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© 2002-2005 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Off

Continuity of Care DocumentContinuity of Care Document

LioraLiora AlschulerAlschulerAlschulerAlschuler Associates, LLCAssociates, LLC

February 2006, HIMSSFebruary 2006, HIMSS

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22© 2006 Health Level Seven ®, Inc. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven, Inc. Reg. U.S. Pat & TM Off

LioraLiora AlschulerAlschulerPrincipal, Principal, AlschulerAlschuler Associates, LLCAssociates, LLC

CDA design, implementation, supportCDA design, implementation, supportTricareTricare Management Activity, Department of Defense, Enterprise Wide Management Activity, Department of Defense, Enterprise Wide Referrals & AuthorizationsReferrals & AuthorizationsSubcontractor, HITSPSubcontractor, HITSPProject Springfield: documentProject Springfield: document--based personal health accountsbased personal health accounts

CoCo--author, CDA & CRS Quick Start Guidesauthor, CDA & CRS Quick Start GuidesMember, HL7 Board of DirectorsMember, HL7 Board of DirectorsCoCo--editor, CDAeditor, CDACoCo--chair HL7 Structured Documents TCchair HL7 Structured Documents TCHL7 IHE LiaisonHL7 IHE Liaisonpast Chair, KEG & XML SIG & HL7 Marketing Committeepast Chair, KEG & XML SIG & HL7 Marketing [email protected]@alschulerassociates.com

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Consult

HL7HL7’’s CDAs CDAClinical Document ArchitectureClinical Document Architecture

ANSI/HL7 R1ANSI/HL7 R1--2000, R22000, R2--20052005

eDocumentseDocuments for Interoperabilityfor InteroperabilityKey component for local, regional, Key component for local, regional, national electronic health recordsnational electronic health recordsGentle onGentle on--ramp to information ramp to information exchangeexchange

oo Everyone uses documentsEveryone uses documentsoo EMR compatible, no EMR requiredEMR compatible, no EMR requiredoo All types of clinical documentsAll types of clinical documents

CDA Health chart

Summary

PathRadiology

Discharge

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ASTMASTM’’s CCRs CCRStandard Specification Standard Specification for Continuity of Care for Continuity of Care Record (CCR)Record (CCR)

a core data set of the most relevant administrative, demographic, and clinical information facts about a patient’s healthcare, covering one or more healthcare encounters.Released fall, 2005

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ASTM CCR vs. HL7 CDAASTM CCR vs. HL7 CDA

Conflicting?Conflicting?Overlapping?Overlapping?What if you could have both!#*?IWhat if you could have both!#*?I!!!!

What if you could have your data elementsWhat if you could have your data elementsAnd send them in a common exchange framework?And send them in a common exchange framework?

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ASTM CCR + HL7 CDA = CCDASTM CCR + HL7 CDA = CCD

CDA is designed to support professional society CDA is designed to support professional society recommendations, national clinical practice guidelines, recommendations, national clinical practice guidelines, standardized data sets, etc.standardized data sets, etc.From the perspective of CDA, the ASTM CCR is a From the perspective of CDA, the ASTM CCR is a standardized data set that can be used to constrain CDA standardized data set that can be used to constrain CDA specifically for summary documents.specifically for summary documents.The resulting specification, known as the Continuity of The resulting specification, known as the Continuity of Care Document (CCD), is being developed as a Care Document (CCD), is being developed as a collaborative effort between ASTM and HL7.collaborative effort between ASTM and HL7.

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CCD maps the CCR CCD maps the CCR elements into a CDA elements into a CDA representation.representation.

ObservationObservationTestTest

Observation.methodCodeObservation.methodCode; ; ProcedureProcedure

ProcedureProcedure

Observation.statusCodeObservation.statusCodeStatusStatus

Observation.codeObservation.codeDescriptionDescription

--nfernfer values from values from observation.codeobservation.code(e.g. by looking at the LOINC class (e.g. by looking at the LOINC class for a LOINC for a LOINC code).code).

Type:Type: Values include: Values include: Hematology, Chemistry, Hematology, Chemistry, Serology, Virology, Serology, Virology, Toxicology, Microbiology, Toxicology, Microbiology, Imaging Imaging -- XX--ray, ray, Ultrasound, CT, MRI, Ultrasound, CT, MRI, Angiography, Cardiac Angiography, Cardiac Echo, Nuclear Medicine, Echo, Nuclear Medicine, Pathology, ProcedurePathology, Procedure

Observation.idObservation.idIDsIDs

Observation.effectiveTimeObservation.effectiveTimeDateTimeDateTime

ObservationObservationResultResult

SectionSectionResultsResults

CDA R2 correspondenceCDA R2 correspondenceCCR data elementCCR data element

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2.16.840.1.113883.19.1

Assessment Time

200004071430

Hematology

CBC WO DIFFERENTIAL

43789009SNOMED CT

Final Results

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Sample sectionSample section

11 INTRODUCTIONINTRODUCTION22 (PROTOTYPE) LAB RESULTS(PROTOTYPE) LAB RESULTS

2.12.1 IntroductionIntroduction2.22.2 Section conformanceSection conformance2.32.3 Clinical statement conformanceClinical statement conformance2.42.4 ExtensionsExtensions2.52.5 Rendered exampleRendered example2.62.6 Encoded exampleEncoded example2.72.7 ASTM CCR MappingASTM CCR Mapping2.82.8 Appendix Appendix -- CCR exampleCCR example

Sample section developed by Dr. Bob Dolin, Kaiser Sample section developed by Dr. Bob Dolin, Kaiser PermanentePermanente

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CCR CDA CCR CDA correspondancecorrespondance

CBC WO DIFFERENTIAL

43789009SNOMED CT

Same Context: Same Context: CDA: observation, code, code systemCDA: observation, code, code systemCCR: description, code, value, coding systemCCR: description, code, value, coding system

CDA: optional unique ID; code system ID; moodCDA: optional unique ID; code system ID; moodDifferent approaches to humanDifferent approaches to human--readable textreadable textThere are differences, but an implementation guide can support There are differences, but an implementation guide can support interoperability interoperability

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Continuity of Care DocumentContinuity of Care DocumentDid this come out of the blue?Did this come out of the blue?There is a history of collaborationThere is a history of collaboration

Many people have participated in both effortsMany people have participated in both effortsPresentation on CDA for continuity of care at ASTM CCR meeting, Presentation on CDA for continuity of care at ASTM CCR meeting, August, 2003August, 2003Memorandum of Understanding, 2004Memorandum of Understanding, 2004Acapulco demo: CDA for CCR, October, 2004Acapulco demo: CDA for CCR, October, 2004oo HL7 partnered with Massachusetts Medical Society, Microsoft, HL7 partnered with Massachusetts Medical Society, Microsoft,

Ramsey Systems (UK)Ramsey Systems (UK)Initial HL7 Care Record Summary ballot, April, 2005:Initial HL7 Care Record Summary ballot, April, 2005:oo Limited to CDA header, no detailed section codingLimited to CDA header, no detailed section codingoo Anticipated: Anticipated: ““Development of detailed (CDA Level 3) Development of detailed (CDA Level 3)

Implementation Guides for Implementation Guides for ““continuity of carecontinuity of care”” (CCR) in (CCR) in collaboration with the ASTM E31 under the 2004 Memorandum of collaboration with the ASTM E31 under the 2004 Memorandum of UnderstandingUnderstanding””

HL7 ballot on CCR, Spring 2005: incorporated changes required foHL7 ballot on CCR, Spring 2005: incorporated changes required for r bibi--directional exchange and semantic interoperabilitydirectional exchange and semantic interoperability

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Will CCD see adoption?Will CCD see adoption?Role of IHE (Integrating the Healthcare Role of IHE (Integrating the Healthcare Enterprise)Enterprise)

2005: Cross2005: Cross--enterprise document sharing (XDS) with enterprise document sharing (XDS) with both CDA and CCRboth CDA and CCR2006: XDS for Patient Care Coordination domain 2006: XDS for Patient Care Coordination domain Medical SummariesMedical Summaries

oo CDA Care Record SummaryCDA Care Record Summaryoo Extend with coded content for three required sectionsExtend with coded content for three required sections

2007: 2007: likely will adopt CCDlikely will adopt CCD

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Current activitiesCurrent activitiesMeeting ~ weekly by Meeting ~ weekly by webinarwebinar, teleconference, teleconferenceSample lab section developed as patternSample lab section developed as patternParticipation by ASTM E31.28, HL7 Structured Participation by ASTM E31.28, HL7 Structured Documents TC and Documents TC and

oo HL7 domain committees for patient care, lab, ED...HL7 domain committees for patient care, lab, ED...oo Clinical societies: ACP, AAFP, ACR...Clinical societies: ACP, AAFP, ACR...

Interest in international harmonizationInterest in international harmonizationoo CDA summary documents in use around the worldCDA summary documents in use around the world

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TimelineTimelineFebruary February –– March: Meet by web/March: Meet by web/telconferencetelconference

oo Individuals developing:Individuals developing:•• HeaderHeader•• List of sectionsList of sections•• LabLab•• Allergies/adverse reactionsAllergies/adverse reactions•• Problems/conditionsProblems/conditions•• MedicationsMedications

April April –– May May oo Initial ballot: header, list of sections, detailed sectionsInitial ballot: header, list of sections, detailed sectionsoo Ballot reconciliation: Spring HL7 Working Group MeetingBallot reconciliation: Spring HL7 Working Group Meeting

June June –– July July oo Develop complete draft for second ballotDevelop complete draft for second ballot

August August –– September September oo Second ballotSecond ballotoo Ballot reconciliation: Fall HL7 Working Group MeetingBallot reconciliation: Fall HL7 Working Group Meeting

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““ASTM is dedicated andASTM is dedicated and privileged to work in privileged to work in collaboration with HL7 on the expression of collaboration with HL7 on the expression of ASTM's Continuity of Care Record content ASTM's Continuity of Care Record content within HL7's CDA XML syntax and the seamless within HL7's CDA XML syntax and the seamless transformation of clinical and administrative data transformation of clinical and administrative data between the two standards.between the two standards.””Rick Peters, MD, E31.28Rick Peters, MD, E31.28

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BenefitsBenefitsIndustry Industry concensusconcensus on summary document contents on summary document contents and requirements through ASTM ballots (2004, 2005)and requirements through ASTM ballots (2004, 2005)Industry Industry concensusconcensus on document exchange on document exchange framework through HL7 ballots (1999framework through HL7 ballots (1999--2005)2005)Summaries for continuity of care Summaries for continuity of care

oo Interoperable with full range of document typesInteroperable with full range of document typesoo Interoperable with HL7 V3 messages, all RIMInteroperable with HL7 V3 messages, all RIM--based based

specifications (public health reporting, clinical trials, specifications (public health reporting, clinical trials, structured product labels and more)structured product labels and more)

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CCD ResourcesCCD ResourcesHL7 Web site:HL7 Web site:

CDA Normative Web EditionCDA Normative Web Editionhttp://www.hl7.org/Special/committees/lists.cfmhttp://www.hl7.org/Special/committees/lists.cfm

oo CDA: [email protected]: [email protected] CCD: [email protected]: [email protected]

ASTM Web site:ASTM Web site:oo ASTM.orgASTM.org

JAMIAJAMIADolin RH, Dolin RH, AlschulerAlschuler L, Boyer S, Beebe C, L, Boyer S, Beebe C, BehlenBehlen FM, FM, BironBiron PV, PV, ShaboShaboA. HL7 Clinical Document Architecture, Release 2. J Am Med InforA. HL7 Clinical Document Architecture, Release 2. J Am Med Inform m Assoc. 2006;13:30Assoc. 2006;13:30––39.39.http://www.jamia.org/cgi/reprint/13/1/30http://www.jamia.org/cgi/reprint/13/1/30

LioraLiora AlschulerAlschuler -- [email protected]@alschulerassociates.com