Clinical Document Architecture
description
Transcript of Clinical Document Architecture
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Clinical Document Architecture
Open Standards-based EPR Incorporating Radiology
Michael LaRocca
![Page 2: Clinical Document Architecture](https://reader035.fdocuments.net/reader035/viewer/2022062309/568144e8550346895db1b8e1/html5/thumbnails/2.jpg)
Agenda
Why are XDS, XDR, and CDA a perfect match?How do XDS, XDR, and CDA come together to achieve an Electronic Patient Record?How do RIS concepts and metadata map to XDS, XDR, and CDA?
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Roles of CDA, XDS, and XDR
Clinical Content Community Sharing Direct Exchange
CDA XDS XDR
Patient SummaryReferral SummaryDischarge SummaryLab ReportMore…
• Document Submission• Document Storage• Document Registration• Document Sharing
• Document Submission• Document Receipt
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Goals of CDA
CDA: Goals
Give priority to delivery of patient care.
Allow cost-effective implementation across as wide a spectrum of systems as possible.
Support exchange of human-readable documents between users, including those with different levels of technical sophistication.
Promote longevity of all information encoded according to this architecture.
Enable a wide range of post-exchange processing applications.
Promote exchange that is independent of the underlying transfer or storage mechanism.
Prepare the design reasonably quickly.
Enable policy-makers to control their own information requirements without an extension to this specification.
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Overlapping Goals of CDA, XDS, and XDR
CDA, XDS, and XDR: Overlapping Goals
Give priority to delivery of patient care.
Allow cost-effective implementation across as wide a spectrum of systems as possible.
Support exchange of human-readable documents between users, including those with different levels of technical sophistication.
Promote longevity of all information encoded according to this architecture.
Enable a wide range of post-exchange processing applications.
Promote exchange that is independent of the underlying transfer or storage mechanism.
Enable policy-makers to control their own information requirements without an extension to this specification.
![Page 6: Clinical Document Architecture](https://reader035.fdocuments.net/reader035/viewer/2022062309/568144e8550346895db1b8e1/html5/thumbnails/6.jpg)
Agenda
Why are XDS, XDR, and CDA a perfect match?How do XDS, XDR, and CDA come together to achieve an Electronic Patient Record?How do RIS concepts and metadata map to XDS, XDR, and CDA?
![Page 7: Clinical Document Architecture](https://reader035.fdocuments.net/reader035/viewer/2022062309/568144e8550346895db1b8e1/html5/thumbnails/7.jpg)
IHE Core Services: Patient Identification via PIX(v3)
PHR Image Viewer Clinician PortalEHRDocument Consumers
Registration System
Lab SystemRadiology System
EMRDocument
Sources
PIX(v3) / PDQ(v3) Manager
Local ID: ABC Local ID: DEF
Global ID: XYZ
Local ID: GHI Local ID: JKL
XDSb Document Registry
Global ID: XYZ
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IHE Core Services: Document Submission via XDSb
PHR Image Viewer Clinician PortalEHRDocument Consumers
Registration System
Lab SystemRadiology System
EMRDocument
Sources
PIX(v3) / PDQ(v3) Manager
Local ID: ABC Local ID: DEF
Global ID: XYZ
Local ID: GHI Local ID: JKL
XDSb Document Registry
Global ID: XYZ
XDSb Document Repository
Repository ID: 123
Document ID: 1
Content
XDSb Document Repository
Repository ID: 456
Document ID: 2
Content
Document ID: 3
Content
Document 1 Document 2
Document 3
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IHE Core Services: Document Consumption via XDSb
PHR Image Viewer Clinician PortalEHRDocument Consumers
Registration System
Lab SystemRadiology System
EMRDocument
Sources
PIX(v3) / PDQ(v3) Manager
Local ID: ABC Local ID: DEF
Global ID: XYZ
Local ID: GHI Local ID: JKL
XDSb Document Registry
Global ID: XYZ
XDSb Document Repository
Repository ID: 123
Document ID: 1
Content
XDSb Document Repository
Repository ID: 456
Document ID: 2
Content
Document ID: 3
Content
Document 1 Document 2
Document 3
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IHE Core Services: Cross Community Access via XCA
PHR Image Viewer Clinician PortalEHRDocument Consumers
Registration System
Lab SystemRadiology System
EMRDocument
Sources
PIX(v3) / PDQ(v3) Manager
Local ID: ABC Local ID: DEF
Global ID: XYZ
Local ID: GHI Local ID: JKL
XDSb Document Registry
Global ID: XYZ
XDSb Document Repository
Repository ID: 123
Document ID: 1
Content
XDSb Document Repository
Repository ID: 456
Document ID: 2
Content
Document ID: 3
Content
Document 1 Document 2
Document 3
XCA Initiating Gateway
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IHE Core Services: Document Exchange via XDR
Point-to-Point
Source Destination
Point-to-Point through intermediary components
Source DestinationSourceHISP
DestinationHISP
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Agenda
Why are XDS, XDR, and CDA a perfect match?How do XDS, XDR, and CDA come together to achieve an Electronic Patient Record?How do RIS concepts and metadata map to XDS, XDR, and CDA?
![Page 13: Clinical Document Architecture](https://reader035.fdocuments.net/reader035/viewer/2022062309/568144e8550346895db1b8e1/html5/thumbnails/13.jpg)
Metadata Mapping: RIS to CDA to XDS and/or XDR
Category RIS CDA XDS / XDR
Patient Information Name name sourcePatientInfo
Date of Birth birthTime sourcePatientInfo
Sex administrativeGender
sourcePatientInfo
Address address sourcePatientInfo
Patient Number id sourcePatientId
National Number id patientId
Patient Class encompassingEncounter
Not Represented
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Metadata Mapping: RIS to CDA to XDS and/or XDR
Category RIS CDA XDS / XDR
Creator Person Name author author
Grade / Function author authorRole
Contact Number author sourcePatientInfo
Responsible Team legalAuthenticator legalAuthenticator
Reporting Source author authorInstitution
Consumer Recipient Name intendedRecipient intendedRecipient
Grade / Function Not Represented Not Represented
Contact Number intendedRecipient Not Represented
Recipient Team intendedRecipient intendedRecipient
Recipient Target intendedRecipient intendedRecipient
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Clinical Mapping: RIS to CDA
Category RIS CDA
Header Report Type ClinicalDocument/code
Accession Number ClinicalDocument/inFulfillmentOf/…order/id
DICOM Objects Section
Study act
Series act/entryRelationship/act
Service-Object Pair (SOP)Instance
act/entryRelationship/act/entryRelationship/observation
Findings Section Findings text (narrative)
Measurement entry/observation
Measurement (WADO) entry/observation/entryRelationship/observation
Conclusions Section Conclusions text (narrative)
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DICOM SR “Basic Diagnostic Imaging Report” in CDA
http://www.hl7.org/documentcenter/public/wg/imagemgt/SrCdaMapping01.pdf
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Clinical Document Architecture
Open Standards-based EPR Incorporating Radiology
Michael LaRocca