Clinical Documentation

The ClinicalDocumentation use case implements a real-time Clinical Documentation Improvement (CDI) service. It currently implements the Epic-integrated NoteReader CDI specification, which communicates with a third-party NLP engine to analyse clinical notes and extract structured data. It helps convert free-text medical documentation into coded information that can be used for billing, quality reporting, and clinical decision support.

ClinicalDocumentation communicates using CDA (Clinical Document Architecture). CDAs are standardized electronic documents for exchanging clinical information. They provide a common structure for capturing and sharing patient data like medical history, medications, and care plans between different healthcare systems and providers. Think of it as a collaborative Google Doc that you can add, amend, and remove entries from.

When	Where	What you receive	What you send back
Triggered when a clinician opts in to a CDI functionality and signs or pends a note after writing it.	Specific modules in EHR where clinical documentation takes place, such as NoteReader in Epic.	A CDA document which contains continuity of care data and free-text data, e.g. a patient's problem list and the progress note that the clinician has entered in the EHR.	A CDA document which contains additional structured data extracted and returned by your CDI service.

Data Flow

Stage	Input	Internal Data Representation	Output
Client	N/A	N/A	CcdData
Service	CdaRequest	CcdData	CdaResponse

CdaConnector handles the conversion of CdaRequests CcdData CdaResponse in a HealthChain pipeline.

Attributes of CcdData are:

• problems
• allergies
• medications
• note

(CcdData API Reference)

Supported Workflows

Workflow Name	Description	Trigger	Maturity
sign-note-inpatient	Triggered when a clinician opts in to a CDI functionality and signs or pends a note after writing it in an inpatient setting.	Signing or pending a note in Epic	✅
sign-note-outpatient	Triggered when a clinician opts in to a CDI functionality and signs or pends a note after writing it in an outpatient setting.	Signing or pending a note in Epic	⏳

We support parsing of problems, medications, and allergies sections, though some of the data fields may be limited. We plan to implement additional CDI services and workflows for different vendor specifications.

Generated API Endpoints

Endpoint	Method	Function	API Protocol
/notereader/	POST	process_notereader_document	SOAP

Note that NoteReader is a vendor-specific component (Epic). This particular note-based workflow is one type of CDI service. Different EHR vendors will have different support for third-party CDI services.

What does the data look like?

Example CDA Request

<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns="urn:hl7-org:v3">
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
  <templateId root="2.16.840.1.113883.10.20.22.1.2"/>
  <id root="2.16.840.1.113883.19.5.99999.1"/>
  <code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
  <title>CDA Document with Problem List and Progress Note</title>
  <effectiveTime value="20240712"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="en-US"/>

  <component>
    <structuredBody>
      <!-- Problem List Section -->
      <component>
        <section>
          <templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
          <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/>
          <title>Problems</title>
          <text>
            <list>
              <item>Hypertension</item>
            </list>
          </text>
          <entry>
            <act classCode="ACT" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.22.4.3"/>
              <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
              <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
              <statusCode code="active"/>
              <effectiveTime>
                <low value="20240712"/>
              </effectiveTime>
              <entryRelationship typeCode="SUBJ">
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.22.4.4"/>
                  <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
                  <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
                  <text>Hypertension</text>
                  <statusCode code="completed"/>
                  <effectiveTime>
                    <low value="20240712"/>
                  </effectiveTime>
                  <value xsi:type="CD" code="59621000" displayName="Essential hypertension" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
                </observation>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>

      <!-- Progress Note Section -->
      <component>
        <section>
          <templateId root="2.16.840.1.113883.10.20.22.2.65"/>
          <code code="11506-3" codeSystem="2.16.840.1.113883.6.1" displayName="Progress Note"/>
          <title>Progress Note</title>
          <text>
            <paragraph>Patient's blood pressure remains elevated. Discussed lifestyle modifications and medication adherence. Started Lisinopril 10 mg daily for hypertension management. Will follow up in 3 months to assess response to treatment.</paragraph>
          </text>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>

Example CDA Response

<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns="urn:hl7-org:v3">
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
  <templateId root="2.16.840.1.113883.10.20.22.1.2"/>
  <id root="2.16.840.1.113883.19.5.99999.1"/>
  <code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
  <title>CDA Document with Problem List, Medication, and Progress Note</title>
  <effectiveTime value="20240712"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="en-US"/>

  <component>
    <structuredBody>
      <!-- Problem List Section -->
      <component>
        <section>
          <templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
          <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/>
          <title>Problems</title>
          <text>
            <list>
              <item>Hypertension</item>
            </list>
          </text>
          <entry>
            <act classCode="ACT" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.22.4.3"/>
              <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
              <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
              <statusCode code="active"/>
              <effectiveTime>
                <low value="20240712"/>
              </effectiveTime>
              <entryRelationship typeCode="SUBJ">
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.22.4.4"/>
                  <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
                  <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
                  <text>Hypertension</text>
                  <statusCode code="completed"/>
                  <effectiveTime>
                    <low value="20240712"/>
                  </effectiveTime>
                  <value xsi:type="CD" code="59621000" displayName="Essential hypertension" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
                </observation>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>

      <!-- Medications Section -->
      <component>
        <section>
          <templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
          <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" displayName="History of medication use"/>
          <title>Medications</title>
          <text>
            <list>
              <item>Lisinopril 10 mg oral tablet, once daily</item>
            </list>
          </text>
          <entry>
            <substanceAdministration classCode="SBADM" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.22.4.16"/>
              <id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
              <statusCode code="active"/>
              <effectiveTime xsi:type="IVL_TS">
                <low value="20240712"/>
              </effectiveTime>
              <routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" displayName="Oral"/>
              <doseQuantity value="1"/>
              <administrationUnitCode code="C48542" displayName="Tablet" codeSystem="2.16.840.1.113883.3.26.1.1"/>
              <consumable>
                <manufacturedProduct classCode="MANU">
                  <templateId root="2.16.840.1.113883.10.20.22.4.23"/>
                  <manufacturedMaterial>
                    <code code="197884" codeSystem="2.16.840.1.113883.6.88" displayName="Lisinopril 10 MG Oral Tablet">
                      <originalText>Lisinopril 10 mg oral tablet</originalText>
                    </code>
                  </manufacturedMaterial>
                </manufacturedProduct>
              </consumable>
              <entryRelationship typeCode="SUBJ">
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.22.4.20"/>
                  <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Indication"/>
                  <value xsi:type="CD" code="59621000" displayName="Essential hypertension" codeSystem="2.16.840.1.113883.6.96"/>
                </observation>
              </entryRelationship>
            </substanceAdministration>
          </entry>
        </section>
      </component>

      <!-- Progress Note Section -->
      <component>
        <section>
          <templateId root="2.16.840.1.113883.10.20.22.2.65"/>
          <code code="11506-3" codeSystem="2.16.840.1.113883.6.1" displayName="Progress Note"/>
          <title>Progress Note</title>
          <text>
            <paragraph>Patient's blood pressure remains elevated. Discussed lifestyle modifications and medication adherence. Started Lisinopril 10 mg daily for hypertension management. Will follow up in 3 months to assess response to treatment.</paragraph>
          </text>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>

Implemented CDA Sections

• Problems
• Medications (including information on dosage, frequency, duration, route)
• Allergies (including information on severity, reaction and type of allergen)
• Progress Note (free-text)