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“Next Generation” CDA Proposal

Prepared by: Bob Dolin, MD

(DRAFT June 19, 2002 DRAFT)

1 Introduction 1

2 CDA Model 2

3 CDA XML DTD 3

4 Sample document 4

5 Sample CDA Level Three-encoded document 6

6 Open Issues 18

6.1 CDA Level Three model 18

6.2 XML ITS Generation 18

6.3 XML Instance 18

6.4 Questions on proper use of the RIM 18

6.5 When there are multiple ways to represent the same thing 19

6.6 Other things to fix or add to the example 19

Introduction

In follow-up to the CDA proposals discussed at the last meeting in Atlanta, we were asked to build more detailed examples to better illustrate how the model will translate ultimately into an XML instance.

So, this proposal enhances the CDA R-MIM previously discussed, and takes the example document from the CDA Level One, Release One specification, and shows how it will look when transformed into a complete RIM-based CDA Level Three instance.

The proposal includes:

• R-MIM for CDA Level One/Two/Three;

• XML DTD for CDA Level One/Two/Three;

• Sample CDA Level Three instance.

There are many many open issues remaining, and there are many simplifications and technical errors in the attached proposal. But if you can see the forest through the trees, you’ll get a sense of where the “next generation” of CDA specifications is envisioned to be.

CDA Model

The clones currently shown in the cda_entry choice structure are the ones needed to support the creation of the sample instance below. This area will need considerable review. There are many other use cases yet to be considered, and there is a need to review the clones coming out of other committees.

Also, the document header is greatly simplified. Refer to the Medical Records ballot for the latest real CDA Header R-MIM.

[pic]

CDA XML DTD

This is a very rough approximation of an XML DTD that might be algorithmically generated from the above R-MIM. It helps illustrate a number of open issues and can serve as a means of clarifying our requirements, even though we may never issue it as part of the standard.

|Option 1 |Option 2 |

|Act relationships stemming from the Document_Section clone come |Act relationships stemming from the Document_Section clone are in|

|one after the other. (Nested sections come before nested |a choice structure. (Nested sections and entries can intermix.) |

|entries.) | |

| |> |

Sample document

Good Health Clinic Consultation note

Consultant: Robert Dolin, MD

Date: April 7, 2000

Patient: Henry Levin, the 7th MRN: 12345 Sex: Male

Birthdate: September 24, 1932

History of Present Illness

Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his teens. He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months.

Past Medical History

• Asthma

• Hypertension

• Osteoarthritis, right knee

Medications

• Theodur 200mg BID

• Albuterol inhaler 2puffs QID PRN

• Prednisone 20mg qd

• HCTZ 25mg qd

Allergies

• Penicillin - Hives

• Aspirin - Wheezing

Social History

• Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.

• Alcohol :: Rare

Physical Exam

• Vital Signs :: BP 118/78; Wt 185lb; Resp 16 and unlabored; T 98.6F; HR 86 and regular.

• Skin :: Erythematous rash, palmar surface, left index finger.

[pic]

• Lungs :: Clear with no wheeze. Good air flow.

• Cardiac :: RRR with no murmur, no S3, no S4.

Labs

• CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.

• Peak Flow today: 260 l/m.

Assessment

• Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.

• Hypertension, well-controlled.

• Contact dermatitis on finger.

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.

• Hydrocortisone cream to finger BID.

• RTC 1 week.

Signed by: Robert Dolin, MD April 8, 2000

Sample CDA Level Three-encoded document

This is a sample CDA Level Three instance that for the most part follows the XML DTD above. It helps illustrate a number of open issues and can serve as a means of clarifying our requirements. As we make progress, the sample will be updated to reflect what a valid and conformant instance will look like.

Henry Levin, the 7th is a 67 year old male referred for

further asthma management. Onset of asthma in his teens. He was

hospitalized twice last year, and already twice this year. He

has not been able to be weaned off steroids for the past

several months.

Asthma

Hypertension

Osteoarthritis, right knee

Asthma

Hypertension

Osteoarthritis, right knee

Asthma

Hypertension

Osteoarthritis, right knee

Theodur 200mg BID

Proventil inhaler 2puffs QID PRN

Prednisone 20mg qd

HCTZ 25mg qd

Penicillin - Hives

Aspirin - Wheezing

Smoking :: 1 PPD between the ages of 20 and 55, and

then he quit.

Alcohol :: rare

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