Clinical Document Architecture Open Standardsbased EPR Incorporating Radiology

Clinical Document Architecture Open Standards-based EPR Incorporating Radiology Michael La. Rocca

Agenda Why are XDS, XDR, and CDA a perfect match? How do XDS, XDR, and CDA come together to achieve an Electronic Patient Record? How do RIS concepts and metadata map to XDS, XDR, and CDA?

Roles of CDA, XDS, and XDR Clinical Content Community Sharing Direct Exchange CDA XDS XDR Patient Summary Referral Summary Discharge Summary Lab Report More… • • Document Submission Document Storage Document Registration Document Sharing • • Document Submission Document Receipt

Goals of CDA: Goals Give priority to delivery of patient care. Allow cost-effective implementation across as wide a spectrum of systems as possible. Support exchange of human-readable documents between users, including those with different levels of technical sophistication. Promote longevity of all information encoded according to this architecture. Enable a wide range of post-exchange processing applications. Promote exchange that is independent of the underlying transfer or storage mechanism. Prepare the design reasonably quickly. Enable policy-makers to control their own information requirements without an extension to this specification.

Overlapping Goals of CDA, XDS, and XDR: Overlapping Goals Give priority to delivery of patient care. Allow cost-effective implementation across as wide a spectrum of systems as possible. Support exchange of human-readable documents between users, including those with different levels of technical sophistication. Promote longevity of all information encoded according to this architecture. Enable a wide range of post-exchange processing applications. Promote exchange that is independent of the underlying transfer or storage mechanism. Enable policy-makers to control their own information requirements without an extension to this specification.

Agenda Why are XDS, XDR, and CDA a perfect match? How do XDS, XDR, and CDA come together to achieve an Electronic Patient Record? How do RIS concepts and metadata map to XDS, XDR, and CDA?

IHE Core Services: Patient Identification via PIX(v 3) Document Consumers EHR PHR Image Viewer PIX(v 3) / PDQ(v 3) Manager XDSb Document Registry Global ID: XYZ Local ID: ABC Local ID: DEF Local ID: GHI Local ID: JKL Document Sources EMR Registration System Lab System Clinician Portal Radiology System

IHE Core Services: Document Submission via XDSb Document Consumers EHR PHR Image Viewer PIX(v 3) / PDQ(v 3) Manager XDSb Document Registry Global ID: XYZ Local ID: ABC Local ID: DEF Local ID: GHI Local ID: JKL Document Sources Document 1 Clinician Portal Document 2 Document 3 XDSb Document Repository ID: 123 Repository ID: 456 Document ID: 1 Document ID: 2 Document ID: 3 Content EMR Registration System Lab System Radiology System

IHE Core Services: Document Consumption via XDSb Document Consumers EHR PHR Image Viewer PIX(v 3) / PDQ(v 3) Manager XDSb Document Registry Global ID: XYZ Local ID: ABC Local ID: DEF Local ID: GHI Local ID: JKL Document Sources Document 1 Clinician Portal Document 2 Document 3 XDSb Document Repository ID: 123 Repository ID: 456 Document ID: 1 Document ID: 2 Document ID: 3 Content EMR Registration System Lab System Radiology System

IHE Core Services: Cross Community Access via XCA Document Consumers EHR PHR Image Viewer PIX(v 3) / PDQ(v 3) Manager XDSb Document Registry Global ID: XYZ Local ID: ABC Local ID: DEF Local ID: GHI Local ID: JKL Document Sources Document 1 Clinician Portal XCA Initiating Gateway Document 2 Document 3 XDSb Document Repository ID: 123 Repository ID: 456 Document ID: 1 Document ID: 2 Document ID: 3 Content EMR Registration System Lab System Radiology System

IHE Core Services: Document Exchange via XDR Point-to-Point Destination Source Point-to-Point through intermediary components Source HISP Destination

Agenda Why are XDS, XDR, and CDA a perfect match? How do XDS, XDR, and CDA come together to achieve an Electronic Patient Record? How do RIS concepts and metadata map to XDS, XDR, and CDA?

Metadata Mapping: RIS to CDA to XDS and/or XDR Category RIS CDA XDS / XDR name source. Patient. Info Date of Birth birth. Time source. Patient. Info Sex administrative. Gender source. Patient. Info Address address source. Patient. Info Patient Number id source. Patient. Id National Number id patient. Id Patient Class encompassing Encounter Not Represented Patient Information Name

Metadata Mapping: RIS to CDA to XDS and/or XDR Category RIS CDA XDS / XDR Creator Person Name author Grade / Function author. Role Contact Number author source. Patient. Info Responsible Team legal. Authenticator Reporting Source author. Institution Recipient Name intended. Recipient Grade / Function Not Represented Contact Number intended. Recipient Not Represented Recipient Team intended. Recipient Target intended. Recipient Consumer

Clinical Mapping: RIS to CDA Category RIS CDA Header Report Type Clinical. Document/code Accession Number Clinical. Document/in. Fulfillment. Of/…order/ id DICOM Objects Section Study Findings Section Conclusions Section act Series act/entry. Relationship/act Service-Object Pair (SOP) Instance act/entry. Relationship/act/entry. Relationshi p/observation Findings text (narrative) Measurement entry/observation Measurement (WADO) entry/observation /entry. Relationship/observation Conclusions text (narrative)