XIII International HL7 Interoperability Conference 2012
IHIC Conference 28th September 2012 Testing a New CDA Development Strategy in aStandardized Infrastructure for Continuity of Care in Chronic Kidney Disease Patients Alberto Moreno, Alicia Martínez, Francisco Núñez, Carlos Parra Research partly funded by the Instituto de Salud Carlos III within RETICS Innovation in Healthcare Technology call (code RD09/0077/00025), Corporación Tecnológica de Andalucia and REDSA S.A.
Haemodialysis ScenarioHospital provides care for more than 500 Patients diagnosed with CKDWhen the patients are stable they are transferred to 8 outsourced externalHD centresAlthough the hospital is responsible of the patient and also pays the patienttreatment the evaluation of the patients once they are transferred is notexhaustive enoughThe communication was previously paper based External HD Referral Private Center Prescription Lab results
Haemodialysis ScenarioPatients transferred back to the hospitalThe information is urgently required when:• Their health condition become unstable• When an organ is available for patients that are included in the transplant list External HD Private Center ?
Project Objectives As research project we aim to develop and test new interoperability approaches in a real scenario. Develop a platform for our Nephrology department able to provide the means for continuity of care in CKD patients. Requirements – Integrated with the regional architecture of the Andalusian Health Service – Interoperable with external nephrology systems based on defined specifications.
Integration with regional infrastructureNephrology platform is integrated with the Andalusian PublicHealth Regional SOA infrastructure through the followingservices:• UDB. User Data Base. This is a central patient management system that includes their demographic data.• OCAM. Operator Centralised Access Module. This system manages professional roles and passwords in order to allow other applications set different access levels.• CCD. Centralised Clinical Data. This system is a registry that contains identifiers and pointers to clinical reports and general information about the patients (encounters, allergies, problems and treatments, etc.).
Interoperability with External Private CentresDefinition of specifications based on IHE profiles forcoordinating document and patient management tasks withinthe different systems in an Affinity Domain.- Cross-Enterprise Clinical Documents Share Profile (XDS.b)- Patient Identifier Cross-referencing for MPI Profile (PIX).
Interoperability with External Private Centres Business Model BServices from the regional External HD External HDinfrastructure Private Center Private Center OCAM LIS UDB ESB Business Health IT CCD Provider Model A External HD External HD External HD Private Center Private Center Private Center Nephrology Platform
Documents shared with HD centers• Referral CDA a patient summary and patient evolution through previous HD sessions.• Prescription CDA. In this document the nephrology professionals specify the patient treatment plan including number of dialysis sessions, dialysis settings and medication list. This document guides nurses in preparation tasks of the sessions.• Session CDA. This document contains the patient evolution through the session including vital sign evolution, weight, dialysis catheter, others accesses. Nurses must record patient vital sign every hour.• Lab Results NP receives all the lab results from the Laboratory Information System (LIS) as HL7 v2.5 messages. Once the patient is transferred to an external private HD centre, NP sends notifications of all previous Lab Results from this patient to the system of the external HD centre which could request these documents at any time based on XDS profile. Referral CDA External HD Prescription CDA Private Center Sessions CDA Lab results (HL7v2)
CDA development Source Target LinkEHR Tool Legacy data schema CDA Archetype (XSD) Export Mappings (Template (XQuery format) in ADL format) XQuery Engine CDA instance XML instanceLinkEHR tool that is able to map information from any XML format to the mostcommon EHR standards such as CDA, HL7v2 and ISO13606. This tooldefines these mapping relationships as a XQuery file and this can be executedby any XQuery engine.
Interoperability with External Private Centres Business Model B Services from the regional External HD External HD infrastructure Private Center Private Center OCAM LIS UDB ESB Xquery Engine Business Health IT CCD Provider Model A External HD External HD External HD Private Center Private Center Private Center Nephrology PlatformValidated with Lantana CDA Validator
CDA development With the large amount of information required byGeneric Header the clinicians, we tried to maximise the reusability of the CDA structures Generic CDA archetypes defined the constrains and semantics required in the CDA model for a local organisation or IT infrastructure specific system
CDA developmentSecondly we defined specialised archetypes, which are conformant to the resultantCDA and include the clinical concepts specified by our nephrology department.Specialised Header Specialised Observation
CDA developmentSuccessfully defined highly complex CDA structures and that are able to becreated from legacy data CDA Document CDAHeader Substance Organiser Observation Administration Referral 1 1 0 16 Prescription 1 1 29 121 Session 1 1 75 389
Conclusions• The platform piloted by the nephrology department and the 8 external HD private centres through an IT Health provider.• Perform a cost-effectivity study about the impact that this new infrastructure has on clinical practice.• The defined specifications have successfully opened a market for different health and technical providers.
Conclusions• Promising results of using CDA templates, provides better management and audit of the semantic structures, aligned with CIMI• These archetypes are expected to be the source for a new implementation guide for CDA in the nephrology domain which has just started within the HL7 Spain Technical Committee.
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