Wednesday, July 30, 2008

Automating the Disability Process with National Standards

At BIDMC and in Massachusetts, we use the structured, vocabulary controlled, XML-based Continuity of Care Document for data exchange between organizations. We've used it for direct clinical care to exchange discharge summaries between hospitals and clinicians. We've used it for Personal Health Record data exchange with Microsoft Health Vault. Our latest go live is the real time exchange of data with the Social Security Administration for disability adjudication.

Here's how it works:
1. A patient signs a consent to release records at an SSA office. That consent is digitized.
2. A SOAP/XML transaction is issued to BIDMC specifying patient demographics and including a base-64 encoded binary copy of the digitized consent.
3. BIDMC responds with a SOAP message containing the Continuity of Care Document of the patient's lifetime medical record.

Last week, we exchanged 1000 Continuity of Care Documents with the SSA after obtaining full patient consent. Here is a sample.

These documents include the following structured data

Problems (diagnoses) – coded
Lab Results (Chem-Heme-Urinalysis-Blood Gases) - coded
Procedures – coded
Encounters section which includes text documents:
Inpatient discharge documents
ED discharge summary
Operative notes
Letters – to patient, referral and referral reply
Progress Notes
Other notes and comments

using the HITSP C32 Continuity of Care Document format which has been recognized as the national standard by HHS for exchange of clinical summary data. These CCDs validate with the Schematron produced to ensure they conform to the standard.

CCD was created by informaticians from ASTM and HL7 working collaboratively to combine the structured tabular data from the ASTM Continuity of Care Record with the narrative document structures of the HL7 Clinical Document Architecture.

These groups are continuing to work together and in 2009 will produce CCD release 2.0 which will re-synchronize CCD with enhancements made to CCR, and address a number of other requirements for stakeholders in government, academia, industry, standards development organizations.

The Social Security Administration spends $500 million per year requesting paper records and disability adjudication can take 1 year. This new process, based on the Continuity of Care Document takes a few seconds, does not require human intervention and will lead to adjudication of many cases in near real time through the use of a business rules engine.

This kind of automation has a value proposition for everyone, reducing cost, saving time, and enhancing patient satisfaction. I look forward to many more such uses of the Continuity of Care Document as we build a Nationwide Health Information Network.


David said...

I think you meant to say "CCD" rather than C32, in the paragraph where you say "C32" was created by informaticians from ASTM and HL7 working collaboratively. C32 was done by HITSP, further constraining CCD, whereas CCD was done by ASTM and HL7 reps, further constraining CDA.

John Halamka said...

You are correct and I made the change. Thanks!

Keith W. Boone said...


You indicate that the automation has value for everyone, and while I agree, I have a few comments.

In your exchange, your describe numerous components of a detailed patient medical record, not a summary of information. CCD like CCR is intended to summarize, not become a complete record.

Other records that you describe, such as laboratory reports, discharge summaries, ED notes, operative notes, letters, and progress notes, are actually separate documents. I would not see these as "parts" of the CCD, but actually separate reports.

The CCD is not a panacea. It solves several problems, but not every problem is a nail (see
If I had a Hammer )

The other clinical documentation described above already exists and if relevant, can be delivered with the same machine readable information as is contained in the CCD, but using it's base standard, the CDA, and templates from CCD.

The same interactions you describe could include a whole packet of information, not just a single CCD that would contain everything. It would include a CCD (perhaps), other CDA documents, existing medical records that have been scanned in, et cetera.

A.K. said...

Combined with the standard data format, I can see that the business rules engine can automate all of the standard work, leaving to people the more complex work of dealing with edge cases and improving the process. I am curious, though, how does one test and prove the validity of the business rules engine? It seems to me that the rule set could get unmanageably complex to test.


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