This is your Questionaire submitted by on Tuesday September 9, 2008, 23:33:28

Show Me Your CDA! My questionnaire

A. Basics

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1. CDA Project Name:   CDA4CDT
   
2. Project Web Site:      http://wiki.hl7.org/index.php?title=CDA_
   
3. Contact Name:           Liora Alschuler
   
4. Contact E-mail*:         liora@alschulerassociates.com
   *Primary contact for information about the project; one or more
   
5. Geographic location:US
   
6. Summary description: (Please write a paragraph describing your project. Include installation sites, demonstrations, and primary purpose 250 words)
   This project develops CDA Implementation Guides (IGs) for common types of electronic healthcare documents, brings them through the HL7 ballot process and promotes their adoption within industry. The standardization and adoption of these standard electronic documents will enlarge and enrich the flow of data into the electronic health record and speed the development of interoperable clinical document repositories for use within the enterprise and regional and national networks. This rapid-development project bridges the gap between narrative documents produced through dictation and the structured, computable records within an EHR
   
   

B. Business Case

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1. What are the exchange sites? [choose multiple]
   Primary care provider (i.e. General Practice)
   Emergency
   Hospital
   Tetriary care
   Document repository (not affiliated with a single provider)
   Internally within an enterprise (provider))
   Other: All of the above
   
2. What were the reasons for beginning your CDA exchange? [choose multiple]
   Improve the delivery of care
   Government mandate
   Business drivers (cost effectiveness)
   Public health reporting
   Quality Reporting
   Standardizing clinical reporting
   Other: Its not a single exchange
   

C. CDA Usage

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1. What document types do you use? [choose multiple]
   Discharge summary (inpatient or outpatient)
   Transfer of Care, Referral or Medical Summary (e.g. U.S. CCD)
   Operative Note
   History and Physical
   Consultation Note
   Progress Note
   Admission Note
   Nursing Assessment
   Public Health Reports
   Other: Diagnostic Imaging Reports
   
   
2. Do you use an implementation guide? [choose multiple]
   HL7 Implementation Guide
   HL7 Affiliate Implementation Guide
   IHE Implementation Guide
   
3. What level of coding do you use?
   Level 0 (non-XML)
   Level 2 (coded sections)
   Level 3 (some coded entries)
   Mixture or unsure
   
   
4. Did your initial exchange begin at a lower level of coding?
   Yes
   No
   If yes, please describe:
   The minimum is Level 2, Level 3 is optional where there are defined templates.
   
5. How are your CDA documents generated: [choose multiple]
   Electronic Medical Record export
   Scanning
   Word processing (converted to XML or left as non-XML)
   Dictation
   Conversion from alternative standard (HL7 V2, DICOM SR, other)
   Natural Language Processing
   Speech recognition
   
6. Please describe your CDA volume:
   Number of CDA documents exchanged over the last year:
   Number of CDA documents exchanged last month:            
   If other, please describe:
   Approximately 5,000,000 documents a year are produced through dictation/transcription which comply with the CDA; when the CDA4CDT implementation guides are finalized, we anticipate that these documents and more will become compliant.
   
7. Do you make your CDAs available to patients through a Personal Health Record system
   or provider portal?
   Yes
   No
   
   
8. Did you extend CDA to fulfill your use case? Have you submitted requirements for consideration in CDA R3?
   Yes
   No
   If yes, please describe:
   
   
9. Have you carried out educational seminars on CDA use?
   Yes
   No
   
   
10. Have you used terminology for...
    10.1 clinical document types: [choose multiple]:
    Local Vocabulary
    LOINC
    SNOMED
    If other, please describe:
    
    
    
10.2 Section Codes [choose multiple]:
Local Vocabulary
LOINC
SNOMED
If other, please describe:


10.3 Clinical Information [choose multiple]:
Local Vocabulary
LOINC
SNOMED
ICD
If other, please describe:

D. Health Information Exchange Methodology

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1. How many sites are involved in exchanging CDA in this project?not applicable
   
   
2. How do you exchange/transport your CDA documents? [choose multiple]:
   Web Services
   ebXML
   SOAP (Simple Object Access Protocol)
   SOA (Service Oriented Architecture mechanism)
   CD/DVD
   Memory stick/Thumb drives
   HL7 v2x MDM
   HL7 v3 RCMR
   IHE XDR/XDS
   If other, please describe:
   not applicable
   
   
   

E. Vendor Applications

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Please share some information about the applications in use:

Vendor or In House development: Name of vendor or in-house development
Supported Functions: Authoring, Distribution, Display, EMPI, Enrichment (Natural Language Processing, coding, etc), Management, Electronic Medical Record (EMR)
Product Status: pre-released, released (Note: applies to the version of the product with the CDA capabilities you are using. If released, but the CDA capability is in beta, indicate pre-release)

F. Bibliography

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Please list any existing bibliographic references to your work including scientific papers, articles in your own language, implementation guides, etc.) Modern Healthcare: "HL7's first ballot in expected series under way" by Joe Conn "Implementation guides for documents containing 'history and physical reports' were submitted Monday to Ann Arbor, Mich.-based HL7. It is the first ballot in what is expected to be a series of interoperability specifications under a project called Clinical Document Architecture for Common Document Types, or CDA4CDT." Standards development expert Liora Alschuler, the CDA4CDT project leader, said balloting is the least of the worries ahead. "The first challenge is to get this adopted," Alschuler said. "We have high hopes that this will see relatively rapid, widespread adoption because it has a really minimal impact on workflow. ... "So what does that do for humanity? If we look at building interoperability and patient-centered records, this is the largest single gain in interoperability that the industry could see," Alschuler said. http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070329/FREE/70329002/1029/FREE Healthcare Informatics: "Guidelines Will Standardize Dictated Documents" by Brian Albright "Dictated medical notes and other types of transcribed patient records are usually available in electronic form, but have traditionally not been very useful in the context of an electronic medical record (EMR) system. Transcribed records follow a variety of formats depending on the clinical setting and type of transcription service used, making them difficult to search. "There's no real structure to the narrative that's being inserted into the EMR," says Jay Cannon, president of the Medical Transcription Industry Association (MTIA), Chicago. "The information is visibly accessible, but within the system it's just a text blob." ...Now, a new standard, based on the Health Level Seven (HL7) Clinical Document Architecture (CDA), could help improve the utilization of these types of documents. http://www.healthcare-informatics.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=C13AB846CD6E403496AFD3B4FD65A023