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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
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Introduction
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Workshop Health Information and Quality Authority Cork, Ireland, March 2011
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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
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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?
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Seman.cs und Structure
Pa/ent? What‘s part of Pa/ent‘s “Data”?
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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
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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
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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
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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.
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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)
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How is it organized?
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Workshop Health Information and Quality Authority Cork, Ireland, March 2011
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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
19 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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”
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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
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• 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
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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
Version 2.1 Published
Charter member of ANSI HISPP
Version 3.0 Norma.ve Edi.on 2005
Version 1.0 Published
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
Version 2.5 Published
Version 2.6 Published
CDA Rel.2
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
Organiza.on
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HL7
In Europe
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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)
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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?
31 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
Workshop Health Information and Quality Authority Cork, Ireland, March 2011
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HL7 Working Groups
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Working Groups
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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
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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)
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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)
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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
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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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43 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
Products: v2
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Basic Principles of HL7 Messaging
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send HL7 message
receive HL7
ACK message
Receive HL7 message
send HL7
ACK message
Trigger event
System A System B
network
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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
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HL7 Version 2
Chapter overview
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Example v2 message
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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
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Example v2 Message
PID segment with fields
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Example v2 Message
Fields with components
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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
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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
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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
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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.
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<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>
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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
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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>
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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
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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
69 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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?
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Reference Informa.on Model RIM
Four (+two) Basic classes (the backbone)
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Role Relationship
Act Relationship
Role Participation Act Entity
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RIM, Example
Prac..oner Perfomer
Encounter
Person B
Pa.ent Subject Person A
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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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RIM (Reference Informa.on Model) Basic (Abstract) data model
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 79
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
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 83
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
85 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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Products: CDA
87 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
Workshop Health Information and Quality Authority Cork, Ireland, March 2011
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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 89
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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 90
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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.
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 91
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.
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 93
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.
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 94
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 96
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Header + Body Text (e.g. when transformed to HTML) “Human interoperability guaranteed”
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 97
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.
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 98
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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.
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 100
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 101
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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 102
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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, …
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
CDA Model
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CDA Header
CDA Body
Structures CDA Body Entries
Ext’l Ref’s
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
Sec.ons: "Levels"
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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”
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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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)
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
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HL7: Message or Document ?
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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?
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
Collaborations, Projects, National Infrastructures
110 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
Workshop Health Information and Quality Authority Cork, Ireland, March 2011
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 111
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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 112
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 113
Visions
114 Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011
Workshop Health Information and Quality Authority Cork, Ireland, March 2011
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 116
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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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 117
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)
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 118
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Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 119
SUMMARY
Workshop Health Information and Quality Authority Cork, Ireland, March 2011
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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 120
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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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Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 121
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)
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 122
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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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Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 123
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
Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 124
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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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Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 125
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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Dr. K. Heitmann – HL7 Family of Standards – HIQA Workshop, Cork, March 2011 126