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A Much-Needed Nudge for Stage 2 Interoperability

by Wes Rishel  |  January 6, 2013  |  3 Comments

The chatter on the HL7 Strucdoc list server this month claims that two EHRs that are fully conform to the HL7 Consolidated CDA (C-CDA) may not interoperate, so the organizations using them could fail to meet Stage 2 meaningful use requirements. This is, indeed, an issue but the members of the list have conceived a solution and are anxious to start. A number of contributors representing major implementers are willing to contribute. In fact, the only concern about the solution is to find a way to do it once and right, rather than have a disjointed set of attempts.

The issue: It is not always clear how to express some clinical thoughts in the C-CDA, at least for some developers. Some examples include  “allergic to latex but no known allergies to medications”, “the patient states she has no allergies” vs “we don’t know if the patient has allergies”, “the patient believes he is allergic to penicillin” vs “a physician has reported anaphylaxis as a reaction to penicillin.” Sometimes there is more than one way to express the same clinical thought in C-CDA-compliant XML. If the system that creates the document expresses it one way, but the system that is interpreting the document is looking for a alternate expression of the clinical thought, it may miss the data altogether.

The Solution: The jointly conceived solution is to publish examples of the XML used by the C-CDA to represent hundreds of important clinical thoughts in a wiki. The wiki has the double benefit of showing newbies how their XML should look and helping all implementors know the preferred choice when there are multiple ways to express a clinical thought.

There is general agreement about the solution and there are a lot of enthusiastic ideas about how to go about it. This is good because the industry needs these examples right now. The developers are working on the code right now that will be the heart of their implementations for Stage 2.

I expect that the at the HL7 Working Group meeting next week the Structured Documents group will be able to settle on a single approach and the HL7 Board and ONC will come forth with the nominal funding that it takes to mount a wiki and facilitate the process of creating and deciding among examples of clinical thoughts. The volunteer spirit has never been higher and the volunteers are pursuing a critical goal. If they end up spinning their wheels for lack of support, the entire notion of semantic interoperability could get a black eye.

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Category: interoperability  vertical-industries  

Tags: c-cda  ehr  health-information-exchange  healthcare-interoperability  hl7  meaningful-use  

Wes Rishel
VP Distinguished Analyst
12 years at Gartner
45 years IT industry

Wes Rishel is a vice president and distinguished analyst in Gartner's healthcare provider research practice. He covers electronic medical records, interoperability, health information exchanges and the underlying technologies of healthcare IT, including application integration and standards. Read Full Bio

Thoughts on A Much-Needed Nudge for Stage 2 Interoperability

  1. why don’t algn efforts and re-use work that have been done in the last two decades collaboratively and in the last two is the initial formalismm chosen by experts (CIMI) to describe clinical models And a virtual library of archetypes and templates which can be used to generate whichever artifact, including CCDA, , with strict governance and peer rebiew? As you say, industry needs it now and to begin a wiki takes a long time.

  2. Reed Gelzer says:

    The EHR-S FM Records Management-Evidentiary Support workgroup will also be especially interested in supporting this effort. The clarifying layers referred to in questions such as “Who/what is the source?”, “How has the data been validated?”, and “Has the data been reconciled from multiple sources?” will include increasing application of functional standards, as assurance supports for the trustworthiness of source information and, where applicable, compliance with exchange agreement in given exchange environments or between specific entities.

    Reed D. Gelzer, MD, MPH
    co-Chair RMES

  3. Rene Spronk says:

    Why not try an approach as used by a developer in the English NHS? Robert Worden created a “CDA examples directory”, where XML snippets representing templates are sourced from example CDA instances.

    See for the examples registry, and (for example) a page showing how examples use/populate the NHS Bloodpressure template. The tool could be used for C-CDA, there’s nothing that limits its functionality to the UK.

    As for “but what’s the right expression of some clinical bit of information if there are multiple possible expressions” – either the example with the most commonly used structure “wins” or one has to somehow designate one as the “winner”.

    Examples, examples, examples – that’s what it’s all about, they’re key to implementation.

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