Alschuler.spinosa copyright 2001, Liora Alschuler HL7s CDA & the EHR TEPR Seattle Liora Alschuler...

alschuler.spinosa

copyright 2001, Liora Alschuler

HL7’s CDA & the EHR TEPR

Seattle

Liora AlschulerMay 13, 2002

alschuler.spinosa (dba)East Thetford, VT

La Jolla, CA

[email protected]

Structured Documents: What a few tags can do

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• alschuler.spinosa: consulting practice with focus on application of XML and related standards to healthcare

• Liora Alschuler– Co-chair HL7 Structured Documents TC– Chair, HL7 Marketing Committee– past Chair, KEG (wrote HL7 Clinical Document Architecture)– coordinator, HL7 HIMSS Technical Demo– consultant, writer– author, ABCD… SGML: A User’s Guide to Structured

Information, 1995

• John Spinosa– MD and Ph.D. from UC San Diego; trained in pathology at

UCSD; hematopathology fellowship, staff member at Scripps La Jolla

– Co-founder of XML TC– Member of the CAP informatics committee

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Outline– Information ecology– XML, a few tags at a time– Gating factors– Why this might work– Conclusions

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Information Ecology

business drivers

data

technology

business drivers

technology

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Information Ecology

• Primary cause of poor information flow in healthcare: lack of usable and re-usable electronic data– 85-95% of clinical data still paper based

• HIMSS Leadership Survey 99-00– 99: 10-11% have implemented EHR– 99: 25% planning to w/in one year– 00: 10-11% have implemented EHR– 00: 25% planning to w/in one year

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Bad ecology• The impact:

– IOM report: poor information leads to poor healthcare

– can’t control costs – some claims, all attachments, most

admin/finan transactions still paper electronic :: paper 3 billion :: 25-30 billion (Wit Capitol, 2000)

• Can track price of peaches in Alberta, but can’t track status of claims

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XML and info ecology

• XML can break the electronic data log jam

• The big breakthrough is not in the CPRI

• The big change is in the– simple XML documents for ubiquitous

access, integration and reuse– encoding of narrative, human language,

for H2H and simple machine processing

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Tim Bray, June, 2001

What matters, what doesn’t?

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#1 80/20 point


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XML for healthcare data• where is the 80/20 point for

healthcare information?• it is not the full-blown “computerized

patient record” (XML-encoded or not)Erica Drazen, VP First Consulting Group, in Healthcare Informatics:There are few organizations claiming complete CPR systems. “As originally defined, a CPR is neither necessary nor sufficient on its own as a tool for improving care.” To be useful, information needs to be available, first and foremost, and only then does it matter if it is coded to the extent that will support a CPR. “It’s doubtful that all the information in current records will ever be duplicated in electronic records, and it certainly will not all be coded.”

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The 80/20 point for healthcare

• Setting new targets for information exchange– more like the Web– healthcare-specific

• Extensible Markup Language (XML)• Clinical Document Architecture

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Clinical Document Architecture

• New specification (Nov. 2000) for healthcare documents

• Uses XML, like the Web, but vocabulary specific to medicine

• Lower, simpler objectives than previous exchange specifications– common format for transcription and EHR

records– Human-readable on Web, PDA, cell,…

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CDA

• Let’s take a look...

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the 80/20 sweet spot:XML, a few tags at a time

<section> <caption> Impressions </caption> <paragraph><content>RLL nodule suggestive of malignancy...

<assessment> <caption> Impressions </caption> <paragraph><content> <concept>

<nodule type=“RLL”/><coded entry domain=“SNOMED” v=“123”/> RLL nodule </concept> suggestive of malignancy...

<assessment> <caption> Impressions </caption> <paragraph><content>RLL nodule suggestive of malignancy...

any transcription system can produce this

or this

or this, with post-process coding, NLP, AI, KM or a better user interface

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BestPractice Hospital

eMedicalFiles

Epic

IPNet

MSBizTalk/CGE&Y

Eclipsys

Sentillion

MercuryMD

Innovision

Sun Microsystems

MercatorMDProductivity

CSI

FPT

NeoTool

SoftwareAG

SNOMED

GoodHealth Clinic

Alpha LabsBeta Labs

Virtual Health Record

Gamma Registry

Speedy Payer

SmallDoc Office

BeWell Hospital

CCOWCCOW AttachmentsAttachmentsV3V3V2V2 CDACDA

ADTADT OrdersOrders ResultsResults ReportsReports VocabVocab ConsultConsult BillBillContextContext VHRVHRVocabVocabVocabVocab

MSDashboard

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• creating CDA documents– Mayo– transcription– EHR– query

CDA: How to Create

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What can you do with a few tags?

• access/portability/exchange– query/locate by patient, provider,

practioner, setting, encounter, date

• integration– multiple transcription systems– with EHR records

• re-use/derivative data– summaries – billing

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XML separates displayformat from structureand content, so you getone file, many displays


provide universal access

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XML data is accessible

<section>Allergy List</section>

<para>…</para>

<para>…</para><section>Medications List</section>automated table of contents creation, linked to content, through style sheet transformations

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• One document, many views

CDA: How to Display

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• One document, many views• Many documents, one view

CDA: How to Display

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transcription


integrate records from multiple applications

standard

XML

CPR/EHR

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BestPractice Hospital

eMedicalFiles

Epic

IPNet

MSBizTalk/CGE&Y

Eclipsys

Sentillion

MercuryMD

Innovision

Sun Microsystems

MercatorMDProductivity

CSI

FPT

NeoTool

SoftwareAG

SNOMED

ADTADT OrdersOrders ResultsResults ReportsReports VocabVocab ConsultConsult BillBill

GoodHealth Clinic

Alpha LabsBeta Labs

Virtual Health Record

Gamma Registry

Speedy Payer

SmallDoc Office

BeWell Hospital

CDA AttachmentsAttachmentsV2V2V2V2 CDACDAV3V3

MSDashboard

CCOWCCOW

ContextContext VHRVHR

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CDA: How to Manage

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CDA::(v)EHR

• a single CDA is not an EHR• a CDA is an episodic snapshot of

care• a single CDA can be EHR input• a single CDA can be EHR output• CDA documents can serve as a

virtual EHR

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CDA::(v)EHR

• CDA is not an EHR– will not drive decision support– will not supply fine-grained clinical data to

drive public health surveillance

• CDA Level One will be extended to Level Three supporting fine-grained clinical data

• CDA Level One provides a gentle on-ramp to gain wider interoperability

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Transcription: problem or solution?

• Remains number one interface for creation of clinical records

• Transcription: seen as cost factor to be minimized or eliminated

• XML can make transcription output: – usable and re-usable– portable– basis for richly encoded record, mixing

narrative, controlled text and images

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Gating factors

• Provider demand • Vendor suppy• Standards

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Provider demand

• Currently, no strong demand for XML as deliverable

• Providers will create demand for clear quality/ROI goals:– access/portability/exchange– integration– re-use/derivative data

• Clinical information as enduring asset

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Vendor supply: Feb. 2001– MedQuist: XML internally for platform integration;

tracking stds– Edix: XML control files, clinical report in ASCII, HTML,

Word– HealthScribe: XML-based technology in development

for transcriptionist use– CareFlow|Net: XML output available, one client using it– Lanier: “air of inevitability”, but no demand– Vianeta: startup, XML-based technology for

transcriptionist use– [2/02: MDProductivity, speech-to-CDA]

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Standard XML

• HL7’s Clinical Document Architecture ANSI/HL7 CDA R1.0-2000 meets current requirements– will extend to specialized document

types– will extend to granular data– will be vehicle for professional/industry

groups to standardize their own practice

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Gating factors: summary

• Healthy information exchange:– technology not the barrier– waiting for provider demand– standards helpful, but pull will come

from providers

business drivers

technology

business drivers

technology

data

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This might work: Why?

• technical issues: not difficult• many P2P models available• 100% solutions have not worked• 80/20 solutions gaining credibilityJim Klein, Gartner Group, on HL7’s CDA, April, 2001 RU:

“HL7's Clinical Document Architecture (CDA) defines a new target for clinical information exchange that is substantially easier to hit than one based on standards for discrete data while delivering 80 percent of the value of the latter approach.”

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This might work: Why?

• technical issues: not difficult• many P2P models available• 100% solutions have not worked• 80/20 solutions gaining credibility• can scale down• The Bosworth/Bray Principle: simple

interoperability wins• supported by early adopters

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Conclusions

• XML bang-for-buck: transcription• Incremental road to CPR/EHR starts

with simple, electronic documents• Impetus is providers• Gradual approach that wins with

physicians, scales down will change the industry

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DiscussionMore info:

[email protected], Structured Documents TC

1st CDA Conference:Oct. 7-9, 2002

Europe

Alschuler.spinosa copyright 2001, Liora Alschuler HL7s CDA & the EHR TEPR Seattle Liora Alschuler...

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