The speaker discusses mapping CDA (Clinical Document Architecture) documents to FHIR (Fast Healthcare Interoperability Resources). CDA was difficult to construct and read, while FHIR provides a more streamlined approach. A joint project maps CDA elements to FHIR specifications and profiles to define the relationship between the standards. The goal is a common syntax and resources that support both documents and APIs, with CDA documents eventually represented in FHIR.

1. CCDA to FHIR
Grahame Grieve
FHIR Developer Days
November 26, 2014
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2. CDA vs FHIR
 I am CDA subject matter expert for the
Australian national program
 I was co-chair of Structured Documents WG,
which owns the CDA standard
 I am the lead for FHIR
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3. CDA vs FHIR
Through 2010/2011, it became clear that:
 CDA was too hard to construct and read
 Documents not good for granular data exchange
 CDA used for exchanging data because the
alternatives were worse
 CDA getting pushback from implementers
 The SD committee was about to double down
 These strategic frustrations were part of why FHIR
was invented
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4. CDA vs FHIR
 The design of FHIR was strongly influenced
by CDA:
 Narrative/Data in every resource
 Need to a document package
 Use of “must understand” ( isModifier)
 CDA content model a first point of reference
 Green CDA simplification
 CDA usage guided our resource priority
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5. CDA vs FHIR
 CDA community was focused on their task
 Mostly didn’t even pay attention to FHIR
 Common Questions to us:
 Why does FHIR have “documents”?
 What is the relationship between CDA and FHIR?
 What does Lantana think about FHIR?
 Do you have a transform from (C)CDA to FHIR?
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6. CDA vs FHIR
 Joint Position Statement from leaders in the
FHIR and CDA community
 Focus: The future of CDA and FHIR
 This statement is not official policy
https://www.lantanagroup.com/wp-content/uploads/Lantana-Position-Statement-CDA-FHIR.pdf
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7. CDA vs FHIR
 Position:
CDA addresses interoperability for clinical
documents, mixing narrative and structured
data. FHIR provides granular access to data,
a contemporary, streamlined approach to
interoperability, and is easy to implement.
FHIR can be the future of CDA, but it is not
there yet
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8. Documents vs APIs
“The medical record is not data. It contains data, as do many
forms of writing, but it is not data, nor is it simply a repository
into which data are poured. Although its raw material is
information—some of which, importantly, can only be
expressed with words and not with numbers—a finished
medical record is information that has been transformed by
the knowledge, skill, and experience of the physician,
motivated by the healing impulse, into an understanding of
human experience that makes the care of the patient
possible.”
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9. Documents vs APIs
 This dual nature of a medical record—the
combination of data and narrative—runs
deeply through the clinical process and,
consequently, through the clinical record
 Why CDA is narrative based
 Why FHIR resources have narrative
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10. Documents vs APIs
 Packaged Access
 Trust from document
context & obligations
 Independent of
system integration
 Import data from
documents
 Granular Access
 System-based trust
framework
 Tightly integrated IT
and business systems
 Export data from APIs
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11. Documents vs APIs
 Documents are the correct way to exchange
information between clinicians in disparate
parts of the healthcare system
 APIs will integrate access to the data
between applications where the context is
unambiguous.
 Both the document and API should
seamlessly use the same syntax and
semantics and Narrative approach
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12. Call to Action (1)
 Recognize the duality and interdependence
of data and narrative in clinical information
 Understand the gaps in support for clinical
documents in the current FHIR Draft
Standard for Trial Use (DSTU)
 Ensure that FHIR 2.0 addresses clinical
document requirements
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13. Call to Action (2)
 Establish, publish, and test CDA/FHIR,
FHIR/CDA mapping
 Define, document, and promote a future
where clinical documents and Application
Programming Interfaces (APIs) share a
common syntax and set of resources
 Establish, in technical and regulatory policy,
a smooth roadmap to the future of clinical
document exchange
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14. CDA -> FHIR project
 Map CDA header to FHIR
 Resolve issues around sections in FHIR
 Map basic CDA entries to FHIR (general)
 Map CCDA sections & entries to FHIR
(specific)
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15. CDA -> FHIR Project
 Work is in a google spreadsheet
 Ongoing calls on a weekly basis
 Up to step #3
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https://docs.google.com/spreadsheets/d/1KctdexG3oB2QBiBQNH1Rbt2uJ6Dx
QFROyIFKo5q95WU/edit#gid=1223244219
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16. Working Spreadsheet
 Basic Information from CDA
 Element
 Cardinality
 Mandatory
 Conformance
 Type
 Domain
 Extensible
 Notes
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17. Working Spreadsheet
 FHIR Specification Mapping – where it goes
in FHIR
 Base Card – what the FHIR cardinality is
 Profile Card – what the CDA-on-FHIR
cardinality will be
 Type – what the FHIR type is
 Notes / CDA on FHIR call decisions –
discussion of issues
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18. CDA  FHIR outcomes
 The mapping spreadsheet itself
 A series of change proposals to the base
FHIR specification
 Corollary: CDA -> FHIR requires DSTU2
 A formal “Clinical Document” profile which
will be part of the FHIR specification
 CCDA section/entry mappings and profiles
 Conversion Libraries?
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19. CDA Profile in FHIR
 http://hl7-fhir.github.io/cda.html
 Profiles and Extensions
 Very incomplete
 This will develop as the project goes on
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20. CCDA
 “Consolidated CDA”
 Harmonised several US and IHE CDA
implementation guide
 In service of “Meaningful Use Minimal Data
Set” though it includes more
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21. CCDA  FHIR
 The project is not up to this
 Some work has been done by a variety of
individuals and groups
 CCDA is hard to understand, and there is
much variance in it’s use
 It’s unclear at what level this needs to be
useful
 ..Demonstration
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22. From CCDA to FHIR
 This is an active area of investigation
 DSTU 2 will be “Clinical Document” ready
 DSTU 2 will include a base Meaningful Use
Profile
 A formal CCDA profile will follow in due
course
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