1) The document discusses a project to develop a platform for a nephrology department to provide continuity of care for chronic kidney disease patients, including those transferred to external dialysis centers. 2) The platform integrates with the regional health infrastructure and allows interoperability with external private dialysis centers through standards like XDS and PIX. Clinical documents like referrals, prescriptions, and lab results are shared. 3) Complex CDA documents were successfully defined from legacy data using a tool that maps to CDA templates. This opens the potential for cost savings and a market for health and technology providers using the defined specifications.

1. IHIC Conference
28th September 2012
Testing a New CDA Development Strategy in a
Standardized 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.

2. Haemodialysis Scenario
Hospital provides care for more than 500 Patients diagnosed with CKD
When the patients are stable they are transferred to 8 outsourced external
HD centres
Although the hospital is responsible of the patient and also pays the patient
treatment the evaluation of the patients once they are transferred is not
exhaustive enough
The communication was previously paper based
External HD
Referral Private Center
Prescription
Lab results

3. Haemodialysis Scenario
Patients transferred back to the hospital
The 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
?

4. 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.

5. Integration with regional
infrastructure
Nephrology platform is integrated with the Andalusian Public
Health Regional SOA infrastructure through the following
services:
• 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.).

6. Interoperability with External
Private Centres
Definition of specifications based on IHE profiles for
coordinating document and patient management tasks within
the different systems in an Affinity Domain.
- Cross-Enterprise Clinical Documents Share Profile (XDS.b)
- Patient Identifier Cross-referencing for MPI Profile (PIX)
.

7. 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
Business
Health IT
CCD Provider Model A
External HD External HD External HD
Private Center Private Center Private Center
Nephrology
Platform

8. 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)

9. 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 instance
LinkEHR tool that is able to map information from any XML format to the most
common EHR standards such as CDA, HL7v2 and ISO13606. This tool
defines these mapping relationships as a XQuery file and this can be executed
by any XQuery engine.

10. 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
Platform
Validated with Lantana CDA Validator

11. CDA development
With the large amount of information required by
Generic 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

12. CDA development
Generic Observation

13. CDA development
Generic SubstanceAdministration

14. CDA development
Generic Organiser

15. CDA development
Secondly we defined specialised archetypes, which are conformant to the resultant
CDA and include the clinical concepts specified by our nephrology department.
Specialised Header Specialised Observation

16. CDA development
Successfully defined highly complex CDA structures and that are able to be
created 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

17. 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.

18. 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.

19. Thank you for your kind attention
alberto.moreno.exts@juntadeandalucia.es