1. National Conference Information Science -2010
Clinical Interoperability to Improve
Quality & the Point-of-Care of EHR
Point-of-
Presented By: Gunjan Patel
PG Student: MS-Medical Software
PGD-QM, BME
MCIS, Manipal University

2. ATM-to-ATM Money Transfer
Money Transaction
Y Bank ATM X bank ATM card +
Machine Y Bank ATM Machine
X Bank
ATM Card
2

3. Motivation
 Why are the patient clinical records need for to be
exchanged for Interoperability?
 How can we improve the quality of patient health
record?
 What are the basic standards to meet specifications?
 What are the basic needs for the design CCD template?
 What is the Module structure and semantics of a patient
summary clinical document for exchange?
3

4. Outline
 Literature view
 Introduction
 Health Level 7
 What is the ASTM CCR?
 How did the CCD develop?
 Development and results
 Conclusion
 Future Work
 References

5. List of Abbreviations
HL7 = Health Level 7
ASTM=American Society for Testing and Materials
ANSI=American National Standards Institute
RIM = Reference Information Model
CDA = Clinical Document Architecture
CCR=Continuity of Care Record
CCD= Continuity of Care Document
HITSP= Healthcare Information Technology Standards Panel
CI= Clinical Interoperability
XML = eXtensible Markup Language
XSD = XML Schema Definition
VB.Net = Visual Basic.Net
5

6. Literature view
Year History & Article Released
The board of Health Level Seven, a standards development organization has
2004 -
specification for a CDA approved the Electronic Health Record System Functional
2005
Model for clinical interoperability.
Health Level 7 - CCD will be a component of hl7's Clinical Document Architecture ->
Dec
balloted by HL7 members and Healthcare Information Technology had included CCR
2006
functionality in its testing criteria for interoperability of EHR systems
CCD structure was developed as a collaborative effort between ASTM and HL7,
JUNE -
combining the benefits of ASTM - Continuity of Care Record (CCR) and the HL7 CDA
2007
specifications
Nov Hl 7 CCD Clinical documents by supporting interoperability through a common
2008 structure and semantics.
The Healthcare Information Technology Standards Panel (HITSP) approved the
Mar Continuity of Care Document (CCD), which set standards for interoperability that
2009 enabled clinical data to be transportable, thus enhancing patient safety and
efficiency.
6

7. Basic Term
 Clinical Interoperability
 The Clinical Interoperability relationship is represented to
support the electronic exchange of patient summary
information and the high reliability exchange of information
between an EHR system and other healthcare IT systems
 Interoperability aims to support clinical documents
 Integration with clinical and non-clinical information
 Medical terminology transfer, mapping at the point of care
7

8. Introduction
 Clinical interoperability is to support the electronic
exchange of patient summary information among
caregivers and other authorized parties via potentially
disparate EHR systems to improve the quality, safety,
and worth of care delivery
 The HL7 Clinical Document Architecture (CDA) is a CCD
document markup standard that specifies the structure
and semantics of ‘clinical documents’ for the purpose of
exchange that would improve quality and the point-of-
care of EHR.
8

9. Scenario of without Interoperability in
Healthcare systems
 Without interoperability, EHR further strengthen
the information that exist in today’s paper-
based medical files & other systems.
Clinical Documents of
Patient’s Record File
Patient File
9

10. How can clinical Interoperability support in
current Healthcare systems ?
To exchange of
Patient Summary of
Information
10

11. Clinical Interoperability Solutions offerings help
healthcare organizations
 Improve patient health and safety:
 CI is to support the electronic exchange patient summary
information among caregivers and other authorized parties via
potentially different EHR systems to improve safety and efficacy
of care delivery
 Delivering medication history, prescriptions & formulary
formation to clinicians on demand for the purpose of exchange
that would improve quality and the point-of-care of EHR
 Achieve operational efficiencies and reduce costs:
 Providing existing information systems the ability to exchange
data electronically, including lab, clinical notes and
demographics

11 Generate Automating patient record location services across
networks and systems

12. Health Level 7 Organization
 HL7 is an organization - clinical interoperability problem
by providing a standard that allows the exchange of
patient health information across diverse medical
systems in healthcare facilities
 HL7 standards in Healthcare
 The data to be exchanged and the timing of the interchange
 The communication of certain errors to the application
 Supports such functions as security checks
 Participant identification and exchange mechanism, data
exchange structuring
12

13. What is the ASTM Continuity of Care Record
(CCR)?
 XML-based standard for clinical data exchange
 Developed by ASTM International
 Provides a “snapshot” of treatment and basic
patient information – it is not comprehensive
like an EHR.
 Information in this record
 Focused on Diagnostics and reason for referral
 Rather than symptoms and treatment chronology
 Important distinction between CCR and CDA
 CCR uses only specified XML code. It does not support/allow
narrative text (free-text) which can sometimes be hindering to
physicians, and it is not electronically acceptable by all systems
13

14. How did the Continuity of Care Document (CCD)
develop for Interoperability?
ASTM CCR + HL7 CDA = CCD
 The resulting specification, known as the Continuity of
Care Document (CCD), is being developed as a
collaborative effort between ASTM and HL7.
 CCD is also a true document, not just a record, and is
designed for the same type of exchanges as those
performed in an EHR – including import, management,
and export data in XML
14

15. Why CCD is universally Accepted for
electronic exchange?
 A universal standard
 Broad compatibility
 Easy incorporation into new and existing technology or standards
 Easy integration
 The HL7 CDA RIM-based specifications
 Compatible existing applications, browsers, EHR and legacy
systems
 Universally rendered as HTML or PDF
 XML
 Encouraging the implementation of XML for clinical document exchange
 CCHIT given approval of CCD as part of their certification process is
an important step in facilitating the widespread adoption of both
CCD and XML
15

16. CCD Template Design Process
The RIM, CDA, Hierarchical Description and XML
Schema defination
Reference Clinical XML < CCD
Hierarchical
Information Document Schema template />
Description
Model Architecture Definition
16

17. Reference Information Model (RMI)
 Primarily based on a data model called RIM.
 Shared information model that offers a consistent
vocabulary for clinical data content.
 Applies an object-oriented development
methodology, expressed with the Unified Modeling
Language (UML), which includes classes, attributes,
relationships and state-machine diagrams
 UML is an industry-standard language for specifying,
visualizing, constructing, and documenting object-
oriented and component-based system
architectures and designs
17

18. Clinical Document Architecture
 The CDA Release 2.0 provides an exchange model
for clinical documents
 By leveraging the use of XML, the HL7 Reference
Information Model (RIM) & Coded vocabularies
 The CDA makes documents both
 Machine – Readable >> Easily parsed and processed electronically
 Human - Readable >> Easily retrieved and used by the people
 Displayed using XML- Web browsers
 It provides state-of-the-art interoperability for machine-
readable coded semantics.
18

19. A CDA Document could be a:-
 Discharge Summary
 Referral
 Clinical Summary Report
 History & Physical examination
 Diagnostic Reports (DI, lab…)
 Medication Prescription Rx
 Public health report
19

20. Allscripts Touchworks
IHE
Medical
Summaries
HIMSS 2006:
GE Centricity a CDA Gallery
Siemens Soarian (XML) MediNotes e
Siemens Soarian (PDF)
Eclipsys Sunrise

21. Hierarchical Description
21

22. Development and results
 The design of the CCD module for the
Interoperability of clinical documents , not just a
record, and is congruently designed for the same
type of exchanges as those performed in an EMR
 Including import
 Management
 Export of information in the XML format
 Because of its small fixed XML tag set
 CCD can be universally rendered as HTML or PDF or print
22

23. CCD template structure components
Template Modules Section
A. Header
B. Body
Purpose Medications
Problems Immunizations
Procedures Medical equipment
Family history Vital signs
Social history Functional status
Payers Results
Advance directives Encounters
Alerts Plan of care
23

24.  Example of birthTime Mapping for CCD XML file
value 19320924
birthTime
<patient> XML
<birthTime value="19320924"/>
</patient>
 Illustration the CDA’s XSD to VB.net
<xs:complexType name="POCD_MT000040.Patient">
<xs:sequence>
<xs:element name="birthTime" type="TS" minOccurs="0"/> XSD
</xs:sequence>
</xs:complexType>
objClinicalDocument.RecordTarget.patientRole.patient.birthTime = New TS VB.net
objClinicalDocument.RecordTarget.patientRole.patient.birthTime.value =
"19320924"
24

25. Clinical Interoperability of CCD module
CCD document generation work flow
Display the
Select the CCD Clinical
Option for XML file Document in
XML Format
Select option for
Rendering
Future
Option
Print out of Display the CCD
Display the CCD Display the CCD
Template in Web Template as PDF CCD template Template in any type
Browser of display device
25

26. A. Implementation Specification the CCD Module
 Operating System:Windows Service Pack 2
 Platform: Microsoft visual studio 2008
 Language: VB.Net, XML
 XML stylesheet: CCD.xsl
 Web Browser: Microsoft visual studio 2008 – toolbox web browser
component
 Supporting Files
 Clinical Interoperability.dll
 POCD_HD000040.xls
 datatypes.xsd,datatypes-base.xsd,NarrativeBlock.xsd,voc.xsd,CDA.xsd
 SampleCCDDocument-QSG-level-3.xml
 ccd_qsg.Ver1.Nov12007.doc
 Validation Tool for CCDDoc.xml file: Online Tool:
http://xreg2.nist.gov/cda-validation/validation.html
26

27. B. Implemented Design of Module
 Implementation, the parameters and classes for
Header and Body
 The Clinical document’s of CCD templates
parameters and class
 Clinical Interoperability.dll
 POCD_HD000040.xls of CDA R2 POCD_HD000040
Hierarchical Description
 StreamWriter method is instantiated and the file
“CCDdoc.xml“ -- writing
 StreamReader method is being read of XML-based
specification for exchange of clinical summary
information
27

28. Standard CCD Document-QSG
28

29. Validation
 NIST in collaboration with Alschuler Associates, LLC,
Integrating the Healthcare Enterprise (IHE) and the
CCHIT Health IT Collaboration Effort "LAIKA", is
working on a series of testing tools for promoting
the adoption of standards-based interoperability by
vendors and users of healthcare information
systems.
29

30. CCD document XML file Validation to meet the standard
specifications
 Validation Tool for CCDDoc.xml file: Online Tool:
http://xreg2.nist.gov/cda-validation/validation.html
Upload the CCD
.xml file for
CCD validation
30

31. Advantage of CCD
 Easy to Rendering as PDF, or on any type of display
device, including local EMRs.
 Discharge Summary, is specifically out of scope for CCR
and therefore CCD
 eDocument Integration Into the Electronic Health
Record
 International and National Acceptance healthcare
organization
 USA, Canada, Asia/Pacific to England, Europe, and
Mexico
31

32. Conclusion
 It summarizes the most commonly needed relevant
information about current and past patient health
status in a form that can be shared by all computer
applications and electronic medical records.
 The HL7 CDA RIM-based specifications in small XML
tag form that the base of CCD are widely
compatible with web browsers, PDF and print
 Overall, the viability and prospects for this clinical
venture appear to be an excellent approach to
reinforce the importance of high quality health care
and services.
32

33. Future Work
 Interoperability is to support the electronic exchange of
patient summary information among caregivers and
other authorized parties via potentially disparate EHR
systems and other aspects of interoperability: “plug and
play” and extensibility
 Furthermore, data mining techniques can be applied on
these module instances to extract substantial
knowledge about the patients health report
 Integrate and testing of Interoperability Module with
EHR system and validation of CCD template
33

34. Any Question
Any <ideas/> or <suggestion/> …
34

35. References
 HL7 Electronic Health Record (EHR) Interoperability,
http://wiki.hl7.org/index.php?title=EHR_Interoperability_WG, wiki
 HL7 Implementation Guide: “CDA Release 2 – Continuity of Care
Document”, Version 1.0 November 1, 2007, pp-7-8,16-18,20-24
 Health Level Seven (HL7),http://en.wikipedia. org/wiki/
Health_Level_7#HL7_Version_3
 Clinical Document Architecture (CDA) Workshops
,http://www.hl7.org.au/CDA.htm
 Continuity of Care Document (CCD) specification, http
//en.wikipedia.org/wiki/Continuity_of_Care_Document
 HL7 Clinical Document Architecture, Release 2, JAMIA 2006 13: 30-
39, Published by group.bmj.com
 HL7 Resources, CCR contents http://
www.corepointhealth.com/resource-center/hl7-resourcess
35

36.  XML Tutorial, http://www.w3schools.com/xml/ default .asp
 Using W3C XML Schema, http://www.xml.com/pub/
a/2000/11/29/schemas/part1.html?page=2#slicing
 Structured Documents of CCD - http://www.hl7.org/
Special/committees/structure/docs.cfm?wg_docs_subfolder_name=
AllDocuments&sortBy=DTCreated&sortDirection=desc&offset=121
 http://wiki.hl7.org/index.php?title=Product_CCD
 http://xreg2.nist.gov/cda-validation/validation.html
 http://www.himssehra.org/ASP/CCD_QSG_20071112.asp
36

37. c
< Thank You />
For your Kind attention …
37