NEHTA: Guidance relating to Clinical Document Presentation

May 22, 2013

I am pleased to be able to draw your attention to a newly released document from NEHTA entitled “Supplementary Notes for Implementers Relating to Clinical Document Presentation”. Quoting from the document:

This document recommends a set of presentation guidelines for CDA document authors. It complements the CDA Rendering Specification and the CDA implementation guides by describing:

  • how to ensure that the data is properly, consistently and safely represented in the presentation
  • the recommended order of the sections in a document

The guidance actually addresses an important issue that the clinical document specifications do not resolve:

The CDA implementation guides (IGs) specify the content of the header and the data at considerable length, but have little to say about the presentation. All the IGs contain an Appendix A, which describes the presentation, but fundamentally the presentation of the document is currently left to the discretion of the user (“There is no canonical markup for specific CDA components”, where canonical means, ‘the correct way to do things’). Two basic rules are given in the IGs:

  •  The presentation “SHALL completely and accurately represent the information encoded in the Section” – but complete and accurate in what sense? How is this defined and/or tested?
  • “The narrative contents SHALL conform to the requirements specified in theCDA Rendering Specification” – which means that the presentation can only use the features (capabilities) described in the rendering specification, but that specification makes no rules concerning what the presentation must be So the presentation is currently left to the discretion of the implementer within the bounds established by these general rules.

Additionally, while the CDA IGs describe the sections of the document in a particular order, the IGs don’t specify any order of sections; IG conformant authors are free to order the sections in any way they see fit, as long as the section logical structures are maintained (i.e. Section B must be a child of Section A). Note that renderers are obliged to follow the order of the sections as provided by the author; they are not permitted to re-order the sections.

  Given that the clinical user sees the narrative, and not the data, this has proven a substantial issue in practice. The advice contained in the document cannot be considered timely, but late is better than never, and all implementers of NEHTA based CDA documents are recommended to read the document carefully.

Some notes about the document:

  • It doesn’t cover NPDR / ETP (where the same issue applies). I’m presently extending it to make recommendations regarding the Prescription and Dispense. The recommendations will align with present practice in the NPDR (they will just formalise that)
  • It doesn’t cover any of the PCEHR views, and won’t - they have their own specifications
  • This advice is only guidance. It’s written as a specification to which applications can choose to conform, and to which conformance can be tested (i.e. conformance points) but**there is nowhere that presently requires conformance to this document **(nor will it be retrospectively applied to any existing CDA specifications)
  • I’m currently working on updating the Rendering Specification (through Standards Australia IT-014-06-06) and a subsequent release of this document, so feedback is welcome - here or in private by email (at grahame at healthintersections…) Note that both documents referred to here are behind licensing gates - you have to register and sign the license to get access, but they are free (you can sign up even if you’re not Australian too)