The document provides information about an upcoming international patient summary workshop. It discusses the history and mission of HL7, an organization that develops standards for health information technology, including growing exponentially since 1987. It also outlines HL7's use and development of CDA (Clinical Document Architecture) standards in various countries, including Finland, Germany, and Austria. The document shares examples of how CDA has been implemented for different use cases like ePrescriptions, electronic health records, and discharge summaries.

1. International Patient Summary Worshop
HL7 Asia Meeting
Catherine Chronaki
Secretary General, HL7 Foundation
euoffice@HL7.org
Funded under
H2020-72745

2. 2
Mission: build the best most widely used HIT standards
History:
Since 1987 HL7 grows exponentially - demand outstrips capacity, HL7 v3, HL7
CDA, 40+ WGs, 50+ standards products in use; HL7 is supported by over 35
national/regional Affiliates and members in over 55 countries
1997: first national affiliate on board/ IHIC conference
2004: HL7 CDA is adopted
2009: HL7 International, USA on the International Council
2010: HL7 International Foundation in Europe established
2012: 25 years youth celebration with FHIR, HL7 Asia
2013: HL7 makes standards available under free license
HL7 Leads HIT Standards development since 1987
1987 1997 2004 2009 2010 2012 2013

3. 3
HL7 CDA in Finland
CDA R1 was used in regional information systems for information sharing
CDA R2 was selected for national eHealth infrastructure (~2005)
Kanta services: National EPR archive, ePrescription centre, national code server, etc.
Transport using HL7 v3 Medical Records Messages (in future: also IHE infrastructure)
CDA R2 localized implementation guides in Finland for:
ePrescription (prescriptions, dispensations)
EPR
core dataset = patient summary, providers, diagnoses and concerns, procedures, examinations,
results, service events, aids, blood group, functional status, medical certificates, queuing, follow-ups,
goals, risks, nursing core dataset including summaries
lab, medication, imaging reference and report, referral and discharge, scanned documents, dental
records
Use of CDA in national ePrescription IGs made it easier to study, understand and comply
with the international ePrescription specifications
According to epSOS experience from the National Insurance Institute (Kela)

4. HL7 CDA legacy in ELGA:
patient summaries in Austria
Information Curtesy of Dr
Stefan Sabutsch, Chair HL7
Austria

5. 5
HL7 CDA in ELGA
The ELGA GmbH is responsible for defining nation-wide HL7 CDA
Implementation Guides in Austria.
The process of creating HL7 CDA Implementation Guides was intense:
3 years of harmonization work in working groups
Inclusive process including Austrian stakeholders
Resulted in nation-wide harmonized and detailed technical
specifications and Implementation Guides
Discharge Summary (Physician)
Discharge Summary (Nurse)
Laboratory report
Radiology report
All documents are available
from http://www.elga.gv.at/index.php?id=28
(German language only).

6. 6
Global IHE Implementation Guides in
the Austrian context
Use of International standards is a fundamental
requirement for ELGA
IHE profiles are adapted to Austrian demands
Why was it impossible to adopt as is the IHE
specifications?
Austrian constraints demanded changing parts of templates
working group experts considered better alternatives.
What type of changes?
stricter or relaxed options of CDA Level 3 entries based on
value-sets for code-lists
New content template that matched perfectly
the Austrian needs.

7. 7
ELGA discharge summaries
Physician and Nursing discharge summary parts
separate CDA documents and Implementation Guides (IGs)
relevant information is responsibity of Physician or Nurse
both accessible in ELGA by both parties.
Austrian Health Record (ELGA) includes documents that follow
the ELGA Implementation Guides.
Organizations must upgrade the information systems to
conform to ELGA IGs to connect to ELGA
Three ELGA Interoperability Levels (EIS)
to enable quick & easy connection of providers, min data quality
The ELGA legislation act mention that in the future the Austrian
MoH will enforce interoperability levels through ordinances.

8. 8
ELGA Interoperability levels (EIS)
EIS “Basic” / “Structured” minimum requirement
coded information for document registry, access control system.
medical content may be unstructured data, e.g. embedded PDF object.
CDA documents conform to the Common Implementation Guide (IG) and
CDA Header-constraints in Specialized IGs
EIS “STRUCTURED” indicates that the human readable content of
an embedded PDF meets the requirements of Specialized IGs
EIS “Enhanced” further to EIS “Basic/Stractured”
documents have to additionally follow the CDA Body constraints of
Specialized IG
Unstructured content is not allowed in this level.
CDA Body is generally structured in CDA 2 sections, may contain CDA L3
elements
EIS “Full support” further to EIS “Enhanced”
CDA documents conform to CDA Body constraints of Specialized IGs
Additional CDA Level 3 entries are required in most of the sections.

9. 9
Patient summaries in ELGA
ELGA to serve as platform for Patient summary
Patient Summary could be automatically created out of
existing documents in ELGA
discharge summary
lab+radiology report
Requirements for ELGA patient summaries
all ELGA documents in EIS “full support”
more documents types to a complete patient summary.
If these basic prerequisites are not fulfilled, an
automatically generated patient summary remains wishful
thinking…

10. HL7 CDA in Germany
Slides Curtesy of: Kai Heitmann
Past Chair HL7 Germany

11. Sciphox (sky-fox) Project (DE)
• Introduction of CDA in the year 2000+ in
Germany, as a cooperation between general
practitioners and hospitals
• Lead later in 2005 to the first CDA R2
Discharge Letter definition
– With ~ 15 vendors involved
– Large show case, implementations
• Was input to similar definitions in Austria
(national infrastructure ELGA) and Switzerland
around 2008-2010

12. German Discharge Letter
Genesis, influence, cooperation
Courtesy of Alexander
Mense, Stefan Sabutsch,
Bernd Blobel, modified
2005 2014

13. ART-DECOR Tool
• DECOR
– Data Elements, Codes, OIDs and Rules
• ART
– Advanced Requirement Tooling
Internet: art-decor.org

14. Patient Summaries in Japan
Information Curtesy of Massaki
Hirai

15. Patient Summaries in Japan
• HL7 CDA has been adopted in Japan
• HL7 Japan work on summary standard using CDA.
• no paper base summary standard in Japan.
• Many researchers have tried to develop the
standard but they are not yet success.
• Current approach is that the standard is using
narrative part and automatically generated
contents.

16. Patient Summaries in the EU

17. European Patient Summary
Guideline (based on epSOS)

18. CEF eHealth DSI (eHDSI)
eHealth DSI
Deploying Countries
PS eP
Austria
Croatia
Cyprus
Czech Republic
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Italy
Luxembourg
Malta
Portugal
Sweden
Switzerland
What is the eHealth DSI?
• Services and Infrastructure using ICTs that
enable cross border Healthcare services. Tools
and services using ICTs that can improve cross
border Healthcare services.
• Tools and services using HL7 and other
standards that can improve interoperability
cross border Healthcare services.
• Use Cases:
• Patient Summary, provides access to health
professional to verified key health data of a patient
during an unplanned care encounter while abroad
• ePrescription, enables patients to receive
equivalent medication treatment while abroad to
what they would receive in their home country

19. eHDSI
Communities
OPERATIONS
Audit Framework TF
Test Framework TF
SEMANTIC
Coordination WG
Organisation WG
Architecture WG
Semantics WG
TECHNICAL
STEERING
COMMITTEE
TECHNICAL
COMMITTEE
SMP/SML TF
Non-Repudiation
DEVELOPERS
eHDSI Operation Communities
Legend:
TF: Task Force
WG: Work Group

20. Moving to CEF
August HL7 Asia 2017

21. The IPS Project: the HL7 Int. CEN/TC
251 agreement (April, 2017)
August 18, 2017HL7 Asia 2017
HL7 Int. CEN/TC 251 agreement (April, 2017)
Implementabl
e
Applicable for
global use
Extensible and
open
Sustainable
Vision
•“In order to further the care for citizens across the globe,
we agree to collaborate on a single, common
International Patient Summary (IPS) specification that
is readily usable by all clinicians for the (cross-border)
unscheduled care of a patient.”
Scope
•“The IPS specification shall focus on a minimal and non-
exhaustive Patient Summary, which is specialty-agnostic
and condition-independent, but still clinically relevant.”
IPSPrinciples

22. August 18, 2017HL7 Asia 2017
class Products Initiatives_fund
EUPS
Guidelines
eHDSI PS IGIPS CDA IG
EN European PSOrganization::
CEN/TC 251
Organization::
HL7
Internatonal
Organization::EC
Project::CEN IPS Project::eHDSI
Project::JAseHN
Issue: Potential Gap.
Undefined process
Issue: Potential Gap.
Undefined process
isResponsibleFor
provideInputs
Funds
isResponsibleFor
«trace»
Funds
isResponsibleFor
refine
useAsInput
implement
isProgressivelyHarmonizedWith
Funds
contributeTo
«trace»
Source: Giorgio Cangioli

23. Compliance / Traceability
August 18, 2017HL7 Asia 2017
Requirements Design Implementation
CEN prEN
Conformance
Products
ART DECOR®; Forge; ..
HL7 CDA IG
HL7 FHIR IG
EU PS Guidelines
The Patient Summary for
Unscheduled, Cross-
border Care
IPS: Guidance for European
Implementation Technical Specification
CEN prTS

24. Patient summaries in the USA

25. US Meaningful Use: Consolidated-CDA/CCD
170.205(a)3 Consolidated CDA (C-CDA): Standardized
representation of the Consult Note,
Diagnostic Imaging Report, Discharge
Summary, History and Physical,
Operative Note, Procedure Note,
Progress Note, and Continuity of Care
Document (CCD).
170.205(h) CDA Guide for Quality Reporting
Document Architecture, Category I
170.205(i) CDA Guide for Reporting to Central
Cancer Registries
170.205(k) CDA Guide for Quality Reporting
Document Architecture, Category III
(QRDA-III)
§ 170.205 Content exchange standards and
implementation specifications for exchanging
electronic health information.

26. Kaiser Permanente overview
06/03/2018
eStandards Roadmap Presentation - PS for
Emergency or Unplanned care
26

27. Kaiser Permanente overview
August 24, 2017 Hangzhou,
China
Building a global community for digital
health innovation: the role of patient
summaries
27

28. 28
Patient summaries: our navigator in the
health and social care ecosystem
Think of the Patient summary as a window to a person’s health or personal
dashboard:
Medications, allergies, vaccinations
problems and procedures, labs, diagnostic imaging
recent or planned Encounters, implantable devices
advance directives
“Bring the Power of Platforms to Health Care” using data to drive:
[Bush & Fox, HBR November 2016]
administrative automation
networked knowledge
resource orchestration
Think of appointments, technology, and productivity
 virtual and f2f just-in-time appointments
HL7 Asia 2017
eStandards need to
• help build trust
• unlock the power of health data
• facilitate decision support
• navigate the health system
August 18, 2017

29. Achievements of Trillium Bridge 2013-2015
• Gap Analysis
- Compared patient summary specifications in EU/US
- Shared clinical elements: problems, medications,
allergies
• Interoperability Assets
- Established a terminology prototype CTS-2 service:
http://extension.phast.fr/STS_UI
- Developed Patient summaries Transformer:
http://informatics.mayo.edu/trillium-bridge
- Identified Gaps in EU/US IHE profiles Patient Identity & Document
Query/Retrieve
• Validation activities: 4 EU countries/ Kaiser Permanente
- EU/US Marketplace; HIMSS 2015; IHE Connectathon 2015, eHealthWeek14,15
• Feasibility study:
- Reflected upon standards, cross-vendor integration, incentives,
clinical research, security and privacy, innovative business models,
education
Recommendation:
“Advance an International Patient Summary (IPS) standard to
enable people to access and share their health information for
emergency or unplanned care anywhere and as needed. At
minimum the IPS should include immunizations, allergies,
medications, clinical problems, past operations and implants.”

30. 30
IPS is out for ballot!
August 18, 2017HL7 Asia 2017

31. 31
Example Patient Summary
August 18, 2017HL7 Asia 2017

32. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Sections
 Medications (Statements, (relevant) ceased and
current) (entries defined) (R)
 Problem list (Concerns) (entries defined) (R)
 Allergies and Intolerances (entries defined) (R)
 History of Procedures (operations, interventions,
implants procedure,..) (entries defined) (R)
 Medical Devices (implanted devices) (entries
defined) (R)
32

33. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Sections
 Immunizations (entries defined)
 Results (including imaging, Path. Lab; Clinical
Path;…) (entries defined)
 Past history of illnesses (entries defined –
entry optional ?)
33

34. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Sections
 Functional Status (Autonomy/Invalidity)
 Plan of care
 Social History
 Pregnancy (expected day of delivery)
 Advance Directive
 (Vital Signs)
34

35. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
PROVENANCE
35

36. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
What is Data
Provenance?
 The term “provenance” refers to
attributes about the origin of health
information at the time it is first created
and tracks the uses and permutations of
the health information over its lifecycle.
 http://wiki.siframework.org/Data+Provena
nce+Pilots+Executive+Summary
36
From “Data Provenance Initiative Launch”

37. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
TYPE OF PATIENT
SUMMARY
37

38. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Type of Patient
Summary
 Related to the previous topic
 Do we want to keep track of information that
describe the “context” of creation of the PS ?
 Single vs Multi Encounter;
 Single vs Multi organization;
 Clinical act VS automatic collection VS mixed
mode (see also provenance)
38

39. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Type of Patient
Summary
 In epSOS/eHDSI (only the third item is
actually handled with a simplified approach)
 automatic collection => author device
 Provider => author human
 Mixed => both
 Do we want to do more ?
 In case how ?
39

40. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
HEADER
40

41. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Header
 clinicalDocument.effectiveTime : different
level of precision
 Different type of adddress
 US city and street line required
 EU at least one element in the AD is required
 US no mixed content, (neither for EU even if not
specified
 )
41

42. © 2016 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Header
 US raceCode (SHALL); sdtc:raceCode
(MAY); ethnicGroupCode (SHALL);
sdtc:ethnicGroupCode (MAY); not used or
prohibited in EU
 There are specific information required or
suggested for the EU PS…
 How we would like to proceed ?
42