- 1. 1HL7 StandardsNawanan Theera-Ampornpunt, M.D.,
Ph.D.Department of Community MedicineFaculty of Medicine
Ramathibodi HospitalCertified HL7 CDA SpecialistSome slides
reproduced & adapted with permission fromDr. Supachai
ParchariyanonNovember 2, 2014
2. 2Some Slides Reproduced withPermission fromDr. Supachai
Parchariyanon@supachaiMDProfile:Dr. Supachai Parchariyanon is a
medical doctorwhos passionate about information technology andturn
himself to be informatician and serialentrepreneurs.Hes also earned
Business Management degreefrom Ramkamhaeng university and
BiomedicalInformatics degree from the US. He led the team tocertify
both HL7 Reference Information Model (RIM)and Clinical Document
Architecture (CDA). Hisinterest is now on standards and
interoperability,clinical informatics and project management.Keep
in touchsupachaimd@gmail.comhttp://www.facebook.com/supachaiMDSlide
reproduced/adapted from Dr. Supachai Parchariyanon 3. 3Thailands
HL7Certified SpecialistsKevinAsavanantHL7 V3 RIM
(2009)SupachaiParchariyanonHL7 CDA
(2010)NawananTheera-AmpornpuntHL7 CDA
(2012)SireeratSrisiriratanakulHL7 V3 RIM (2013) 4. 4Standards Are
Everywhere 5. 5Standards: Why? The Large N ProblemN = 2, Interface
= 1# Interfaces = N(N-1)/2N = 3, Interface = 3N = 5, Interface =
10N = 100, Interface = 4,950 6. 6Health Information Exchange
(HIE)Hospital A Hospital BClinic CGovernmentLab Patient at Home 7.
7Why Health Information Standards?Objectives Interoperability
Inter-operablesystemsUltimate Goals Continuity of Care Quality
Safety Timeliness Effectiveness Equity Patient-Centeredness
Efficiency 8. 8What is interoperability?It is the ability of two or
more systemsor components to exchange information,and to use the
information that has beenexchanged predictably (IEEE
StandardComputer Dictionary)Slide reproduced/adapted from Dr.
Supachai Parchariyanon 9. 9Levels of
InteroperabilityFunctionalSemanticSyntactic 10. 10Goal of
interoperability HL7s key goal of interoperability hastwo aspects:
Syntactic interoperability has to do withstructure Semantic
interoperability has to do withmeaningSlide reproduced/adapted from
Dr. Supachai Parchariyanon 11. 11Things that can go wrong inmessage
exchangeSlide reproduced/adapted from Dr. Supachai Parchariyanon
12. 12Standards are not equalInteroperabilityStandards only create
the opportunityfor interoperability and are not equal
tointeroperabilitySlide reproduced/adapted from Dr. Supachai
Parchariyanon 13. 13Various Kinds of Standards Unique Identifiers
Standard Data Sets Vocabularies & Terminologies Exchange
Standards Message Exchange Document Exchange Functional Standards
Technical Standards: Data Communications,Encryption, Security 14.
Functional Standards (HL7 EHRFunctional
Specifications)Vocabularies, Terminologies,Coding Systems (ICD-10,
ICD-9,CPT, SNOMED CT, LOINC)Information Models (HL7 v.3 RIM,ASTM
CCR, HL7 CCD)Standard Data SetsUnique IDExchange Standards (HL7
v.2,HL7 v.3 Messaging, HL7 CDA,14How Standards Support
InteroperabilityFunctionalSemanticSyntacticDICOM)Technical
Standards(TCP/IP, encryption,security)Some may be hybrid: e.g. HL7
v.3, HL7 CCD 15. 15What is HL7? HL7 is an ANSI-accredited
StandardsDevelopment Organization (SDO)operating in the healthcare
arena. It is a non-profit organization made up ofvolunteers
providers, customers,vendors, government, etc.Slide
reproduced/adapted from Dr. Supachai Parchariyanon 16. 16What is
HL7? (Cont.) HL7 is an acronym for Health Level Seven Seven
represents the highest, or applicationlevel of the International
StandardsOrganization (ISO) communications model forOpen Systems
Interconnection (OSI) networks.Slide reproduced/adapted from Dr.
Supachai Parchariyanon 17. 17OSI ModelSlide reproduced/adapted from
Dr. Supachai Parchariyanon 18. 18What HL7 does? HL7 focuses on the
clinical and administrativedata domains. It defines data exchange
standards for thesedomains called messages or
messagingspecifications (aka HL7 messages) Messages are developed
by technical committees andspecial interest groups in the HL7
organization. HL7 organization defines 2 versions of themessaging
standard: HL7 v2.x (syntactic only) HL7 v3.0 (semantic capability
added)Slide reproduced/adapted from Dr. Supachai Parchariyanon 19.
19What HL7 does?Slide reproduced/adapted from Dr. Supachai
Parchariyanon 20. 20HL7 Standards HL7V2.x Defines electronic
messages supporting hospitaloperations HL7V3 HL7 Clinical Document
Architecture(CDA) Releases 1 and 2 HL7 Arden Syntax Representation
of medical knowledge HL7 EHR & PHR Functional Specifications
Etc. 21. 21The Industry StandardHL7 version 2 (HL7 v2) Not Plug and
Play - it provides 80 percent of theinterface and a framework to
negotiate the remaining 20percent on an interface-by-interface
basis Historically built in an ad hoc way because no otherstandard
existed at the time Generally provides compatibility between 2.X
versions Messaging-based standard built upon pipe and hatencoding
In the U.S., V2 is what most people think of when peoplesay
HL7Slide reproduced/adapted from Dr. Supachai Parchariyanon 22.
22HL7 version2 HL7 v2 is still the most commonly used HL7standard
Over 90% of US hospitals have implemented someversion of 2.x HL7
messages The HL7 v2 messaging standard is considered: The workhorse
of data exchange in healthcare The most widely implemented standard
for healthcareinformation in the world HL7 v2.5 was approved as an
ANSI standard in2003Slide reproduced/adapted from Dr. Supachai
Parchariyanon 23. 23Part of Sample HL7 v.2 Message(Lab
Result)OBX|1|NM|10839-9^TROPONIN-I^LN||5|ng/ml|0-1.3|H||H|F|19980309Slide
reproduced/adapted from Dr. Supachai Parchariyanon 24. 24HL7 v2
Message Messages composed of Segments composed of Fields composed
of Components Delimiters Field separator: | Component separator: ^
Repetition separator: ~ Escape character: Subcomponent: &
Segment terminator: Slide reproduced/adapted from Dr. Supachai
Parchariyanon 25. 25Message Header Segment -
MSHSendingUnitReceivingUnit
DateTimeMessagetypeTriggerIDMSH|^~|&|SMS|OR2|TMR|SICU|201010191535|password|ADT^A01|MSG1632|P|2.7SendingPlace
ReceivingPlaceMessageNumberversionDelimitersproductionSlide
reproduced/adapted from Dr. Supachai Parchariyanon 26. 26PID
Segment 1/3Check digitPatient IDMethodLast nameFirst
nameMiddleInitialSuffixPID|Z12345^5^M11||||PATIENT^JOSEPH^M^IV|Patient
nameNull fieldsData fieldField delimiterSlide reproduced/adapted
from Dr. Supachai Parchariyanon 27. 27PID Segment 2/3Mothersmaiden
nameDate of birth RaceMAIDEN|19610605|M||C|1492 OCEAN
STREET^GenderStreetaddressData component ComponentdelimiterSlide
reproduced/adapted from Dr. Supachai Parchariyanon 28. 28PID
Segment 3/3CityStateZip
CodeCountyTelephoneDURHAM^NC^27705|DUR|(919)684-6421Segment
terminatorSlide reproduced/adapted from Dr. Supachai Parchariyanon
29. 29PV1
SegmentPV1|1|1|N2200^2200|||OR^02|0846^WELBY^MARCUS^G||SURPatient
locationAttendingServiceSequencenumberPatientclassSlide
reproduced/adapted from Dr. Supachai Parchariyanon 30. 30OBR
SegmentPlacer ordernumberFiller ordernumberUniversalservice
IDTextorder Local
setOBR|1|330769.0001.001^DMCRES|0000514215^RADIS1|77061^U/S
PEVLIC^L||201010211145|||||||||||||0491909||||U999|M||||||^FIBROIDS,
R/O|207484^CARROLL&BARBARA&A|||089657&BROWN&JOANNERequesteddate-time
ofserviceReason forstudyPrincipal resultsinterpreterSlide
reproduced/adapted from Dr. Supachai Parchariyanon 31. 31Typical
Result Message
-ORUMSH|^~&|||||19981105131523||ORU^R01PID|||100928782^9^M11||Smith^John^JOBR||||Z0063-0^^LNOBX||XCN|Z0063-0^^LN||2093467^Smits^J^OBX||Z0092-0^^LN||203BE0004Y^^X12PTXData
fieldData componentsegmentAgain, this slide shows a typical order
result message. In this case, thesegments include the header, the
patient identifier, the order request,and two result segments. The
OBX segment is examined in detail inthe next slide. The last OBX
shows the hierarchical nature of thesegment. The test ID data field
is broken into the triplet of code (withcheck-digit), text name,
and vocabulary source (LOINC).Slide reproduced/adapted from Dr.
Supachai Parchariyanon 32. 32Problems with HL7v2 HL7 v2 cannot
support all this! Ad Hoc design methodology Ambiguous lacking
definition Complicated, esoteric encoding rules. Artifacts left to
retain backward compatibility Too much optionality Cant specify
conformance No standard vocabularySlide reproduced/adapted from Dr.
Supachai Parchariyanon 33. 33Whats Different About v3? Conceptual
foundation A single, common reference information model to be used
acrossHL7 Semantic foundation Explicitly defined concept domains
drawn from the bestterminologies Abstract design methodology That
is technology-neutral Able to be used with whatever is the
technology de jour XML, UML, etc. Maintain a repository Database of
the semantic content Ensures a single source and enable development
of supporttoolingSlide reproduced/adapted from Dr. Supachai
Parchariyanon 34. 34How is v3 different than v2? v3 is approaching
Plug and Play v2 uses pipe and hat messaging, while v3uses the
Reference InformationModel(RIM) and XML for messaging v3 is a brand
new start it is NOTbackward compatible with v2Slide
reproduced/adapted from Dr. Supachai Parchariyanon 35. 35Sample HL7
v.3 Message(Patient
Registration)...NawananTheera-Ampornpunt...Message source adapted
from Ramathibodi HL7 Project by Supachai Parchariyanon,Kavin
Asavanant, Sireerat Srisiriratanakul & Chaiwiwat
Tongtaweechaikit 36. 36HL7 V3 Standards A family of standards based
on V3information models and developmentmethodology Components HL7
V3 Reference Information Model (RIM) HL7 V3 Messaging HL7
Development Framework (HDF) 37. 37How HL7 V3 Works Message sent
from sending application toreceiving application Mostly triggered
by an event Typical scenario portrayed in a storyboard Message in
XML with machine-processableelements conforming to
messagingstandard Data elements in message conform to RIM Not
designed for human readability 38. 38v3 Messaging Standard Based on
an object informationmodel, called the ReferenceInformation Model,
(RIM)Slide reproduced/adapted from Dr. Supachai Parchariyanon 39.
39HL7 V3 Messaging V3 provides messaging standards for Patient
administration Medical records Orders Laboratory Claims &
Reimbursement Care provision Clinical genomics Public Health Etc.
40. 40HL7 v3 ReferenceInformation ModelActRelationship Referral
Transportation Supply Procedure Consent Observation Medication
Administrative act Financial act Organization Place Person Living
Subject Material Has component Is supported by0..* 1 Patient Member
Healthcare facility Practitioner Practitioner assignment Specimen
LocationEntity0..*1Role10..*10..*1..*1Participation Act Author
Reviewer Verifier Subject Target TrackerSlide reproduced/adapted
from Dr. Supachai Parchariyanon 41. 41HL7 v3 Components and
Process: RIM UML InstanceScenarioEntity Role Participation ActJohn
Doe Patient SubjectDr. Smith Classes are color coded: Green =
Entity, Yellow = Role, Blue = Participation, Red/Pink = Act, Purple
= Infrastructure, Lilac = messagecontroller.HealthCareProvider
SurgeonJohn Doe Patient SubjectHas PertinentAct Relationship
Information(Clinical Trial Act)Protocol
ECOG1112XYZHospitalHealthCareFacility Location(Procedure
Act)ProstectomySlide reproduced/adapted from Dr. Supachai
Parchariyanon 42. 42Reference Information Model (RIM)42 43. 43V3
Messaging Concerns Difficult to implement No one understands v3
Overhead too much 1% of message is payload compared to v2
(delimiters)is about 90-95% No one understands what implementation
of v3messaging means Need stability, clarity, definition of v3
messagingSlide reproduced/adapted from Dr. Supachai Parchariyanon
44. 44Additional Information Health Level Seven www.hl7.org HL7
Reference Information Model
https://www.hl7.org/library/data-model/RIM/C30202/rim.htm HL7
Vocabulary Domains
http://www.hl7.org/library/data-model/RIM/C30123/vocabulary.htm HL7
v3 Standard
http://www.hl7.org/v3ballot/html/welcome/environment/index.htm
HL7v3: Driving Interoperability & Transforming Healthcare
InformationManagement by Charles Mead, MD, MSc.
http://www.healthcare-informatics.com/webinars/05_20_04.htmSlide
reproduced/adapted from Dr. Supachai Parchariyanon 45. 45HL7
Clinical DocumentArchitecture (CDA)Nawanan Theera-Ampornpunt, M.D.,
Ph.D.Department of Community MedicineFaculty of Medicine
Ramathibodi HospitalCertified HL7 CDA SpecialistSome slides
reproduced & adapted with permission fromDr. Supachai
ParchariyanonNovember 2, 2014 46. 46Exchange StandardsMessage
Exchange Goal: Specify formatfor exchange of data Internal vs.
externalmessages Examples HL7 v.2 HL7 v.3 Messaging DICOM
NCPDPDocument Exchange Goal: Specify formatfor exchange ofdocuments
Examples HL7 v.3 Clinical DocumentArchitecture (CDA) ASTM
Continuity of CareRecord (CCR) HL7 Continuity of CareDocument (CCD)
47. 47Exchange StandardsMessages Human Unreadable Machine
ProcessableClinical Documents Human Readable (Ideally)
MachineProcessable 48. 48Message ExchangeMessageMessageHospital A
Hospital BClinic CGovernmentLab Patient at HomeMessageMessage
Message 49. 49Clinical Document ExchangeMessage containingReferral
LetterMessage containingClaims RequestMessage
containingCommunicableDisease ReportHospital A Hospital BClinic
CGovernmentLab Patient at HomeMessage containingLab ReportMessage
containingPatient Visit Summary 50. 50What Is HL7 CDA? A document
markup standard thatspecifies structure & semantics of
clinicaldocuments for the purpose of exchange[Source: HL7 CDA
Release 2] Focuses on document exchange, notmessage exchange A
document is packaged in a messageduring exchange Note: CDA is not
designed for documentstorage. Only for exchange!! 51. 51What is
CDA? CDA is based on XML XML is eXtensible Markup Language In XML,
structure & format are conveyedby markup which is embedded into
theinformationSlide reproduced/adapted from Dr. Supachai
Parchariyanon 52. 52Clinical DocumentsSlide reproduced/adapted from
Dr. Supachai Parchariyanon 53. 53A Clinical Document (1) A
documentation of clinical observationsand services, with the
followingcharacteristics: Persistence - continues to exist in
anunaltered state, for a time period defined bylocal and regulatory
requirements Stewardship - maintained by an organizationentrusted
with its care Potential for authentication - an assemblageof
information that is intended to be legallyauthenticated Source: HL7
CDA R2 54. 54A Clinical Document (2) A documentation of clinical
observationsand services, with the followingcharacteristics:
Context - establishes the default context for itscontents; can
exist in non-messaging contexts Wholeness - Authentication of a
clinicaldocument applies to the whole and does notapply to portions
of the document without fullcontext of the document Human
readability - human readableSource: HL7 CDA R2 55. 55A Clinical
Document (3) A CDA document is a defined & completeinformation
object that can include Text Images Sounds Other multimedia
contentSource: HL7 CDA R2 56. 56CDA & HL7 Messages Documents
complement HL7 messagingspecifications Documents are defined and
complete informationobjects that can exist outside of a
messagingcontext A document can be encoded within an
HL7messageSource: What is CDA R2? by Calvin E. Beebeat HL7
Educational Summit in July 2012 57. 57CDA & Message Exchange
CDA can be payload (or content) in any kind ofmessage HL7 V2.x
message HL7 V3 message EDI ANSI X12 message IHE Cross-Enterprise
Document Sharing (XDS)message And it can be passed from one kind
toanotherSource: What is CDA R2? by Calvin E. Beebeat HL7
Educational Summit in July 2012 58. 58CDA & Message
ExchangeClinical Document(Payload)HL7 V3 Message(Message)HL7 V2
Message(Message)Source: Adapted from What is CDA R2? by Calvin E.
Beebeat HL7 Educational Summit in July 2012 59. 59CDA As
PayloadSource: From What is CDA R2? by Calvin E. Beebeat HL7
Educational Summit in July 2012 60. 60Major Components of aCDASlide
reproduced/adapted from Dr. Supachai Parchariyanon 61. 61CDA
ModelSource: From What is CDA R2? by Calvin E. Beebeat HL7
Educational Summit in July 2012 62. Human Readable PartMachine
Processable Parts62A Closer Look at a CDA Document ... CDA Header
...... SingleNarrative Block ...............Source: HL7 CDA R2 63.
63Rendering CDA Documents (1)Source: From What is CDA R2? by Calvin
E. Beebeat HL7 Educational Summit in July 2012 64. 64Rendering CDA
Documents (2)Source: From What is CDA R2? by Calvin E. Beebeat HL7
Educational Summit in July 2012 65. 65CDA & Document Management
CDA focuses on document exchange, notstorage or processing Clinical
documents are used for various reasons Clinical care Medico-legal
reasons (as evidence) Auditing Etc. Clinical documents may contain
errors or needdata updates (e.g. preliminary lab results vs.
finalresults) 66. 66CDA & Document Management CDA supports
appending and replacement ofdocuments through use of Document ID,
setID,versionNumber & parent document Supports version control
of documents Both old (replaced) and new versions of documentscan
be stored in and retrieved from documentmanagement systems
depending on situation Addendum is possible through append Addendum
itself can also be replaced with sameversion control mechanism
Document management system (not CDA) isresponsible for keeping
track of most up-to-datedocuments 67. 67Document Management
ExamplesSource: From What is CDA R2? by Calvin E. Beebeat HL7
Educational Summit in July 2012 68. 68Some Possible Use Cases of
CDA Intra-institutional Exchange of parts of medical records
(scanned orstructured electronic health records) Lab/Imaging
requests & reports Prescriptions/order forms Admission notes
Progress notes Operative notes Discharge summaries Payment receipts
Other forms/documents (clinical or administrative) 69. 69Some
Possible Use Cases of CDA Inter-institutional Referral letters
Claims requests or reimbursement documents External lab/imaging
reports Visit summary documents Insurance eligibility &
coverage documents Identification documents Disease reporting Other
administrative reports 70. 70Achieving Interoperability CDA is a
general-purpose, broad standard Use in each use case or context
requiresimplementation guides to constrain CDA Examples Operative
Note (OP) Consultation Notes (CON) Care Record Summary (CRS)
Continuity of Care Document (CCD) CDA for Public Health Case
Reports (PHCRPT) Quality Reporting Document Architecture (QRDA) 71.
71CDA Summary CDA is a markup standard for documentexchange Not
message exchange CDA is a general-purpose standard Use in specific
context requiresImplementation Guides (and possiblyExtensions) 72.
72CDA Summary CDA is XML-based and RIM-based CDA documents can be
exchanged asencapsulated data (payload) in any message(HL7 V2, HL7
V3, etc.) CDA is not dependent on using HL7 V3messages Most likely
early use cases for CDA Referrals Claims & Reimbursements
Lab/imaging Reports Electronic Health Records Documents 73.
73Q/ASlide reproduced/adapted from Dr. Supachai Parchariyanon