PDF Healthcare Frequently Asked Questions (FAQ)

PDF Healthcare is a "Best Practices Guide" (BPG), supplemented by an "Implementation Guide" (IG), describing (generally unknown) attributes of the Portable Document Format (PDF) to facilitate the capture, exchange, preservation and protection of healthcare information. PDF Healthcare allows healthcare providers and consumers to develop a secure, electronic container that can store and transmit relevant health information, including but not limited to personal documents, handwritten clinical notes, laboratory test result reports, electronic forms, scanned images, photographs, digital X-rays, and ECGs, important for maintaining and improving one's health.

Why a proposed PDF "Healthcare Standard"?

PDF Healthcare is not a proposed standard. PDF Healthcare is a Best Practices Guide, supplemented by an Implementation Guide that enables the use of existing Portable Document Format (PDF) functionality with guidance specific to the healthcare industry. PDF Healthcare is intended to be used as a secure and portable container of personal and electronic health record information rather than adding to or replacing existing standards for health information interoperability. Version 1 (published in 2008) of the BPG and IG supports the use of the existing ASTM CCR (Continuity of Care Record) standard as a sample of this implementation. However, PDF Healthcare is extensible to contain any well-formed XML. Future implementations in healthcare could include HL7 CDA (Clinical Document Architecture) and the balloted and passed harmonization of the HL7 CDA and the ASTM CCR, the CCD (Continuity of Care Document).

What is the difference between PDF and PDF Healthcare?

PDF is:

• An ISO-approved, open, international, and published standard, originally created by Adobe Systems, Inc., but now developed and maintained by ISO.
  

PDF Healthcare is:

• A Best Practices Guide, supplemented by an Implementation Guide that:
  • Focuses on the specific needs of the healthcare industry by providing use cases for the interoperability of health information.
  • Is developed and maintained by an external, voluntary committee with healthcare industry knowledge and expertise.
  • Describes (generally unknown) attributes of the Portable Document Format (PDF) to facilitate the secure capture, exchange, preservation, and protection of health information.
  • Is supported by the internationally-recognized standards development organizations, ASTM and AIIM. 

The objective of the voluntary PDF Healthcare Committee is to develop and maintain a secure, electronic container that can store and transmit relevant structured and unstructured health information, including but not limited to personal documents, handwritten clinical notes, laboratory test result reports, electronic forms, scanned images, photographs, digital X-rays, and ECGs, important for maintaining and improving one's health. This objective is realized by the 2008 publication of the PDF Healthcare Best Practices Guide and Implementation Guide.

Why the need for a "container" for storing, transporting, and viewing health information when many commercially available Personal Health Record (PHR) and Electronic Health Record (EHR) systems already exist?

PDF has the following advantages for healthcare:

• PDF has had a long-standing success and adoption, including its dissemination as an open ISO standard 
• PDF allows for the sharing, storing and viewing of health information regardless of the origin, source, or destination of the digitized information
• PDF provides a secure and universal container/wrapper for all types of digital data (structured and unstructured) 
• PDF provides data integrity and partitioning functionality that are desirable for a myriad of use cases
• PDF is platform- and system-neutral
• The Adobe Reader is ubiquitous, freely available on almost every laptop/desktop around the world
• PDF allows for interoperability and bi-directional information exchange
• PDF allows selected records to be easily and quickly printed, if necessary
• PDF complements and enhances many usage models for the exchanging, storing, and viewing of health data
• PDF is NOT just a display format for a document!

What do the PDF Healthcare Best Practices Guide and Implementation Guide include?

The PDF Healthcare Best Practices Guide:

• Provides direction for developing documents and describes practices for the importing and exporting of the documents in a PDF container specifically designed to store, view and share health information 
• Utilizes a subset of the common PDF components for development and implementation purposes
• Provides guidance for embedding any standardized data set in a PDF "container" and then linking the data to the actual display of the data
  • For example, if a consumer, provider, or provider organization must send a patient's (structured) medication list and (unstructured) radiology exam result report to multiple physician offices - some with office EHRs, some without - the consumer, provider, or provider organization is able to embed those documents in the PDF container and securely send them. If the reports were sent to a provider who does not have an office EHR, the receiving provider can view the documents and/or print them to paper. Also, the receiving provider can print the documents to paper from his/her smart phone without the need of a computer! However, if the reports were sent to a provider who has an office EHR, the EHR can consume the XML data in that PDF container and populate their EHR.

• Provides sample use case models that:
  • Highlight the means by which data can easily be shared between healthcare organizations
  • Help to ease the transition from paper to digital records
  • Help to bridge the gap between health providers and consumers
    

Version 1 (published 2008) of the PDF Healthcare Best Practices Guide and Implementation Guide supports patients and healthcare providers by including the following health information:

• patient demographics
• insurance information
• problems and diagnoses
• medication list
• allergies
• immunizations

When will the PDF Healthcare Best Practices Guide and Implementation Guide be available for use?

Version 1 of the PDF Healthcare Best Practices Guide and Implementation Guide were published in early 2008 and are available for use.

To pruchase and download a copy of the PDF Healthcare BPG, go to http://www.aiim.org/productcatalog/product.aspx?ID=1675. To download a copy of the PDFHealthcare IG, go to http://www.aiim.org/standards/article.aspx?ID=33284. To email AIIM, contact Betsy Fanning at mailto:bfanning@aiim.org. To email ASTM, contact Dan Smith at mailto:dsmith@astm.org.

Will there be updates to the PDF Healthcare Best Practices Guide and Implementation Guide?

Yes, there will be updates to both the PDF Healthcare Best Practices Guide and Implementation Guide.

Why were AIIM and ASTM chosen as the standards development organizations to promote the development of PDF Healthcare?

AIIM was selected as the preferred standards development organization for the formulation of the PDF Healthcare Committee as a result of AIIM's:

• Experience in PDF-based standards including PDF/A (archive), PDF/E (engineering) and PDF/UA (universal access). PDF/A and PDF/E are current ISO standards and PDF/UA is currently proposed to ISO.
• Familiarity with the ISO process
• Experience as an international standards development organization
• Strong presence in healthcare industry
• Successful promotion of PDF-based standards

ASTM is co-sponsoring this initiative with AIIM as part of their efforts for driving interoperability with existing personal healthcare data standards and to provide a use case sample with the Continuity of Care Record (CCR) for the PDF Healthcare Best Practices Guide and Implementation Guide. This use case will provide an important example of interoperability and will support the use of PDF Healthcare for patients and physicians alike.

Given the experience of ASTM combined with that of AIIM for the development and promotion of International Standards, their expertise remains a valuable asset as the PDF Healthcare Committee moves forward with the publication of the next versions of the BPG and IG.

What is the difference between PDF Healthcare and HL7's CDA (Clinical Document Architecture) format?

The HL7 CDA is an electronic container/wrapper and the PDF Healthcare is a Best Practices Guide supplemented by an Implementation Guide that supports the use of PDF as an electronic container/wrapper.

How does PDF Healthcare "fit" into the balloted and passed harmonized standard from HL7 and ASTM?

The harmonized HL7/ASTM Clinical Care Document (CCD) standard is an XML-based clinical data standard. This standard contains collections of clinical data.

Version 1 (2008) of the PDF Healthcare Best Practices Guide and Implementation Guide illustrate several sections of the ASTM's CCR for its sample implementation. However, because the PDF Healthcare Best Practices Guide can accommodate any well-formed XML, future guides might deal specifically with the utilization of the HL7/ASTM CCD depending on industry interest.

In any case, the role of PDF Healthcare is to provide a secure, protected container for transmission of multiple types of data which can be viewed by an authorized recipient using freely distributed software or re-rendered without loss of data to the native XML with an appropriate tool.

What organizations are currently supporting and/or participating on the PDF Healthcare Committee?

Currently, there are multiple organizations and companies participating on the committee. These leading companies represent a cross section of thought leadership in the healthcare industry, specifically as it pertains to the development and deployment of consumer-oriented healthcare information.

The companies/organizations currently participating at the time of publication are:

• Adobe Systems Inc.
• American Academy of Family Physicians (AAFP)
• American Academy of Pediatrics (AAP)
• American Society for Testing and Materials (ASTM) International
• AIIM
• CapMed
• Cerner
• Dak Systems Consulting
• DrFirst
• eClinicalWorks LLC
• Generator LLC
• Good Health Network
• HealthString LLC 
• Intel
• Massachusetts Medical Society
• MEDecision
• MediKeeper
• Medirex Systems Inc.
• MinuteClinic
• National Health Council
• NextGen Healthcare Information Systems Inc.
• Northern Illinois Physicians for Connectivity
• Northrop Grumman
• Pfizer
• Point and Click Solutions
• Schering-Plough
• SureScripts
• YourTimeMatters

The PDF Healthcare Best Practices Guide is based on the PDF 1.6 Reference and the XFA Specification which are both published specifications and freely available from Adobe Systems Incorporated (Adobe Acrobat, Version 9). By developing this Best Practices Guide, the PDF Healthcare Committee provides direction on how to best utilize PDF as a container for healthcare information. Consequently, it will be up to users of the PDF Healthcare Best Practices Guide to determine how they capture or convert information into a PDF file.

PDF files can be produced directly by application programs using templates and formatting information like XSL-FO or XFA, or by converting other file formats to PDF. Many applications can generate PDF files from any file format that can be printed, or from any file that can produce printable output in formats such as PostScript, PCL, HPGL or DVI which can then be converted to PDF by a translation program.

Where can one get more information?

There is a considerable amount of information about PDF Healthcare listed on the AIIM website at www.aiim.org/standards.asp?ID=31832 . For example, Committee meeting minutes, white papers, and presentation materials are available on this site.

How can one get involved?

Any interested party wishing to participate in the project can contact AIIM at www.aiim.org/standards or via email at standards@aiim.org for more information.