Are today’s CDA® documents fulfilling the vision set by the Health Story Project?

This compelling question was explored by Lisa Nelson, MS, MBA during a recent HIMSS Health Story Project Roundtable. The Health Story Project vision is fulfilled by electronic patient records that hold a meaningful and complete health story. But what does that mean for an implementer of Clinical Document Architecture (CDA®)? A provider? A patient? Is the information in electronic health records relevant and pertinent? Is the information accurate? Is it authentic? Lisa and other leaders in the standards and health IT community are asking these critical questions and the answers are prompting the community to examine the possibility for improvements in how standards are being applied.
When examining these questions, definitions are important to help build a common framework for understanding. The key concepts discussed at the roundtable:

  • Relevant: capable of being applied, appropriate
  • Pertinent: logically connected to the matter at hand
  • Accurate: perfect conformity to fact or truth, strictly correct
  • Authentic: something that is what it purports to be, nothing more, nothing less

The key concepts provide a way to assess how well the CDA documents used to exchange health information reflect the actual semantics of the patient health story. Lisa shows in her presentation entitled, Using CDA Documents to Share a Person's Health Story and the Data Within, that there is still much to discuss.

An important topic area is the ‘H>=M’ debate. ‘H’ represents the human readable information in a CDA document, and ‘M’ represents the machine readable information. The debate centers on the conflict between principles in the CDA standard and practices of use with the standard to date. During Lisa’s presentation, she claimed that the CDA standard provides guidance to suggest that clinical content in the machine-readable portion should not be greater than the content viewable in the human readable portion. Others argue that the CDA standard does not explicitly prohibit inclusion of machine readable clinical content that is not viewable in the human readable text. Is the integrity of the record undermined if a human cannot attest to the validity of machine readable entries that may have significant clinical meaning? What does this mean for systems that receive CDA documents?

Lisa says it this way, “Specific machine readable syntax and semantics changes the meaning of the narrative that gets generated to represent that information….AND IT MATTERS. We are talking about the equality and inequality of the meaning of the information, not the quantity of information.” She warns that as the use of clinical decision support (CDS) systems increases, the equality of information used by humans and information used by machines will become increasing important because it directly affects patient safety.

A recording of the presentation is available on the Health Story Project Roundtable Archives webpage. Members of the HIMSS Health Story project encourage dialogue in the community on this topic, and we welcome your comments. The leadership council of the Health Story project strongly supports wider adoption and use of existing interoperability standards, while at the same time challenges the health IT community to identify potential semantic gaps in patient information even when interoperable exchange documents conform to standards.

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