Optimizing the HL7 C-CDA?

Viet Nguyen, MD, Systems Made Simple
Viet Nguyen, MD, Systems Made Simple,
Optimizing the HL7 C-CDA?

As healthcare organizations move toward population health management and care coordination models, they are becoming increasingly dependent on technology to enable meaningful information exchange across the continuum.
Underpinning electronic information exchange is HL7’s C-CDA (Health Level Seven International’s Consolidated-Clinical Data Architecture), which defines the structure and semantics of key clinical documents to allow complete and accurate information sharing between healthcare organizations.  HL7 C-CDA Release 1.1 governs nine document types, which represent the major information resources for clinical care: Continuity of Care Document (CCD), Consultation Note, Diagnostic Imaging Report (DIR), Discharge Summary, History and Physical (H&P), Operative Note, Procedure Note, Progress Note, and Unstructured Documents.
At this time, most EHRs can only share one of the aforementioned reports externally—the CCD—which provides a patient snapshot, including past medical history, medications, the problem list and allergies. While sharing the CCD is a step toward interoperability, it is a relatively small one. EHR vendors have been focused on exchanging this particular report to meet Meaningful Use requirements, but they now need to take the next step and enable additional C-CDA documents that include more detailed and timely information.
Consider the example of an 85-year-old patient who comes to his primary care physician with respiratory symptoms and a fever. The physician is concerned the patient may have pneumonia and refers him to the local hospital, which admits the patient and starts treatment. While the CCD provides the hospital with basic information, the primary care physician’s progress notes would be much more valuable as they go into greater detail on the patient’s current condition and the physician’s perceptions of the patient’s needs. Being able to share the progress notes electronically would not only save the hospital time and facilitate faster treatment but also ensure delivery of the most appropriate care given the patient’s existing condition and past history.
The hospital also has a key document worth sharing. Before sending the patient home, the hospital creates a discharge summary describing the care the patient received in the hospital—chest x-ray, IV antibiotics and so on. This summary needs to be shared with the primary care physician, so he or she can be fully informed about what occurred in the hospital when examining the patient at the scheduled follow-up visit.
To raise the bar for interoperability, providers should be working closely with their EHR vendors to determine their plans for expanding C-CDA offerings. How do you leverage HL7 C-CDA document types in your system? Your vendor should be able to describe how it currently uses HL7 C-CDA to encourage interoperability and problem-free document sharing. If the vendor is still working toward using the standard but is not ready to roll-out a software upgrade, make sure you ask for specific timeframes and implementation expectations.
What documents can I share using your system? As mentioned previously, most vendors using C-CDA are focused on the CCD, which only offers a brief picture of patient care. By expressly asking about other documents, you can get a sense of the vendor’s commitment to interoperability. Also, you can seize the opportunity to outline the benefits of sharing the various documents and gauge whether the vendor will be pursuing this in the future. 
What is your long-term strategy for data interoperability? Embracing HL7 C-CDA is just one step along the interoperability journey. For example, the next evolutionary stage is HL7 Fast Healthcare Interoperability Resources (FHIR). This evolutionary interoperability paradigm will enable more granularity in sharable data as well as real-time information exchange. Right now, C-CDA documents represent one point in time, and as such, may quickly become outdated. FHIR resources, on the other hand, will give providers up-to-the minute information on which to base patient care decisions. When asking vendors about their interoperability goals, organizations should listen for information about FHIR and the vendor’s plans to incorporate it going forward.
Viet Nguyen, MD, is a clinical informaticist and chief medical information officer for Systems Made Simple.