Transcript Development, implementation, and initial evaluation of a

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Development, implementation, and
initial evaluation of a
foundational open interoperability
standard for oncology
treatment planning and
summarization
Jeremy L. Warner, Suzanne E. Maddux, Kevin S. Hughes, John C. Krauss, Peter Paul Yu,
Lawrence N. Shulman, Deborah K. Mayer, Mike Hogarth, Mark Shafarman, Allison
Stover Fiscalini, Laura Esserman, Liora Alschuler, George Augustine Koromia, Zabrina
Gonzaga, Edward P. Ambinder
Consider this Realistic
Situation
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A postmenopausal, diabetic woman has been diagnosed
with early-stage invasive breast cancer
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She will require surgery, adjuvant (postoperative)
chemotherapy, radiation treatment, and hormonal therapy
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She has an established relationship with a local primary
care physician (PCP) and an endocrinologist
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She lives 150 km from a National Accreditation Program for
Breast Centers (NAPBC) Center of Excellence
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The nearest infusion center for chemo is 50 km away
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None of her providers share an interoperable electronic
health record (EHR)
A Tangled Web
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Patient
Caregivers
PCP
Visiting
Nurse
Nursing
Home
Rad Onc
Med Onc
Surg Onc
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Without standards, communication pathways may
be haphazard, incomplete, and nonsynchronous.
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2013 Oncology Standards Summit
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2013 Oncology Standards Summit
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2013 Oncology Standards Summit
Initial Project Vision
2013 Oncology Standards Summit
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2013 Oncology Standards Summit
ASCO’s Approach to HL7
Working with Lantana Consulting to develop HL7 CDA
templates for ASCO’s Breast Cancer Adjuvant TPS
Develop oncology-specific CDA templates
CDA templates are re-usable, incremental, and extensible.
C-CDA is referenced in MU Stage 2.
Harmonize and re-use existing oncology profiles
–
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NCI templates
CDC Implementation Guide for Healthcare Reporting to Central
Cancer Registries
Adapted from 2013 Oncology
Standards Summit
Templated CDA
• Many different kinds of documents
• A selection of reusable templates
CDA document
using CCD templates plus others
CDA document using CCD templates
© CDA Academy, 2012
New Section…
CDA
Discharge Diet
Surgical Finding
Mode of
Transport
Discharge
Diagnosis
Payer
Problems
Medications
Vital Signs
Social History
Family History
Allergies
Demographics
....
Chief Complaint
CCD
Consolidated CDA R1 (Cited in MU2)
CDA templates for common
document types:
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Continuity of Care Document (CCD) plus
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Consultation Note
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Diagnostic Imaging Report
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Discharge Summary
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H&P
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Operative Note
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Procedure Note
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Progress Note
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Unstructured Document
Benefits
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More comprehensive patient information than
the CCD
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Continuity of care is improved
© CDA Academy, 2012
Deconvoluting
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Patient
PCP
Med Onc
Visiting
Nurse
Secondary
needs
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Surg Onc
Rad Onc
Nursing
Home
Standards enable reliable, complete, and replicable
communication—with or without a central source of truth,
such as a health information exchange
Hurricane Katrina, 2005
© Associated Press
Public domain
”…tens of thousands of records have been lost.” - Economist
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Chemotherapy Treatment
Plan and Summary Templates
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Goal: to enable continuity of care even with the
loss of medical records e.g. Katrina
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Paper-based documents used during the cancer
work-up and treatment planning phase,
treatment, and as a summary after completion of
treatment
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Breast, Colon, Lung (SCLC/NSCLC), Lymphoma
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Curable breast cancer is a common but fairly
complex scenario, selected for CDA DSTU1
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80+ data elements
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Numeric (e.g. medical record number; OncotypeDX recurrence
score)
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Dated (e.g. patient date of birth)
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Encodeable to an HL7-recognized terminology (e.g. Breast TNM
node category  SNOMED-CT, US Realm)
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Encoded to an HL7 RIM Class (e.g. Practice site  Entity Class)
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Narrative representation
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Warner et al. JAMIA 2015
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eCOTPS New Template
Example
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First Implementation of
eCOTPS: Health Story Project
2014 Oncology Standards Summit
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2014 Oncology Standards Summit
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Second Implementation of eCOTPS:
Project INSPIRE
INSPIRE: INteroperability to Support
Practice Improvement, Disease REgistries,
and Care Coordination
GOAL: Improve acquisition and exchange
of patient data in high impact conditions in
order to support longitudinal disease
registries, care coordination, and practice
improvement
Adapted from 2014 Oncology
Standards Summit
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Athena-INSPIRE: Today and the Future
EHR 1
ASCO/HL7
eCOTPS
CAP
eCC XML
ASCO/HL7
eCOTPS
EHR 2
EHR
ASCO/HL7
eCOTPS
Dynamic Form for Data Capture
(XML-driven and questionnaire like
with skip/branch, etc…. Rendered *within* EHR)
ASCO/HL7
eCOTPS
State Central
Cancer Registry
Health
Information
Home
ASCO/HL7
eCOTPS
HTML window rendering
external web app
Cloud
Web-app
Prototype
Health
Information
Home (HIH)
Visual Force Web App
Epic Desktop Client
EpicCare
Adapted from 2014 Oncology
Standards Summit
The eCOTPS Mapping Project
• Task: Map Athena checklist data elements using eCOTPS
• Challenges:
– Athena checklist elements are much more comprehensive
than those specified in the eCOTPS and meant to be
entered in real-time to facilitate care coordination
– Athena checklist data are often at a finer level of detail than
is specified in the eCOTPS specification
– Use cases for the Health Information Home (HIH) also
specify a finer level of detail
– Requires adding appropriate templates to the eCOTPS, and
deciding on their location in the eCOTPS structures
Adapted from 2014 Oncology
Standards Summit
The Mapping Project: Issues I
• Discovering the proper codes to represent the Athena
concepts: using SNOMED, LOINC, PhinVads, and other
terminology browsers
– Requires working with terminology standards organizations
to create new codes, and/or using codes from several
organizations not mentioned in the eCOTPS specification
– Often requires creating combinations of codes (and
structures) to create a better mapping (using the CTS2
strategies for mapping codes to HL7 V3 structures)
• Creating, adapting and using the CDA templates
required by the Athena use of the eCOTPS specification.
Adapted from 2014 Oncology
Standards Summit
The Mapping Project: Issues II
• The eCOTPS needs to be sent multiple times to
the HIH as a patient proceeds through their
“cancer journey.”
• This means that additional administrative details
(id’s, signatures, etc.) must be added to the
eCOTPS.
• The current stage of the project deals primarily
with the machine-readable, structured aspects of
the eCOTPS. Human-readable representation
details left for a second stage.
Adapted from 2014 Oncology
Standards Summit
Summary
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eCOTPS is the first oncology-specific CDA
standard to achieve HL7 DSTU status
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Lessons learned during design and
implementation have led to improvements in the
draft standard
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eCOTPS is now in DSTU R2, with addition of Colon
Cancer Adjuvant Treatment Plan & Summary
template definitions
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Future roadmap includes adding other disease
sites, survivorship, patient-reported outcomes,
and balloting for normative status