Development of a HL7 CDA R2 Compliant Discharge Summary Teaching Template for the QEII Renal Clinic

Abstract

Internships give students of Health Informatics opportunities to receive on-the-job training and to connect their academic health informatics knowledge to the real world. This internship is composed of two objectives, encoding lab tests into multiple coding systems and designing a HL7 CDA R2 compliant discharge summary teaching template. Both objectives aim at implementation of standardization and interoperability. The first objective allowed the intern to learn how medical terminologies are organized to represent medical concepts, and how they are related to each other in a common ontology to enable sharing among health care providers. As the main task of this internship, the second objective provided a test bed for the intern to experiment how such a template can serve as a boundary object among physicians, residents, and health informaticians to bridge the knowledge gap, how the concepts of HL7 template and archetypes are applied, and how the CDA document is produced and enables interoperability among health care providers. The success of health informatics depends on the cooperation between health informaticians and healthcare providers. There is a need for widely accepted terminology. Considering the HL7 standard is still under development, this template should be updated and refined accordingly to keep it up-to-date.