cda- attachments tutorial - hl7 international · psych medications per plan lithium

Proposal: Attachments in CDA 28 April 2003

© 2003 HL7 1

CDA-Attachments

Tutorial28 April 2003

Wes RishelChair, HL7

[email protected]

28 April 2003 2© 2003 HL7

Topics

• Introduction• A Reader’s Guide to XML• HL7 Clinical Document Architecture Overview• HL7 CDA Supplementary Information• MIME• Introduction to the Proposed Implementation Guide


© 2003 HL7 2

28 April 2003 3© 2003 HL7

Reviewing the Goals:

• Preserve the notion of predictable content

• Preserves all the work the ASIG has done inidentifying the content of specific attachments.

• Provides a less painful ways for payers andproviders to get started with attachment

• Switches from HL7 version 2.4 to HL7 ClinicalDocument Architecture, which is XML-based

28 April 2003 4© 2003 HL7

Structured Data:Must We Sell the Future to Gain the Present?

• Present– Limited ability of

providers to providestructured data

– ROI available by savingPeople, Paper, andPostage

• Future– increasing levels of

autoadjudication– better medical

management– more extensive

collection of qualitydata

– requires structured data

• Web-based communication models


© 2003 HL7 3

28 April 2003 5© 2003 HL7

Syntax

“Legacy” Syntaxes– HL7 v2 and X12– Only dealt with through

mappers– Awkward for dealing with

text– Will be used for many

years– Not the best choice for

new endeavors

XML– Was “the future” in 1998– Ubiquitous low-cost

tooling plus part of mostmapping products

– XSL = auto-rendering– equally at home with

structured data and text– Currently the syntax of

choice for new endeavors,especially Web-basedendeavors

28 April 2003 6© 2003 HL7

Topics



© 2003 HL7 4

28 April 2003 7© 2003 HL7

Syntax vs. Standard vs. Implementation Guide:XML Is Only a Syntax

Syntax:

Standard:

Imp.Guide:

X12 Syntax

277 Transaction

Set

004020X104or

004010X093

HL7 v2.4 Syntax

ORU Message

AttachmentsIG or

NEDSS IG

XML

HL7Clinical

DocumentArchitecture

AttachmentsIG

28 April 2003 8© 2003 HL7

XML is a Set of Standards (Recommendations)

• Extensible Markup Language (XML) 1.0 (SecondEdition): www.w3.org/TR/REC-xml

• Extensible Stylesheet Language (XSL), Version 1.0:www.w3.org/TR/xsl/

• XML Schema Language: www.w3.org/TR/2001/REC-xmlschema-0-20010502/

• XML Path Language (XPATH): www.w3.org/TR/xpath• and many others (www.w3.org)


© 2003 HL7 5

28 April 2003 9© 2003 HL7

XML Documents and Elements

Document: the XML name for a complete utterance (like“message”)

<content></content>

Element: Opening and Closing Tags

<content>Thiothixene 5 mg by mouth three times aday.</content>

PCDATA

PCDATA: “parseable character data”

28 April 2003 10© 2003 HL7

XML Attributes

<local_markup descriptor="dt_ts">2000-06-28</local_markup>

Name and value inside the angle brackets of the tag.

attribute

<caption_cd V="18648-6"></caption_cd>Sometimes all the info for an element is in attributes

<caption_cd V="18648-6"/>

A special form of element with only one tag:

Slash at end


© 2003 HL7 6

28 April 2003 11© 2003 HL7

Elements Can Bracket Other Elements

<section><caption><caption_cd V="18651-0"/>Psych Medications per Plan</caption><paragraph>

<content>Lithium 600 mg by mouth each morning and 900 mg by mouth before sleeping.</content>

</paragraph><paragraph>

<content>Thiothixene 5 mg by mouth three times a day.</content></paragraph><paragraph>

<content>Benztropine 1 mg by mouth three times a day.</content></paragraph>

</section>

28 April 2003 12© 2003 HL7

Recursion

<section> <caption>HL7 Standards</caption> <paragraph> <content>HL7 has two kinds of standards</content> </paragraph> <section> <caption>XML-Based HL7 Standards</caption> <paragraph> <content>HL7 XML-based standards include the CDA and Version 3 messaging</content> </paragraph> </section></section>

section element within a section element


© 2003 HL7 7

28 April 2003 13© 2003 HL7

Tags and Attributes Do NOT Describe Text“Decoration”

<section> <caption>EMS TRANSPORT, ADMITTED AT DESTINATION FACILITY ON TRANSFER<caption_cd V="18589-2"/> </caption> <paragraph> <caption>EMS TRANSPORT, ADMITTED AT DESTINATION FACILITY ON TRANSFER<caption_cd V="18589-2"/> </caption> <content>Yes <coded_entry> <coded_entry.value V="Y" SN="HL70136"/> </coded_entry> </content> </paragraph></section>

XML

EMS TRANSPORT, ADMITTED AT DESTINATION FACILITY ON TRANSFER. Yes

Alternate“Rendered” XML

EMS TRANSPORT, ADMITTED AT DESTINATION FACILITY ON TRANSFER. Yes

“Rendered” XML

28 April 2003 14© 2003 HL7

Case Matters: What’s Wrong With This Picture?

<Content>Lithium 600 mg by mouth each morning and 900mg by mouth before sleeping.</content>


© 2003 HL7 8

28 April 2003 15© 2003 HL7

“White Space” Is For People

<section> <paragraph> <content>Lithium 600 mg by mouth each morning and 900 mg by mouth before sleeping.</content> </paragraph> <paragraph> <content>Thiothixene 5 mg by mouth three times a day.</content> </paragraph></section>

<section><paragraph><content>Lithium 600 mg by mouth each morning and 900mg by mouth before sleeping.</content></paragraph><paragraph><content>Thiothixene 5 mg by mouth three times a day.</content></paragraph></section>

To Computer Programs These Two are the Same

28 April 2003 16© 2003 HL7

915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT ON 7/17,22,24,27,29,31WITH PSYCHOLOGIST: PATIENT MADE ATTEMPTS TO COME AND PARTICIPATEIN SYMPTOM MANAGEMENT GROUP. PATIENT WAS URGED TO USE ANXIETYCONTROL TECHNIQUES HE HAD BEEN TAUGHT TO TOLERATE INCREASINGLONGER STAGES IN GROUP. PATIENT RESPONDED BY BEING ABLE TO STAY ANDPARTICIPATE IN GROUP 50% LONGER. LABWORK DONE ON {DATE} 07/17/98{TEST} LITHIUM LEVEL {RESULT}90 {JUSTIF.} ROUTINE MONITORING OFTHERAPEUTIC RESPONSE.

“Normalizing” White Space Obscures Paragraphs

paragraph> <content>915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT ON 7/17,22,24,27,29,31 WITH PSYCHOLOGIST: PATIENT MADE ATTEMPTS TO COME AND PARTICIPATE IN SYMPTOM MANAGEMENT GROUP.

PATIENT WAS URGED TO USE ANXIETY CONTROL TECHNIQUES HE HAD BEEN TAUGHT TO TOLERATE INCREASING LONGER STAGES IN GROUP. PATIENT RESPONDED BY BEING ABLE TO STAY AND PARTICIPATE IN GROUP 50% LONGER.

LABWORK DONE ON {DATE} 07/17/98 {TEST} LITHIUM LEVEL {RESULT}90 {JUSTIF.} ROUTINE MONITORING OF THERAPEUTIC RESPONSE.</content> </paragraph>


© 2003 HL7 9

28 April 2003 17© 2003 HL7

Peek Ahead to CDA: <paragraph> element

<paragraph> <content>915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT ON7/17,22,24,27,29,31 WITH PSYCHOLOGIST: PATIENT MADE ATTEMPTS TO COME ANDPARTICIPATE IN SYMPTOM MANAGEMENT GROUP. </content></paragraph><paragraph> <content>PATIENT WAS URGED TO USE ANXIETY CONTROL TECHNIQUES HE HADBEEN TAUGHT TO TOLERATE INCREASING LONGER STAGES IN GROUP. PATIENTRESPONDED BY BEING ABLE TO STAY AND PARTICIPATE IN GROUP 50%LONGER.</content></paragraph><paragraph> <content>LABWORK DONE ON {DATE} 07/17/98 {TEST} LITHIUM LEVEL {RESULT}90{JUSTIF.}ROUTINE MONITORING OF THERAPEUTIC RESPONSE.</content></paragraph>

28 April 2003 18© 2003 HL7

Rendered Using HL7’s CDA Attachments Stylesheet

915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT ON7/17,22,24,27,29,31 WITH PSYCHOLOGIST: PATIENT MADE ATTEMPTS TOCOME AND PARTICIPATE IN SYMPTOM MANAGEMENT GROUP.

PATIENT WAS URGED TO USE ANXIETY CONTROL TECHNIQUES HE HADBEEN TAUGHT TO TOLERATE INCREASING LONGER STAGES IN GROUP.PATIENT RESPONDED BY BEING ABLE TO STAY AND PARTICIPATE INGROUP 50% LONGER.

LABWORK DONE ON {DATE} 07/17/98 {TEST} LITHIUM LEVEL{RESULT}90 {JUSTIF.} ROUTINE MONITORING OF THERAPEUTICRESPONSE.


© 2003 HL7 10

28 April 2003 19© 2003 HL7

Well-Formed XML Documents

• A document is “well-formed” if:– The beginning and end tags must nest within one

another, instead of overlapping.– There must be a single out element, called the

root element, that contains all other elements andtext in the document.

28 April 2003 20© 2003 HL7

Why Are These Items Not Well Formed Documents?

<caption_cd V="18648-6">

<paragraph><content>Lithium 600 mg by mouth each morning and 900 mg bymouth before sleeping.</paragraph></content>

<paragraph> <content>Lithium 600 mg by mouth each morning and 900 mg by mouth before sleeping.</content></paragraph><paragraph> <content>Thiothixene 5 mg by mouth three times a day.</content></paragraph>


© 2003 HL7 11

28 April 2003 21© 2003 HL7

VALID

<section> <caption>History of Present Illness</caption> <paragraph> <content>Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his teens. He was h twice last year, and already twice this year. He has not been be weaned off steroids for the past several months. </content> </paragraph></section><section> <caption>Past Medical History</caption>

Parser

Schema:Provides application over the

syntax by defining what elementnames are legal, their attributes

and how they nest

“Valid” XML Documents: Compliant With A Schema

28 April 2003 22© 2003 HL7

Schema Languages: Document Type Definition vs.XML Schema Language

• DTD the original language– controls the structure of elements and attibutes– leaves format of PCDATA and attribute values unspecified

• XSD is the newer approach– much more complete than DTD– includes data types for PCDATA or attribute values: e.g., number,

date– allows new data types to be added: (e.g., LOINC code with the

hyphen)

• Original CDA used DTD• XSD schemas developed later• We use XSD for Attachments


© 2003 HL7 12

28 April 2003 23© 2003 HL7

Why Use a Schema?

• Not all applications use a schema

• Those that do:– Make it absolutely clear to their trading partner what is

acceptable

– Greatly reduce the amount of editing code they have towrite and maintain to avoid “garbage in, garbage out”

28 April 2003 24© 2003 HL7

Schema is Only Part of the Specifications forInformation Exchange

• Similar to X12 syntax rules being available inmachine readable form

• A complete specification includes semantics thatmust be expressed in natural language

• A complete specification includes business rulesthat cannot be expressed in a schema


© 2003 HL7 13

28 April 2003 25© 2003 HL7

Is This Document Well-Formed? Is it Valid?

<section><caption><caption_cd V="18651-0"/>Psych Medications per Plan</caption><paragraph>





</section>

28 April 2003 26© 2003 HL7

“Valid” Was A Trick Question!You Must State Valid With Respect to What Schema

<section xsi:schemaLocation=“urn:hl7-org:v3/cda” schema.xsd”schema.xsd>

<caption><caption_cd V="18651-0"/>Psych Medications per Plan</caption><paragraph>





</section>

© 2003 HL7 14

28 April 2003 27© 2003 HL7

Other Parts of an XML Document

<?xml version="1.0"?>

XML Declaration

<?xml-stylesheet type="text/xsl" href="cda.ns.1.xsl"?>

Processing Instruction

Comment

<signature_cd V="S"/>

28 April 2003 28© 2003 HL7

Introducing XPATH

<section><caption>Outer Section Added</caption><section>

<caption><caption_cd V="18651-0"/>Psych Medications per Plan</caption><paragraph>





</section></section>


© 2003 HL7 15

28 April 2003 29© 2003 HL7

Nested Elements Thought of as a Tree

<section>

<caption

<caption_cd

V="18651-0"

PsychMedications

per Plan

<paragraph>

<content>

Lithium 600mg by moutheach morning

and 900 mg bymouth before

sleeping.

<paragraph>

<content>

<paragraph>

<content>

Benztropine 1mg by mouththree times a

day.

Thiothixene 5mg by mouththree times a

day

section

caption

OuterSectionAdded

><

><

>

>

28 April 2003 30© 2003 HL7

A Tree is a Connected Set of “Nodes”

ElementNode

AttributeNode Text Node

<section>

<caption

<caption_cd

V="18651-0"

PsychMedications

per Plan

<paragraph>

<content>



sleeping.

<paragraph>

<content>

<paragraph>

<content>


day.


day

section

caption

OuterSectionAdded

><

><

>

>


© 2003 HL7 16

28 April 2003 31© 2003 HL7

XPATH is a Language For Specifying Sets of Nodes

/section/section/caption

<section>

<caption

<caption_cd

V="18651-0"

PsychMedications

per Plan

<paragraph>

<content>



sleeping.

<paragraph>

<content>

<paragraph>

<content>


day.


day

section

caption

OuterSectionAdded

><

><

>

>

28 April 2003 32© 2003 HL7

<section>

<caption

<caption_cd

V="18651-0"

PsychMedications

per Plan

<paragraph>

<content>



sleeping.

<paragraph>

<content>

<paragraph>

<content>


day.


day

section

caption

OuterSectionAdded

><

><

>

>

A Node Set With Heterogeneous Elements

/section/*


© 2003 HL7 17

28 April 2003 33© 2003 HL7

<section>

<caption

<caption_cd

V="18651-0"

PsychMedications

per Plan

<paragraph>

<content>



sleeping.

<paragraph>

<content>

<paragraph>

<content>


day.


day

section

caption

OuterSectionAdded

><

><

>

>

A Node Set With Elements at Different Levels

/section/caption //section/caption

28 April 2003 34© 2003 HL7

<section>

<caption

<caption_cd

V="18651-0"

PsychMedications

per Plan

<paragraph>

<content>



sleeping.

<paragraph>

<content>

<paragraph>

<content>


day.


day

section

caption

OuterSectionAdded

><

><

>

>

Selecting Attribute Nodes

//caption_cd/@V


© 2003 HL7 18

28 April 2003 35© 2003 HL7

Why Use XPATH?

• Programmer: understood directly by many softwaretools �shorthand for programming

• Analyst: concise, unambiguous way tocommunicate with programmers

• Analyst: concise, unambiguous way tocommunicate with trading partners

• ASIG: precise shorthand for use in specifications

28 April 2003 36© 2003 HL7

XML Stylesheets

<section> <caption>History of Present Illness</caption> <paragraph> <content>Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his teens. He was h twice last year, and already twice this year. He has not been be weaned off steroids for the past several months. </content> </paragraph></section><section> <caption>Past Medical History</caption>

Style SheetProcessor

XSL Style Sheet:Mapping rules in a standard

language

HTML. PDF, Word-Processing, XML, Data File ...


© 2003 HL7 19

28 April 2003 37© 2003 HL7

XML Namespaces:Bringing Order out of Multi-Group Chaos

<order><number>X1234-99</number><ship-date>2003-02-18</ship-date><item>

<quantity>24</quantity><product>#123A2 Size 12 cashmere sweaters</product>

</item></order>

International Merchant’s Association Defines an “Order”

28 April 2003 38© 2003 HL7


<product><number>123A2</number><description>cashmere sweaters</description><size system='US-Ladies'>12</size>

</product>

Consolidated Clothes Cutters Defines “Product” In Detail


© 2003 HL7 20

28 April 2003 39© 2003 HL7



<quantity>24</quantity><product>

<number>123A2</number><description>cashmere sweaters</description><size system='US-Ladies'>12</size>

</product></item>

</order>

Can we combine the IMA peanut butterwith the CCC chocolate?

28 April 2003 40© 2003 HL7



<quantity>24</quantity><product>

<number>123A2</number><description>cashmere sweaters</description><size system='US-Ladies'>12</size>

</product></item>

</order>

Can we combine the IMA peanut butterwith the CCC chocolate?

Using the Same Tagfor Different Things:

Not Good!


© 2003 HL7 21

28 April 2003 41© 2003 HL7


<ima:order xmlns:ima='urn:intl-merchants-assoc.org'><ima:number>X1234-99</ima:number><ima:ship-date>2003-02-18</ima:ship-date><ima:item>

<ima:quantity>24</ima:quantity><ccc:product xmlns:ccc='urn:consolidated-clothes-cutters.org'>

<ccc:number>123A2</ccc:number><ccc:description>cashmere sweaters</ccc:description><ccc:size system='US-Ladies'>12</ccc:size>

</ccc:product></ima:item>

</ima:order>

Namespaces Allow the Tags to be Mixed Without Confusion

28 April 2003 42© 2003 HL7


<ima:order xmlns:ima='urn:intl-merchants-assoc.org'><ima:number>X1234-99</ima:number><ima:ship-date>2003-02-18</ima:ship-date><ima:item>

<ima:quantity>24</ima:quantity><ccc:product xmlns:ccc='urn:consolidated-clothes-cutters.org'>

<ccc:number>123A2</ccc:number><ccc:description>cashmere sweaters</ccc:description><ccc:size system='US-Ladies'>12</ccc:size>

</ccc:product></ima:item>

</ima:order>

Namespaces can allow HL7 CDA to co-exist in a future X12 XML-based transactions

*


© 2003 HL7 22

28 April 2003 43© 2003 HL7

Attachments/CDA Uses Two Namespaces(Well, OK, Actually Three)

<levelone

xmlns="urn:hl7-org:v3/cda"

xmlns:v3dt="urn:hl7-org:v3/v3dt"

xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">

Version 3 Data Types

Implicit CDA

Required When Using XML Schema Language

28 April 2003 44© 2003 HL7

What is the Namespace for the GIV Element?What is the Namespace for the provider Element?

<levelone xmlns="urn:hl7-org:v3/cda" xmlns:v3dt="urn:hl7-org:v3/v3dt" >... <provider>

<provider.type_cd V="PRF"/><person>

<id EX="298379" RT="2.16.840.1.113883.3.933"/><person_name>

<nm><v3dt:GIV V="George"/><v3dt:MID V="F"/><v3dt:FAM V="Carson"/><v3dt:SFX V="MD" QUAL="PT"/>

</nm><person_name.type_cd V="L"

S="2.16.840.1.113883.5.200"/></person_name>

</person></provider>

…</levelone>


© 2003 HL7 23

28 April 2003 45© 2003 HL7

Topics


28 April 2003 46© 2003 HL7

CDA Overview

• (See separate presentation)


© 2003 HL7 24

28 April 2003 47© 2003 HL7

Topics


28 April 2003 48© 2003 HL7

ISO Object Identifiers (OIDs)

• ISO/IEC 8824:1990(E)• Defines identifiers that are unique in the world• Can identify anything, … organizations, code sets, satellites,

fire hydrants … anything• Delegated assignment authority• Sequence of numbers, like 2.16.840.1.113883.5.949

represent something like:– 2.16.840.1.113883 the delegated assignment authority– .5 the kind of thing being assigned– .949 the individual entity so identified


© 2003 HL7 25

28 April 2003 49© 2003 HL7

Delegated assignment authority

2.16.840.1.113883

28 April 2003 50© 2003 HL7

Some HL7 Uses for OIDs

• Code sets, e.g., 2.16.840.1.113883.6.5 = SNOMED

• The data type “II” (instance identifier)– Extension is a an ID such as a patient number, member

number, organization ID, serial # for DME, etc.– Root is an OID that makes the extension unique

<coded_entry.value V="D2-51000" S="2.16.840.1.113883.6.5"/>

<person><id EX="KP00017" RT="2.16.840.1.113883.3.933"/><person_name>

<nm><GIV V="Robert"/><FAM V="Dolin"/><SFX V="MD"/>

</nm><person_name.type_cd V="L" S="2.16.840.1.113883.5.200"/>

</person_name></person>


© 2003 HL7 26

28 April 2003 51© 2003 HL7

Topics


28 April 2003 52© 2003 HL7

CDA Uses Images/External Documents in 3 Ways

• Observation Media (<observation_media>)– part of the “attestable” content; without the picture, the

document may not be completely understood– associated with a specific <content> element

• Non-XML Body (<non_xml>)– replaces the body– combined with the header, the Non-XML body IS is the

attestable content

• Link (<link>)– reference to a document or image that is not a part of the

attestable content


© 2003 HL7 27

28 April 2003 53© 2003 HL7

Use of Observation Media<section>

<caption><caption_cd V="8709-8"/>Skin</caption>

<paragraph><content>Erythematous rash, palmar surface, left index finger.

<observation_media><observation_media.value MT="image/jpeg"><REF V="rash.jpeg"/>

</observation_media.value></observation_media></content>

</paragraph></section>

XSLRendering to

HTML

28 April 2003 54© 2003 HL7

Keeping the Observation MediaWith the CDA Document: MIME

• Multipurpose Internet Mail Extensions• Standard promulgated by the Internet Engineering

Task Force (IETF) as RFC 2045• Originally used for email with attachments, now

used for Web and in other contexts• Divides the entire “message” into sections for the

message itself and associated files (e.g.,attachments)

• http://www.ietf.org/rfc/rfc2045.txt?number=2045


© 2003 HL7 28

28 April 2003 55© 2003 HL7

Sending an “Attachment” to a CDA Attachment

• The entire MIME document goes in the BINsegment of the 275

• The MIME Document is broken down in to parts– Part 1: The XML Document– Parts 2 - N: The related documents (e.g., rash.jpg)

• Each of parts 2-N includes a file name• When any part is binary (e.g., rash.jpg) it is encoded

in Base64

28 April 2003 56© 2003 HL7

Example Using MIME PackageMime-version: 1.0Content-Type: multipart/mixed;

boundary="192.168.0.132.1.69632.1044136280.905.11308"

--192.168.0.132.1.69632.1044136280.905.11308Content-Type: application/x-hl7-cda-level-one+xmlContent-Disposition: inline; filename=CDA_rich_sample.noDTD.xml

<?xml version="1.0"?><levelone>......

<content>Erythematous rash, palmar surface, left index finger.<observation_media><observation_media.value MT="image/jpeg"><REF V="rash.jpeg"/>

</observation_media.value></observation_media></content>...

--192.168.0.132.1.69632.1044136280.905.11308Content-Type: image/jpegContent-Transfer-Encoding: base64Content-Disposition: attachment; filename=rash.jpeg

/9j/4AAQSkZJRgABAQEAeAB4AAD/2wBDAAEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQEBAQH/2wBDAQEBAQEBAQEBAQEBAQEBAQEBAQEB...

--192.168.0.132.1.69632.1044136280.905.11308--


© 2003 HL7 29

28 April 2003 57© 2003 HL7

When the Entire Attachment is an Image: <non_xml>

• Procedure and format is the same as the example• The XML portion includes only the header and the

<non_xml> body• The attachments represent the pages of the actual

document

28 April 2003 58© 2003 HL7

Topics



© 2003 HL7 30

28 April 2003 59© 2003 HL7

Reviewing the Goals:

• Preserve the notion of predictable content

• Preserves all the work the ASIG has done inidentifying the content of specific attachments.

• Provides a less painful ways for payers andproviders to get started with attachment

• Switches from HL7 version 2.4 to HL7 ClinicalDocument Architecture, which is XML-based

28 April 2003 60© 2003 HL7

“Human-Decision” vs. “Computer-Decision” Variants

Human-Decision Variant– Matches the most prevalent

workflow: a person reviewingthe information to make adecision

– “Low-impact” on health plans(easy to display using commontools)

– “Low-impact” on providers(supports low-cost documentpreparation and “fax-like” useof existing paper or documentimages)

Computer-Decision Variant– Permits computer-assisted

adjudication or autoadjudication– Includes specifications for

breaking data down intocomputer-accessible elements

– Includes LOINC codes toidentify the questions

– Includes answer codes suitableto the question

– Processable in “Human-Decision” mode by health plansthat have not adopted acomputer-decision approach.

– Can be applied selectively, oneattachment at a time.


© 2003 HL7 31

28 April 2003 61© 2003 HL7

Outline of a Proposed Approach

• 277 and 275 are largely unchanged -- LOINC stillused to identify questions and answers; however,the BIN segment contains CDA documents

• Substantive content of booklets are unchanged (i.e.,no change to what may be asked and what must besent when the whole attachment is requested) --unless we want to tinker for other reasons

• Each booklet supports structured/coded data orplain text or a document image

28 April 2003 62© 2003 HL7

What Happens to Computer-Decision Structure?

• Providers ”may" code the details with LOINC codesif they “can”, but initially have no incentive to do so

• Payers "can" ignore the LOINC detailed codes --indeed they will do so automatically if they use theviewing stylesheet

• Payers that choose to auto-adjudicate claims in aprocess that includes attachments will announce toproviders that those that choose to add use structureand detailed LOINC codes will have their claimsadjudicated faster– no need for a new standard at that time– the move to the higher level is incentive-based


© 2003 HL7 32

28 April 2003 63© 2003 HL7

Uniform Treatment of Structure

Provider(Sends Computer-Processable CDA)

Provider(Sends Person-Readable CDA)

Provider(Sends page images

within CDA)

Payer(Uses People

ReadingAttachments to

Adjudicate Claims)

Payer(Uses Computer to

AutoadjudciateCertain Claims)

Display in BrowserRender for DocumentManagement SystemPrint

Autoadjudicate

“HumanReadable”Style Sheet

“ComputerProcessable”Style Sheet

28 April 2003 64© 2003 HL7

Gain Immediate Benefits...

• Providers– Maximum opportunity for

immediate participation– ROI available by saving

People, Paper, and Postage

• Payers– limit early

implementation costs tobasic Qs and As

– less early use of LOINCcodes (could limit it toattachment IDs if theypreferred)

– initial investment morejustified by higherprovider participation


© 2003 HL7 33

28 April 2003 65© 2003 HL7

...But Don’t Sell Out the Future

• Providers– Health plan incentives

for structured dataprovides financialbenefit for acquiring acomputer-based patientrecord

– Timing for conversionis a business decisionrather than an enforceddecision

• Health Plans– After the basic ROI is

obtained, advance to theuse of structured datawithout anotherregulatory cycle

– Selectively approach theuse of structured data asbusiness opportunitiesarise, rather than beingforced to by a regulation

28 April 2003 66© 2003 HL7

“CDA” vs. “CDA Attachment”CDA– Very general -- accepts virtually

any content

– Many optional features imposeobligations on receiver to dealwith them

– LOINC codes optional

– No data types in body

Computer-Decision Variant– Very specific content, specified

by booklets

– Disallow those optional featuresthat are not necessary forAttachments use cases

– LOINC codes required fordocument type

– LOINC codes required for eachanswer part in “computer-decision variant”

– Uses local_markup withspecified data types incomputer-decision variantXML Documents

CDA DocumentsCDA Attachments


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28 April 2003 67© 2003 HL7

Documents and Authorities Only Slightly ChangedWorkgroup for

SpecificAttachment

Type

LOINCConsortium

HL7 CDASpecification

Health LevelSeven

X12Transaction

Sets 277,275

ASC X12 &Subcommittee

X12N

X12 277 Transaction X12 275 TransactionC C

HL7 CDA Document

C C C

C C

X12Implementation Guides

277, 275

HL7Claims

AttachmentsImplementation

Guide

AdditionalInformation

MessageBooklet

28 April 2003 68© 2003 HL7

Organizations of HL7 Attachments IG

• I - Introduction (not normative)– Minor updates from prior version

• II - Attachment (not normative)– Introduction of terms and concepts

• III CDA Attachments Compliance Statements(normative)– definitions of terms– usual use of “shall” and “should”– yes-no statements about a CDA document or determine if

sender is compliant– yes-no statements about actions of the receiver determine

if the receiver is compliant


© 2003 HL7 35

28 April 2003 69© 2003 HL7

Additional Information Message Booklets

• Substantive content (questions, answer parts, andresponse code tables) unchanged

• Previous “message variant” sections removed• Coding examples for both the human-decision and

computer-decision variants• Altered headings for the value table

28 April 2003 70© 2003 HL7

Revised Value Table

27513-1 ALCOHOL-SUBSTANCE ABUSE REHABILITATIONTREATMENT PLAN, DATE RANGE (FROM/THROUGH)OF NEXT PLANNED TREATMENT (COMPOSITE)

1,1

27488-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATIONTREATMENT PLAN, NEXT PLANNED TREATMENTSTART DATE

DT 1,1

27489-4 ALCOHOL-SUBSTANCE ABUSE REHABILITATIONTREATMENT PLAN, NEXT PLANNED TREATMENTEND DATE

DT 1,1

18671-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATIONTREATMENT PLAN, NEXT PLAN OF TREATMENTTEXT (NARRATIVE)

0,1

18671-8 TX 0,118672-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION

TREATMENT PLAN, ALCOHOL/SUBSTANCE ABUSESYMPTOMS WITH PHYSIOLOGICAL DEPENDENCEINDICATOR

1,1

18672-6 N NoY Yes

CE 1,1 HL70136

LOINC code©Element Answer

Part

Value DataType

Card ResponseCode