implementation guide. Patient data and rule infer-ence results are mapped respectively to and from the CDSS by means of a binding method based on an XML binding file. As an
Companion Guide to HL7 Consolidated CDA R2.1 Page 2 HL7 CDA R2 IG: C-CDA Templates for Clinical Notes R2.1 Companion Guide, Release 2 STU- US Realm
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HL7 CDA & C-CDA Primer Clinical Data Architecture & Consolidated Clinical Data Architecture Prepared for Washington State B&T Workgroup November 2019 . image file or as unstructured text in an electronic file such as a word processing or Portable Document Format (PDF) documents The ‘component’ element is the first element of the CDA Body. .
HL7 Messaging Tool - EHR Vendor All new products will be listed under Your Product List. To start validating products go to the Validating EHR Projects/Versions section under Validating HL7 Messages. Validating HL7 Messages This section will go into detail on how to validate each EHR Product, Group HL7 Messages, and Practice HL7 Messages.
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