XML, HL7 Messaging and the Clinical Document Architecture.
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XML, HL7 Messagingand the Clinical Document Architecture
Contents
• Introduction to XML
• Introduction to Heath Level 7 (HL7)
• HL7 messaging, current and future
• HL7 Clinical Document Architecture (CDA)
Generalized Markup Languages
• Markup identifies structural elements of a document rather than specific formatting features
• Markup is expressed as standard text sequences (markup "tags")
• Formatting instructions are applied separately to the specified document elements
• Markup tags can be human-readable
Markup Expresses Metadata
• Documents naturally have content and metadata• Metadata may help specify:
> Meaning of data (e.g., standard coding)
> Arrangement of data (display)
> Correct use of the data (business rules)
> Context and relationships between data elements
• Example of display markup:
Documents contain <emph>metadata</emph> and "primary" data
Embedded "tag" Tag content
Heritage of Generalized Markup Languages
SGML
Internal workat IBM
TeX, nroff, troff
Many special-purpose markup
languages
HTML
XML
Many special-purpose markup
languages
1984
~1990
1998
XHTML
Frameworks
Implementations
Tag formatsDTD formatProcessing rules
Extensable Markup Language (XML)
• HTML originally specified structural components of documents> HTML has evolved to become a presentation syntax
• SGML is complex and requires complex processing software• XML is a simplified version of SGML designed for electronic
document archiving and exchange> Allows creation of special-purpose markup languages> Can represent a variety of data structures and semi-structured data as well
as metadata> Arbitrary tag nesting, recursion and granularity> Human-readable and machine readable> Expected to be useful for creation of special purpose data-interchange
standards as well as document structuring
XML Document Detail
<procedure cpt="1234"><pat_phys pnum="abcd">
<firstName>Elmer</firstName><lastName>Fudd</lastName><degree>M.D.</degree>
</pat_phys><proc_name>Upper endoscopy of gizzard</proc_name><proc_date>09/09/1999</proc_date><location name="ER"/>
</procedure>
Element name AttributeOpening tag
Closing tagSingleton tag
Content
HL7Health Level 7
• Founded by healthcare providers in 1987
• Version 1.0 late in 1987
• Version 2.0 late in 1988
• Versions 2.1, 2.2 and 2.3 published in 1990, 1994 and 1997; ANSI standards
• Pragmatic approach
• Work on Version 3 (XML-based) is ongoing
Organized to create standards for the exchange, management and integration of data that supports clinical patient care and the management, delivery and evaluation of healthcare services
"Level Seven"
A protocol for the exchange of health care information
ISO-OSI Layered Protocol Model
1 Physical 1 Physical 2 Data Link 2 Data Link 3 Network 3 Network 4 Transport 4 Transport
Communication
5 Session 5 Session 6 Presentation 6 Presentation 7 Application 7 Application
Function
HL7 Transactional Model
(external) admitevent
trigger event
network
sendHL7 A01 msg
receive HL7 ACK msg
ADT system
Lab system
Receive A01,send ACK
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Current Message-Router-Based Interfaces
HL7 Abstract Messages
• Identifies data fields
• Describes error conditions
• DOES NOT describe the byte string contained in the message.
Admit Message
MSH|^~\&|ADT1|MCM|LABADT|MCM|198808181126|SECURITY|ADT^A01|MSG00001|P|2.3|<cr>
EVN|A01|198808181123||<cr>
PID|||PATID1234^5^M11||JONES^WILLIAM^A^III||19610615|M||C|1200 N ELM
STREET^^GREENSBORO^NC^27401-1020|GL|(919)379-1212|(919)271-3434||S||
PATID12345001^2^M10|123456789|987654^NC|<cr>
NK1|JONES^BARBARA^K|WIFE||||||NK^NEXT OF KIN<cr>
PV1|1|I|2000^2012^01||||004777^LEBAUER^SIDNEY^J.|||SUR||||ADM|A0|<cr>
segments, fields, components & subcomponents
Variability in HL7 Interfaces
• Site 1:OBX|1|CE|ABO^ABO GROUP||O^Type O|
• Site 2:OBX|1|CE|BLDTYP^ABO GROUP||TYPEO^Type O|
• Site 3:OBX|1|CE|ABOTYPE^ABO GROUP||OPOS^Type O|
"when you've seen one HL7 interface you've seen one HL7 interface"
HL7 v2.x is not Plug and Play
• Cost of installing an HL7 interface: 2-4 weeks of analyst time
• Issues> Different implicit information models
> Misunderstanding of specifications
> No vocabulary to describe conformance except by detailed specs
> Significant local demands on vendors
Goals for Version 3
• Substantially reduce interface development time> Clarify spec for messages
> Create a specified information model
• Method for conformance specification• Support modern communications infrastructures• Reference Information Model (RIM)
> Coherent shared information model
> Includes all content of HL7 messages
> Provides consistency to messages across usage settings
Reference Information Model (RIM)
Observation_intent_or_orderpatient_hazard_codereason_for_study_cdrelevant_clinical_information_txtreporting_priority_cdspecimen_action_cd
Clinical_observation
abnormal_result_ind : IDlast_observed_normal_values_dttm : DTMnature_of_abnormal_test ing_cd : CEclinically_relevant_begin_dttm : DTMclinically_relevant_end_dttm : DTMobservation_value_txt : NMprobability_number : NMreferences_range_text : STvalue_units_code : CE
Assessment
Healthcare_service_providerspecialty_cd : CNE
Stakeholder_identifierid : STidentif ier_type_cd : ID
Organizationorganization_name_type_cd : CNEorganization_nm : STstandard_industry_class_cd 0..*
0..1 is_a_subdivision_of
0..*
has_as_a_subdivision
0..1
Person
birth_dttm : DTMgender_cd : CNEmarital_status_cd : CNEprimary_name_representation_cd : CNEprimary_name_type_cd : CNEprimary_prsnm : PNrace_cd : CNE
Individual_healthcare_practitionerdesc : TXpractitioner_type_cd : CNE
1
0..1
takes_on_role_of1
is_a_role_of0..1
Stakeholderaddr : XADphon : XTN
0..*
1
is_assigned_to0..*
is_assigned1
Healthcare_provider_organization
0..1
1
is_a_role_of0..1
takes_on_role_of
1
Collected_specimen_samplebody_site_cd : CEcollection_end_dttm : DTMcollection_start_dttm : DTMcollection_volume_amt : CQhandling_cd : IDid : IIDmethod_of_collection_desc : TXspecimen_addit ive_txt : STspecimen_danger_cd : IDspecimen_source_cd : CE
0..*1
is_collected_by
0..*
collects
1
Patient
ambulatory_status_cdbirth_order_numberliving_arrangement_cdliving_dependency_cdmultiple_birth_indnewborn_baby_indorgan_donor_indpreferred_pharmacy_id
0..1
1
is_a_role_of
0..1takes_on_role_of
1
0..*
0..1
has_a_primary_provider
0..*is_the_primary_provider_for
0..1
0..*
0..1
is_sourced_from0..*
is_source_for0..1
Active_participation
participation_type_cd : ID
0..1
0..*
participates_in0..1
has_as_participant0..*
Master_patient_service_location
addr : XADemail_address : XTNid : IDnm : STphon : XTN
1..*
0..*provides_patient_services_at
1..*
provides_services_on_behalf_of0..*
0..*
0..1
is_included_in
0..*
includes 0..1
0..1
0..*
is_primary_facility_for0..1
has_as_primary_facility
0..*
Target_participationparticipation_type_cd : CE
0..1
0..*
is_target_of
0..1
has_as_target0..*
0..1
0..*
is_target_of
0..1
has_as_target
0..*
0..1
0..*
is_target_for0..1
has_as_target
0..*
Service_intent_or_orderfiller_order_id : IIDfiller_txt : TXorder_idorder_placed_dttm : DTMorder_quantitytiming_qt : TQplacer_order_id : IIDplacer_txt : TXreport_results_to_phone : XTNintent_or_order_cd : ID
0..* 0..1
participates_in
0..*
has_as_participant
0..1
1..*
0..1
is_target_of
1..*
has_as_target
0..1
1
0..*
is_entry_location_for
1
is_entered_at
0..*
Master_service
method_cd : CEmethod_desc : TXservice_desc : TXtarget_anatomic_site_cd : CEuniversal_service_id : CE
0..*
1
is_an_instance_of
0..*
is_instantiated_as
1
Service_event
service_desc : STservice_event_descspecimen_received_dttm : DTMname : CE
0..*
0..1
participates_in0..*
has_as_active_participant
0..1
0..*
0..1
is_performed_at
0..*
is_location_for
0..1
0..*
0..1
is_target_of
0..*
has_as_target
0..1
0..1
0..*
is_fulfilled_by0..1
fulfills0..*
1
0..*
is_delivered_during1
delivers
0..*
Advantages of XML for Message Formatting
• The syntax handles recursion and nesting> Variably nested structures to arbitrary depth
> More flexible than segments, fields, components & subcomponents
> Objects (including contained objects) can be represented
> Relational structures can be represented
• Simple syntax, easy to debug (human readable)• Software tools (parsers, etc.) are generally available• Language- and platform-independent• Compatibility with other industries
HL7 2.3 Message Format
HL7 v3 Message Format
HL7 Clinical Document Architecture (CDA)
• Level 1: XML-coded header> Contents may be flat or tagged text
• Level 2: Coded document sections> Generic architectural DTD with multiple derived DTDs
• Level 3: Coded content> Text tagging based on RIM
> Generic architectural DTD with multiple derived DTDs
• Initial focus is documents used directly in clinical care
A multilevel representation of medical documents that can be passed as messages and which make up the medical record.
Definition of a Document
• Persistence> Defined by local and regulatory requirements
• Stewardship> Maintained by an organization or person
• Authentication> A collection of information that is to be legally authenticated
• Wholeness> Legal authentication applies to the document as a whole and not to
parts of the document out of context. The document also establishes a context for use of the contained information.
• Human readability
Advantages of XML for Document Management
• Adaptable to unstructured and semi-structured data• Tagging does not destroy the document or its text
flow> The text of the document can be recovered by ignoring
the tags
• Tagged document are human readable• If tagging is well-documented and/or tags are
logically named, XML documents will remain readable over the long term
CDA Level 1 Markup
Header & "wrapper"
Clinical Documentas text
CDA Level 2 Markup
Header & "wrapper"
Clinical Documentwith structural markup(main sections)
CDA Level 3 Markup
Header & "wrapper"
Clinical Documentwith detailed markupincluding local extensions
Why Not Standardize DTDs?
• DTDs support local processes• Single documents may use multiple DTDs• Achieving consensus on details is lengthy• DTDs evolve with local needs• Strategy:
> Create generic architectural DTDs
> Allow local extension
> Local extensions can be ignored when necessary
Key Header Elements
• ID, set ID, version, addendum vs. replacement• Fulfills order• Document type (LOINC)• Origination time• Confidentiality level• Patient encounter• Service actors (care providers; individuals and organizations)
> Authenticator, legal authenticator, originator, intended recipient, originating organization, provider, transcriptionist
• Service target (living or inanimate)> If patient, one and only one
Structural Markup
• HTML-like (captions/headings, paragraphs, lists, tables)
• Recursive relationships• Content tag: generic identifier and target for text
sequences• Coded entry: standard vocabulary entry, can be
targeted to a text span defined by content tags• Generic design yields limited ability to specify
structure of particular document types (schemas?)• Complex style sheets for particular documents?
Summary
• XML is a flexible framework for creating tag vocabularies that add metadata to textual documents
• HL7 is a core standard in healthcare systems communications that has strengths and also specific weaknesses
• A new version of the HL7 messaging standard attempts to address those weaknesses through definition of a reference information model and XML message formatting
• HL7 has also defined a generic XML standard for clinical documents that is intended to improve the structure, accessibility and longevity of the electronic medical record.
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