Transcript Clinical Document Architecture for Reporting Healthcare-Associated Infection Data

Clinical Document Architecture for
Reporting Healthcare-Associated
Infection Data
Marla Albitz
NHSN Project Manager
Lockheed Martin
Division of Healthcare Quality Promotion and National Center for
Preparedness, Detection and Control of Infectious Diseases
September 10, 2008
Atlanta, Georgia
Acknowledgements
Surveillance Branch/Informatics Staff
Venu Sarraff
Monica Shepard
Jonathan Edwards
Teresa Horan
Maggie Dudeck
Dan Pollock
Dawn Sievert
Wenkai Li
Mary Andrus
Carlasha Jenkins
Kelly Peterson
Bobby Ray
Ben Kupronis
SAIC Development Staff
David McClanahan
Romaine Tenney
Consultants
Alschuler Associates
Frazier Consulting
Vendors
Theradoc,
ICPA
Medmined
Premier Inc.
Epiquest
Vecna
Association of Professionals in Infection
Control
NCPHI
Sundak Ganesan
John Vrtachnik
GB Kesarinath
Objectives
• Overview of the National Healthcare Safety
Network (NHSN)
• The what, why and how of Clinical Document
Architecture (CDA) for NHSN and Healthcare
Associated Infection (HAI) Reporting
• Challenges and Lessons Learned
• Web-based system that combines facility-level clinical
performance measurement with national-level public
health surveillance
• http://www.cdc.gov/ncidod/dhqp/nhsn_members.html
• Participating healthcare facilities use the NHSN
application to enter, analyze, and share data
• CDC uses data collected through NHSN for aggregate
analysis and reporting
NHSN’s technical design enables data
entry via secure web pages or file
transfers (standard electronic
messages or documents) via secure
internet connections.
• Over 1700 healthcare facilities enrolled; many
more expected to join
• Facilities in 47 states currently enrolled.
• Collaborations with Center for Medicare and
Medicaid Services, Veterans Health
Administration, and other federal agencies
• Collaborations with vendors of infection control
surveillance systems.
NHSN Data Collection Forms
• Bloodstream Infection
• Surgical Site Infection
• Urinary Tract Infection
• Pneumonia
• Multi-drug Resistant Organism
• Influenza vaccination coverage Central Line
Insertion Practices
• Non-protocol events such as Skin and Soft
Tissue Infection
• Associated denominators
Surgical Site Infection Form
What is CDA?
Paper
XML*
<text xmlns:cda="urn:hl7-org:v3">
<table>
<tbody>
<tr>
<td valign="top">Fever</td>
<td valign="top">Yes</td>
</tr>
</tbody>
</table>
</text>
* Extensible Markup Language
What is XML?
• XML stands for EXtensible Markup
•
•
•
•
•
Language
XML is a markup language much like
HTML
XML was designed to carry data, not to
display data
XML tags are not predefined. You must
define your own tags
XML is designed to be self-descriptive
XML is a W3C Recommendation
NHSN Web Interface and CDA
Healthcare Facility
CDC
Entry of location
mapping codes
and monthly
reporting plan
Web-based
data entry
and access
NHSN Application
Facility
Firewall
Vendor
system used
to collect
HAI data and
create CDA
document
CDC
Firewall
CDA
Document
NHSN
Database
Parsing
and
Validating
Objectives of CDA
• Standardize the structure and content of
clinical documents for electronic exchange
between systems or stand alone use
• Achieve semantic interoperability, i.e., the
ability of two systems to share data, with no
prior negotiations
• Provide a structured document foundation
for standards-based electronic health record
systems
Technical features
• CDA documents are encoded in Extensible Markup
Language (XML)
• CDA documents derive their meaning from the
HL7 v3 Reference Information Model (RIM ) and use
HL7 v3 Data Types and vocabulary
• A CDA document consists of a header and a body
• Header is consistent across all clinical documents
- identifies and classifies the document, provides
information on patient, provider, encounter, and
authentication
• Body contains narrative text / structured content
CDA Characteristics
1) Persistence - Documents exist over time
2)
3)
4)
5)
and can be used in many contexts
Stewardship - Documents must be
managed, shared by the steward
Potential for authentication - Intended use
as a legal documentation
Wholeness - Document includes its
relevant context
Human readability - Essential for human
authentication
CDA Implementation Guides
• The Continuity of Care Document (CCD ) is an
•
•
•
•
approved HL7 standard.
Operative Notes (under development)
Patient history and physical examination (under
development)
HAI Reporting (under development, first for
public health)
Morbidity reporting from healthcare to state and
local health departments (awarded)
What is Electronic messaging?
• An HL7 message is a dataset that serves a
particular communication purpose and is
expressed consistent syntax with standard
vocabulary.
• Messages are used to exchange data in realtime. They convey status information and
provide “current” data.
• Microbiology results, ADT, Pharmacy data
from already established mission critical
systems in healthcare.
Electronic Messaging vs. CDA
Messages
Documents
Lifetime
Temporary
Persistent
Communication
Trigger based
Human initiated
Source
Designed per
system use case
Defined by clinical
precedent
Context
Must be defined
in each segment
Document as a
whole
Collaborators for HAI CDA
Development
•
•
•
•
NHSN Subject Matter Experts
Implementation Guide consultants
Vocabulary Specialists
HL7 Structured Documents Work
Group
• Infection Control Surveillance
System Vendors
Components of CDA workflow
1) Implementation Guide – provides guidance to
2)
3)
4)
5)
implementers of CDA.
Validator – xsl file that validates that a given CDA is
well formed in accordance to the CDA R2 standard.
Schematron – validates the conformance to the
Implementation Guidance.
Source application that generates the CDA document
Parsing tool that receives the CDA document –
validates that the data received within the CDA
document adheres to the data validation of the
receiving application.
What is a clinical statement?
Provides a standard way of expressing a
discrete item of clinical information that is
recorded because of its relevance to the
care of a patient.
Why is the clinical statement
approach important in the
context of data exchange?
The end result is that clinical
observations such as a “fever”
observation can be communicated
consistently whenever it is expressed.
Clinical Statement Types
• Observation (e.g. lab result)
• Procedure (e.g. Knee replacement)
• SubstanceAdministration (e.g. administer a
•
•
•
•
medication)
Supply (e.g. dispensing a drug)
Encounter (e.g. hospitalization)
Organizer (e.g. pairing of a pathogen and
susceptibility test)
Consent (e.g. consent for the information contained
in the document to be released to a third party)
Implementation Guide:
Conformance statements
The Implementation Guide further constrains the RIM and specific
direction to the implementer through conformance statements.
Conformance statements are
used to create clinical
statements in XML
<!-- Criterion of Diagnosis Observations -->
<component>
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<!-- template for observation: Criterion of Diagnosis Observation -->
<templateId root="upd-9"/>
<code codeSystem="2.16.840.1.113883.5.4" code="ASSERTION"/>
<statusCode code="completed"/>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED" code="386661006" displayName=“Fever"
</observation>
</component>
Example of NHSN
Clinical Criteria for
Bloodstream Infection
Required narrative block
Structured Body
<text xmlns:cda="urn:hl7-org:v3">
<table>
<tbody>
<tr>
<td valign="top">Fever</td>
<td valign="top">Yes</td>
</tr>
</tbody>
</table>
</text>
<!-- Criterion of Diagnosis Observations -->
<component>
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<!-- template for observation: Criterion of Diagnosis Observation -->
<templateId root="upd-9"/>
<code codeSystem="2.16.840.1.113883.5.4" code="ASSERTION"/>
<statusCode code="completed"/>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED" code="386661006" displayName=“Fever"/>
</observation>
</component>
Required narrative block
<text xmlns:cda="urn:hl7-org:v3">
<table>
<tbody>
<tr>
<td valign="top">Fever</td>
<td valign="top">Yes</td>
</tr>
</tbody>
</table>
</text>
Structured Body
<!-- Criterion of Diagnosis Observations -->
<component>
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<!-- template for observation: Criterion of Diagnosis Observation -->
<templateId root="upd-9"/>
<code codeSystem="2.16.840.1.113883.5.4" code="ASSERTION"/>
<statusCode code="completed"/>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED" code="386661006" displayName=“Fever"
</observation>
</component>
Coded Value within the
structured body
codeSystemName="SNOMED" code="386661006"
displayName=“Fever"/>
Standard Vocabulary in NHSN’s
CDA Surgical Site Infection Report
Signs & Symptoms
Source
Code
□ Purulent drainage or material
SNOMED
307491001
□ Pain or tenderness
NSHN term
SS_pain
□ Localized swelling
NSHN term
SS_locSwell
□ Redness
SNOMED
386713009
□ Heat
SNOMED
304214002
□ Fever
SNOMED
386661006
NSHN term
SS_incision
□ Incision deliberately opened
by surgeon
NHSN/CDA status
• Bloodstream Infection pilot Fall 2007
• Surgical Site Infection pilot Summer 2008
• Implementation Guides currently under ballot for
MDRO and clinical criteria.
• Implementation Guides currently under
construction for Patient Flu and Central Line
Insertion Practices events.
• Coming soon – Custom Events, UTI and PNEU
Lessons learned
• NHSN data requirements gathering - required work
on a detailed data level that in some instances called
for clarification from Subject Matter Experts and
close collaboration with CDA modelers.
• Identified the value of working with vendors in terms
of close reviews of the IG and reality checks in the
form of pilot projects while the IG remains a work in
progress
• Identified the value of working with Alschuler
Associates (technical expertise with CDA and knowhow with respect to HL7 processes)
• Identified the value of considering receiving data
electronically and through a user interface when
designing business rules.
Q&A
Contact Information
Marla Albitz
NHSN Project Manager
Lockheed Martin contractor
Centers for Disease Control and Prevention
1600 Clifton Road, NE Mail Stop A24
Atlanta, GA 30333
Office (404) 639-4292
e-mail: [email protected]