alschuler spinosa Structured Documents HL 7 s CDA

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alschuler. spinosa Structured Documents: HL 7’s CDA & the EHR TEPR What a few tags can do Seattle Liora Alschuler May 13, 2002 alschuler. spinosa (dba) East Thetford, VT La Jolla, CA liora@the-word-electric. com copyright 2001, Liora Alschuler

alschuler. spinosa • alschuler. spinosa: consulting practice with focus on application of XML and related standards to healthcare • Liora Alschuler – – – Co-chair HL 7 Structured Documents TC Chair, HL 7 Marketing Committee past Chair, KEG (wrote HL 7 Clinical Document Architecture) coordinator, HL 7 HIMSS Technical Demo consultant, writer author, ABCD… SGML: A User’s Guide to Structured Information, 1995 • John Spinosa – MD and Ph. D. from UC San Diego; trained in pathology at UCSD; hematopathology fellowship, staff member at Scripps La Jolla – Co-founder of XML TC – Member of the CAP informatics committee 2 copyright 2001, Liora Alschuler

alschuler. spinosa Information Ecology • Primary cause of poor information flow in healthcare: lack of usable and reusable electronic data – 85 -95% of clinical data still paper based • HIMSS Leadership Survey 99 -00 – – 99: 10 -11% have implemented EHR 99: 25% planning to w/in one year 00: 10 -11% have implemented EHR 00: 25% planning to w/in one year copyright 2001, Liora Alschuler 5

alschuler. spinosa Bad ecology • The impact: – IOM report: poor information leads to poor healthcare – can’t control costs – some claims, all attachments, most admin/finan transactions still paper electronic : : paper 3 billion : : 25 -30 billion (Wit Capitol, 2000) • Can track price of peaches in Alberta, but can’t track status of claims copyright 2001, Liora Alschuler 6

alschuler. spinosa XML and info ecology • XML can break the electronic data log jam • The big breakthrough is not in the CPRI • The big change is in the – simple XML documents for ubiquitous access, integration and reuse – encoding of narrative, human language, for H 2 H and simple machine processing copyright 2001, Liora Alschuler 7

alschuler. spinosa XML for healthcare data • where is the 80/20 point for healthcare information? • Ericais not VP First Consulting Group, in Healthcare it Drazen, the full-blown “computerized Informatics: patient organizations claiming complete CPR not) There are fewrecord” (XML-encoded orsystems. “As originally defined, a CPR is neither necessary nor sufficient on its own as a tool for improving care. ” To be useful, information needs to be available, first and foremost, and only then does it matter if it is coded to the extent that will support a CPR. “It’s doubtful that all the information in current records will ever be duplicated in electronic records, and it certainly will not all be coded. ” copyright 2001, Liora Alschuler 11

alschuler. spinosa The 80/20 point for healthcare • Setting new targets for information exchange – more like the Web – healthcare-specific • Extensible Markup Language (XML) • Clinical Document Architecture copyright 2001, Liora Alschuler 12

alschuler. spinosa Clinical Document Architecture • New specification (Nov. 2000) for healthcare documents • Uses XML, like the Web, but vocabulary specific to medicine • Lower, simpler objectives than previous exchange specifications – common format for transcription and EHR records – Human-readable on Web, PDA, cell, … copyright 2001, Liora Alschuler 13

alschuler. spinosa the 80/20 sweet spot: XML, a few tags at a time

Impressions RLL Impressions nodule suggestive of RLL malignancy. . . nodule suggestive of malignancy. . . any transcription system can produce this or this, with postprocess coding, NLP, AI, KM or a better user interface Impressions RLL nodule suggestive of malignancy. . . copyright 2001, Liora Alschuler 15

Orders Results Reports Beta Labs alschuler. spinosa ADT Alpha Labs Neo. Tool Vocab Consult Context CSI MDProductivity Gamma Registry SNOMED Bill VHR Speedy Payer Mercator Small. Doc Office Good. Health Clinic e. Medical. Files IPNet Virtual Health Record Software. AG Epic MSBiz. Talk /CGE&Y Sun Microsystems FPT Be. Well Hospital Mercury. MD Best. Practice Hospital Innovision Eclipsys V 2 V 3 MSDashboard Sentillion CDA CCOW Attachments copyright 2001, Liora Alschuler 16

alschuler. spinosa What can you do with a few tags? • access/portability/exchange – query/locate by patient, provider, practioner, setting, encounter, date • integration – multiple transcription systems – with EHR records • re-use/derivative data – summaries – billing copyright 2001, Liora Alschuler 18

alschuler. spinosa What can you do with a few tags? XML separates display format from structure and content, so you get one file, many displays provide universal access copyright 2001, Liora Alschuler 19

alschuler. spinosa XML data is accessible

Allergy List

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Medications List

alschuler. spinosa CDA: : (v)EHR • • • a single CDA is not an EHR a CDA is an episodic snapshot of care a single CDA can be EHR input a single CDA can be EHR output CDA documents can serve as a virtual EHR copyright 2001, Liora Alschuler 27

alschuler. spinosa CDA: : (v)EHR • CDA is not an EHR – will not drive decision support – will not supply fine-grained clinical data to drive public health surveillance • CDA Level One will be extended to Level Three supporting fine-grained clinical data • CDA Level One provides a gentle onramp to gain wider interoperability copyright 2001, Liora Alschuler 28

alschuler. spinosa Transcription: problem or solution? • Remains number one interface for creation of clinical records • Transcription: seen as cost factor to be minimized or eliminated • XML can make transcription output: – usable and re-usable – portable – basis for richly encoded record, mixing narrative, controlled text and images copyright 2001, Liora Alschuler 29

alschuler. spinosa Provider demand • Currently, no strong demand for XML as deliverable • Providers will create demand for clear quality/ROI goals: – access/portability/exchange – integration – re-use/derivative data • Clinical information as enduring asset copyright 2001, Liora Alschuler 31

alschuler. spinosa Vendor supply: Feb. 2001 – Med. Quist: XML internally for platform integration; tracking stds – Edix: XML control files, clinical report in ASCII, HTML, Word – Health. Scribe: XML-based technology in development for transcriptionist use – Care. Flow|Net: XML output available, one client using it – Lanier: “air of inevitability”, but no demand – Vianeta: startup, XML-based technology for transcriptionist use – [2/02: MDProductivity, speech-to-CDA] 32 copyright 2001, Liora Alschuler

alschuler. spinosa Standard XML • HL 7’s Clinical Document Architecture ANSI/HL 7 CDA R 1. 0 -2000 meets current requirements – will extend to specialized document types – will extend to granular data – will be vehicle for professional/industry groups to standardize their own practice copyright 2001, Liora Alschuler 33

alschuler. spinosa Gating factors: summary • Healthy information exchange: – technology not the barrier – waiting for provider demand – standards helpful, but pull will come from providers technology business drivers copyright 2001, Liora Alschuler data 34

alschuler. spinosa This might work: Why? • • technical issues: not difficult many P 2 P models available 100% solutions have not worked 80/20 solutions gaining credibility Jim Klein, Gartner Group, on HL 7’s CDA, April, 2001 RU: “HL 7's Clinical Document Architecture (CDA) defines a new target for clinical information exchange that is substantially easier to hit than one based on standards for discrete data while delivering 80 percent of the value of the latter approach. ” copyright 2001, Liora Alschuler 35

alschuler. spinosa This might work: Why? • • • technical issues: not difficult many P 2 P models available 100% solutions have not worked 80/20 solutions gaining credibility can scale down The Bosworth/Bray Principle: simple interoperability wins • supported by early adopters copyright 2001, Liora Alschuler 36

alschuler. spinosa Conclusions • XML bang-for-buck: transcription • Incremental road to CPR/EHR starts with simple, electronic documents • Impetus is providers • Gradual approach that wins with physicians, scales down will change the industry copyright 2001, Liora Alschuler 37