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Exchanging Care Plans, Discharge Summaries, and other Unstructured Narrative Content

In an ongoing debate about the readiness of HIE for Medicaid Health Homes and other ACOs, one of the issues has been the need to exchange care plans. Unfortunately, I think people are hung-up on the concept of structured XML documents and structured data. Just because the document is structured and contains many areas of coded, structured data; should not be interpreted as though there cannot be sections of data that are unstructured narratives with limited structured elements describing the content such as date/time, author, and type of report.
Recently, we have gone so far as to add narrative data in several areas of the CCD where it can be supported. These include pathology reports, image studies, discharge summaries, and care plans. Part of the problem with exchanging this type of data is that the default stylesheet (XSLT) from HL7 for viewing a CDA R2 document, such as a CCD/C32, as an HTML document, does not display narrative data properly. Basically, it just needs to respect the carriage returns that are in the narrative section. This can be done by adding the following code to any stylesheet.
<xsl:template match="text()">
                              <xsl:when test="contains(.,'&#x0A;')">
                                                            <xsl:value-of select="."/>
                                             <xsl:value-of select="."/>
I have tested adding this code to multiple stylesheets from HL7, HIE vendors, and EMR vendors. So far, it seems to work well for all.

Another solution would be to insert XHTML breaks <br/> into the narrative data. This should be respected by all of the stylesheets used to view CCDs, but in reality older stylesheet versions from HL7 do not always seem to work properly with this solution either. So, many EMR implemented stylesheets, which are based on the older stylesheets, may not work properly with this solution. Furthermore, since the structure portion of the CCD, refers to the unstructured portion for this data, the structured portion will pick-up this XHTML coding inside of the narrative text. That may not work well for some systems that may try display the data in a form other than in HTML.
While there is no perfect solution using the current CDA schema, which would probably require a new version of the CDA that did not have the dependency between the structured sections and the XHTML sections, we have a workable solution, which simply requires some guidance to EMR vendors on upgrading their stylesheets for better document viewing. I'll keep posting updates on this solution as we work with EMR vendors to include it in thier stylesheets of use one that we provide.


  1. I work for a large health system and we are close to going live with our HIE. However, as we finish our testing, two of our partners' systems can't process/accept CDAR2/HIE 1.0 files that they retrieve from us. For some reason, our file type has changed from urn:ihe:pcc:xphr:2007 to CDAR2/HIE 1.0 in the last month. We use GE Centricity for our EMR and our partners are on Epic. I thought this article might be the answer but it is aimed more at formating. Any suggestions?

    1. We had a similar problem a few months back with the same EMR. We changed our logic to create groupings of document types that we want to treat the same. We use the groupings to force the deprication of older CCDs when a new one is posted to the provide and register web service. We also consolidate any document type in the grouping into the on-demand document.


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