A Family of Standards HL7 V2 AND V3 - hiqa.ie · HL7 V2 AND V3 A Family of Standards ... HL7 Version 2 Sincemid ... Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop,

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HL7 V2 AND V3 A Family of Standards

Dr. Kai U. Heitmann Owner, Heitmann Consulting and Services (Germany) Past Director International Affiliates HL7 Board International Chair Elect HL7 Germany Co‐Chair Technical Committee “HL7 Version 3”

Workshop Health Information and Quality Authority Cork, Ireland, March 2011

Agenda

  Introduc/on   How is it organized?   How are standards created?   Products: v2   Products: v2.xml   Products: Version 3 (with a short exercise)   Products: CDA   Collabora/ons, Projects, Na/onal Infrastructures   Visions: tomorrow and the day aMer tomorrow

Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 2

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Dr Kai U. Heitmann Owner Heitmann Consulting and Services Germany eMail: [email protected]

Roles in HL7 and other standards developing organizations: •  Chair elect and Board member HL7 Germany •  Past Director International Affiliates - Board of Directors HL7 International •  Co-chair of the HL7 v3 Committee, HL7 Germany •  Member of the Technical Steering Committee, HL7 Netherlands •  Member of HL7 Germany, HL7 The Netherlands •  Representative at DIN (German Normalization Institute), Berlin •  HL7 Volunteer of the Year 2004 •  Former Manager SCIPHOX GbR mbH •  Former co-chair of the HL7 International XML Special Interest Group

3 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011

Introduction



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Communica.on – understanding

  Communica/on with direct contact   Language, gestures   “I can ask, if something is unclear”

  Electronic Communica/on   Certain format and structure   Asking back is not so easy   Unambiguous


Meaning (Semantics)

Structure

That fits?!

  World‘s Electricity Wall Plugs   Same Concept   Different Plug (Structure)

  Different Characteris/cs

  Need for “Adapters”


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Seman.cs

  Dog?


Seman.cs und Structure

  Pa/ent?   What‘s part of Pa/ent‘s “Data”?


Given name

DOB

Gender

Family name

Insurance

Next of kin Address

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Terminology

Communication PCP MI

Sodium

Group I PCP MI

Sodium

Group G PCP

Sodium Gynecologist

Internist

Group D MI

PCP

Dermatologist


Terminology

  Seman/c Interoperability, Concepts and Codes

System A Male 1 Female 2

System B Male 2 Female 1

System NL mannelijk m vrouwelijk v


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Concepts and Codes


System IRL mna m

fír f

V3 Enables Seman.c Interoperability

Functional interoperability

Semantic interoperability

  interoperability: ability of two or more systems or components to exchange informa/on and to use the informa/on that has been exchanged.


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Interoperability

  Exchange of Informa/on   Safe Networks, Security

  Iden/cal Ideas of Concepts   e.g. What is an encounter?

  Defini/on of Structures (Content)   e.g. What data belongs to a pa/ent?

  Terminologies


Where do HL7 standards help?

  HL7 standards assist in   moving healthcare informa/on in a standardized way to the point of pa/ent care

  moving informa/on within and beyond the four walls of hospitals among all healthcare stakeholders

  the sharing of public health informa/on   enabling the electronic healthcare record and the crea/on of na/onal healthcare informa/on networks


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Basic principles of HL7

  no assump/ons about the soMware architecture

  few assump/ons about the technical communica/on infrastructure

  implementa/on guides, based on the underlying standards   No agreed upon business process standardiza/on in healthcare ‐> HL7 has to support variability in the models.


16 Cre

ativ

eCom

mon

s B

Y N

C li

cens

e - E

ko

Commission Regulation (EC) No. 2257/94: bananas must be "free from malformation or abnormal curvature“.

Commission Regulation (EEC) No. 1677/88: ..are allowed a bend of 10mm per 10cm of length

.. The latter regulation is actually about Class I and "Extra class" cucumbers.

Variability .. Versus straight bananas

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HL7 Standards

  Version 2.x   Messaging Paradigm (1987..)   V2.xml (2003..)

  Version 3   Messaging Paradigm (1995..)

  Services paradigm (work in progress)   CDA: Clinical Document Architecture (1999..)

  Other:   CCOW: Clinical Context Object Working Group (= Desktop Integra/on)

  Arden Syntax (Decision Support)


How is it organized?



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Health Level 7

  Accredited ‘Standards Developing Organisa/on’ (SDO)

  All‐volunteer open organisa/on   Small permanent paid staff; Board   Working groups with healthcare subject maier experts and informa/on scien/sts

  Working Group Mee/ngs, List Servers, TelCons, Wiki


Health Level Seven (HL7)

  Goal: Interoperability   Global defini/ons for eHealth   Structure and Seman/cs

  Exchange of Messages and Documents

To create the best and most widely used

standards in healthcare.


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‘Mission Statement’

  HL7 creates prac/cal standards for the exchange, management and integra/on of electronic healthcare informa/on.

  “Standards for electronic data interchange in all healthcare environments.”

  A way for “inherently disparate [healthcare] applica/ons and data architectures to communicate”


The “Seven” in HL7 HL7 supports the exchange, management and integra/on of

electronic healthcare informa/on.

ISO‐OSI Communication Architecture Model

Image © HL7, Inc – reused by permission 22 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011

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HL7 Membership

23

• Worldwide • 1800 organizations, 1000 individuals

Europe 45%

Asia/Oceania 15%

North America 32%

Other 8%

2007 figures. Based on the “average 3 individuals per org rule” Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011

Stakeholder Loca.on

24

2007 figures. Based on the “average 3 individuals per org rule” Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011

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History of HL7

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HL7 Version 3

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

First Mee.ng Hospital

University of PA..

Version 2.0 Published


Charter member of ANSI HISPP

Version 3.0 Norma.ve Edi.on 2005


Implementa.on Support Guide published Version 2.2

Published Version 2.2

ANSI

Version 2.3 Published and ANSI

Version 2.3.1 Published and ANSI

Arden Syntax 2.0

2.4

CCOW

More Than Messages

CDA Rel.1

1993 : HL7 Germany



CDA Rel.2

Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011

Organiza.on


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HL7

  In Europe


HL7

  In the rest of the world


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HL7 Affiliates   Argen/na   Australia   Austria   Brazil   Canada   Chile   China   Columbia   Croa/a   Czech Republic   Finland   France   Germany

  Greece   Hong Kong   India   Ireland (lapsed)   Italy   Japan   Korea   New Zealand   Norway   Pakistan   Romania   Russia   Singapore

  Spain   Sweden   Switzerland   Taiwan   The Netherlands   Turkey   United Kingdom   Uruguay   (USA)


IHIC

  “Interna/onal HL7 Interoperability Conference”

  a two day conference   Started in 2000 in Dresden, different loca/ons   Presenta/ons: interoperability in prac/ce, scien/fic aspects


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How are standards created?




HL7 Working Groups

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Working Groups


Working Group Mee.ng

  Synchronisa/on + Decisions   (Regular) Conference Calls in between

  Meets three /me a year   At different Loca/ons

  Two /me a year in the US, one /me somewhere else   Canada: Toronto 1998; The Netherlands: Noordwijkerhout 2005; Germany: Cologne 2007; Canada: Vancouver 2008; Japan: Kyoto 2009; Brazil: Rio de Janeiro 2010

  Australia: Sydney 2011   France: Paris?: 2012


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Posi.ons

  Board Member   Chair, Chair‐Elect, Past Chair   Secretary, Treasurer   Director‐at‐Large   Affiliate Director

  Co‐Chair   Facilitator

  Vocabulary, Methodology, Publishing   Mentor   Ambassador   Speaker


Standards Developing Process

  Proposal (in database)   Discussion in TC during WGM

  Preliminary vote   Enhancement Process

  Ballot process   Vote   Reconcilia/on

  Substan/al change? => reballot   Publica/on


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Ballo.ng Process

  Announcement   30 days in advance

  Signup Period, ends a week before ballot closes

  Ballot opens, material is available   Cast a Vote

  Before ballot closes   Vote: Affirma/ve, Abstain, Nega/ve (requires comments or reference to other nega/ve voters)


Ballot Home Page


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Types of Ballot Documents

  DraM for Comments   Informa/ve

  60% affirm (of combined affirm+nega/ve)

  DraM Standard for Trial Use (DSTU)   Valid for 2 years   60% affirm (of combined affirm+nega/ve)

  Norma/ve   90% affirm (of combined affirm+nega/ve)


Awards and Nomina.ons

  HL7 Fellowship (since 2010)   Volunteer of the Year Award

  “Ed Hammond Award”   Honors very ac/ve HL7 members in good standing

  New: IHIC presenta/ons   “Joachim Dudeck Award”   Honors „newbees“ for their scien/fic work

  HL7 Ambassador


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Other sources

  Website   Document Server   Wiki   Gforge   Listserver


Mee.ngs: Sharing Experiences

  Work Group Mee/ng, Conferences   Developing the standard   S/mula/ng Co‐ Labora/ons

  Ins/tu/onalizing exchange

  Culture of ideas   Remain concerned


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Products: v2



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Basic Principles of HL7 Messaging

 

45

send HL7 message

receive HL7

ACK message

Receive HL7 message

send HL7

ACK message

Trigger event

System A System B

network


HL7 Version 2

  Since mid 80ies   Commonly used in hospitals

  Well suited for hospital workflows   Focus on administra/ve/logis/cal aspects of the workflow

  Is able to convey medical data of low complexity (e.g. laboratory result, radiology report)

  Pragma/c Standard   Widely used in most industrialized countries


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HL7 Version 2

  Well suited for hospital workflows   Cannot be used for cross organiza/onal communica/on


HL7 Version 2

  Chapter overview


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Example v2 message

49

MSH|^~\&|PAS|HBE|RAD||2008040112149||ADT^A01|20080401112149

|P|2.5|||AL|NE| <cr>

EVN|A01|200804010800|20080401112149|||<cr>

PID||""|8005069^^^HBE^PI~24109642356^^^F-NUM^NPNO|

|Haugen^^Terje^^^L||19961024|M|||

Jonas Storm vei 23^^Bergen^^5022^^HP||

70555366|""||""|||||||""|""|||| <cr>

Message Type

Segment

Segment Field

Subfield

Subfield


Example v2 Message

  ADT A01 – Admission, Inpa/ent


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Example v2 Message

  Message Type with 3 segments   Message Header   Event Type   Pa/ent Iden/fica/on


Example v2 Message

  PID segment with fields


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Example v2 Message

  Fields with components


PID||""|8005069^^^HBE^PI~24109642356^^^F-NUM^NPNO|

|Haugen^^Terje^^^L||19961024|M|||

Jonas Storm vei 23^^Bergen^^5022^^HP||

70555366|""||""|||||||""|""|||| <cr>

Products: v2.xml



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Background v2.xml

  Ini/a/ve around the year 2000 of the HL7 XML SIG

  Version 2 with | encoding rules

  Transi/on to XML   Overcome shortcomings of the pipe encoding


Norma.ve HL7 Database

  MicrosoM Access Database containing the official defini/ons for events, messages, segments, fields, data types, data type components, tables and table values.

  Developed by HL7 Germany (Frank Oemig) in response to issues with consistency in the wriien standard.

  XML Representa/on is algorithmically derived directly from the HL7 Database


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Design Considera.ons

  XML DTD Op/miza/on   Message length   Structural complexity

  Localiza/on   ‘Looseness’ of the DTD   Conformance with HL7 Version 3 XML Representa/on that was current at the /me of its development   V3 XML Representa/on now is very different


Algorithms

  HL7 Database used as basis for XML DTD/schema

  SQL queries used to extract tables containing defini/ons of messages, segments, fields and data types

  Perl scripts are applied to ASCII files to generate XML DTDs/schemas

  Issues with HL7 Database are reflected in the defini/ons


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Schemas provided

  Single schema that contains all the HL7 V2.3.1 defini/ons   Contains four separate DTD defini/ons:   Messages.dtd   segments.dtd   fields.dtd   datatypes.dtd

  Single schema for each message structure


HL7 2.xml Element Naming Conven.on

  message element names   message name and trigger event

  ORM_O01, ADT_A01, etc.   segment element names

  segment name   MSH, PID, OBX, etc.

  field element names   segment name and sequence number

  MSH.1, PID.11, OBX.5, etc   Data type component

element names   datatype name and component number   CE.2, HD.1, XAD.3, etc.


<ORM_O01> ...<OBX> <OBX.1> 1 </OBX.1> <OBX.2>ST</OBX.2> <OBX.3> <CE.1>9804-6</CE.1> <CE.2>Weight</CE.2> <CE.3>LN</CE.3> </OBX.3> <OBX.5>135</OBX.5> <OBX.6> <CE.1>lb</CE.1> </OBX.6> <OBX.11>F</OBX.11> </OBX>...

</ORM_O01>

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Single component is populated

  Where a field has a data type with mul/ple components but only a single component is populated, the data type element must s/ll be sent.

  OBX:6 = CE data type

  Valid: <OBX.6> <CE.1> lb </CE.1> </OBX.6>

  Invalid: <OBX.6> lb </OBX.6>


v2.3.1 naming conven.ons (cont)

  Field elements have the following fixed aiributes   Item, Table, LongName, Type

  Datatype component elements have the following fixed aiributes   Table, LongName, Type


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An overview example

  ADT A01 message

  Three segments   Message Header   Event   Pa/ent Iden/fica/on


Minimized XML Example <ORM_O01>

…<OBX> <OBX.1>1</OBX.1> <OBX.2>ST</OBX.2> <OBX.3> <CE.1>9804-6</CE.1> <CE.2>Weight</CE.2> <CE.3>LN</CE.3> </OBX.3> <OBX.5>135</OBX.5> <OBX.6> <CE.1>lb</CE.1> </OBX.6> <OBX.11>F</OBX.11> </OBX>…

</ORM_O01>


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Expanded XML Example <ORM_O01>

…<OBX> <OBX.1 LongName='Set ID - OBX' Type='SI’ Item='569'>1</OBX.1> <OBX.2 Table='125' LongName='Value Type' Type='ID' Item='570'>ST</OBX.2> <OBX.3 LongName='Observation Identifier' Type='CE' Item='571'> <CE.1 LongName='identifier' Type='ST'> 9804-6</CE.1> <CE.2 LongName='text' Type='ST'>Weight</CE.2> <CE.3 LongName='name of coding system' Type='ST'>LN</CE.3> </OBX.3> <OBX.5 LongName='Observation Value' Type='WILDCARD' Item='573'>135</OBX.5> <OBX.6 LongName='Units' Type='CE' Item='574'> <CE.1 LongName='identifier' Type='ST'>lb</CE.1> </OBX.6> <OBX.11 LongName=‘Observation Result Status' Type=‘ID‘ Item='578'>F</OBX.11> </OBX>…

</ORM_O01>


View on “classics” vs XML

  Event segment   note: data type components are XML elements


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Use of v2.xml

  Less used than expected   Ireland

  messaging between GPs and hospitals and between GPs and GP Out of Hours Coops   HL7 version 2.4 with XML encoding   broker is Healthlink

  Project: electronic cancer referrals from GPs to the eight cancer centres of the Na/onal Cancer Control Programme   HL7 version 2.4 with XML encoding


Products: Version 3



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Drivers for v3

  Enable inter‐organiza/onal workflows   Process support, EHRs, na/onal healthcare informa/on networks

  Support the exchange of complex clinical models   EHR, decision support

  Consistent seman/c modeling across the board


V3 is Model Based

  The central Healthcare informa4on model for HL7 Version 3 is called the Reference Informa4on Model (RIM)

  All V3 products are based on this model   ANSI standard since 2003   ISO standard since 2006


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How are V3 messages formed?


Reference Informa.on Model RIM

  Four (+two) Basic classes (the backbone)

72

Role Relationship

Act Relationship

Role Participation Act Entity


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73

RIM, Example

Prac..oner Perfomer

Encounter

Person B

Pa.ent Subject Person A


74

Refined Model

Encounter classCode <= xy moodCode <= xy id: II [1..1] ...

Pa.ent classCode: <= PAT id: II [1..1] addr: AD [0..1] telecom: TEL [0..*]

subject typeCode*: <= SBJ

1..1 pa2ent

Prac..oner classCode: <= PRT id: II [1..1] telecom: TEL [0..*]

performer typeCode*: <= PRF /me: IVL<TS>

1..1 prac22oner

Person classCode: <= PSN determinerCode: <= INSTANCE id: II [0..1] name: EN [0..*] birthTime: TS [0..1] …

1..1 pa2entPerson

Organiza.on

scopedBy

Person

playedBy

Organiza.on

scopedBy


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75

RIM (Reference Informa.on Model) Basic (Abstract) data model


HL7 V3 Uses Object Oriented Design

  Not ad hoc design   V3 = Object Oriented soMware methodology and informa/on architecture

  Object Oriented means that HL7 V3 can be extended incrementally   whenever new healthcare informa/on domains need to be added

  doesn’t require changing what already exists   Scalable, flexible


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Version 3 is a Family of standards   ALL based on a shared informa/on model and terminology   Version 3 RIM (ISO/HL7 21731:2006 RIM)   V3 Messaging   Documents

  Clinical Document Architecture (CDA – Release 2)   Service Oriented Architecture:

  En/ty Iden/fica/on Services (EIS)   Common Terminology Services (CTS)   Resource Loca/on and Update Services (RLUS)   Decision Support Services (DSS)

  RIM Based Applica/on Architectures (RIMBAA)   Java APIs


Version 3 Domains

  Accoun/ng and Billing   Blood, Tissue, and Organ   Care Provision   Clinical Genomics   Claims and Reimbursement   Clinical Document Architecture   Clinical Decision Support   Clinical Statement   Common Message Element Types   Imaging Integra/on   Immuniza/on   Laboratory   Medica/on   Materials Management

  Medical Records   Observa/ons   Orders   Pa/ent Administra/on   Personnel Management   Pharmacy   Public Health   Registries   Regulated Products   Regulated Studies (Clinical Trials)   Scheduling   Shared Messages   Specimen Domain   Therapeu/c Devices

…some in ballot phase Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 78

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HL7 V3: built to support inter‐organiza.onal care processes

Patient

Aftercare

Specialist

Hospital

Lab

Rad

Surg.

G. P.

Other areas like: Research, clinical trials, administrative, utilization, financial, public health, drug certification, genomics…

Information flow


Three development phases

  Modeling process   How are HL7 v3 models created? What has been created already? How do I find/interpret appropriate exis/ng models?

  Localiza/on process   How do I adapt the exis/ng HL7 v3 models to fit my specific context? How to apply constraints?

  Implementa/on process   How do I write soMware to send/receive the localized v3 models? Any recommended architectural approaches?


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Version 3 Enables the inter‐organiza2onal sharing of healthcare informa/on

  For example a lab result ordered in an outpa/ent clinic and obtained from the local laboratory could be:   a part of a pa/ent summary

(V3 CDA document) retrieved using a Resource Loca/on and Upda/ng Service (HL7 RLUS SOA)

  the reason to order a specific medicine using a computerized physician order entry system (CPOE) (V3 Rx Order message)

  an indica/on of a par/cular disease to a decision support system …input to a RIM Based Applica/on Architecture (RIMBAA) decision support system


Addi.onal V3 features

  Formal vocabulary binding   Extensive tools library   Implementa/on Guides   Iden/fiers Globally Unique   Explicit Seman/cs (model based) makes automa/c conformance tes/ng possible

  Incorporates Web technology   XML (Extended Markup Language) as primary implementa/on technology

  Use of Web Services protocols for transport


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Snippets of V3…

Class

Class


Snippets of V3… Class

Instance

<observationEvent classCode="OBS" moodCode="EVN"> <id root="1.9.99.999.99.10.3" extension="APH65597960" /> <code code="3141-9" codeSystem="2.16.840.1.113883.6.1" displayName="Body Weight"/> <statusCode code="completed" /> <effectiveTime value="20100514" /> <value xsi:type="PQ" value="81" unit="kg"/> </observationEvent>

Kind?

Activity!

When?

What?


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A short liile Exercise

  Miles O‘Keefe, born 17.10.1975, lives in 27 Saint Stephen's Green, Dublin 2, Co. Dublin, Ireland

  He is registered as a pa/ent at the Good Health Hospital with iden/fica/on number 4321

  His private phone number is +353 1 677 3243, he can also be reached at his office +353 1 407 0800

  Pa/ent’s primary language is English but he also understands Gaelic

  Good Health Hospital’s address: 1 Harcourt Street, (off St. Stephens Green), Dublin 2


Guess where?

86

Miles O‘Keefe

Good Health H

1 Harcourt Street, Dublin 2

2x

17.10.1975

en

ga G

P

+353 1 677 3243 (private)

+353 1 407 0800 (business)

27 Saint Stephen's Green, Dublin 2, Co. Dublin, Ireland

4532


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Products: CDA



Tension of Documenta.on   Extensible Markup Language (XML)

  Two extremes in today's data processing   “Narra/ve text” vs. “Fields in a database”

  “enrich” text – for various purposes

Slide used by permission of Kai Heitmann Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 88

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eDocuments

  Documents are the most natural method to convey health status   Prac//oners are trained in the crea/on of documents

  All “electronic health records” use documents   Every EHR includes a document repository

  Data fragments useful within a known context; for exchange across /me, context, signed documents required


HL7 Mission ‐ Interoperability Paradigms

  HL7's mission is to provide standards for interoperability that:   improve care delivery,   op/mize workflow,   reduce ambiguity and   enhance knowledge transfer

  Three interoperability paradigms are used to achieve this:   The exchange of electronic messages   The use of (web‐)services   The process of sharing documents


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Clinical Document Architecture

  Interoperability   Human

  The “paper world” with documents, forms...   Applica/on

  Storage, management of clinical data   Context driven analysis   Reusability

  An approved standard way to exchange dictated, scanned, or electronic reports on a pa/ent between various health informa/on technology systems and pla�orms.


Goals

  Persistence   Stewardship (administra/on)   Poten/al for Authen/fica/on   Wholeness   Human readability   Context preserva/on   Render arbitrary documents   Addi/onal informa/on for computa/on

  Flexibility to support different document types

Example Docs:   Discharge letter   Referrals   Observations   Medical Histories

  ...

Slide courtesy of François Macary Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 92

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CDA Business Case

  CDA hits the “sweet spot”   CDA encompasses all of clinical documents.   A single standard for the en/re EHR is too broad. Mul/ple standards and/or messages for each EHR func/on are difficult to implement.

  CDA is “just right”.   Implementa/on experience

  CDA has been a norma/ve standard since 2000, and has been balloted through HL7's consensus process. CDA is widely implemented.


CDA Business Case (cont‘d)

  Gentle on‐ramp to informa/on exchange   CDA is straight‐forward to implement, and provides a mechanism for incremental seman/c interoperability.

  Improved pa/ent care   CDA provides a mechanism for inser/ng evidence‐based medicine directly into the process of care (via templates), making it easier to do the right thing.

  Lower costs   CDA’s top down strategy let’s you implement once, and reuse many /mes for new scenarios.


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Structure of a CDA Document

•  Form –  A header providing the context: •  To facilitate the exchanges and the management of the documents, their compila/on in the pa/ent record

–  A body •  clinical informa/on, ordered into sec/ons, paragraphs, lists, tables, …

•  Encoding in XML –  Comprehensive for the human… –  …and for the computers –  can be validated by a schema

Header structured and coded

Body structured content with coded „sections“ • Salutation • Problem/Subjective • History

• Physical/Objective • Diagnoses • Epicrisis • Plan • ............

• Family History • Past Medical History

• Admit diagnoses • Intermediate diagnoses • Discharge diagnoses

coded (e.g. ICD 10)

Slide used by permission of Kai Heitmann and Francois Macary Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 95

Entries (Clinical Statements)

Observation

Procedure

Medication

Patient

Provider

Encounter

Body Structures (textual section)

Body Header

...

Clinical Document

Based on HL7 v3 models, data types and development methodology

Structure of a CDA Document


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Header + Body Text   (e.g. when transformed to HTML) “Human interoperability guaranteed”


A CDA Implementa.on Guide..

  Specifies document type   Specifies mandatory and op/onal textual sec/ons

  Specifies mandatory and op/onal entries   Specifies terminology codes, iden/fica/on schemes and other sta/c model constraints

  Most implementa4on guides are country‐specific: e.g. the CCD is U.S.‐only.


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Text vs. Coded Entries

t

Message

Coded Entries

100%

2005 2006 2007 2008

Slide used by permission of Ringholm GmbH Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 99

Known use of the CDA

  Europe   England   Estonia   Finland   France   Germany   Greece   Italy   Netherlands   Russia   Switzerland

  Asia/Pacific   Australia   Korea   Japan   New Zealand

  Americas   Argen/na   Canada   USA

  ‘Transna/onal’   IHE PCC/Lab   US D.o.D.


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Summary

  Model for electronic documents   …a ‘paradigm’ that is well familiar to healthcare providers

  CDA is an interna/onally recognized and implemented standard.

  Based on XML and HL7 v3 technology   this eases implementa/on and allows for re‐use of tools

  CDA can be implemented incrementally   allows for a migra/on phase   ‘lowest common denominator’ = human interoperability   Incremental Interoperability = an implementer can begin

with a simple CDA, structured data elements are added over /me

Text

Structured Data


For More Informa.on….

  Structured Documents Working Group   hip://www.hl7.org/Special/commiiees/structure/index.cfm

  Wiki (see also plans for CDA Release 3)   hip://wiki.hl7.org (Structured Documents WG)

  CDA resource page   hip://hl7book.net/index.php?/tle=CDA


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Format and Representa.on •  Form

–  A header providing the context: •  To facilitate the exchanges and the management of the documents, their compila/on in the pa/ent record

–  A body •  clinical informa/on, ordered into sec/ons, paragraphs, lists, tables, …

103

courtesy of François Macary

Header

Body

•  Encoding in XML –  Comprehensive for the

human… –  …and for the computers –  can be validated by a

schema

Diagnosis:

Asthma, former smoker

<section> <title>Diagnosis:</title> <text>Asthma, former smoker</text> </section>

general style sheet


CDA Model

104

CDA Header

CDA Body

Structures CDA Body Entries

Ext’l Ref’s


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105

The header: context of the document

  Iden/fica/on of the document (ID, category, /tle, date, version)

  Confiden/ality, language, consent, authoriza/ons   Signatory, of which a single legal signatory   Recipient of the contents   Manager of the document   Transcrip/onist (who entered the informa/on)   Responsible Par/es   Pa/ent   Author   "informant" (the content producer)   …

Header

Body


Sec.ons: "Levels"

106

CDA Release 2 CDA Level 1

The unconstrained CDA specifica/on.

CDA Level 2

The CDA specifica/on with sec/on‐level templates applied. “My discharge leSer has the following structure”

CDA Level 3

The CDA specifica/on with entry‐level (and op/onally sec/on‐level) templates applied. “My discharge leSer contains the following granular data”


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Summary: CDA Release 2

107 courtesy of François Macary

Header RIM R-MIM HMD W3C Schema

Body

Text

Observa/on Substance Administra/on Region of interest Procedure Pa/ent Encounter « Organizer »

Narrative blocks

human

Entries

machine

Structured Header

Sections (text/title)

L2: section codes

L3: coded entries

Observa/on (mul/‐media)


108

A CDA Implementa.on Guide..

  Specifies document type   Specifies mandatory and op/onal sec/ons and Level 2 codes for those sec/ons

  Specifies mandatory and op/onal Level 3 elements

  Specifies terminology codes, iden/fica/on schemes and other sta/c model constraints


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HL7: Message or Document ?

109

Latest state of things Supports ongoing process

Subset of data Finalized process

Formal transfer of care

Document

Message

However, what is a prescription, or a radiology report?


Collaborations, Projects, National Infrastructures



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HL7 Version 3 Projects worldwide

  Methods   V3 Messages   Clinical Document Architecture (CDA)

  Canada   Canada Health Infoway to create Pan‐Canadian Electronic Health Records

  Finland   Na/onal Infrastructure with exchange based on CDA

  Great Britain   Na/onal Infrastructure of the Na/onal Health Service with messages and documents


HL7 Version 3 Projects worldwide

  The Netherlands   Electronic Medica/on Records (EMD) and exchange of health informa/on between Primary Care Providers (WHD) based on HL7 Version 3 and Web Services

  Europe   Exchange of data about dialysis treatment in dialysis care, treatment centers to na/onal registries, na/onal registries to interna/onal ERA‐EDTA registry in Amsterdam


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Version 3: other related work

  Diagnoses   transmission of diagnoses   defines informa/on exchange between prac//oners, and for reimbursement purposes, public health, and cancer treatment and research

  No/fiable Diseases   Communica/on Physician/Lab to Public Health Department

  Robert‐Koch‐Ins/tute + AGFA HealthCare

  Based on “Arztbrief” CDA   Assessment and Scores


Visions



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Narrative blocks

human

Entries

machine

Future Prospect

  Four aspects   Clinical   Personal   Technical   Administra/ve

  Narra/ve Text = essen/al ingredient of an EHR   HL7’s Clinical Document Architecture provides BOTH

  ...makes incremental shared seman/cs possible   Easy Crea/on, Access, Delivery Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 115

Future Prospect

  Related work all over the world by different organiza/ons, mainly following the same concepts of constraining the generic specifica/ons

  Messages for processes, documents for documenta/on

  Problem areas:   Medica/on: coding difficult

  unique and commonly used code system to classify medica/on

  codes from other pharmacy standards organiza/ons?!   Not a big problem: Implementa/on


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Future Prospect

  Constraining the generic models   Templates, Archetypes

  Marriage of “good things” from different SDOs   Joint Ini/a/ve of ISO, CEN and HL7

  Messaging view vs Architecture view towards an EHR


Looking Ahead: Recent Developments and Plans   Collabora/ons with ISO TC 215 and CEN TC 251 and WHO (planned) and other global & na/onal organiza/ons

  Global adop/on and implementa/on of EHR and PHR

  Healthcare Informa/on integra/on in the developing world

  Public health, Research, Decision Support, Prac/ce Paierns, Quality

  Implementa/on Guides for Version 3

Joint Initiative Council (JIC)


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SUMMARY


What is the future of Version 2?

  Commonly used within hospitals   Accepted by industry   “Never touch a running system” – will remain standard in hospitals for some more years

  V2.xml allows “transi/on” to XML interfacing (V3) and other “modern” techniques


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Where is V3 in use today?

  CDA is used in many countries, including Australia, Canada, UK, Germany, the US, the Netherlands, Greece, Japan...

  V3 messaging is used in Canada, UK, the Netherlands…

  V3 SOA (service oriented architecture): in the US, the NCI and the VHA have significant projects…

  V3 RIMBAA in Japan, Austria, Italy…

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V3 implementa.ons

  Registries (Pa/ent, Provider, Organiza/on)   Transfer of care (Pa/ent Care domain)   Clinical Documents (CDA)   Medica/on (Pharmacy domain)   Billing (Charges, insurance)   “Niche” clinical areas (immuniza/on, clinical genomics, implantable therapu/c devices, blood and organ banks...)

  Research (clinical trials)


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Do I need to be a modelling / informa.cs expert to use V3?

  No, V3 implementa/on guides are usable without a detailed theore/cal background. Many HL7 affiliates have also created detailed V3 implementa/on guides

  HL7 offers a variety of tutorials to jump start implementa/on

  If an IT staffer knows XML, and the system is using V3 messages or CDA documents or services, all you need is an implementa/on guide

  Start “small scale” – CDA Quick Start Guide

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Messaging, documents, SOA, RIM based application development

Free form CDA documents, implementation guides, extensive tooling, educational opportunities

XML and Web Services, for universal application

For a higher level of semantic interoperability

The V3 Family solving the BIGGER problems of healthcare interoperability

  Not just messaging!

  Easy to get started

  Employs Web technologies

  Model based: the RIM


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How can I learn more about HL7?

  Web sites   hip://www.hl7.org hip://wiki.hl7.org

  Interna/onal Affiliates   hip://www.hl7.org/Special/commiiees/interna/onal/intl.htm

  Educa/on and Tutorials   hip://www.hl7.org/educa/on/index.cfm

  How to request and HL7 Ambassador speaker   mailto:[email protected]

  Contact info for HL7 HQ   mailto:[email protected]

  Product and Services Guide   hip://productsandservices.hl7.org/Report/Report.aspx?varReport=Product

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How can I learn more about V3?

  Tutorials   At Working Group Mee/ngs   Affiliate mee/ngs   Educa/onal Summits   On site

  Distance learning class   CDA Quick Start Guide and V3 Primer

  RIM and CDA Cer/fica/on

  HL7.tv with a lot of V3 related videos

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Thank you ‐ Ques.ons?

Later? mailto: [email protected]

Go raibh mile maith agaibh

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