Apologies—it has been almost a year since my last entry. For a long time, I was so traumatized that I thought I would never write about Wild CDAs again, but this last story must be told. You must be prepared. You must protect yourself. Shortly after my last report, I found myself short on funds and long on spare time. I reluctantly accepted a job from a wealthy but eccentric benefactor. The task: research what I considered to be nothing more than a conspiracy theory, the Wild CDA equivalent of Big Foot or the Loch Ness Monster. I was to prove the existence of the mythical MeaninglessUseless Rex, the titan of the CDA genus, for which only the most fragmentary fossil evidence was ever found. Easy paycheck then back to real work—or so I thought. The beast lives! I’m at a loss to describe the encounter. We all thought this genus of Wild CDA to be extinct, if it ever truly existed in the first place. After all, it served no useful purpose. But MeaninglessUseless Rex, has survived, unlike my research team. We began our search in the East Haven Refuge (EHR), where the most convincing fossils of the beast were found. Imagine my surprise when we found not bones, but footprints so large that an intern could curl in the fetal position and fit inside them with room to spare. Surely this must be a hoax! We followed the tracks, expecting to find a prank among the grad students on my team. We found horror instead. Patient record after patient record messily devoured and excreted in a terribly summarized form. Practitioner directories ripped to shreds with only their most basic contact information left to identify them. Steaming piles of coded allergies, problems, and medications fermenting on the putrefied landscape. Then the beast itself emerged from the EHR thicket. My team did not survive the encounter. A mangled patient record is all that remains of them. But I did not consent to such a demise. I stood tall and roared back at the beast, hoping that a display of aggressive narrative that refused to be codified would be enough to allow my escape; but that proved to be wishful thinking, for MeaninglessUseless Rex devours all, leaving only an indigestible common clinical data set. I am now half the patient I used to be, reduced to codes and null flavors, everything else ruthlessly amputated. My story ends here – your story can begin. Band together. Save the medical record from regulatorily-correct mish-mash as you cherish traditional values in a narrative-safe electronic record! Obesity is a huge problem in the US; and it applies to CDA documents as well. You can think of CDA obesity as the kitchen sink problem: how do I fit everything I know about a patient into a single document? Meaningful Use decided for us that Allergies, Problems, Meds, Results were the key elements to be exchanged using the document paradigm. Key elements, certainly, but sufficient? Not necessarily and no one knows where to stop. “Valid” CDA documents became 60+ page “summaries”. Some examples of CDA kitchen sink issues:
- Dump everything we know about a patient into one Continuity of Care Document (CCD): 10,000 lab tests, all medications administered ever, etc.
- Cram dozens, or even hundreds, of discrete documents into one CCD
- Enter one question/answer pair per section (i.e., Q is the section title, A is section text)
- A reduction in the number of summary documents exchanged over the wire replaced by queries for the needed data elements when a selected set of data elements will suffice.
- The documents exchanged should be clinically relevant, and largely narrative with only those codes that add value.
- A shift from HL7 V3 syntax (CDA) to the simple, easily implementable syntax of FHIR documents (e.g., C-CDA on FHIR).