You really don't understand the CCDA standard when ...

I often hear the complaint (about CDA documents) that: I just want to see ...

At the ONC meeting on Tuesday a provider remarked that in order to understand what was happening for a patient a provider read through 18 hundred pages of CCDA documents.  This was accompanied by the statement that they understood the standard.

I do (and did) protest.  If providers are reading that many pages, then the only thing understood about the standard is the word "Document", and understanding of the application of standards to interoperability in general is also lacking.  Just as in medicine where there is no singular magic pill to make a patient healthy, there isn't just one standard to apply to the various problems associated with interoperability.

CDA documents are snapshots in time of the data associated with a patient care event.  All the data elements found in the the dozen and a half elements defined by the Common Clinical Data Set. The CCD is supposed to contain the relevant and pertinent data, but we know that what is relevant and pertinent to one provider isn't necessarily to another. Even so, it's how the data that is presented to the end user (the provider) that is the problem, not the standard that gets the data from that data set from one provider to another.

Consider multiple ways to address this issue that have all been worked in other standards efforts:

1. Consolidate data from multiple documents into a reasonable longitudinal view that reconciles information from across multiple sources of data.  There are OTHER standards that explain how to do this (e.g., the IHE Reconciliation Profile).  CCDA is about moving the data, and just like the web, you have to apply other standards to solve other problems.
2. Use an XSL Stylesheet to make the data easier to read and arrange according to provider preferences.  HL7 and ONC ran a CDA Rendering challenge that produced a number of freely available open source solutions.  CDA is about communication of data.  It is up to applications to make it usable.  CDA isn't a standard for display, or a standard for application function.  It's a standard for communication.  
3. Allow providers to incorporate the data as it becomes available.  If you implement workflows that support a 360 Closed Loop referral / consultation processes, and enable incorporation of the data into the EHR when it becomes available, you avoid trying to manage and consume multiple documents in "one swell FUPE*".

FHIR isn't going to magically change the challenge of viewing "all the data", but it is going to change the approach used by folks (and that will be the subject of a future post).

   -- Keith

* That's not a mispelling, but rather an acronym standing for Fowled-Up Process Execution