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Healthcare Development & Architecture

greenCDA- A Standard for Sustainable Health Records

Healthcare Development & Architecture

Health information technology (HIT) manages the information surrounding patient care delivery, reimbursement, monitoring, research and reporting. It is critical to involve the patient in our own care and to coordinate care among the people and institutions that we depend on. So, what is HIT’s impact on environmental sustainability? Is it a plus, minus or neutral factor?

Health Information Technology: green, yellow or brown?

Hospitals today are wired for basic administrative functions – the who, what, where and how much does it cost for healthcare. Clinical data, the patient record itself, is just going online in electronic lab systems, radiology information systems, practice management and electronic health records.

The government, state and federal, would like to change this and has invested substantially through the HITECH and Affordable Care Acts in incentives to induce greater use of EMRs and greater (responsible) sharing of clinical information.

Kaiser Permanente has moved decisively to electronic record keeping and provided us with a detailed and methodical study of the impact of its environmental footprint. The title of the study gives away the punch line: “Use of Electronic Health Records can Improve the Industry’s Environmental Footprint”.

The study found these results from its HealthConnect project:


  • Eliminated 1,000 tons of paper
  • Eliminated 68 tons of x-ray film
  • Lowered gasoline consumption by 3,000,000 gallons/year


  • Higher energy consumption
  • Generated additional 250 tons of waste

It found a net positive impact and also that the general method employed for the assessment could be applied more broadly. We won’t know the results of doing so until some other entity takes up the challenge; however, we can learn a great deal about the variables involved and the determining factors by digging into the data provided by the Kaiser study.

The Impact of Kaiser’s HealthConnect

Kaiser applied the Eco-Health Footprint to identify areas of environmental impact through greenhouse gases, toxic chemicals and water usage. It found the largest effect on greenhouse gases came from changes to paper consumption, energy use and plastic and electronic waste. Expressed as equivalent acres of carbon sequestration, the numbers come out like this:

  • Positive impact (in acres):

+4,200 from decreased use of paper records

+ 257 from decreased use of x-ray covers and forms

+ 6,400-9,200 from fewer trips (less gasoline)

  • Negative impact (in acres):

–810 from print-out of summaries

–283 from PC packaging

–13,300 from PC and data center power usage

From this we can suggest that other facilities may want to focus on these critical areas – reducing patient visits and maximizing energy efficiency in the deployed hardware. The first area, reducing patient visits, links directly to the green revolution in health information standards.

Making Information Flow

HealthConnect spans the full spectrum of care supporting information flow among inpatient facilities, clinics, labs and pharmacies. Kaiser is exceptional among American providers in covering this full spectrum of care. For most of us, it is estimated that 80 percent of the information needed to care for a patient at some point will cross an institutional boundary.

Kaiser is also exceptional in its financial model, which does improve with increased patient traffic. To reproduce these positive effects, organizations must have both the means to share information freely and the incentive to do so.

Information flows freely among 2.2 million global automated cash machines. You can log onto your stock portfolio anywhere in the world and make a trade. The record of your health providers, latest vaccinations, current problems, medications and why you take them and where your latest chest x-ray can be located is not likely to be available without resorting to time consuming manual and paper-based processes.

With more than 50 years of experience in building computer systems, why does healthcare, generally so sophisticated, remain so behind in clinical information management?

For one thing, the domain is big. Make that BIG and getting bigger by the day. A typical information exchange standard, for an ATM, for example, or for wire transfers, might have a data dictionary of 10,000 terms, all fairly consistent around the globe.

Just one HIT terminology set – and there are dozens in common use – has over 250,000 concepts and is growing. The set of data elements that could be mission-critical information in patients’ records is practically unbounded, relies heavily on narrative and differs substantially across areas of practice and location.

The first wave of HIT specifications addressed the reasonably low hanging fruit – administrative, financial and laboratory data. Development began in the late 80s and is widely adopted in the U.S. and growing in adoption around the world.

What was not encompassed by that first wave is the core of the clinical data: discharge summaries, consult notes, progress notes, procedure notes, diagnostic imaging reports and so on. The second wave, initiated in the late 90s and just coming into common use today, is exemplified by the Health Level Seven (HL7) Clinical Document Architecture (CDA).

CDA is about Big Data for Healthcare

CDA addresses the core information set required to start moving “big data” and makes it reusable for public health and quality reporting as well as clinical trials. CDA has been adopted as a national standard in the U.S. as well as countries in South America, Asia, Europe and the Middle East.

In the U.S., it is a keystone specification for what the Department of Health and Human Services calls “meaningful use” of electronic health records.

Clinical information exchange is possible on a wide scale today supported by simple XML documents.

Exchanging documents that are “semantically inter-operable,” however, is a higher bar and is required for reuse of the detailed clinical data. Semantic interoperability means that the information is not only discoverable and viewable, but it is also interpretable by arbitrary down steam applications.

Sending information created under one database schema into a database with a foreign database – as occurs across the enterprise boundary – without lose of fidelity is a rare feat in any field today, much less in healthcare with its size, complexity and lack of tolerance for error.

CDA can bridge this gap on a global basis because it is built on a series of increasingly narrow constraints such that at the highest, most general level, any application can display and interpret a minimal data set and at the most granular, specific level, applications tuned to that set of uses, expressed as “templates,” can exchange complex concepts with high reliability.

The price for this flexibility and extensibility is a fair degree of complexity when the full range of expression is in play. Creation of an instance conforming to a particular CDA Implementation Guide may require knowledge of the base specification, HL7 Version 3 data types, CDA templates defined in and referenced by that Guide plus terminology and code sets in any number of coding schemas.

Enter greenCDA

greenCDA takes the complexity out of CDA creation by providing a single simple XML schema that uses business names (not abstractions) and that, at will, can be transformed automatically back into canonical CDA for conformance with the most general global specification. At design time, the specification developer takes requirements and develops the CDA templates along with the green schemas and transforms.

In implementation, simple XML applications create documents which are automatically transformed to the canonical CDA. Senders get expedited implementation; recipients get the flexibility and full semantic interoperability of CDA, making it possible to integrate and reuse information across a wide spectrum of use cases. Where canonical CDA might require nested tags for <component>, <section>, <code> and <value>,greenCDA can express the equivalent with one tag such as <allergies>.

While still early days for greenCDA, early indications are that it can introduce time savings of up to 10:1 and pave the way for large scale information sharing, which brings us to the “green” part in greenCDA. As an expedient to the full electronic record and free flow of information, the Kaiser study indicates that techniques like greenCDA could be an essential ingredient in the general greening of healthcare.

Sharing information makes it possible to do two things that are in short supply today: 1) communicate within a community of practice so information, instead of patients in fuel-burning vehicles, can travel, and 2) inaugurate large scale shift to payment for quality improvement in place of payment for quantity.

Lord Kelvin, the patron saint of quality measurement, said, “If you cannot measure it, you cannot improve it.” Accurate, low effort, large-scale reporting directly out of EMRs is a key enabler of healthcare reform and cost reduction.

The other side of the green/brown equation, of course, is getting smarter about how we power the machines needed for EMRs and data mobility. The existing guidelines on green building, the LEED for Healthcare and the Green Guide for Healthcare, could do much more to promote energy efficient IT. One can achieve LEED certification today without consideration for energy saving achievable in IT infrastructure.

When smart electronic records are interconnected through smart data exchange standards like greenCDA, health IT infrastructure is optimized for efficiency. When we have financial incentives to reward quality of care, we can say information technology has contributed its share to the greening of healthcare.

About the Author

Liora Alschuler is the CEO of the Lantana Consulting Group, designing and implementing standards-based solutions for the nation’s largest providers and public health agencies. She is a developer of XML-based standards for the exchange of electronic healthcare information and a consultant in their application to providers and system vendors.

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