E-discharge: standard clinical headings required by Dec

Original article here http://www.digitalhealth.net/integration/47336/e-discharge:-standard-clinical-headings-required-by-dec

For NHS (trust) Developers this has been going on for a while, this linkedin group is littered with comments https://www.linkedin.com/groups/3831338
I think this is a better place to continue them (?)

In summary:

Trust Developer:

  • Don’t have a consistent way of sending information to GP’s, this being being worked on (see Transfer Of Care - eDischarge for current versions) but it’s not here yet.
  • Directory Services - we also need a way of finding out what methods the GP’s system supports, where the GP wants the letters delivered (Docman, TPP, EMIS, ITK, DTS, etc) and addresses (email, IP, DTS address)

Trust Clinicians/Secretaries:

  • Need to create documents formatted with these headings (it’s not an IT issue at present but it’s sitting with IT – am I missing something here?)


I’ve heard a number of comments around CDA not being suitable. It works for now to send a PDF across but it’s a bit of an overkill for this. People doubt we would move to full blown CDA as it’s complicated and more simple alternatives are available.

Am I correct in thinking it helps doctors to understand information if the letter is laid out in a standard form.

Related but does not need embedded in the letter (electronically). Doctors should expect in electronic form (not included everything)

  • Findings
  • diagnosis
  • actions
  • plan (discharge instructions) which includes medications, careplan, etc

Which can easily be done and quickly understood by a developer using FHIR ClinicalImpression rather than persisting with CDA. To highlight the difference: most developers could get this working within a few days day or two. The CDA option would still be on the drawing board.

One reason I ask this is I think we could make a FHIR version (open source) which outputs CDA (using part of HSCIC CIAO project). This would allow trusts to work with FHIR rather than everyone trying to use CDA (as an analogy: trusts can use lego rather than mecanno - https://en.wikipedia.org/wiki/Meccano)

Transfer of Care initiative hub is here: http://systems.hscic.gov.uk/interop/tci

If the e-Discharge payload is an unstructured blob (like a PDF of a Word doc), it’s great if the same headings are used within the formatted “letter” but as far as I’m aware this isn’t the requirement. Open to correction on this but from my reading of the implementation guidance here http://systems.hscic.gov.uk/interop/tci/standards/implementguide.pdf

it is a step on the road to fully structured messaging. Whatever else is sent, some free text narrative must be sent under each of the mandatory headings in the “semi-structured” CDA message, so this can go into the right sections of the patient’s record.

I don’t believe we will get to structured messaging - it’s too complex.

FHIR is capable of going 0-60mph very quickly whereas structured messaging/CDA needs a series of meetings, courses, webinars, etc just to get off the driveway.

More seriously CDA won’t be able to support interactions around a patients pathway. It’s a 00’s technology and so we know it’s faults and weaknesses. We had similar faults in the past with Choose and Book/eReferral2 - the simple appointment booking (HL7v2) part works but the complex HL7v3 element fails to get the referral letter to hospital systems.

New to this forum, so just spotted this thread…

  • Kevin, you are right to point out that FHIR might be the best route forward (and I would not disagree), however GP System providers are - as far as I know - contracted to support DTS/MESH as a transport and generic CDA as a payload - at least to the level of displaying the CDA.

Anyway for what it is worth we have built an ITK Transfer of Care form demonstrator where you can send yourself a PDF and/or CDA - see http://www.forms4health.com/XForm/LoadForm?patientId=2&formName=ITK-Transfer-Of-Care

Were FHIR to be chosen as the new format that would be fine for us assuming the information model were consistent (we could just re-bind our form controls), however I do worry that we - as technologists - focus overly on stnadards etc. when my understanding of the initiative is that it is looking for consistency at the higher, human level (consistent heading layout etc.).

I’ve got a job lot of Fax machines for sale…

I’m really thinking about the base requirement across the board. Which I’ve seen as an electronic document and some indexing data. Everyone can do that and if they can’t they should be taken to task. Ok let’s give them a year.

This standard headings is trying to add things to something we don’t have. Organisations will have legitimate reasons for not being able to do e-discharge (technical, organisational, systems, etc).
You can still keep the headings, it’s not technology dependent, but let’s not bring in out dated technology when we know we know HL7+industry is moving away complex hl7v3.

Ps in the trust I work with, we can convert a document feed (any format except CDA/hl7v3) into FHIR in less than a day. we have no CDA/ITK feeds at present. These feeds carry as much metadata/indexing ITK CDA or XDS does.

Cross purposes? GP system suppliers will continue with human readable approaches for documents - CDA, including level 3 structured using conventional HL7 V3 compositions.

FHIR based APIs are for real time granular data request or post (get me a list of blood pressures, current medication etc). GP suppliers have committed to these using FHIR under the program “GP-Connect”

Meanwhile HL7 US are talking about replacing the HL7 V3 composition in CDA with a FHIR composition. This will happen over time I expect but suspect it will be post 2020 before this is in place in UK.

Slightly on a tangent but if secondary provided observations, encounters, medication API access to gp’s would we need all the headings in the e-discharge?

So the discharge would be a summary only and a form of communication not a detailed clincal record (use the API for that).

Just thinking the e-discharge is digitising a paper communication model but really we should be opening up the record for a different and better model of working?
It might be easier - depending on the detail required in future CDA doc, it may require access to lab system, observation system(s), pas (appointment) system, etc.

David - I’ve never heard this mentioned before. It would be incredibly complicated to mix CDA and FHIR. I’m not sure why anyone would choose to do that. I’d be interested to know where this is being discussed.

Hi Richard - exactly what we are up to here in NEHTA / ADHA . Graham Grieve in the thick of it as we get ready for the testing of our FHIR mobile device gateway for My Health Record (nee PCEHR). I’m not the best person to explain it. I’ll see if any NEHTA colleagues are on and if not will try and promote !

I expect this means using FHIR for all the CDA structures (“CDA on FHIR”). It sounded a bit like only the Clinical Statement core of CDA was being replaced, making a V3/FHIR combo. Which would indeed be complicated. No plans for that I think.

It’s based on the composition


See also https://www.hl7.org/fhir/cda-intro.html

Like this line: Support exchange of human-readable documents between users, including those with different levels of technical sophistication.
Which I suppose is meant to hold for HL7v3/CDA but … why is it so technical :grinning: