Quality of C-CDA documents

Monday, December 22, 2014

Consolidated Clinical Document Architecture (C-CDA) documents are being used in the United States to exchange patient data between providers. In the current issue of JAMIA, the authors D’Amore, Mandel, Kreda, et al, evaluated the quality of a sample of these documents. They conducted a detailed review of 21 C-CDA samples received from different vendors.

A manual review of these 21 documents identified a total 615 errors and heterogeneities. While heterogeneities are not as serious as errors, they nevertheless limit the value of these documents for machine-to-machine interoperability. An example of an error they identified was the use of an RxNorm medication code for Drug A, along with a text string identifying a completely different Drug B. Which is correct – the code or the text string? An example of a heterogeneity they identified was the optional use of an interpretation code to describe the results of a lab test. For example, the interpretation code might indicate whether the result was High, Low, or Normal. In some cases, the interpretation could be interpreted from the result value and the reference range, but if receiving systems need to look in different places for the same information, there could be negative implications for both performance and reliability.

The authors also conducted two types of automated reviews – one basically for syntax and one basically for semantics. The syntactical review essentially checked whether the XML documents conformed to the XML schema. Eleven of the 21 documents had syntax errors; in fact, these 11 documents had an average of 71 errors each! The semantic review looked at the content of the XML, for example to see if units were expressed in the prescribed standard format. The average semantic score was 63%, with a range of 23% to 100%. Only 4 of the 21 documents scored above 80% on the semantic assessment.

I am not surprised by these results. The specification for HL7 C-CDA release 1.1 is 581 pages. It’s easy to imagine how errors could be made in producing documents to conform with this specification, and it’s even easier to imagine how heterogeneities could be introduced. The authors suggested some steps that could be taken to improve C-CDA quality, including providing more sample documents, validating codes against some reference, reducing the number of optional data elements, and tracking the quality of these documents as they are used in the real world.

For continuity of care purposes, the C-CDA will probably continue to be an important document for exchanging healthcare information. For other purposes, such as clinical decision support (CDS), other standards such as HL7’s FHIR may be more appropriate.

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