Comp9 Unit4f Audio Transcript

Networking and Health Information Exchange: Basic Health Data Standards
Audio Transcript
Slide 1
Welcome to Networking and Health Information Exchange, Basic Health Data
Standards. This is Lecture f.
This component, Networking and Health Information Exchange, addresses what is

required to accomplish networking across and among disparate organizations who have
heterogeneous systems. As one might imagine, this topic covers a lot of territory
fraught with new topics and a lot of acronyms. Our apologies, but thats what it is. We
suggest you keep your glossary beside you as you study this material.
Unit 4 covers Basic Health Data Standards and consists of six lectures. Over these 6
lectures, we will identify the set of standards necessary to establish semantic
interoperability.
Lecture f presents three related document standards that are in major use globally
today.
Slide 2
The Objectives for this unit, Basic Health Data Standards are to:
Understand why it is necessary to use a common set of data elements with common
names to be able to exchange and understand data from other places,
Understand what is meant by semantic interoperability,
Understand many of the sets of controlled vocabularies in use today how they are
used and who requires their use,
Slide 3
Additional Objectives for this unit, Basic Health Data Standards, are to:
Understand the use, purpose and interrelation among sets of controlled vocabularies
in use today,
Identify the more common controlled vocabularies in use today: ICD, CPT, DRG,
NDC, RxNorm, and LOINC,
Identify the more common controlled vocabularies in use today: SNOMED, MEDCIN,
MedDRA, Nursing terminologies, MeSH and UMLS,
Understand data elements; attributes of data elements,
Health IT Workforce Curriculum Networking and Health Information Exchange 1

Version 3.0/Spring 2012 Basic Health Data Standards
Lecture f
This material Comp9_Unit4f was developed by Duke University funded by the Department of Health and Human Services, Office of the
National Coordinator for Health Information Technology under Award Number IU24OC000024.
Slide 4
Additional Objectives for this unit, Basic Health Data Standards, are to:
Understand the contribution of the master meta-dictionary of data elements to

semantic interoperability,
Explain how data structures can be built from basic data components,
Explain how templates and archetypes facilitate networking and information
interchange, and
Discuss Clinical Data Architecture (CDA), Continuity of Care Document (CCD), and
Continuity of Care Record (CCR) Standards.
This lecture is the last of the series and focuses on a higher level of data structures.
Slide 5
The CDA is a document markup standard that specifies the structure and semantics of
clinical documents. The architecture should impose minimal constraints or requirements
on document structure and content required for exchange. The CDA can include text,
images, sounds, and other multimedia content. A CDA document can exist outside a
message. The architecture specifies the schemas required for exchange.
The CDA typically contains observations and services of a specific patient. The current
version is Release 2 (R2).
We will begin by defining the term health. We often think of health as the absence of
disease but this is a somewhat narrow description of the term. In 1946, representatives
of 61 countries attended the International Health Conference in New York to ratify the
Preamble to the Constitution of the World Health Organization, which is the specialized
agency of the United Nations that deals with global health. The WHO definition of
health is that health is the state of complete physical, mental, and social well being and
not merely the absence of disease or infirmity. Thus, illness represents a state of poor
health.
Slide 6
This slide presents characteristics of the CDA.
Persistence continues to exist in an unaltered state, for a time period defined by local
and regulatory requirements; it may or not be important, depending on what happens on
the receiving end. It can be stored as a persistent document, or its contents can be
extracted and included in an EHR.

Lecture f
Stewardship is maintained by an organization entrusted with its care. Its potential for
authentication is an assemblage of information that is intended to be legally
authenticated.
Context establishes the default context for its contents.
Wholeness means that authentication of a clinical document applies to the whole and
does not apply to portions of the document without the full context of the document.
Human readability means the contents can be read by a human. Why is this
important? CDA can include both structured data for input into EHR in systems that
have a structured EHR, or, for systems that are text based, can include human readable
narrative that can be directly displayed. In the absence of interoperability, this still
provides a method for sharing data.
Slide 7
The CDA specification is richly expressive and flexible. CDA uses XML as the markup
language. It is based on the HL7 Reference Information Model, and it uses the HL7 data
types which are consistent with the ISO data types. Data elements derive their meaning
from the HL7 RIM. CDA uses HL7 data types. Document-level, section-level and entry-
level templates can be used to constrain the generic CDA specification.
Slide 8
The CDA allows a cost effective implementation across a wide spectrum of systems.
Promotes longevity of all information encoded according to this architecture. It enables
a wide range of post-exchange processing applications. It is compatible with a wide
range of document creation applications.
CDA documents are human-readable using widely-available and commonly-deployed

XML-aware browsers and print drivers and a generic CDA style sheet written in a
standard style sheet language.
The architecture must be scalable to accommodate fine-grained markup such as highly

structured text and coded data.
The CDA promotes exchanges that are independent of the underlying transfer or
storage mechanism.
Slide 9
A CDA document is wrapped by a <ClinicalDocument> element. The major components
of the CDA are a Header and a Body. The header includes all data necessary to identify

Lecture f
the document, sender and receiver, date and time, and other data discussed in detail in
a following slide. The body contains all the clinical data.
The CDA is expressed in XML. The document wrapper is the XML Tag
<ClinicalDocument> with the ending tag </ClinicalDocument>. The Body is wrapped by
the tag <StructuredBody>.
Slide 10
Note the syntax for the XML markup language. An XML tag is expressed as <tag>. Data
is identified by the data element name. Data has a value. These fields are identified by
the XML tags. Each entry has a start <tag> and a stop </tag>. An example is: start
<code> code = 11488-4 stop </code>
Nested structures are indented to make it easier to see the structure of the content.
Programs can check syntax conformant document to make sure all beginnings have
an end and that structures are intact.
Slide 11
This slide shows a graphic of a complete CDA. Note the sections of Document, Header,
Body, Section, Entries, and External references.
The Header will be discussed in detail in the next slide.

BODY
The body contains the clinical report and can be either an unstructured blob or
can be comprised of structured markup.
A structured body, which is wrapped by the <StructuredBody> element, is divided
up into recursively nest-able document sections.
SECTION
Is wrapped by the <Section> element.
It can contain a single narrative block and any number of entries {0 to many}
It may have external references.
NARRATIVE BLOCK
The CDA narrative block is wrapped by the <text> element within the <Section>
element and provides a slot for the human readable content needing to be
rendered.
EXTERNAL REFERENCES
External references refer to things that exist outside the CDA document - such as
some other image, some other procedure, or some other observation.
Wrapped by the <ExternalObservation> element.
These sections may repeat.

Lecture f
Slide 12
This is the structure for the header;
Author
Confidentiality
Data enterer
Human language
Informant
Legal authenticator
Participant
Record target
The header sets the context for the entire body. However, structure can be changed
within the document or for a section of a document. For example, the header can set
the confidentiality as public, but within the document can set confidentiality to private for
an indicated section.
Slide 13
This slide shows the major components of the CDA with the XML tags in place.
Creating an XML by hand will consist of putting in the specific tags, data names, and the
data. Sections would be repeated as necessary.
CDA Conformance specifies the principles governing the representation of the narrative
block, conformance requirements on the part of originators when populating the block,
and recipients when rendering it.
Within a document section, the narrative block represents content to be rendered,

whereas CDA entries represent structured content provided for a computer. CDA entries
encode content present in the narrative block of the same section.
CDA external references always occur within the context of a CDA entry and are
wrapped by the <reference> element.
The CDA entry that wraps the external reference can be used to encode the specific
portions of the external reference that are addressed in the narrative block.
This hierarchical structure reflects the structural diagram on slide 11.
Slide 14
The CDA specification permits the definition of many documents and identifies them by
assigned codes. Sections within the document can also be identified by codes. Thus, it
is possible to differentiate a "Consultation Note" CDA from a "Discharge Summary" CDA
because the two will have distinct document codes in the document instance.

Lecture f
An HL7 Template provides a formal mechanism to say that a particular consultation note
or discharge summary must contain certain sections, or that an assessment or plan
section must contain certain observations.
The CDA requirement for human readability guarantees that a receiver of a CDA
document can algorithmically display the clinical content of the note on a standard Web
browser. CDA, Release Two, with its blend of narrative and CDA entries, presents new
challenges to this requirement.
Slide 15
This example shows the use of rendering tags in this case BOLD to enhance the
presentation of the data.
Slide 16
This slide illustrates the use of a section code to identify and specify the content of a
section = past history. If there was no past history, that section would be omitted.
Slide 17
The LOINC terminology set includes LOINC codes for CDA documents.
Examples include:
28568-4 Visit Note Emergency Department Physician
34862-3 Admission Evaluation Note Inpatient Attending General Medicine
11488-4 Consultation Note {Setting} {Provider}
Slide 18
The Continuity of Care Document is the union of the ASTM CCR standardized data set
that is used to constrain CDA specifically for a patient summary document.
The approach taken in the development of CCD is to reflect the CCR requirements in
a CDA R2 framework, and to do so in such a way that CDA is constrained in
accordance with models being developed by other HL7 committees.
This process has helped accelerate convergence within HL7 around a common
clinical statement model, leading to closer collaboration with several domain
committees, such as results, family history, allergies, problems and medications.

Lecture f
Slide 19
The sections of CCD have been extended beyond the CCR and now include:
Payers,
Advance Directives,
Support,
Functional Status,
Problems,
Family History,
Social History,
Alerts, allergies, adverse events,
Medications,
Medical Equipment,
Immunizations,
Vital Signs,
Results,
Procedures,
Encounters, and
Plan of Care.
Slide 20
This slide shows a sample CCD. The section shown is the Result Section and provides
the result for a hematology test. In this example both LOINC codes and SNOMED-CT
codes are used. The date and time of the test are included as part of the Result
Section.
Slide 21
Another sample of a CCD section continues. This section provides laboratory results
for a battery.
Slide 22
The primary use case for the ASTM CCR is to provide a snapshot in time containing a
summary of pertinent clinical, demographic and administrative data for a specific
patient. The CCR provides a patient health summary detail. It is a flexible document
and can contain whatever the sender wishes. It provides relevant and timely core
information about patients for exchange among patients. The CCR is available from
ASTM at a cost. CCR uses the XML syntax.

Lecture f
Slide 23
The CCR content includes:
Demographics,
Diagnosis,
Problem list,
Medication,
Allergies,
Insurance, and
Care Plan.
Compare this content with the content of the CCD.
Slide 24
This concludes Basic Health Data Standards.
The increased power of these structured documents to enable interoperability holds

great promise for HIT. The structure might be considered complicated but the content is
simple data elements with XML tags.
The structured/narrative section of the CDA clearly provides a gradual pathway from
unstructured free text to highly structured data. The capability provided by this
technology opens a new opportunity to exchange data on a significantly elevated level
in which true information is exchanged. Internationally, the CCD is becoming the
exchange document of choice.
Slide 25
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Lecture f

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Networking and Health Information Exchange: Basic Health Data Standards

This component, Networking and Health Information Exchange, addresses what is

Health IT Workforce Curriculum Networking and Health Information Exchange 1

Understand the contribution of the master meta-dictionary of data elements to

Health IT Workforce Curriculum Networking and Health Information Exchange 2

Context establishes the default context for its contents.

CDA documents are human-readable using widely-available and commonly-deployed

The architecture must be scalable to accommodate fine-grained markup such as highly

Health IT Workforce Curriculum Networking and Health Information Exchange 3

The Header will be discussed in detail in the next slide.

Health IT Workforce Curriculum Networking and Health Information Exchange 4

Within a document section, the narrative block represents content to be rendered,

This hierarchical structure reflects the structural diagram on slide 11.

Health IT Workforce Curriculum Networking and Health Information Exchange 5

Health IT Workforce Curriculum Networking and Health Information Exchange 6

Health IT Workforce Curriculum Networking and Health Information Exchange 7

Compare this content with the content of the CCD.

The increased power of these structured documents to enable interoperability holds

Health IT Workforce Curriculum Networking and Health Information Exchange 8

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