CDA implementation experiences in the UK
Publication date: Dec 04, 2012
The initial joint HL7 UK / DHID CDA Implementation Forum meeting focused on the implementation aspects of CDA, on template and example repositories, and featured a panel discussion on the best approach for the implementation of CDA documents within an application.
On November 4th (2012) HL7 UK held a joint meeting with the DHID CDA Implementation Forum. The CDA Implementation Forum is an initiative (started in August 2012) by the English NHS to share implementation best practices related to its CDA specifications (i.e. those part of the English ITK/MIM specifications).
Note for non-UK readers: the Interoperability Toolkit (ITK) is a HL7 v2, HL7 v3 message and CDA based implementation guide for use at the local/regional level within England. The Message Implementation Manual (MIM) is a HL7 v3 and CDA based implementation guide for use at the national level within England – the development of this specification has been on hold for the past 2 years or so, the focus is currently on the ITK. The Department of Health Information Directorate (DHID, part of the English NHS), and more precisely Connecting for Health (CfH) is responsible for the creation of the ITK and for accrediting compliant systems.
UK CDA Implementation experiences
First we had three presentations from those with CDA implementation experience in the UK . Below are the key points that I got out of the presentations:
- Keith Strahan (on behalf of the London health and social care information sharing programme) talks about their Adapter project. Current interoperability scenarios (e.g. Admit and Discharge forms) are based on sending fax. Theirs is a gradual approach: (a) start to use secure e-mail as a transport mechanism, maybe move to the ITK infrastructure afterwards, and (b) use a piece of middleware to map structured (MIM v3 messages) and unstructured documents (word documents) data to/from CDA for those organizations that can use structured data as defined in the ITK CDA profiles. The ITK specification needs updates to deal with the concept of middleware.
- Nigel Miller (on behalf of the CLCH project for e-Communication, a London based primary healthcare provider oriented project) discusses a project related to the exchange of data between GPs. They looked at CDA as a potential format. However, CDA isn’t currently supported by GP systems, so they decided to fall back on Kettering XML (a legacy, non governed standard) which works with all GP systems. Need somehow to put pressure on suppliers to achieve ITK compliance. Keith Naylor (DHID/NHS) points out that there is an as of yet unsigned directive that GP systems at some point in the future will have to provide (at zero cost) support for the receipt of CDA.
- Dunmail Hodkinson (Black Pear Software) discusses a project that focuses on the implementation of an ophthalmology system based on iPads, and to link the outreach clinics that use these with hospital systems, particularly the OpenEyes application (an open source ophthalmology system). For example glaucoma findings (CfH already had a well-defined Glaucoma dataset, also inclusive of the IHE Eye Care profile). The clinical model is based on CKM (the OpenEHR Clinical Knowledge management tool). They ended up using the attachment feature in a CDA entry to convey the OpenEHR XML (mime type application/openehr+xml), in addition to a human readable text version in the section. This (in due time) allows for a migration of the openEHR XML content to CDA entries. They used the CDA API (an open source API for the ITK non-structured CDA specification) to create CDA quickly. Their conclusion: it’s a lot work to create CDA interfaces. Typically for a small projects: an ad hoc interface takes a week, this took 2 to 3 months.
Richard Kavanagh (head of data standards, NHS CfH) presented the new CfH Template Library. The CfH approach towards templating was developed years ago, much ahead of any other international project, now enshrined in our legacy. There are currently about 280 templates (available on TRUD - requires a login), a next release with instance examples is expected in February 2013) of various types and status. CfH is now moving to template definitions that are specific to the underlying serialized XML - effectively the template is no longer a model constraint but an XML constraint. Provide ability for local projects or vendors to define new CDA profiles (using a “CDA Profile builder”) based on a pick-n-mix selection of assured templates from the Template library.
During the subsequent panel discussion two main topics were discussed:
- Template versioning (because of the iterative process of defining them), and
- the different methods of implementing CDA (Example based, model/code generation based, green CDA) and what would be suitable for a particular project. I argued the case for model based implementation (see j.mp/gDwZKm), it being the only method that scales well – especially for vendors that have to deal with templates from lots of sources, and not just the CfH specifications. Dunmail pointed out that as a vendor he doesn’t want to focus on things like schema and schematron, so any generated code that has been made available would make life a lot easier for him.
Robert Worden (Open Mapping Software), talks about (the proof of concept) of a CDA Examples Repository, with multiple examples for each template. Examples are sourced from example CDA documents. It is also a discussion forum (on a template level, or on an XML node level), and a validation service (checks for XML elements that are populated in this instance, but in no other known example, and a crude CDA/template validation).
It is apparent from the discussions and the experiences of CfH with the CDA Forum (the online ITK CDA implementer community) that it’s still early days for implementers: most of them are still facing the steep learning curve.
Implementers on the CDA Forum currently don’t raise a lot of issues or implementation approaches on their own. Given that the number of well experienced implementers is low some of the implementers may choose not to discuss experiences because of competitive reasons. Newbies probably wish not to be (publicly) seen as being ignorant. Once there is a certain critical mass of experienced CDA implementers the CDA Forum probably will find much more active participation than it currently does. HL7 UK may be involved in organizing a hack-a-thon which is likely to bring yet more implementers to the table. It may be the right incentive for both newbies as well as experienced implementers to show up, to informally test and develop against the ITK CDA specifications.
The need for examples was raised at various points during the day – which isn’t just beneficial for newbie CDA implementers but also to those that want to test their own implementation. As such Robert Worden’s CDA Examples Repository really fills a need – provided HL7 UK can somehow convince the various implementers to share their own examples/test documents.
As part of the next steps Ann Wrightson (TSC chair, HL7 UK) suggests that HL7 UK and the DHID CDA Forum have future joint meetings (this one had a good mixture of regular HL7 UK attendees and CDA Forum participants), whether those be face to face or in the form of a series of webinars. Given that we need to increase the number of CDA implementations to reach the necessary critical mass to get the implementer community going it seems we (as a community) have to do a lot of education and marketing.
I’m personally convinced we’re close to the tipping point – the ever increasing interest in purchasing ITK enabled applications on the supplier side will ensure a higher uptake of CDA over time.
PermaLink to this page: http://www.ringholm.com/column/Joint_HL7_UK_NHS_DHID_CDA_Forum.htm
Index of columns:
- FHIR DevDays and the year in review (Dec 27, 2018)
- Creation and Curation of FHIR Profiles - process and governance (Dec 14, 2017)
- De Algemene Verordening Gegevensbescherming (AVG) in de zorg (Dutch, Sep 19, 2017)
- Impact of the GDPR on the use of interoperability standards (Jun 27, 2017)
- News from the FHIR DevDays in Amsterdam (Dec 15, 2016)
- Next XDS Release (Oct 27, 2016)
- Five years of FHIR (Aug 11, 2016)
- Interoperability projects in Ireland - FHIReland (Mar 14, 2016)
- 2016 FHIR Jedi Calendar (Jan 06, 2016)
- Top 10 HL7 videos watched in 2015 (Dec 24, 2015)
- Update from the trenches on CDA R2.1/R3 and HL7v2. (Oct 15, 2015)
- FHIR DevDays - UK GP System APIs (Sep 16, 2015)
- IHE XDS - testing and implementation tools (Aug 25, 2015)
- Most often implemented IHE Profiles (Jun 08, 2015)
- Why we sponsor the HL7 WGM (May 10, 2015)
- FHIR in Paris (Apr 21, 2015)
- Mapping HL7v2 messages to FHIR. (Apr 13, 2015)
- Analysis of CDA R2 testing tools - most requirements are neither tested nor respected. (Feb 13, 2015)
- HL7 and IHE in Sweden (Feb 08, 2015)
- 2015 FHIR Chiefs Calendar (Jan 07, 2015)
- The Merry FHIR Choir caroling the 12 Days of Christmas (Dec 09, 2014)
- Chicago FHIR Update (Oct 13, 2014)
- Internationalization of HL7 (Sep 25, 2014)
- New XDS Advanced training course on offer by IHE Services and IHE Academy (Jul 14, 2014)
- Recent and Future developments of the DICOM standard (Mar 06, 2014)
- Top 10 HL7 videos watched in 2013 (Jan 02, 2014)
- Report from the HL7 WGM in Cambridge (Oct 16, 2013)
- Documenting the history of HL7 (Sep 03, 2013)
- Histology Lab Device Automation using HL7 version 2 (Jul 23, 2013)
- HL7 FHIR Elevator Pitch (Jul 15, 2013)
- Interoperability Standards - the no-sales pitch (Jul 09, 2013)
- HL7 UK - new landscape, new opportunities (Jun 26, 2013)
- Validation and error correction at the IHE Connectathon (Apr 25, 2013)
- CDA Implementation Guides - (not) invented here (Apr 17, 2013)
- Usage of IHE Profiles (Feb 25, 2013)
- 10 year anniversary - Dutch Ringholm HL7 v2 training courses. (Feb 19, 2013)
- About IHE Academy and new IHE training courses (Jan 12, 2013)
- CDA implementation experiences in the UK (Dec 04, 2012)
- Musings on free HL7 IP (Oct 01, 2012)
- HL7 Connectathons (Sep 09, 2012)
- Renovate HL7 version 3 (Aug 03, 2012)
- Frequency of use of HL7 message types (Jul 24, 2012)
- Lighting the FHIR, HL7s new major interoperability standard (Jun 15, 2012)
- Reflections on the HL7 membership model - the affiliate life cycle (Dec 28, 2011)
- Thinking like an OWL reasoner (Sep 17, 2011)
- RFH (Resources for Health): HL7 version 3 taken to the next step (Aug 18, 2011)
- What's so great about the HL7 organization? (Aug 04, 2011)
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- Increasing demand for IHE training courses (Dec 18, 2010)
- Context issues with the IHE QED profile (Dec 15, 2010)
- The changing role of HL7 country organizations (Jul 16, 2010)
- Implementing HL7 version 3 - the book (May 06, 2010)
- Adding openness to a closed world (Feb 09, 2010)
- How to lower the hurdle for HL7 v3 implementers (Jan 21, 2010)
- HL7 v3 deployment statistics (Dec 17, 2009)
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- Internationalization of HL7 (Sep 24, 2009)
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- The HL7 Wiki reaches 2000 pages (Mar 02, 2009)
- The HL7 roadmap for CDA R3 and the CCD (Jan 17, 2009)
- HL7 Affiliates Meeting in Orlando (Jan 11, 2009)
- Swiss and Dutch HL7 News (Dec 31, 2008)
- Devices and Prizes (Nov 22, 2008)
- HL7 in Norway: a situation report (Sep 02, 2008)
- Russian whitepaper (Jul 09, 2008)
- The HL7 Interoperability Conference - IHIC 2008 (May 30, 2008)
- HL7 creates a RIM Based Application Architecture (RIMBAA) group (May 18, 2008)
- Notes from the HL7 WGM in Phoenix (May 08, 2008)
- Germany embraces CDA eReferral document specification (May 02, 2008)
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Ringholm bv is a group of European experts in the field of messaging standards and systems integration in healthcare IT.
We provide the industry's most advanced training courses and consulting on healthcare information exchange standards.
See http://www.ringholm.com or call +31 33 7 630 636 for additional information.
Rene is the Tutor-in-chief of Ringholm.