Care Record Summary

Implementation Guides for CDA Release 2

April 19, 2005

Keith W. Boone
keith.boone@dictaphone.com
Dictaphone Corporation

Clinical Language Understanding

Agenda
What is a Care Record Summary?
Why is it Important?
What is in the Ballot Package?
Schematron Validation
Level 1 Implementation Overview
Level 2 Implementation Overview

Clinical Language Understanding

What is a Care Record Summary?

Summary of Care Provided for a Patient
Summary of Episode
Discharge Summary
Transfer Summary

Documents the Provision of Care Act

Commonly used in Transfer of Care scenarios

Clinical Language Understanding

Why is it Important?
Common to every Inpatient Stay
Similar content is required for accreditation
Common first application of CDA
Existing Projects in Germany, Finland and Greece
New Projects in Canada and Japan, and elsewhere
And now in the US

Clinical Language Understanding

What is in the Ballot Package?

The Implementation Guide Documentation
Sample CDA Release 2 documents
Rendering Stylesheet
Schematron Schema
XSLT Stylesheet for Validation
Alternative to Schematron Validation

Supporting Vocabulary Data

Clinical Language Understanding

Schematron Validation
Implementation Guide uses Schematron 1.5
A language system for specifying and declaring
assertions about arbitrary patterns in XML
documents.

Schematron 1.5 implementation is via XSLT

Convert Schema to a validation style sheet
Apply it to the Instance

More at http://xml.ascc.net/schematron/.
Clinical Language Understanding

Schematron Validation
Schema is a collection of patterns.
Patterns contain one or more rules with a
context.
Rules assert that a test has passed.
Failures issue diagnostics
Now you can read the Schema

Clinical Language Understanding

Sample Schema
<schema xmlns="http://www.ascc.net/xml/schematron">
<title>Sample Schematron schema</title>
<ns prefix="cda" uri="urn:hl7-org:v3" />
<pattern name='ClinicalDocument' see=Sample.htm#ClinicalDocument'>
<p>This schema applies to CDA Release 2.0 documents.</p>
<rule id='cda-root' context='/*'>
<assert diagnostics="CNF-1" test='self::cda:ClinicalDocument'>
The root of a Care Record Summary must be a ClinicalDocument
element from the <emph>urn:hl7-org-v3</emph> namespace.
</assert>
</rule>
</pattern>
<diagnostics>
<diagnostic id=CNF-1>
Ensure the appropriate namespace declaration exists.
The root element must be ClinicalDocument.
</diagnostic>
</diagnostics>
</schema>
Clinical Language Understanding

Level 1 Implementation Overview

Constrains elements of the CDA Header
In most cases times are at least to the day
Participants in general have a telephone number
and address on the entity
Telephone numbers use a restricted form of RFC2806 to simplify interchange

Makes use of Existing Vocabularies

HL7, LOINC, SNOMED CT

Introduces Policy Holder Role Vocabulary

Simple Inversion of CoverageRoleType
Clinical Language Understanding

Level 1 Implementation Overview

Describes how to represent various Participants
author
authenticator
dataEnterer
informant
informationRecipient
legalAuthenticator

participant
payers
other supporting parties

recordTarget
performers

Considers Patient Authorship Issues

Clinical Language Understanding

Level 1 Areas for Further Thought

The following elements are allowed, but not
described in detail.
Confidentiality
Orders
Authorizations

Clinical Language Understanding

Level 2 Implementation Overview

Defines Required and Optional Sections
Specifies LOINC Codes for Sections
Order of required and optional sections is fixed.
Other Sections can be included where necessary.

Derived from Existing and Draft Specifications

JCAHO Guidelines
British Columbia eb-MS Project
Numerous Example Documents
Common Practices

Specifies information expected of content

Does not constrain presentation
Consistent examples show the expected information
Clinical Language Understanding

Required Sections
Conditions (Problems)

Active
Resolved
Chief Complaint
Reason for Visit
Diagnoses

Admission
Discharge
Preoperative
Postoperative

Clinical Language Understanding

Allergies and Intolerances

Pharmacy
Dietary
General

Medications

History
Administered
Discharge
Current

Optional Sections
Advanced Directives
Functional Status
Procedures
Encounters
Family History
Social History
Clinical Language Understanding

Immunizations
Vital Signs
Fetal Vital Signs
Lab Results
Plan of Care

Patient:

Sample CDA

Ellen Ross

MRN: 12345

17 Daws Rd.
Blue Bell, MA 02368
HP: (781) 555-1212
Birthdate: January 27, 1960
Consultant: Bernard Wiseman , Sr.

Sex: Female
Created On: March 29, 2005

Good Health Clinic Care Record Summary

Advance Directives
Documentation

Contact

1994

Power of
Attorney

Obtain from her Husband

1994

Organ Donor

Massachuesetts Registry of
Motor Vehicles

1/27/2004 -

Comments

Registered Organ
Donor

Gall Bladder Surgery

3/21/2002 Community Hospital Labor and Delivery

10/28/2001 Community Hospital ED Visit for Acute Cholecystitis
Family History
Family Member Problem Cause of Death?
Father
Alcoholism No
Liver Cancer Yes

Social History
Social History
Smoking

Conditions
Active

Comments
1/2 pack per day

Date Range
? - 1996

Alcohol Use 1-2 drinks per week

Allergies and Intolerances
Medication
Type Description
Comments
Allergy Penicillin
Amoxicillin is OK
Dietary

Problem
Date
Comments
Ankle Sprain 3/28/2005 Slipped on ice and fell
Resolved
Problem
Date
Comments
Cholecystitis 9/28/2002 - 6/2003 Surgery postponed until after delivery
Pregnancy 7/2001 - 4/22/2002 Prior history of miscarraige
Reason for Visit
Ankle Sprain
Procedures
Procedure
Date
Laparoscopic Cholecystectomy 9/28/2002
Cesarian Section

9/28/2002 City Hospital

Father
Effective
Date

Copy on file or obtain from

her Husband

Living Will

Encounters
Date
Provider
Description
3/28/2005 Community Hospital ED Visit for Ankle Sprain

3/22/2002

Clinical Language Understanding

Type

Description

Comments

Intolerance Pork and Pork Products Causes severe gastric distress.

General
Type Description Comments
Allergy Bee Stings Severe Reaction

Sample CDA
Medications
History
Medication Prescription or Dose Dates of Use
Indomethacin 50mg bid with food 12/10/2003
Administered
None
Discharge
Medication
Prescription or Dose Dates of Use
Acetaminophen with codiene #3 1-2 tablets prn for pain 03/28/2005
Current
Dates of
Medication
Prescription or Dose
Use
Acetaminophen with
#3 1-2 tables for pain as
03/28/2005
codiene
needed
Indomethacin
Immunizations

Authored by:

Bernard Wiseman , Sr. on March 29, 2005

21 North Ave
Burlington, MA 01803
WP: (999) 555-1212
Good Health Clinic System v1.0 on March 29, 2005

Informed by:

Bernard Wiseman , Jr.

Informed by:

Abigail Ruth (Mother)

Informed by:

Joseph Jones

Informed by:

Jane Queen , (General Physician)

Reviewed by:

Bernard Wiseman , Jr. on March 29, 2005

21 North Ave
Burlington, MA 01803
WP: (999) 555-1212
Bernard Wiseman , Sr. on March 29, 2005
21 North Ave
Burlington, MA 01803
WP: (999) 555-1212
Bernice Wiseman on March 29, 2005
Phil Green
Good Health Clinic
21 North Ave
Burlington, MA 01803
P: (999) 555-1212

Authored by:

50mg bid with food

12/10/2003

DTP - 1962
Polio Virus - 1961
MMR - 1961

Lab Results
Test
Result Normal Range Abnormal Date of Measurement
Serum HCG 14
7/28/2001
Plan of Care
Acetaminophen with codiene prn for pain. Stay off the foot. Keep foot elevated,
and use supplied air splint and crutches. Advise follow-up with orthopedist if not
significantly better in 5 days.

Clinical Language Understanding

Signed by:

Entered by:
Copy to:

Sample CDA
Healthcare Providers
Bernard Wiseman , Sr. (General Physician)
21 North Ave
Burlington, MA 01803
WP: (999) 555-1212

primary care physician

Support Providers
Abigail Ruth
17 Daws Rd.
Blue Bell, MA 02368
WP: (999) 555-1212

Mother

Insurance Information
Subscriber:

Kenneth Ross
ID:123456789
17 Daws Rd.
Blue Bell, MA 02368
WP: (999) 555-1212

Clinical Language Understanding

Payer: Good Health Insurance Company

3191 Broadbridge Avenue
Stratford, CT 06614-2559
WP: (203) 555-1212

Next Steps
Ballot Reconcilliation
Develop Implementation Profile with IHE
Level 3 IG with Patient Care
Possible Level 3 IG on CCR in partnership
with ASTM
Additional Guides in other Domains
Internationalization

Clinical Language Understanding

Questions?

Clinical Language Understanding

References
HL7 Ballot Site
http://www.hl7.org/ctl.cfm?action=ballots.home

Care Record Summary Level 1 IG

http://www.hl7.org/documentcenter/ballots/2005may/downloads/CDACareRecordSummaryIGLevel1.zip

Care Record Summary Level 2 IG

http://www.hl7.org/documentcenter/ballots/2005may/downloads/CDACareRecordSummaryIGLevel2.zip

Schematron
http://xml.ascc.net/schematron/

Clinical Language Understanding