1、通过成功案例分析 CDA在医疗信息交互 (HIE)中的应用 张俊平博士 执行副总裁兼首席技术官 美国凯尔飞（ CarefxCorporation) 什么是 CDA? CDA解决什么问题？ CDA应用案例研究 -医院，医院集 医院集团 团，区 区 域，全国域，全国 CDA发展计划 Agenda议程 A lady was picking through the frozen turkeys at the grocery store but she couldn t find one big enough for her family. She asked a stock boy, “ Do the
2、se turkeys get any bigger?” The stock boy replied, “ No ma am, they re dead.” 要有效地进行沟通与交互，就必须双方说的是同一 种语言，而且可以相互理解（基于共同名词术语 、结构以及语义等） Communication Barrier 沟通的障碍信息孤岛 - Information Gaps 影像中心 医院 检验中心 紧急护理 家庭诊所 护理院 社区医疗 康 复 院 专科 诊所医疗 卫生 信息共 享 与互通 影像中心 医院 检验中心 紧急护理 家庭诊所 护理院 社区医疗 康 复 院 专科 诊所医疗 卫生 信息共 享到业务
3、协 同 统 一的名词术语 数据元 ， 数据 集， 字典 语 法层面 （结构） -系统之间数据格式和传输协议的一致性 语义 层面 -信息内容理解的一致性 . 一个药品代码在 A医院代表某个 特定含义，但在 B医院可能代表另一个含义，这种语境的不同可能导致 A 系统发出的信息，被 B系统收到后无法理解的问题。 没 有共同名词术语、结构以及语义， 不能 有效地进行沟通与交互，就 不 可 能实现 信息的互通、交 换 与共 享 只 有区域医疗 卫生 信息共 享才需 要 吗 ？ 区域医疗卫生信息网 -跨机 构共享 个 人健康档案 -跨机 构 院内 ： 系统 改造或更换 -更换 数据 库 ， 迁移保存多年
4、的数据 院内 ： 医院内 部 不同 科室 的 交换与共享 Confidential 6Confidential Name= BYRD,MELLON ALPHONSE Age= 16YSex= MMRUN= 004-02-998 Report Title= PROGRESS NOTE 2/4/04, 1500 Medicine Attending: S: feels better today, slept through the night w/o pnd, orthopnea; min sob walking to br, tolerating low salt diet, uses o2 f
5、or walking only O: afebile, vss, p95, bp 110/89/ o2 sat 92% on r/a, wt 155 (lost 2# past 24h, dry wt 150#), i/o net out 500 ml/24h; Chest-clear w/ sparse dry bb crackles, heart-rrr w/ gr2/6 mr m lsb rad to apex, + faint s3, no gallup,jvp 10 cm;abd bs nl, not distended, soft nontender w/o r,g,m; extr
6、em-no calf tenderness, 1+ pitting edema ankles r+l, skin intact Labs: K 4.3, na 127, bun/creat27/1.3, ecg unchanged, muga ef 34% A/P: 1) CHF improving on current regimen -decr lasix to 40 bid -incr lisinopril to 40 qd, for bp 90 w/o sx -t/c starting carvedolol once stable -re chk lytes in 2d 2) mr s
7、table -continue afterload redux w/ acei 3) hyponatremia 低钠血症 sec to vigorous diuresis 利尿 -continue to monitor -decr lasix 速尿 -t/c fluid restrict if no better next labs 4) hyper tg 高甘油三酯血症 stoppped meds 1ya sec adverse effects -contin dietary trial -t/c niacin if remains 400 -re chk lipid panel 2 mos
8、 j. clyman, md Section Six Fundamental Requirements Existing Waveform New Interpretation New Assessment Existing Lab 1. Context Patient, Visit, Author, 2. Document Structure (and Format) 3. External Results/Orders 4. New Results/Orders 5. Relationships Between Entries 6. Different Classes of Entries
9、 Diagnosis, Meds, Labs, Diagnosis Subsection, Paragraph, Table, List Order ContextWhat is the CDA? 临床文档 结构（ CDA）是 HL7组织制定 的以交 换临床文档为目 的的，一种 指定 语 法 (结构 )和 语 意 的 文档标记标准。临床文档 中 包括观测 、 服务 等 持续性 （ Persistence）： 一个 临床文档 在一个被定义的 局部 和 调整好 的 需求 内 会 在一个 时 间 段 内 保持稳 定不 变 。 可 管 理 性 (Stewardship 管家 ): 一个 临床文档是由
10、一个 受 医疗 所委托 的 人或组织维 护 。 真实性 （可 鉴定 authentication) 一个 临床文档是 一 组有 法 律效应 的 临床 信息 集合 。 完整性 (Wholeness) 文档鉴 定 是适用于整 个 文档 ， 并非只适用于整 个 文档 的一 部分 。 可 读性 Human readability 一个 临床文档是 可 方便计算 机 读 , 同 时保证 CDA文档是 人 可 读 的 A CDA document is a defined and complete information object that can exist outside of a message
11、, and can include text, images, sounds, and other multimedia content. 临床文档是 一个 自 定义的 、完全 的 临床 信息 集 ， 它包括文本、图像、 声音 和 其 它多 媒体 内 容 标记 CDA用的是 XML语言（ self defined, readable, actionable) CDA文档内容 在 RIM中 定 义 ， CDA本 身 不 对 文档 内容 建模 ， 只 对 需 要 交换 的 临床文档 的 结 构 和语 意制 定 了标准CDA的发展 July 1997 “ Kona Proposal” is publ
12、ished Nov 2000 CDA Release 1 May 2005 CDA Release 2 Today CDA Release 2 Implementation Guides Template tooling and reuse are hot topics. Value set definition and binding are hot topics. Sept 2009 begin CDA Release 3 balloting New Header use cases will be incorporated. Identified areas of ambiguity w
13、ill be revised. Clinical statement model will include more of the RIM. Tooling for template generation and for ensuring greater consistency with domain models built in other HL7 working groups.Major Components of a CDA Document A CDA document has a Header and a Body. A CDA document Body is comprised
14、 of Sections. A CDA Section contains one Narrative Block and zero to many Entries. 11 Header 11 Body 1* Sections 11 Narrative block 0* Entries Confidential. CDA Header .Discoverable, Readable, Actionable: CDA Provides the Structure CDA = Header + Body 标头 + 正文 Body = Sections Nested Sections = Docume
15、nt Structure Readable Narrative Actionable Entries Links to Images and “ Known” Data 文 件标头 （ Header） ， 包括：文档 的 基 本 信息（ 地 域代码 、文档 标 题 、 检验报告标准 代码 、 生 效时 间 等 ）、 病 人 基 本 信息 、 作者 （ 指 定 人 员 ）、文档保管方、 法定 审核 人、 参 与 者 （ 如申请 医生 ）、 检验项目 医 嘱 （ 推 荐使 用 LONIC、 SNOMED标准 ）、 执行 者等项目 结构 化正文 -由 一个 或多 个 专业小节 的 结果 组 成 D
16、O C U M E N T B O D Y Header S E C T I O N S Narrative Block E N T R I E S External References Structure of a CDA DocumentConfidential An ExampleConfidential An ExampleConfidential An ExampleCDA and Incremental Interoperability Incremental Interoperability means that an implementer can begin with a
17、simple CDA, and then add structured data elements over time. Syntactic interoperability. Narrative interoperability. Profile-driven interoperability (i.e. trading partners agree to use a constrained CDA profile). CDA R2 consists of a single CDA XML Schema, and you can apply one or more “ templates”
18、which serve to constrain the richness and flexibility of CDA. Professional society recommendations, national clinical practice guidelines, standardized data sets can be expressed as CDA templates. There are many kinds of templates that might be created. Two are particularly relevant for documents: T
19、hose that constrain the document sections based on the type of document (section-level templates); Those that constrain the entries within document sections (entry-level templates). CCD 连续 性 照 护文档CCR + HL7 CDA = CCD 连续 性 照 护文档 The primary use case for the ASTM CCR is to provide a snapshot in time co
20、ntaining a summary of the pertinent clinical, demographic, and administrative data for a specific patient. From the perspective of CDA, the ASTM CCR is a standardized data set that can be used to constrain CDA specifically for summary documents. The resulting specification is known as the Continuity
21、 of Care Document (CCD).2.16.840.1.113883.19.1Assessment Time200004071430HematologyCBC WO DIFFERENTIAL43789009 SNOMED CTFinal ResultsLaboratory resultsCBC (04/07/2000): HGB 13.2; WBC 6.7; PLT 123*Continuity of Care Document (CCD) CCD maps the CCR elements into a CDA representation.Continuity of Care
22、 Document (CCD) CCD sections include: Payers Advance Directives Support Functional Status Problems Family History Social History Alerts (e.g. Allergies, Adverse Events) Medications Medical Equipment Immunizations Vital Signs Results Procedures Encounters Plan of CareConfidential CCD Organizes Conten
23、t Requires section-level coding (i.e. CDA Level-2) Requires source of information (person, organization, reference) to be explicit Allows locally-defined markup in specific cases Section (component level templates) Defined section types All optional Arbitrary sequencing (may be resequenced for displ
24、ay) At most one of each type Entry (clinical statement level templates)Confidential Section Level Templates Must contain: Specific Template ID Specific LOINC Code Specific Title Narrative Block May (should) contain: Clinical Statementsxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxxtypeCode=“ xxxx” clinical
25、 statement clinical statementConfidential CCD Components (Sections) 2.16.840.1.113883.10.20.1.1 42348-3 Advanced Directives 3.2 Advance Directives 2.16.840.1.113883.10.20.1.2 48765-2 Allergies, Adverse Reactions, Alerts 3.8 Alerts 2.16.840.1.113883.10.20.1.3 46240-8 History of Encounters 3.15 Encoun
26、ters 2.16.840.1.113883.10.20.1.4 10157-6 History of Family Member Diseases 3.6 Family History 2.16.840.1.113883.10.20.1.5 47420-5 Functional Status Assessment 3.4 Functional Status 2.16.840.1.113883.10.20.1.6 11369-6 History of Immunizations 3.11 Immunizations 2.16.840.1.113883.10.20.1.7 46264-8 His
27、tory of Medical Device Use 3.10 Medical Equipment 2.16.840.1.113883.10.20.1.8 10160-0 History of Medication Use 3.9 Medications 2.16.840.1.113883.10.20.1.9 48768-6 Payment Sources 3.1 Payers 2.16.840.1.113883.10.20.1.10 18776-5 Treatment Plan 3.16 Plan of Care 2.16.840.1.113883.10.20.1.11 11450-4 Pr
28、oblem List 3.5 Problems 2.16.840.1.113883.10.20.1.12 47519-4 History of Procedures 3.14 Procedures 2.16.840.1.113883.10.20.1.13 48764-5 Summary Purpose 2.8 Purpose 2.16.840.1.113883.10.20.1.14 30954-2 Relevant Diagnostic Tests 3.13 Results 2.16.840.1.113883.10.20.1.15 29762-2 Social History 3.7 Soci
29、al History 2.16.840.1.113883.10.20.1.16 8716-3 Vital Signs 3.12 Vital Signs案例研究 Evidence-based medicine （ CDA与 循 证 医 学 ）Confidential 电子病历 的发展方 向 (Gartner Vision) Getting to the “ Helper” generation Enable Simple linkages: decision support information workflow Much clinical information (and most clin
30、ical reasoning) is text Enable Easy Discovery Readable Wt 185lb; Resp16 and unlabored; T 98.6F; HR 86 and regular. Lungs : Clear with no wheeze. Good air flow. Cardiac : RRR with no murmur, no S3, no S4. Labs PFTs 02/03/1999: FEV1 1.2; FVC 1.9; FEV1/FVC = 0.63. CBC 02/03/1999: Hgb15.1; WBC 7.2; PLT
31、279k; MCV 88. ABG 02/03/1999: (room air) pO2 78; pCO2 48; pH 7.38. CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs. PFTs today: FEV1 1.4; FVC 2.0; FEV1/FVC = 0.70. Peak Flow today: 260 l/m. Assessment Asthma, with prior smoking history. Difficulty weaning off steroids. Will try
32、 gradual taper. Hypertension, poorly controlled. Add lopressor. Plan Complete PFTs with lung volumes. Chem-7 Provide educational material on inhaler usage and peak flow self-monitoring. Decrease prednisone to 20qOD alternating with 18qOD. Lopressor25mg BID. RTC 1 week. A typical day in the officeAm
33、I following the NHLBI guidelines? NHLBI: Clinical Guidelines Contains NHLBI clinical guidelines for asthma, cholesterol and cholesterol screening, hypertension, and obesity. www.nhlbi.nih.gov Information for Health Professionals The NHLBI Asthma Guidelines can be expressed as a template that sits at
34、op CDA. A CDA document that is authored with the NHLBI Asthma Template will conform to the CDA standard AND will conform to the additional constraints in the template. NHLBI Guideline defines the Template. HL7 RIM defines the fields. Standard terminologies define the field values. And it s all packa
35、ged together in a standardized way within the CDANHLBI Asthma Template atop CDANHLBI Asthma Template atop CDA HL7 RIM defines the fields. Standard terminologies define the field values. NHLBI Asthma Template atop CDA Which environmental and occupational triggers did I ask about? Have I provided prop
36、er patient education? Confidential 33NHLBI Asthma Template atop CDA Is my assessment of asthma severity c/w NHLBI?案例研究 Regional Health Information Network (CDA与区域医疗信息 网 RHIN)波 士 顿 卫生信息网 Boston Health Net (BHN) Applications Transaction Services BMC CHC a Analytics Surveillance eReferrals Health / Wel
37、lness Alerts Clinical Decision Support Small Practice Partners Information Exchange Patient Info Reconciliation Family Patient CHC B Community Hospital Partners Another HIE基于区域医疗信息 网 的 自动化 双 向转 诊 病 人 看望社 区医生， 社 区医生发 起上转 申请 . EMR 发 送 临床 总 结 和医 嘱 到 CIE 社区医院 转诊 协 调人 员 (RC)使 用 eReferral 门户 管 理 转 诊申请 与 审
38、核 专 科 医院 审核者 ， 接 到 转诊申 请 ， 从 CIE获得患者病情 和 其他 有 关 信息， 结 合本 机 构 的医疗 资 源进 行 安排 并 做回复 专科 医院 患者前去相 应 转诊接 收机 构 就诊 ， 专 家 写诊断报告 和医 嘱 ， EMR提 交临床 报告 和医 嘱给 CIE. 登录 eReferral门户 , 结束转诊工 作 . 转 出 单位查询浏览 CIE中 的 有 关 报告 ， 实现服务跟踪 转诊申请 Refer Report 跟踪 与管 理 报 表 Report 转诊回复 Respond 社区医疗信息交 换基 于 CDA和 IHE的 医疗信息交互 38 遵守 标准 :
39、 C32 Clinical Summary using CCD, TP13 Document Set Management, TP30 Consent Management, TP22 Patient ID Cross- Referencing (PIX), TP23 Patient Demographic Query for MPI (PDQ)A Simple CDA Sample -双 向转 诊A Simple CDA Sample -双 向转 诊 (续 ）A Simple CDA Sample -双 向转 诊 (续 ）A Simple CDA Sample -双 向转 诊 (续 ）A S
40、imple CDA Sample -双 向转 诊 (续 ） Confidential 43A Simple CDA Sample -双 向转 诊 (续 ） Confidential 44A Simple CDA Sample -双 向转 诊 (续 ） Confidential 45A Simple CDA Sample -双 向转 诊 (续 ） Confidential 46A Simple CDA Sample -双 向转 诊 (续 ） Confidential 47案例研究 National Health Information Network (CDA与 NHIN)1. Joe Smit
41、h receives his care at the VA New Orleans, which stores data in a local EMR, and contributes clinical documents to a national health information network (NHIN), which contains all clinical data that exists throughout the national VA health care system. 2. Due to Hurricane Katrina, Joe Smith drives h
42、is family to Houston to stay with relatives, leaving their belongings behind. In Houston, Joe Smith starts experiencing chest pain, and he is taken to the VA Houston ER. Nurse Jane asks the patient to provide his Veteran Information Card (VIC), finds no data in the local system, and submits a query
43、for information about Joe Smith to the VA NHIN. 3. The VA NHIN sends a response back, containing a listing of all clinical documents identified for Joe Smith. VA New Orleans National Repository VA Houston 1. (Event) 3. (Response) 2. (Query) 5. (Response) 4. (Query) 6. (Event) National Health Informa
44、tion Network4. Nurse Jane finds a recent CCD, several progress note documents, and recent reports of a treadmill and coronary angiogram, and submits a query to the VA NHIN for the documents of interest. 5. The VA NHIN responds back with the requested documents. Once the documents are available, they
45、 can be viewed in the local system. 6. Meanwhile, Physician Doug has begun evaluating Joe Smith. Sublingual NTG and O2 have been applied, and chest pain has resolved. An ECG is normal. Physician Doug reviews the coronary angiogram report, which found no evidence of coronary artery disease. Physician
46、 Doug reviews the CCD, which includes a history of GERD. Joe Smith is diagnosed with GERD, reassured, and discharged. Physician Doug then enters an ER visit note into the local system. When the visit note is completed and signed, a copy of it is uploaded to the VA NHIN. VA New Orleans National Repository VA Houston 1. (Event) 3. (Response) 2. (Query) 5. (Response) 4. (Query) 6. (Event) National Health Information Network
