Transcript Content Management - Dalhousie University

HICSS-35 Hawaii International Conference on System Sciences
Using the XML-Based Clinical
Document Architecture for
Exchange of Structured Discharge
Summaries
Grace I. Paterson, Michael Shepherd, Xiaoli
Wang, Carolyn Watters, and David Zitner
DALHOUSIE
University
HICSS-35 Hawaii International Conference on System Sciences
Overview
Health Level Seven (HL7) and XML
Clinical Document Architecture (CDA)
Levels within the CDA
Vocabulary Domains
Implementation
Clinical/Admin Information Exchange
Current Status
HICSS-35 Hawaii International Conference on System Sciences
Health Level Seven (HL7)
HL7 is an ANSI-accredited Standards
Development Organization
Domain is clinical and administrative data
Focus is the interchange of health care data
Level 7 refers to the highest level,
applications, of the communications model
for Open Systems Interconnection
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HL7 Mission
Clinical Interoperability
Interoperability
:ability of two of more systems or components
to exchange information and to use the
information that has been exchanged.
[Source: IEEE Standard Computer Dictionary: A Compilation of
IEEE Standard Computer Glossaries, IEEE, 1990]
Functional
Interoperability
Semantic
Interoperability
HICSS-35 Hawaii International Conference on System Sciences
HL7 and SGML/XML
 Initial release of HL7 Version 3 slated for
December 2001 will use only XML encoding
 Two groups in HL7 SGML/XML
 XML as an alternative syntax for messages
 Structured Documents Technical Committee
 An architecture for structured documents defines
relationships between documents and document
specifications in terms of specialization and
inheritance – a Clinical Document Architecture
HICSS-35 Hawaii International Conference on System Sciences
Clinical Document Architecture (CDA)
 Kona Proposal drafted in 1996 (Kona Mansion)
 Clinical Document Architecture (CDA) is a
specification for exchanging clinical documents
using eXtensible Markup Language (XML)
 Leverages the use of XML, the HL7 Reference
Information Model and coded vocabularies to
specify the structure and semantics
 Machine and Human-readable documents
 Approved as an ANSI standard November 2000
HICSS-35 Hawaii International Conference on System Sciences
A CDA Document
A CDA document is a defined and
complete information object
Can exist outside of a messaging context
and/or can be a payload within an HL7
message
HICSS-35 Hawaii International Conference on System Sciences
Clinical Documents in QEII
Currently each page of paper chart reviewed
to produce Discharge Summary and Abstract
Demographic information
Length of Stay
Diagnoses and Procedures
Most of this information is produced by
clinicians
Huge potential cost savings if the summary
could be captured concurrent with care and
used for discharge communication
HICSS-35 Hawaii International Conference on System Sciences
Discharge Summary –Hospital
Communication to Family Doctor
QEII Department of Medicine Structured
Discharge Summary
 Header Information (Participants and Roles –
Patient, Sender, Recipient)
 Most Responsible Diagnosis
 Comorbidities/Cardiac Risk Factors
 Course in Hospital and Conclusions
 Pertinent Investigations/Lab Results
 Further steps and scheduling
HICSS-35 Hawaii International Conference on System Sciences
Referral Communications
From Family Physician to Hospital
Patient Information
Reason for referral
Symptoms and Duration
Investigations and Results
Diagnosis and Treatment
Prescribed Medications
HICSS-35 Hawaii International Conference on System Sciences
Features of DoctorPortal
Adding a discharge or referral
Finding a discharge or referral
Editing a discharge or referral
Querying a discharge or referral
Listing all discharges and referrals
assigned to a given doctor
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HICSS-35 Hawaii International Conference on System Sciences
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Query the Database
HICSS-35 Hawaii International Conference on System Sciences
Levels within the CDA
Level One is the root
Most general specification (low-hanging fruit)
Defined and complete information object – web
implementation of paper documents to start
RIM classes are used in the CDA Header
Terms from controlled vocabularies in body
Level Two will be a specialization of Level One
Level Three: Clinical content can be marked up
to the extent that it is modeled in the HL7 RIM
HICSS-35 Hawaii International Conference on System Sciences
Level One CDA Document
Composed of CDA Header and CDA
Body
Purpose of the CDA Header is to enable
clinical document exchange across and
within institutions
Coded entries uses HL7 Version 3 Data
Types
HICSS-35 Hawaii International Conference on System Sciences
HL7 Version 3 Data Types
XML Element Names map to Data Types
_cd vocabulary domain has coding strength
 CNE coded, no extensions
 CWE coded, with extensions (allows local codes)
 Make use of published authoritative sources of code values
_tmr document time stamp
 _id identifier
_nbr number
Vocabulary domains may be HL7-defined
concepts or recognized coding schemes such as
SNOMED, READ, ICD10, Medcin
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Captions, Coded Captions, and
Registered Vocabularies
<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>
HICSS-35 Hawaii International Conference on System Sciences
Level One Document Instance
<?xml version="1.0"?>
<!DOCTYPE levelone PUBLIC "-//HL7//DTD
CDA Level One 1.0//EN"
"dischargesummary.dtd">
<levelone>
<clinical_document_header>
…
</ clinical_document_header>
<body confidentiality= “CONF1”>
…
</body>
</levelone>
HICSS-35 Hawaii International Conference on System Sciences
Level One: CDA Header
1. Document information includes <id>, <set id>,
<version_nbr>, <document_type_cd>,
<confidentiality_cd>, <document_relationship>
2. Encounter data describe the setting in which the
documented encounter occurred and includes
<patient_encounter>, <practice _setting_cd>,
<encounter_tmr>, <service_location>, <addr>.
3. Provider includes the persons who participated
in the services being documented
4. Patient includes the patient and other significant
participants (such as family members)
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Level One: CDA Body
Nested containers in Level One body:
sections, paragraphs, list and tables.
Minimal amount of markup and minimal
constraint for this markup
HICSS-35 Hawaii International Conference on System Sciences
Doctor Portal Implementation
 The portal has three features:
1. Ability to add, edit, find, and query discharge
summaries
2. Ability to add, edit, find, and query referral forms
3. Ability to list all discharges and referrals assigned
to a specific doctor
 Javascript and HTML implement the interface
and interact with the user as information is
entered into the form
HICSS-35 Hawaii International Conference on System Sciences
HTML
Web interface
JAVA
Servlet
XML DB
API
Performs dbXML
Operations
Handles requests
& responses
SAX
Parser
Validates XML
dbXML
Database
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Database Platform
dbXML is an open source Native XML
Database
stores and indexes compressed XML documents in
order to provide that data to a client application with
very little server-side processing overhead
provides functionality that is unique to XML data,
which can't easily be reproduced by relational
databases
http://www.dbxml.org/ for Users Manual
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Clinical/Administration
Information Exchange
CDA is sufficient backbone for
communication between Information
Systems in Physician Offices and
Hospital
Canadian hospitals abstract each patient
record for Canadian Institute for Health
Information
Information should support clinical,
administration, education and research
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Current Status
Working demonstration system
Planned implementations for 2002
HealthInfoRx™: Lifelong Learning for
Chronic Disease Patients
CDA will be used for physician to physician
referral/discharge communications for patients in
Inflammatory Bowel Disease Clinic (Level Two)
Concurrent Review Document
Data collection January 2002 using XML system
Test of implementation in a District (Level Three)
HICSS-35 Hawaii International Conference on System Sciences
Thank You
Questions?
Further Information:
www.medicine.dal.ca/dmedinfo
[email protected]
HICSS-35 Hawaii International Conference on System Sciences
Acknowledgements
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Dr. Michael Shepherd, Computer Science, Dalhousie
Dr. Carolyn Watters, Computer Science, Dalhousie
Dr. David Zitner, Director, Medical Informatics, Dalhousie
Dr. John Ginn, Medical Informatics, Dalhousie
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
Dr. Elizabeth Cowden, Head, Department of Medicine, QEII
Ron Soper, Computer Science CO-OP Student