© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

CDA <-> FHIRConversion Strategies

Rick GeimerFHIR Developer Days

November 2016

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Lantana Consulting Group Our Mission:

Improve healthcare through health information technology (IT) Lead the industry through our consulting and volunteer practice

Our Services: Software & standard development & implementation Terminology, data governance, and education Strategic advice for health IT planning, design, and purchasing

Rick Geimer Developer of standards & software HL7 C-CDA on FHIR Lead HL7 Structured Documents Co-chair Co-author C-CDA and many other specifications Day job: Lantana CTO

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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This Presentation

Included Overview of key differences between

CDA and FHIR Analytical mappings available Strategies for converting parts of CDA to FHIR

and visa versa

Not included Line by line tutorial on CDA data conversion

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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CDA Templates vs.FHIR Resources and Profiles

Reference Information Model• Highly abstract• Act, Participation, Role…

Refined Information Model• Generic CDA• Observation, Procedure, etc.

Templated CDA• CCD or C-CDA or QRDA• Allergy – Intolerance Observation,

Problem Observation, etc.

Reference Information Model• Highly abstract• Act, Participation, Role…

Resource• FHIR component for msg, doc• AllergyIntolerance, Condition,

etc.

Profile• Localized resource• DAF-AllergyIntolerance, DAF-

Condition, etc.

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© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Argonaut C-CDA to FHIR Mappings For analysis, not computable mappings Series of Google spreadsheets, one for each

major section of C-CDA CDA Header’s for various document types

not included Pre-FHIR DSTU2 Leveraged by the C-CDA on FHIR http://tinyurl.com/zhj2u9s

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Argonaut C-CDA to FHIR Mappings

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An Argonaut Mapping Spreadsheet

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Other Mapping Sources CDA Mappings in

Individual Resources Click the Mappings tab on a

Resource page Scroll down and look for

CDA mappings CDA Logical Model and

StructureMaps Expresses CDA as a FHIR

Logical Model Allows StructureMap to be

used for conversion Status…Grahame?

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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CDA Header to Composition

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CDA Header to Composition Details Seems straightforward at first… Actual mapping is spread across multiple

resources (Bundle, Composition, Patient, Practitioner, etc.)

Some data don’t map to core FHIR Unnecessary for your use case? Need realm specific extensions?

Some data doesn’t exist in CDA Composition.status Need appropriate defaults

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Sections

Section mapping is fairly straightforward. Not much to do here but minor renaming

(section.code to section.type, etc.) Both CDA and FHIR documents allow

recursive sections. But section nesting is pretty rare in practice (at

least in US Realm CDA documents)

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Converting CDA Narrative Content CDA markup is not XHTML However, the CDA.xsl contains the basic

mappings from CDA narrative to XHTML Decide how much styling you want to add

The FHIR rendering stylesheet currently displays only the XHTML of any given resource

You may need more formatting in your narrative than you would in CDA for good looking documents

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Populating Composition.text Everything you want rendered from the CDA

Header, except the Patient Title, type, author, attester, etc.

Remember the rules for rendering FHIR documents: Patient Composition.text Composition.Section.text This is a SHOULD constraint, but the default stylesheet

applies this order

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CDA vs. FHIR Context Conduction CDA

Hierarchical structure Association through

nested constructs Context conducts

through the hierarchy Set once in the header,

applies to everything that follows unless overridden

FHIR Flat structure Association through

references Context must be set

explicitly in each resource

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Converting Coded Entries Templates to resources

Use mappings where available Note Argonaut mappings are pre-DSTU2 Be aware that moodCodes can impact this

(supply/@moodCode=RQO maps to MedicationRequest, not MedicationDispense)

Conform to profiles if applicable/available US Realm use DAF

Nested entryRelationships become references to discrete resources

Need to explicitly define context for each resource

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Converting Datatypes

Mostly mechanical mappings @code value @codeSystem system

OID to URI mappings 2.16.840.1.113883.6.1 to

urn:oid:2.16.840.1.113883.6.1 works but 2.16.840.1.113883.6.1 to http://loinc.org is much better

CDA Logical Model and StructureMap resources Lots of good mapping detail

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Terminology Mapping

The elephant in the room Use ConceptMap resources where they

exist; build them where they don’t Can get very expensive when local codes are

involved Commercial Terminology Service? Decide if all that coding is really necessary

Maybe plain text is good enough for your use case

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Bundling It All Up

Do it yourself. Conversion code creates the Bundle resource. Need to make sure that type=document, Bundle.id

is globally unique, all references are contained in the Bundle, etc.

Let a FHIR server do it for you. POST the Composition and other resources to a

FHIR server as you are converting, then just call $document at the end.

Side benefit: incremental validation

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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When things go wrong…

What you expect What you get

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CDA Quality Report (QRDA-I) Submission Statistics

Submission Year Total Files Files that passed validation

Successful Submitters

2014 237097 54795 14

2015 (partial) 82481 4495 17

77% of submissions were invalid in 2014, and 95% at the start of 2015 after minor implementation guide changes

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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But hope is not lost… More like a recycling center than a

dump Many validation errors are minor and

easily correctable Old template IDs Whitespace where not allowed Misnamed attributes (displayname vs.

displayName) Missing classCode and typeCode Missing elements that can be nulled Knowing the target (document level

templateId), you know the intent and can often apply corrections.

Others are more difficult Local codes instead of those required

by C-CDA

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Real-World CDA to FHIR Conversion

Pre-Process

Validate

Transform

Map Terms

Post-Process

Validate

The amount of pre/post processing will depend on many factors, such as the quality of input data and the capabilities of your transformation tools.

You may need separate pre-processors for each source system.

Whatever you do, don’t forget to validate both input and output so you know what you are getting and what you are producing.

© 2016 HL7 ® International and Lantana Consulting Group. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Going from FHIR to CDA Bundle = ClinicalDocument Composition = CDA Header + Sections Resources and Profiles become templates Rename fields Map data types References become nested elements XHTML to CDA narrative

Potential loss of some formatting What to do with Composition.text?

Lots of structural stuff to add classCode, moodCode, etc.

When in doubt, use the CDA Example Task Force data http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force

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CDA Example Task Force

No known allergies: 50+ lines of C-CDA XML

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Open Source C-CDA on FHIR Transforms Coming Bi-directional C-CDA to FHIR XSLT transforms

Under development as part of an ONC High Impact Pilot (HIP) grant

Initial focus will be on the Electronic Pharmacist Care Plan (ePhCP) Based on C-CDA on FHIR, so will cover most of the basics US Realm Header, many DAF profiles, etc.

Intended to evolve over time, contributions welcome Not available yet

Q1/Q2 2017

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ONC-HIP ePhCP Pilot

CCNC (CDA)

Vendor 1 (FHIR)

Vendor 2 (CDA)

Vendor 3 (CDA)

FHIR/CDA Conversion

CCNC: Community Care of North Carolina

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Live Demo

My hackathon project CDA -> DSTU1 -> STU3

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Questions?