The economics of Interoperability - Health Level …...• Interoperability is a driver for...

The economics of Interoperability

Catherine Chronaki

Affiliate Director, HL7 International Board of Directors

• Interoperability is a driver for innovation in health care.. – ...leading disruptive exploration of novel care pathways

– …upholding patient safety

– …facilitating seamless and integrated care

– …enabling cost effective clinical trials

• Standardization is changing: …after a standard is published – This is when work begins!

• There is need to close the loop with health information technology standards, their implementation and adoption: – Implementation Guides, best practices, expectations, marketing!

– rich feedback from Implementation to SDOs

– partnerships, Community, Tools: check out HL7 CDA!

– Adopt third party certification: Close the cycle of Trust!

Main Points

Economics of Interoperability 2

What is CDA?

• CDA is a document markup standard for the structure and semantics of an exchanged "clinical document".

• CDA embodies business critical characteristics – Persistence, Stewardship

– Potential for authentication

– Context, Wholeness, Human readability

• A CDA document can – exist outside of a message

– include text, images, sounds, multimedia content.

• Enables data reuse – Patient summaries, Lab and pharmacy messages

– Clinical research, Electronic prescriptions

– Clinical Decision Support, Public Health

– Quality assessment

• Constrained by Templates, conformance profiles, implementation guides to be fit for purpose


Key Aspects of the CDA

– CDA documents are encoded in Extensible Mark-up Language (XML).

– CDA is derived from HL7's central Reference Information Model (RIM), thereby enabling data reusability with lab or pharmacy messages, claims attachments, clinical trials, etc.

– The CDA specification is richly expressive and flexible. Templates, conformance profiles, and implementation guides can be used to constrain the generic CDA specification.

<ClinicalDocument>

...

<structuredBody>

<section>

<text>...</text>

<observation>...</observation>

<substanceAdministration>

<supply>...</supply>

</substanceAdministration>

<observation>

<externalObservation>

...

</externalObservation>

</observation>

</section>

<section>

<section>...</section>

</section>

</structuredBody>

</ClinicalDocument>

D

O

C

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M

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T

B

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D

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Header

S

E

C

T

I

O

N

S

Narrative Block

E

N

T

R

I

E

S

External

References

Major Components of a CDA Document

Example

– Temperature is 36.9 C

<section>

<code code="8716-3" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC"/>

<title>Vital Signs</title>

<text>Temperature is 36.9 C</text>

<entry>

<observation classCode="OBS" moodCode="EVN">

<code code="386725007" codeSystem="2.16.840.1.113883.6.96"

codeSystemName="SNOMED CT" displayName="Body temperature"/>

<statusCode code="completed"/>

<effectiveTime value="200004071430"/>

<value xsi:type="PQ" value="36.9" unit="Cel"/>

</observation>

</entry>

</section>

Example – Father had fatal heart attack in 1970.

<section> <code code="10157-2" codeSystem="2.16.840.1.113883.6.1"


<title>Family history</title>

<text>Father had fatal heart attack in 1970.</text>

<entry>


<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>

<value xsi:type=“CD” code="22298006"

codeSystem="2.16.840.1.113883.6.96"

codeSystemName="SNOMED CT" displayName="MI"/>


<subject>

<relatedSubject classCode="PRS">

<code code="FTH" codeSystem=“2.16.840.1.113883.5.111”/>

</relatedSubject>

</subject>

<entryRelationship typeCode="CAUS">


<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>

<value xsi:type=“CD” code="399347008"

codeSystem="2.16.840.1.113883.6.96" displayName="death"/>


</observation>

</entryRelationship>

</observation>

</entry>

Example • Suture removal from left forearm performed

<section>

<code code="29554-3" codeSystem="2.16.840.1.113883.6.1"


<title>In-office Procedures</title>

<text>Suture removal from left forearm performed.</text>

<entry>

<procedure classCode="PROC" moodCode="EVN">

<code code="30549001"

codeSystem="2.16.840.1.113883.6.96"

codeSystemName="SNOMED CT"

displayName="Suture removal">

<qualifier>

<name code="363704007" displayName="Procedure site"/>

<value code="66480008" displayName="Left forearm"/>

</qualifier>

</code>


</procedure>

</entry>

</section>

CDA is based on a principle of Incremental Interoperability.

• Incremental Interoperability means that an implementer can begin with a simple CDA; then add structured data elements over time.

• CDA R2 consists of a single CDA XML Schema and the “architecture” arises from the ability to apply one or more “templates” that serve to constrain the richness and flexibility of CDA.

• Professional society recommendations, national clinical practice guidelines, and standardized data sets can be expressed as CDA templates.

• There are many kinds of templates that might be created. Particularly relevant for documents are: – Document-level templates, which constrain the CDA header and allowable sections

– Section-level templates, which constrain the allowable entries

– Entry-level templates, which define the atomic clinical statements within document sections

Med

ications

Pay

er

So

cial Histo

ry

Dem

og

raph

ics

Allerg

ies

. . . .

Vital S

ign

s

Ch

ief C

om

pla

int

Dis

ch

arg

e

Dia

gn

osis

Pro

blem

s

A CDA document using CCD templates

A CDA document

using CCD templates plus others

Mo

de

of

Tran

sp

ort

Ne

w Te

mp

late

…

Fam

ily H

istory

Su

rgic

al F

ind

ing

Dis

ch

arg

e D

iet

CDA

CCD

• Many different kinds of documents

• A bucket of reusable templates

Templated CDA

Consolidated CDA

• Many different kinds of documents: o CCD

o Consultation Note

o Diagnostic Imaging Report

o Discharge Summary

o H&P

o Operative Note

o Procedure Note

o Progress Note

o Unstructured Document

• A bucket of reusable templates

CDA Interoperability Roadmap

Narrative

Text

HL7 CDA Structured Documents

Coded Discrete Data Elements

Decision Support

Meaningful Use!

Clinical Applications

Decision Support

Meaningful Use!

Clinical Applications

SNOMED CT

Disease, DF-00000

Metabolic Disease, D6-00000

Disorder of glucose metabolism, D6-50100

Diabetes Mellitus, DB-61000

Type 1, DB-61010

Insulin dependant type IA, DB-61020

Neonatal, DB75110

Carpenter Syndrome, DB-02324

Disorder of carbohydrate metabolism, D6-50000

Quality Reporting

1. Incremental Interoperability: begin with a simple CDA, and then add structured data elements over time.

2. Key message: Get the data flowing, … get the data flowing, get the data flowing!


Why CDA is so widely adopted?

• Numerous implementations worldwide • CDA hits the “sweet spot”

– CDA expresses clinical documents. A single standard for the entire EHR is too broad. Multiple standards and/or messages for each EHR function may be difficult to implement. CDA is “just right”.

• Implementation experience – green CDA – CDA has been a normative standard since 2000, and has been balloted through

HL7's consensus process. CDA is widely implemented.

• Gentle on-ramp to information exchange – CDA is straight-forward to implement, – provides a mechanism for incremental semantic interoperability.

• Improved patient care – CDA provides a mechanism for inserting evidence-based medicine into the

process of care

• CDA crosses institutional borders/Lower costs – CDA’s top down strategy let’s you implement once, and reuse many times


Standard EHR Interface

Local EHR

National /xborder Requirements

Clinical reuse

Decision support

Secondary use Quality reporting

CDA

Implementation

Guide

CDA Template

Library

CDA Template

Library


Standards as a driver of innovation, quality, and safety

• Is the investment to interoperability worth it? Can do without it?

• at what level, or type of ehealth investment does interoperability switch from being a cost to a benefit?

• having invested in interoperability for benefits, what is a typical time and range of times needed to realise net benefits?

• Go beyond marketing: get serious about implementation

• HL7 CDA has wide adoption because it embodies the principles of collaboration & incremental interoperability

• Focus on Trust and Acceptability to change the culture

• Studies of economic Impact to be shared

• …So that patients are empowered, and eHealth is simply health


Introduction to HL7 Clinical Document Architecture

What is the CDA?

– The CDA is a document mark-up standard for the structure and semantics of an exchanged “clinical document.”

– A clinical document is a documentation of observations and other services with the following characteristics: • Persistence

• Stewardship

• Potential for authentication

• Context

• Wholeness

• Human-readability

– A CDA document is a defined and complete information object that can exist outside of a message and can include text, images, sounds, and other multimedia content.

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