In our continuing efforts to promote the value of document-based information exchange using the Clinical Document Architecture (CDA) standard, the Health Story Project presented a roundtable on August 7 to highlight the storytelling power of CDA documents. Whereas to date the Continuity of Care Document (CCD) is the most commonly implemented document defined in the Consolidated CDA (C-CDA) library, our goals for this presentation were to highlight the other eleven document types and describe each one’s purpose within the healthcare documentation ecosystem. Furthermore, the Health Story Project aimed to demonstrate the power of using the SOAP framework to increase the usefulness of C-CDA documents as a clinical communication tool
Current ordering obscure the patient’s story
CDA documents have typically been rendered with sections (aka headings) arranged alphabetically or some other order that didn’t follow a common framework. Imagine reading a book bound with chapters arranged alphabetically by chapter title; the storyline would be difficult to grasp when read in that order, and flipping back and forth through chapters to follow the storyline would be tedious. This is the predicament of clinicians using C-CDA documents that are organized with sections in alphabetical order instead of the order of the patient’s story.
SOAP adds order and meaning to clinical documents
SOAP is an acronym for Subjective, Objective, Assessment and Plan. It is more than just an organizational framework, it is also a heuristic for the diagnostic process. Clinicians have used this framework for organizing their notes for decades, often referring to their routine documentation as “SOAP notes”. Although this organizing principle is commonplace among clinicians, it had never before been applied to the rendering or generation of CDA documents. In our recent webinar, we describe how clinical documents such as the History & Physical Note (H&P), Consult Note, Progress Note, and other common clinical documents can be organized and rendered using the SOAP paradigm to more clearly convey the patient’s story.
Imagine a visit to your physician. Typically, your “clinical story” begins by describing your situation and symptoms; this is called the Subjective (S) part of the story. Next, your physician adds to your story by examining you and documenting what they observe—writing the Objective (O) part of your story. The clinical story continues to build until your doctor reaches a conclusion or a diagnosis, referred to as the Assessment (A). Finally, your story culminates with a list of actions such as prescribed medications, x-rays, lab tests, or recommended lifestyle changes; this is known as the Plan (P). Creating documents that organize information around a storytelling framework personalizes the information, provides vital context, and integrates the narrative and discrete aspects of a clinical document in a way that increases the clinician’s understanding, enhances clinical decision-making, and supports quality care.
As part of our presentation, we included live demonstrations from three vendors using CDA rendering technology that employs this SOAP storytelling framework. To support these technologies, Health Story Project organized the 70 document sections defined in C-CDA into one of the four categories of the SOAP framework. The rendering technology demonstrated in the webinar used the SOAP categorization scheme to programmatically order the sections within a given document. Seeing these powerful tools in action was the highlight of the webinar.
Limitations of SOAP in C-CDA
The process of categorizing the 70 C-CDA sections revealed some difficulties in applying the SOAP framework across all sections and all document types. Documents focused on assessment and planning, notably the H&P, Consult Note, Progress Note, and Discharge Summary, fit the paradigm perfectly. Documents primarily used for transfers are less amenable to the framework, as they are not focused on diagnosis and planning, but rather conveying information for continuity of care. That being said, applying the framework to transfer-of-care documents still creates a more coherent story than the alphabetical approach.
We also learned through the categorization process that some of the sections defined in C-CDA do not fall clearly into a single SOAP category. For example, by definition, the Nutrition section in C-CDA contains observations (Objective information), Assessment information, and recommendations (Plan information). Multiple purposes for a single section can lead to confusion as to the type of information expected in that section and thus where within the report the section should be placed. The primary purpose of standardized sections is to make referencing simple and efficient; information placed in the wrong section of a document, especially a long document, is easily overlooked.
Expanding the story beyond the CCD
We were thrilled to see recording-breaking registrations and attendance at this webinar, demonstrating that interest in implementing more C-CDA document types is growing. The majority of the documents described in the C-CDA library have long been the foundation of meaningful communication between clinicians, and many organizations are recognizing that the CCD is not always the right document type for exchanging clinical information. Implementing other document types defined in C-CDA may be the solution to your organization’s communication needs, and rendering them in the user-friendly, storytelling format of SOAP may be the perfect prescription for more effective information exchange.
Learn more about the intended purposes of each C-CDA documents and explore the application of SOAP to reveal the storytelling power of these documents in the Health Story Project’s latest webinar.