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CCDA to FHIR 
Grahame Grieve 
FHIR Developer Days 
November 26, 2014 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA vs FHIR 
 I am CDA subject matter expert for the 
Australian national program 
 I was co-chair of Structured Documents WG, 
which owns the CDA standard 
 I am the lead for FHIR 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA vs FHIR 
Through 2010/2011, it became clear that: 
 CDA was too hard to construct and read 
 Documents not good for granular data exchange 
 CDA used for exchanging data because the 
alternatives were worse 
 CDA getting pushback from implementers 
 The SD committee was about to double down 
 These strategic frustrations were part of why FHIR 
was invented 
3 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA vs FHIR 
 The design of FHIR was strongly influenced 
by CDA: 
 Narrative/Data in every resource 
 Need to a document package 
 Use of “must understand” ( isModifier) 
 CDA content model a first point of reference 
 Green CDA simplification 
 CDA usage guided our resource priority 
4 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA vs FHIR 
 CDA community was focused on their task 
 Mostly didn’t even pay attention to FHIR 
 Common Questions to us: 
 Why does FHIR have “documents”? 
 What is the relationship between CDA and FHIR? 
 What does Lantana think about FHIR? 
 Do you have a transform from (C)CDA to FHIR? 
5 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA vs FHIR 
 Joint Position Statement from leaders in the 
FHIR and CDA community 
 Focus: The future of CDA and FHIR 
 This statement is not official policy 
https://www.lantanagroup.com/wp-content/uploads/Lantana-Position-Statement-CDA-FHIR.pdf 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA vs FHIR 
 Position: 
CDA addresses interoperability for clinical 
documents, mixing narrative and structured 
data. FHIR provides granular access to data, 
a contemporary, streamlined approach to 
interoperability, and is easy to implement. 
FHIR can be the future of CDA, but it is not 
there yet 
7 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Documents vs APIs 
“The medical record is not data. It contains data, as do many 
forms of writing, but it is not data, nor is it simply a repository 
into which data are poured. Although its raw material is 
information—some of which, importantly, can only be 
expressed with words and not with numbers—a finished 
medical record is information that has been transformed by 
the knowledge, skill, and experience of the physician, 
motivated by the healing impulse, into an understanding of 
human experience that makes the care of the patient 
possible.” 
8 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Documents vs APIs 
 This dual nature of a medical record—the 
combination of data and narrative—runs 
deeply through the clinical process and, 
consequently, through the clinical record 
 Why CDA is narrative based 
 Why FHIR resources have narrative 
9 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Documents vs APIs 
 Packaged Access 
 Trust from document 
context & obligations 
 Independent of 
system integration 
 Import data from 
documents 
 Granular Access 
 System-based trust 
framework 
 Tightly integrated IT 
and business systems 
 Export data from APIs 
10 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Documents vs APIs 
 Documents are the correct way to exchange 
information between clinicians in disparate 
parts of the healthcare system 
 APIs will integrate access to the data 
between applications where the context is 
unambiguous. 
 Both the document and API should 
seamlessly use the same syntax and 
semantics and Narrative approach 
11 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Call to Action (1) 
 Recognize the duality and interdependence 
of data and narrative in clinical information 
 Understand the gaps in support for clinical 
documents in the current FHIR Draft 
Standard for Trial Use (DSTU) 
 Ensure that FHIR 2.0 addresses clinical 
document requirements 
12 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Call to Action (2) 
 Establish, publish, and test CDA/FHIR, 
FHIR/CDA mapping 
 Define, document, and promote a future 
where clinical documents and Application 
Programming Interfaces (APIs) share a 
common syntax and set of resources 
 Establish, in technical and regulatory policy, 
a smooth roadmap to the future of clinical 
document exchange 
13 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA -> FHIR project 
 Map CDA header to FHIR 
 Resolve issues around sections in FHIR 
 Map basic CDA entries to FHIR (general) 
 Map CCDA sections & entries to FHIR 
(specific) 
14 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA -> FHIR Project 
 Work is in a google spreadsheet 
 Ongoing calls on a weekly basis 
 Up to step #3 
15 
https://docs.google.com/spreadsheets/d/1KctdexG3oB2QBiBQNH1Rbt2uJ6Dx 
QFROyIFKo5q95WU/edit#gid=1223244219 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Working Spreadsheet 
 Basic Information from CDA 
 Element 
 Cardinality 
 Mandatory 
 Conformance 
 Type 
 Domain 
 Extensible 
 Notes 
16 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Working Spreadsheet 
 FHIR Specification Mapping – where it goes 
in FHIR 
 Base Card – what the FHIR cardinality is 
 Profile Card – what the CDA-on-FHIR 
cardinality will be 
 Type – what the FHIR type is 
 Notes / CDA on FHIR call decisions – 
discussion of issues 
17 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA  FHIR outcomes 
 The mapping spreadsheet itself 
 A series of change proposals to the base 
FHIR specification 
 Corollary: CDA -> FHIR requires DSTU2 
 A formal “Clinical Document” profile which 
will be part of the FHIR specification 
 CCDA section/entry mappings and profiles 
 Conversion Libraries? 
18 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CDA Profile in FHIR 
 http://hl7-fhir.github.io/cda.html 
 Profiles and Extensions 
 Very incomplete 
 This will develop as the project goes on 
19 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CCDA 
 “Consolidated CDA” 
 Harmonised several US and IHE CDA 
implementation guide 
 In service of “Meaningful Use Minimal Data 
Set” though it includes more 
20 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
CCDA  FHIR 
 The project is not up to this 
 Some work has been done by a variety of 
individuals and groups 
 CCDA is hard to understand, and there is 
much variance in it’s use 
 It’s unclear at what level this needs to be 
useful 
 ..Demonstration 
21 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
From CCDA to FHIR 
 This is an active area of investigation 
 DSTU 2 will be “Clinical Document” ready 
 DSTU 2 will include a base Meaningful Use 
Profile 
 A formal CCDA profile will follow in due 
course 
22 
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

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Route from CCDA to FHIR by Grahame Grieve

  • 1. CCDA to FHIR Grahame Grieve FHIR Developer Days November 26, 2014 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 2. CDA vs FHIR  I am CDA subject matter expert for the Australian national program  I was co-chair of Structured Documents WG, which owns the CDA standard  I am the lead for FHIR © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 3. CDA vs FHIR Through 2010/2011, it became clear that:  CDA was too hard to construct and read  Documents not good for granular data exchange  CDA used for exchanging data because the alternatives were worse  CDA getting pushback from implementers  The SD committee was about to double down  These strategic frustrations were part of why FHIR was invented 3 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 4. CDA vs FHIR  The design of FHIR was strongly influenced by CDA:  Narrative/Data in every resource  Need to a document package  Use of “must understand” ( isModifier)  CDA content model a first point of reference  Green CDA simplification  CDA usage guided our resource priority 4 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 5. CDA vs FHIR  CDA community was focused on their task  Mostly didn’t even pay attention to FHIR  Common Questions to us:  Why does FHIR have “documents”?  What is the relationship between CDA and FHIR?  What does Lantana think about FHIR?  Do you have a transform from (C)CDA to FHIR? 5 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 6. CDA vs FHIR  Joint Position Statement from leaders in the FHIR and CDA community  Focus: The future of CDA and FHIR  This statement is not official policy https://www.lantanagroup.com/wp-content/uploads/Lantana-Position-Statement-CDA-FHIR.pdf © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 7. CDA vs FHIR  Position: CDA addresses interoperability for clinical documents, mixing narrative and structured data. FHIR provides granular access to data, a contemporary, streamlined approach to interoperability, and is easy to implement. FHIR can be the future of CDA, but it is not there yet 7 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 8. Documents vs APIs “The medical record is not data. It contains data, as do many forms of writing, but it is not data, nor is it simply a repository into which data are poured. Although its raw material is information—some of which, importantly, can only be expressed with words and not with numbers—a finished medical record is information that has been transformed by the knowledge, skill, and experience of the physician, motivated by the healing impulse, into an understanding of human experience that makes the care of the patient possible.” 8 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 9. Documents vs APIs  This dual nature of a medical record—the combination of data and narrative—runs deeply through the clinical process and, consequently, through the clinical record  Why CDA is narrative based  Why FHIR resources have narrative 9 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 10. Documents vs APIs  Packaged Access  Trust from document context & obligations  Independent of system integration  Import data from documents  Granular Access  System-based trust framework  Tightly integrated IT and business systems  Export data from APIs 10 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 11. Documents vs APIs  Documents are the correct way to exchange information between clinicians in disparate parts of the healthcare system  APIs will integrate access to the data between applications where the context is unambiguous.  Both the document and API should seamlessly use the same syntax and semantics and Narrative approach 11 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 12. Call to Action (1)  Recognize the duality and interdependence of data and narrative in clinical information  Understand the gaps in support for clinical documents in the current FHIR Draft Standard for Trial Use (DSTU)  Ensure that FHIR 2.0 addresses clinical document requirements 12 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 13. Call to Action (2)  Establish, publish, and test CDA/FHIR, FHIR/CDA mapping  Define, document, and promote a future where clinical documents and Application Programming Interfaces (APIs) share a common syntax and set of resources  Establish, in technical and regulatory policy, a smooth roadmap to the future of clinical document exchange 13 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 14. CDA -> FHIR project  Map CDA header to FHIR  Resolve issues around sections in FHIR  Map basic CDA entries to FHIR (general)  Map CCDA sections & entries to FHIR (specific) 14 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 15. CDA -> FHIR Project  Work is in a google spreadsheet  Ongoing calls on a weekly basis  Up to step #3 15 https://docs.google.com/spreadsheets/d/1KctdexG3oB2QBiBQNH1Rbt2uJ6Dx QFROyIFKo5q95WU/edit#gid=1223244219 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 16. Working Spreadsheet  Basic Information from CDA  Element  Cardinality  Mandatory  Conformance  Type  Domain  Extensible  Notes 16 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 17. Working Spreadsheet  FHIR Specification Mapping – where it goes in FHIR  Base Card – what the FHIR cardinality is  Profile Card – what the CDA-on-FHIR cardinality will be  Type – what the FHIR type is  Notes / CDA on FHIR call decisions – discussion of issues 17 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 18. CDA  FHIR outcomes  The mapping spreadsheet itself  A series of change proposals to the base FHIR specification  Corollary: CDA -> FHIR requires DSTU2  A formal “Clinical Document” profile which will be part of the FHIR specification  CCDA section/entry mappings and profiles  Conversion Libraries? 18 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 19. CDA Profile in FHIR  http://hl7-fhir.github.io/cda.html  Profiles and Extensions  Very incomplete  This will develop as the project goes on 19 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 20. CCDA  “Consolidated CDA”  Harmonised several US and IHE CDA implementation guide  In service of “Meaningful Use Minimal Data Set” though it includes more 20 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 21. CCDA  FHIR  The project is not up to this  Some work has been done by a variety of individuals and groups  CCDA is hard to understand, and there is much variance in it’s use  It’s unclear at what level this needs to be useful  ..Demonstration 21 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
  • 22. From CCDA to FHIR  This is an active area of investigation  DSTU 2 will be “Clinical Document” ready  DSTU 2 will include a base Meaningful Use Profile  A formal CCDA profile will follow in due course 22 © 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.