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Transcript of Electronic Exchange of Structured Interim Discharge Summaries Using the XML- based Clinical Document...
Electronic Exchange of Structured Interim Discharge Summaries Using the XML-
based Clinical Document Architecture
Grace Paterson, Medical Informatics
Xiaoli Wang, Dalhousie Computer Science
http://www.medicine.dal.ca/dmedinfo
XML Standard for Healthcare
Comprehensive healthcare information exchange standard must include the full electronic health record, not just fielded data
Clinical Document Architecture (CDA) is a specification for exchanging clinical documents using eXtensible Markup Language (XML)
Bob Dolin’s Ehealth 2001 Workshop presentation available on CIHI HL7 website
Power of XML
XML, like HTML, is a derivative of Standard Generalized Markup Language (SGML)
Information Technology’s “lingua franca” Current “must-have” feature in software
Browsers, Notepad, SAS, Oracle, Internet Security E-Commerce and Automating Transactions
E-Health gets a tremendous boost at low cost
Power of a Think Tank - Kona Proposal
Week of July 7, 1997, a group of physicians, healthcare system
vendors and consultants met at Kona Mansion, NH
OUTCOME: a multi-level architecture for the exchange of
Electronic Health Care Records
April 2000. Kona Proposal was revised into the PRA (Patient
Record Architecture) but went to HL7 ballot August 2000 as
CDA (Clinical Document Architecture)
Xiaoli phoned Liora Alschuler for specifications
CDA and Shared Care
CDA gives priority to documents generated by clinicians involved in direct patient care
Care occurs where the patient’s pillow is - hospital, family physician, long term care
CDA standard can be readily implemented, and is platform and application independent
Promotes shared care in appropriate setting
Structured Discharge Summary
QEII DEPARTMENT OF MEDICINE Header Information (Participants and Roles) Most Responsible Diagnosis/Admitting Dx Comorbidities/Cardiac Risk Factors Allergies Course in Hospital Pertinent Investigations/LabResults
Structured Discharge (con’d)
Follow Up Recommendations for Family Doctor Medications on Discharge (unchanged from
admission, altered, new) Discharge Outcome Measures Physician’s Signature/Status/Print Name Discharge Summary and Dictated Job #
CDA and Knowledge Integration
Publishers submit abstracts to MedLine in XML XML tag <FullText> provides external link to
fulltext for MedLine abstract CDA has <content>, <link>, <coded_entry>,
<observation_media>, and <local_markup> Nova Scotians can link from CDA document to
Electronic Bookshelf entries in doctorsns.com for prompts and “Information Given to Patient”
CDA and Outcomes Research
• From time of Florence Nightingale to mid-60s, Hospital Annual Reports documented discharges as recovered, improved, no change, worsened, died
• Generic scales (SF-36) • Disease specific scales (IBDQ)• Health Status (comfort, function, lifespan) • Health Outcomes and HL7 V3 Data Types
FeedbackModel
Key features of CDA A clinical document should be human readable. The clinical document will be legally authenticated, and the
authentication of a clinical document will be applied to the whole, not portions of the document.
Entrusted person or organization will maintain the clinical document.
A CDA document can include text, images, sounds and other multimedia content.
CDA documents are encoded in XML. CDA documents will be consistent with HL7 data types.
Necessary and Sufficient Components
Persistence
Stewardship
Potential for Authentication
Wholeness
Human Readability
SpecificationOverview of CDA Architecture In Level One, the level one DTD is for all kinds of clinical
document. In Level Two, a specific clinical document will be defined in
consultation with Professional Societies QEII Hospital has gone through up to 12 revisions of Cardiology,
Internal Medicine, Geriatrics, COPD templates We were able to implement each template in Level One
Defined process for going from CDA Level One to CDA Level Three - tightly coupled with HL7 V3 Data Types
Deliberate decision to wait for V3 ballot results Aug 2001
XML Design (Header) CDA Header is used to uniquely identify a clinical document in order to
exchange it among organizations There are four components for header: document information, Encounter data,
providers and patients Document information includes <id>, <set id>, <version_nbr>,
<document_type_cd>, <confidentiality_cd>, <document_relationship> Encounter data describe the setting in which the documented encounter
occurred. It includes <patient_encounter>, <practice _setting_cd>, <encounter_tmr>, <service_location>, <addr>.
Provider include the person who participated in the services being documented.
Patient include the patient and other significant participants (such as family members)
XML (Level One Body)
Nested containers in Level One body: sections, paragraphs, list and tables.
Minimal amount of markup and minimal constraint for this markup.
Coded entries uses HL7 Version 3 Data Types Appendix A lists object identifiers, e.g.,
2.16.840.1.113883.6.3 is the external coding scheme ICD10
<coded_entry><section>
<caption>Most Responsible Diagnosis</caption>
<section>
<caption>Unstable Angina
<caption_cd V=“I20.0” S=“2.16.840.1.113883.6.3”/>
</caption>
<paragraph>
<content>Y</content>
</paragraph>
</section>
Object Identifier for ICD10 coding scheme
ICD10
Implementation To generate a Discharge Summary, the user
enters the information into Web form Information is POSTed to Web server where a
Java servlet parses the input data and marks up the data into the CDA format
Written to disk as an XML file Retrieved as XML file by Java servlet and parsed
into constituent elements by SAX parser, converted to HTML and displayed
Implementation
XML describes the meaning of content, independent of its display
There are two style sheets for XML CSS (Cascading Style Sheet) XSL (XML Style Sheets Language)
User enters chart number for search and choice of display style (web form or discharge summary)
Implementation
Parser of XML We must access information in XML
documents through an XML parser. There are two kinds of parser: SAX and
DOM, SAX is event-based parser and DOM is object-based parser, the core object is Node.
Implementation
• Several events for SAX:• startDocument()/endDocument()
• startElement()endElement()
• Characters()
• Several methods for DOM:• NodeType, parentNode, childNode, firstchild,
getElementByTagName(), getText(), getNameItem().
Summary and Next Steps The procedure of this project includes understanding
specification, designing a system, implementing the system, and the final testing.
The purpose of the system is to meet the need of an extensible, hierarchical, structured clinical document exchange.
Work-in-progress with other CS Students: CDA document storage in Statistical Analysis System (SAS) CDA integrated with Electronic Bookshelf Automatic Indexing Using UMLS for Coded Entries
Acknowledgements• Dr. Michael Shepherd, Computer Science
• Dr. Carolyn Watters, Computer Science
• Dr. David Zitner, Director, Medical Informatics; Chair, Health Records Committee, QEII Health Sciences Centre
• Kathy MacNeil, Director, Patient Information Services, QEII Health Sciences Centre
• Patient Care Record Committee, Capital Health District Authority
• Mary Eileen Wall, Clinical Informatics Coordinator, QEII Health Sciences Centre
• Sandra Cascadden, Director of IT Services, QEII Health Sciences Centre
• Ron Soper, Computer Science CO-OP Student