HL7 v3.0 Clinical Interoperability to Improve Quality and the point-of-care EHR system

Presented By: Gunjan PatelPG Student: MS-Medical Software

PGD-QM, BME

National Conference Information Science -2010

MCIS, Manipal University

Clinical Clinical Interoperability to Improve Interoperability to Improve Quality Quality & the Point& the Point--ofof--Care of EHRCare of EHR

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Motivation

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Why are the patient clinical records need for to be exchanged for Interoperability?

How can we improve the quality of patient health record?

What are the basic standards to meet specifications? What are the basic needs for the design CCD template? What is the Module structure and semantics of a patient

summary clinical document for exchange?

Outline Literature view Introduction Health Level 7 What is the ASTM CCR? How did the CCD develop? Development and results Conclusion Future Work References

List of Abbreviations HL7 = Health Level 7ASTM=American Society for Testing and MaterialsANSI=American National Standards Institute RIM = Reference Information ModelCDA = Clinical Document ArchitectureCCR=Continuity of Care Record CCD= Continuity of Care Document HITSP= Healthcare Information Technology Standards PanelCI= Clinical Interoperability XML = eXtensible Markup LanguageXSD = XML Schema DefinitionVB.Net = Visual Basic.Net

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Literature view

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Year History & Article Released

2004 -2005

The board of Health Level Seven, a standards development organization has specification for a CDA approved the Electronic Health Record System Functional Model for clinical interoperability.

Dec 2006

Health Level 7 - CCD will be a component of hl7's Clinical Document Architecture -> balloted by HL7 members and Healthcare Information Technology had included CCR functionality in its testing criteria for interoperability of EHR systems

JUNE -2007

CCD structure was developed as a collaborative effort between ASTM and HL7, combining the benefits of ASTM - Continuity of Care Record (CCR) and the HL7 CDA specifications

Nov 2008

Hl 7 CCD Clinical documents by supporting interoperability through a common structure and semantics.

Mar 2009

The Healthcare Information Technology Standards Panel (HITSP) approved the Continuity of Care Document (CCD), which set standards for interoperability that enabled clinical data to be transportable, thus enhancing patient safety and efficiency.

Basic Term Clinical Interoperability The Clinical Interoperability relationship is represented to

support the electronic exchange of patient summary information and the high reliability exchange of information between an EHR system and other healthcare IT systems

Interoperability aims to support clinical documents Integration with clinical and non-clinical information Medical terminology transfer, mapping at the point of care

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Introduction Clinical interoperability is to support the electronic

exchange of patient summary information among caregivers and other authorized parties via potentially disparate EHR systems to improve the quality, safety, and worth of care delivery

The HL7 Clinical Document Architecture (CDA) is a CCD document markup standard that specifies the structure and semantics of ‘clinical documents’ for the purpose of exchange that would improve quality and the point-of-care of EHR.

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Scenario of without Interoperability in Healthcare systems

Without interoperability, EHR further strengthen the information that exist in today’s paper-based medical files & other systems.

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Clinical Documents of Patient’s Record File

Patient File

How can clinical Interoperability support in current Healthcare systems ?

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To exchange of Patient Summary of Information

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Clinical Interoperability Solutions offerings help healthcare organizations

Improve patient health and safety: CI is to support the electronic exchange patient summary

information among caregivers and other authorized parties via potentially different EHR systems to improve safety and efficacy of care delivery

Delivering medication history, prescriptions & formulary formation to clinicians on demand for the purpose of exchange that would improve quality and the point-of-care of EHR

Achieve operational efficiencies and reduce costs: Providing existing information systems the ability to exchange

data electronically, including lab, clinical notes and demographics

Generate Automating patient record location services across networks and systems

Health Level 7 Organization

HL7 is an organization - clinical interoperability problem by providing a standard that allows the exchange of patient health information across diverse medical systems in healthcare facilities

HL7 standards in Healthcare The data to be exchanged and the timing of the interchange The communication of certain errors to the application Supports such functions as security checks Participant identification and exchange mechanism, data

exchange structuring

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What is the ASTM Continuity of Care Record (CCR)?

XML-based standard for clinical data exchange Developed by ASTM International

Provides a “snapshot” of treatment and basic patient information – it is not comprehensive like an EHR.

Information in this record Focused on Diagnostics and reason for referral Rather than symptoms and treatment chronology

Important distinction between CCR and CDA CCR uses only specified XML code. It does not support/allow

narrative text (free-text) which can sometimes be hindering to physicians, and it is not electronically acceptable by all systems

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ASTM CCR + HL7 CDA = CCD

The resulting specification, known as the Continuity of Care Document (CCD), is being developed as a collaborative effort between ASTM and HL7.

CCD is also a true document, not just a record, and is designed for the same type of exchanges as those performed in an EHR – including import, management, and export data in XML

How did the Continuity of Care Document (CCD) develop for Interoperability?

Why CCD is universally Accepted for electronic exchange? A universal standard Broad compatibility Easy incorporation into new and existing technology or standards

Easy integration The HL7 CDA RIM-based specifications Compatible existing applications, browsers, EHR and legacy

systems Universally rendered as HTML or PDF

XML Encouraging the implementation of XML for clinical document exchange

CCHIT given approval of CCD as part of their certification process is an important step in facilitating the widespread adoption of both CCD and XML

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CCD Template Design Process

Reference Information

Model

Reference Information

Model

Clinical Document

Architecture

Clinical Document

ArchitectureHierarchical DescriptionHierarchical Description

XML Schema

Definition

XML Schema

Definition

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The RIM, CDA, Hierarchical Description and XML Schema defination

< CCD template />

Reference Information Model (RMI) Primarily based on a data model called RIM. Shared information model that offers a consistent

vocabulary for clinical data content. Applies an object-oriented development

methodology, expressed with the Unified Modeling Language (UML), which includes classes, attributes, relationships and state-machine diagrams

UML is an industry-standard language for specifying, visualizing, constructing, and documenting object-oriented and component-based system architectures and designs

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Clinical Document Architecture The CDA Release 2.0 provides an exchange model

for clinical documents By leveraging the use of XML, the HL7 Reference

Information Model (RIM) & Coded vocabularies The CDA makes documents both Machine – Readable >> Easily parsed and processed electronically

Human - Readable >> Easily retrieved and used by the people

Displayed using XML- Web browsers It provides state-of-the-art interoperability for machine-

readable coded semantics.

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A CDA Document could be a:- Discharge Summary Referral Clinical Summary Report History & Physical examination Diagnostic Reports (DI, lab…) Medication Prescription Rx Public health report

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IHE IHE MedicalMedical

Summaries Summaries HIMSS 2006: HIMSS 2006:

a CDA Gallerya CDA Gallery

Allscripts TouchworksAllscripts Touchworks

Eclipsys Sunrise Eclipsys Sunrise

GE Centricity GE Centricity

MediNotes eMediNotes eSiemens Soarian (XML) Siemens Soarian (XML)

Siemens Soarian (PDF) Siemens Soarian (PDF)

Hierarchical Description

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Development and results The design of the CCD module for the

Interoperability of clinical documents , not just a record, and is congruently designed for the same type of exchanges as those performed in an EMR Including import Management Export of information in the XML format

Because of its small fixed XML tag set CCD can be universally rendered as HTML or PDF or print

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CCD template structure components

Template Modules Section

A. HeaderB. Body

Purpose Medications

Problems Immunizations

Procedures Medical equipment

Family history Vital signs

Social history Functional status

Payers Results

Advance directives Encounters

Alerts Plan of care23

Example of birthTime Mapping for CCD XML file

Illustration the CDA’s XSD to VB.net

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<xs:complexType name="POCD_MT000040.Patient"><xs:sequence>

<xs:element name="birthTime" type="TS" minOccurs="0"/></xs:sequence>

</xs:complexType>

XSD

VB.net

19320924birthTime

XML

value

<patient><birthTime value="19320924"/>

</patient>

objClinicalDocument.RecordTarget.patientRole.patient.birthTime = New TSobjClinicalDocument.RecordTarget.patientRole.patient.birthTime.value = "19320924"

Clinical Interoperability of CCD module

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Select the CCD Option for XML file

Display the Clinical

Document in XML Format

Select option for Rendering

Display the CCD Template in Web

Browser

Display the CCD Template as PDF

Display the CCD Template in any type

of display device

Print out of CCD template

CCD document generation work flow

Future Option

A. Implementation Specification the CCD Module

Operating System:Windows Service Pack 2 Platform: Microsoft visual studio 2008 Language: VB.Net, XML XML stylesheet: CCD.xsl Web Browser: Microsoft visual studio 2008 – toolbox web browser

component Supporting Files Clinical Interoperability.dll POCD_HD000040.xls datatypes.xsd,datatypes-base.xsd,NarrativeBlock.xsd,voc.xsd,CDA.xsd SampleCCDDocument-QSG-level-3.xml ccd_qsg.Ver1.Nov12007.doc

Validation Tool for CCDDoc.xml file: Online Tool: http://xreg2.nist.gov/cda-validation/validation.html

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B. Implemented Design of Module

Implementation, the parameters and classes for Header and Body

The Clinical document’s of CCD templates parameters and class Clinical Interoperability.dll POCD_HD000040.xls of CDA R2 POCD_HD000040

Hierarchical Description

StreamWriter method is instantiated and the file “CCDdoc.xml“ -- writing

StreamReader method is being read of XML-based specification for exchange of clinical summary information

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Standard CCD Document-QSG

Validation NIST in collaboration with Alschuler Associates, LLC,

Integrating the Healthcare Enterprise (IHE) and the CCHIT Health IT Collaboration Effort "LAIKA", is working on a series of testing tools for promoting the adoption of standards-based interoperability by vendors and users of healthcare information systems.

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CCD document XML file Validation to meet the standard specifications

Validation Tool for CCDDoc.xml file: Online Tool: http://xreg2.nist.gov/cda-validation/validation.html

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Upload the CCD .xml file for

CCD validation

Advantage of CCD Easy to Rendering as PDF, or on any type of display

device, including local EMRs. Discharge Summary, is specifically out of scope for CCR

and therefore CCD eDocument Integration Into the Electronic Health

Record International and National Acceptance healthcare

organization USA, Canada, Asia/Pacific to England, Europe, and

Mexico

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Conclusion It summarizes the most commonly needed relevant

information about current and past patient health status in a form that can be shared by all computer applications and electronic medical records.

The HL7 CDA RIM-based specifications in small XML tag form that the base of CCD are widely compatible with web browsers, PDF and print

Overall, the viability and prospects for this clinical venture appear to be an excellent approach to reinforce the importance of high quality health care and services.

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Future Work Interoperability is to support the electronic exchange of

patient summary information among caregivers and other authorized parties via potentially disparate EHR systems and other aspects of interoperability: “plug and play” and extensibility

Furthermore, data mining techniques can be applied on these module instances to extract substantial knowledge about the patients health report

Integrate and testing of Interoperability Module with EHR system and validation of CCD template

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Any Question

Any <ideas/> or <suggestion/> …

References HL7 Electronic Health Record (EHR) Interoperability,

http://wiki.hl7.org/index.php?title=EHR_Interoperability_WG, wiki HL7 Implementation Guide: “CDA Release 2 – Continuity of Care

Document”, Version 1.0 November 1, 2007, pp-7-8,16-18,20-24 Health Level Seven (HL7),http://en.wikipedia. org/wiki/

Health_Level_7#HL7_Version_3 Clinical Document Architecture (CDA) Workshops

,http://www.hl7.org.au/CDA.htm Continuity of Care Document (CCD) specification, http

//en.wikipedia.org/wiki/Continuity_of_Care_Document HL7 Clinical Document Architecture, Release 2, JAMIA 2006 13: 30-

39, Published by group.bmj.com HL7 Resources, CCR contents http://

www.corepointhealth.com/resource-center/hl7-resourcess

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XML Tutorial, http://www.w3schools.com/xml/ default .asp Using W3C XML Schema, http://www.xml.com/pub/

a/2000/11/29/schemas/part1.html?page=2#slicing Structured Documents of CCD - http://www.hl7.org/

Special/committees/structure/docs.cfm?wg_docs_subfolder_name=AllDocuments&sortBy=DTCreated&sortDirection=desc&offset=121

http://wiki.hl7.org/index.php?title=Product_CCD http://xreg2.nist.gov/cda-validation/validation.html http://www.himssehra.org/ASP/CCD_QSG_20071112.asp

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< Thank You />< Thank You />For your Kind attention …For your Kind attention …

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