hl7 standards (september 15, 2016)
TRANSCRIPT
1
HL7 Standards
Nawanan Theera-Ampornpunt, M.D., Ph.D.Department of Community Medicine
Faculty of Medicine Ramathibodi Hospital
Certified HL7 CDA Specialist
Some slides reproduced & adapted with permission from Dr. Supachai Parchariyanon
September 15, 2016
2
»Profile:
Dr. Supachai Parchariyanon is a medical doctor
who’s passionate about information technology and
turn himself to be informatician and serial
entrepreneurs.
He’s also earned Business Management degree
from Ramkamhaeng university and Biomedical
Informatics degree from the US. He led the team to
certify both HL7 Reference Information Model (RIM)
and Clinical Document Architecture (CDA). His
interest is now on standards and interoperability,
clinical informatics and project management.
»Keep in touch
»http://www.facebook.com/supachaiMD
Supachai Parchariyanon
@supachaiMD
Slide reproduced/adapted from Dr. Supachai Parchariyanon
3
Nawanan Theera-Ampornpunt
2003 M.D. (Ramathibodi)
2009 M.S. in Health Informatics (U of MN)
2011 Ph.D. in Health Informatics (U of MN)
2012 Certified HL7 CDA Specialist
Former Deputy Chief, Informatics Division
Deputy Executive Director for Informatics,
Chakri Naruebodindra Medical Institute
Faculty of Medicine Ramathibodi Hospital
http://groups.google.com/group/ThaiHealthIT
Research interests:• EHRs & health IT applications in clinical settings
• Health IT adoption
• Health informatics education & workforce development
4
Outline
• Introduction to Standards & Interoperability
• What is Health Level Seven (HL7)?
• What HL7 does?
• HL7 Version 2
• HL7 Version 3 Messaging Standard
• Reference Information Model (RIM)
• Clinical Document Architecture (CDA)
Slide reproduced/adapted from Dr. Supachai Parchariyanon
5
Standards Are Everywhere
6
Standards: Why?
• The Large N Problem
N = 2, Interface = 1
# Interfaces = N(N-1)/2
N = 3, Interface = 3
N = 5, Interface = 10
N = 100, Interface = 4,950
7
Health Information Exchange (HIE)
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
8
Objectives
• Interoperability
• Inter-operable
systems
Ultimate Goals
• Continuity of Care
• Quality
Safety
Timeliness
Effectiveness
Equity
Patient-Centeredness
Efficiency
Why Health Information Standards?
9
Levels of Interoperability
Functional
Semantic
Syntactic
10
Various Kinds of Standards
• Unique Identifiers
• Standard Data Sets
• Vocabularies & Terminologies
• Exchange Standards
– Message Exchange
– Document Exchange
• Functional Standards
• Technical Standards: Data Communications,
Encryption, Security
11
Functional
Semantic
Syntactic
How Standards Support Interoperability
Technical Standards
(TCP/IP, encryption,
security)
Exchange Standards (HL7 V2,
HL7 V3 Messaging, HL7 CDA,
DICOM)
Vocabularies, Terminologies,
Coding Systems (ICD-10, ICD-9,
CPT, SNOMED CT, LOINC)
Information Models (HL7 V3 RIM,
ASTM CCR, HL7 CCD)
Standard Data Sets
Functional Standards (HL7 EHR
Functional Specifications)
Some may be hybrid: e.g. HL7 V3, HL7 CCD
Unique ID
12
What is HL7?
• HL7 is an ANSI-accredited Standards
Development Organization (SDO)
operating in the healthcare arena.
• It is a non-profit organization made up of
volunteers – providers, customers, vendors, government, etc.
Slide reproduced/adapted from Dr. Supachai Parchariyanon
13
What is HL7? (Cont.)
• HL7 is an acronym for Health Level Seven
– Seven represents the highest, or “application”
level of the International Standards
Organization (ISO) communications model for
Open Systems Interconnection (OSI) networks.
Slide reproduced/adapted from Dr. Supachai Parchariyanon
14
OSI Model
Slide reproduced/adapted from Dr. Supachai Parchariyanon
15
What HL7 does?
• HL7 focuses on the clinical and administrative
data domains.
• It defines data exchange standards for these
domains called messages or messaging
specifications (aka HL7 messages)
– Messages are developed by technical committees and
special interest groups in the HL7 organization.
• HL7 organization defines 2 versions of the
messaging standard:
– HL7 v2.x (syntactic only)
– HL7 v3.0 (semantic capability added)
Slide reproduced/adapted from Dr. Supachai Parchariyanon
16
What HL7 does?
Slide reproduced/adapted from Dr. Supachai Parchariyanon
17
HL7 Standards
• HL7 V2.x
– Defines electronic messages supporting hospital
operations
• HL7 V3
• HL7 Clinical Document Architecture
(CDA) Releases 1 and 2
• HL7 Arden Syntax
– Representation of medical knowledge
• HL7 EHR & PHR Functional Specifications
• Etc.
18
The Industry Standard
HL7 Version 2 (HL7 V2)
• Not “Plug and Play” - it provides 80 percent of the
interface and a framework to negotiate the remaining 20
percent on an interface-by-interface basis
• Historically built in an ad hoc way because no other
standard existed at the time
• Generally provides compatibility between 2.X versions
• Messaging-based standard built upon pipe and hat
encoding
• In the U.S., V2 is what most people think of when people
say “HL7″
Slide reproduced/adapted from Dr. Supachai Parchariyanon
19
HL7 version2
• HL7 V2 is still the most commonly used HL7
standard
– Over 90% of US hospitals have implemented some
version 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 healthcare
information in the world
• HL7 V2.5 was approved as an ANSI standard in
2003
• HL7 is currently working on version 2.7Slide reproduced/adapted from Dr. Supachai Parchariyanon
20
HL7 V2 Message
• Composed of reusable segments, each
identified by a 3-letter mnemonic
• All messages must start with header segment
MSH which includes sender, receiver, date-
time, message identifier, message type, and
trigger event
• Segments used in a message are determined
by message type
Slide reproduced/adapted from Dr. Supachai Parchariyanon
21
Part of Sample HL7 V2 Message
(Lab Result)
OBX|1|NM|10839-9^TROPONIN-I^LN||5|ng/ml|0-1.3|H||H|F|19980309…
22
HL7 Basic Transaction Model
send
HL7 ADT
A01 msg
receive HL7
ACK msg
ADT system
Lab system
Receive A01,
send ACK
(external) admit
event
trigger event
network
Slide reproduced/adapted from Dr. Supachai Parchariyanon
23
Patient Admission Scenario, Inform Lab System
• Trigger event is admission : A01
• Message type is: ADT
• Messages composed of:
– MSH (message header)
– PID (patient identification)
– PV1 (visit data)
Slide reproduced/adapted from Dr. Supachai Parchariyanon
24
HL7 V2 Message
• Messages composed of
– Segments composed of
• Fields composed of
– Components
• Delimiters
– Field separator: |
– Component separator: ^
– Repetition separator: ~
– Escape character: \
– Subcomponent: &
– Segment terminator: <cr>
Slide reproduced/adapted from Dr. Supachai Parchariyanon
25
Message Header Segment - MSH
MSH|^~|&|SMS|OR2|TMR|SICU|201010191535|password|ADT^A01|MSG1632|P|2.7<cr>
Sending
UnitReceiving
Unit Date
TimeMessage
typeTrigger
ID
Sending
Place Receiving
Place
Message
Number
version
Delimiters
production
Slide reproduced/adapted from Dr. Supachai Parchariyanon
26
PID Segment – 1/3
PID|Z12345^5^M11||||PATIENT^JOSEPH^M^IV|
Patient ID
Check digit
Method
Last name
First name
Middle
Initial
Suffix
Patient name
Null fields
Data field
Field delimiter
Slide reproduced/adapted from Dr. Supachai Parchariyanon
27
PID Segment – 2/3
MAIDEN|19610605|M||C|1492 OCEAN STREET^
Mother’s
maiden name
Gender
Date of birth Race
Street
address
Data component Component
delimiter
Slide reproduced/adapted from Dr. Supachai Parchariyanon
28
PID Segment – 3/3
DURHAM^NC^27705|DUR|(919)684-6421<cr>
City
State
Zip Code
County
Telephone
Segment terminator
Slide reproduced/adapted from Dr. Supachai Parchariyanon
29
PV1 Segment
PV1|1|1|N2200^2200|||OR^02|0846^WELBY^MARCUS^G||SUR<cr>
Patient locationAttending
ServiceSequence
number
Patient
class
Slide reproduced/adapted from Dr. Supachai Parchariyanon
30
Summary
Slide reproduced/adapted from Dr. Supachai Parchariyanon
31
Rules
Slide reproduced/adapted from Dr. Supachai Parchariyanon
32
Problems with HL7 v2
• 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
– Can’t specify conformance
– No standard vocabulary
Slide reproduced/adapted from Dr. Supachai Parchariyanon
33
What’s Different About V3?
• Conceptual foundation– A single, common reference information model to be used across
HL7
• Semantic foundation– Explicitly defined concept domains drawn from the best
terminologies
• 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 support tooling
Slide reproduced/adapted from Dr. Supachai Parchariyanon
34
How is V3 different than V2?
• V3 is approaching “Plug and Play”
• V2 uses pipe and hat messaging, while V3
uses the Reference Information
Model(RIM) and XML for messaging
• V3 is a brand new start – it is NOT
backward compatible with V2
Slide reproduced/adapted from Dr. Supachai Parchariyanon
35
HL7 V3 Standards
• A family of standards based on V3
information models and development
methodology
• Components
– HL7 V3 Reference Information Model (RIM)
– HL7 V3 Messaging
– HL7 Development Framework (HDF)
36
How HL7 V3 Works
• Message sent from sending application to
receiving application
• Mostly triggered by an event
• Typical scenario portrayed in a storyboard
• Message in XML with machine-processable
elements conforming to messaging
standard
• Data elements in message conform to RIM
• Not designed for human readability
37
V3 Messaging Standard
• Based on an object information model, called the
Reference Information Model, (RIM)
– This model is “abstract,” that is, it is defined without
regard to how it is represented in a message “on the
wire” or in a “service architecture” method or in a
“clinical document”
– In fact, each of these representations can contain the
same “instance” of information
• Consequently, can be extended incrementally
when new clinical information domains need to
be added, in a way that doesn’t require changing
what has already been createdSlide reproduced/adapted from Dr. Supachai Parchariyanon
38
HL7 V3 Messaging
• V3 provides messaging standards for
– Patient administration
– Medical records
– Orders
– Laboratory
– Claims & Reimbursement
– Care provision
– Clinical genomics
– Public Health
– Etc.
39
Sample HL7 V3 Message
(Patient Registration)<?xml version="1.0" encoding="UTF-8"?>
<PRPA_IN101311UV02 xmlns="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
ITSVersion="XML_1.0" xsi:schemaLocation="urn:hl7-org:v3
../schemas/PRPA_IN101311UV02.xsd">
...
<name use="SYL" >
<given>นวนรรน</given>
<family>ธีระอมัพรพนัธุ์</family>
</name>
<name use="ABC">
<given>Nawanan</given>
<family>Theera-Ampornpunt</family>
</name>
<administrativeGenderCode code="M"/>
...
</PRPA_IN101311UV02>
Message source adapted from Ramathibodi HL7 Project by Supachai Parchariyanon,
Kavin Asavanant, Sireerat Srisiriratanakul & Chaiwiwat Tongtaweechaikit
40
HL7 V3 Reference Information Model
• Referral
• Transportation
• Supply
• Procedure
• Consent
• Observation
• Medication
• Administrative act
• Financial act
• Organization
• Place
• Person
• Living Subject
• Material
• Patient
• Member
• Healthcare facility
• Practitioner
• Practitioner assignment
• Specimen
• Location
Entity0..*
1Role
1
0..*
1
0..*
Act
Relationship
1..*
10..*
1Participation Act
• Author
• Reviewer
• Verifier
• Subject
• Target
• Tracker
• Has component
• Is supported by
Slide reproduced/adapted from Dr. Supachai Parchariyanon
41
HL7 V3 Components and Process: RIM UML Instance Scenario
Classes are color coded:
Green = Entity, Yellow = Role, Blue = Participation, Red/Pink = Act, Purple = Infrastructure, Lilac = message
controller.
John Doe Patient Subject
Entity Role Participation Act
Dr. SmithHealthCare
ProviderSurgeon
John Doe Patient Subject
Has Pertinent
InformationAct Relationship
(Clinical Trial Act)
Protocol ECOG
1112
XYZ
HospitalHealthCare
FacilityLocation
(Procedure Act)
Prostectomy
Slide reproduced/adapted from Dr. Supachai Parchariyanon
42
Reference Information Model (RIM)
Slide reproduced/adapted from Dr. Supachai Parchariyanon
43Source: “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
44
The HL7 V3 Solution
• Approaching “Plug and Play” - less of a
“framework for negotiation”
• Utilizes RIM for data model
• Utilizes XML as transport method
• HL7 V3 is not the next release of HL7 V2 -It is a paradigm shift
Slide reproduced/adapted from Dr. Supachai Parchariyanon
45
The HL7 V3 Solution (Cont.)
• HL7 V3 addresses the problems of HL7 V2
by:– Reducing HL7 V2 optionality
– Including testable conformance rules
• HL7 V3 is based on a formal development
methodology:– Follows an Object Oriented (OO) approach
– Uses Universal Modeling Language (UML) principles
• Most importantly, HL7 V3 supports
semantic interoperabilitySlide reproduced/adapted from Dr. Supachai Parchariyanon
46
Interoperability in HL7 V3
• The Four Pillars of Semantic
Interoperability in HL7 V3– A common Reference Information Model (RIM) which
spans the entire patient care, administrative and
financial healthcare universe
– A well-defined and tool-supported process for deriving
data exchange specifications ("messages") from the
RIM
– A formal and robust Data Type Specification upon
which to ground the RIM
– A formal methodology for binding concept-based terminologies (vocabulary) to RIM attributes
Slide reproduced/adapted from Dr. Supachai Parchariyanon
47
HL7 Model Repository
• Database holding the core of HL7semantic specifications
– RIM
– Storyboards
– Vocabulary domains
– Interaction models
– Message designs
– Message constraints
Slide reproduced/adapted from Dr. Supachai Parchariyanon
48Slide reproduced/adapted from Dr. Supachai Parchariyanon
49
Navigating the V3 Ballot Publication
Slide reproduced/adapted from Dr. Supachai Parchariyanon
50
Navigating the V3 Ballot Publication
• Domains: The Functional Content of the
Publication
– Universal Realm Domains
• Administration Domains
• Health and Clinical Practice Domains
• Common Use Domains
– US Realm domains
• Medicaid Information Technology Architecture
(MITA)
– Other realm specific domains..
Slide reproduced/adapted from Dr. Supachai Parchariyanon
51
Domain Publication Structure
Each Realm contains a collection of
Domains. Domains are further divided into
Topics
• Domain• Topic
Slide reproduced/adapted from Dr. Supachai Parchariyanon
52
V3 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 V3
messaging means
• Need stability, clarity, definition of V3 messaging
Slide reproduced/adapted from Dr. Supachai Parchariyanon
53
The Future of HL7
• FHIR: Fast Healthcare Interoperability
Resources
– Pronounced “Fire”
• FHIR defines a set of “Resources” that
represent granular clinical concepts, which
can be managed in isolation, or
aggregated into complex documents
• Resources are based on simple XML or
JSON structures, with an http-based
RESTful protocolhttp://wiki.hl7.org/index.php?title=FHIR
54
HL7 Clinical Document
Architecture (CDA)
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Department of Community Medicine
Faculty of Medicine Ramathibodi Hospital
Certified HL7 CDA Specialist
Some slides reproduced & adapted with permission from
Dr. Supachai Parchariyanon
55
Message Exchange
• Goal: Specify format
for exchange of data
• Internal vs. external
messages
• Examples HL7 V2
HL7 V3 Messaging
DICOM
NCPDP
Document Exchange
• Goal: Specify format
for exchange of
“documents”
• Examples HL7 V3 Clinical Document
Architecture (CDA)
ASTM Continuity of Care
Record (CCR)
HL7 Continuity of Care
Document (CCD)
Exchange Standards
56
Messages
• Human Unreadable
• Machine Processable
Clinical Documents
• Human Readable
• (Ideally) Machine
Processable
Exchange Standards
57
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Message Exchange
Message
Message
Message
MessageMessage
58
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Clinical Document Exchange
Message containing
Referral Letter
Message containing
Claims Request
Message containing
Lab Report
Message containing
Patient Visit Summary
Message containing
Communicable
Disease Report
59
What Is HL7 CDA?
• “A document markup standard that
specifies structure & semantics of “clinical
documents” for the purpose of exchange” [Source: HL7 CDA Release 2]
• Focuses on document exchange, not
message exchange
• A document is packaged in a message
during exchange
• Note: CDA is not designed for document
storage. Only for exchange!!
60
What is CDA?
• CDA is based on XML
• XML is eXtensible Markup Language
• In XML, structure & format are conveyed
by markup which is embedded into the
information
Slide reproduced/adapted from Dr. Supachai Parchariyanon
61
Clinical Document
Slide reproduced/adapted from Dr. Supachai Parchariyanon
62
A Clinical Document (1)
• A documentation of clinical observations
and services, with the following
characteristics:
Persistence - continues to exist in an
unaltered state, for a time period defined by
local and regulatory requirements
Stewardship - maintained by an organization
entrusted with its care
Potential for authentication - an assemblage
of information that is intended to be legally
authenticated Source: HL7 CDA R2
63
A Clinical Document (2)
• A documentation of clinical observations
and services, with the following
characteristics:
Context - establishes the default context for its
contents; can exist in non-messaging contexts
Wholeness - Authentication of a clinical
document applies to the whole and does not
apply to portions of the document without full
context of the document
Human readability - human readable
Source: HL7 CDA R2
64
A Clinical Document (3)
• A CDA document is a defined & complete
information object that can include
Text
Images
Sounds
Other multimedia content
Source: HL7 CDA R2
65
CDA Releases
• CDA Release 1 (ANSI-approved in 2000)
– First specification derived from HL7 RIM
• CDA Release 2 (2005) - Current Release
– Basic model essentially unchanged from R1
• Document has a header & a body
• Body contains nested sections
• Sections can be coded using standard vocabularies and can
contain entries
– Derived from HL7 RIM Version 2.07
Source: HL7 CDA R2
66
Key Aspects of CDA
• CDA documents are encoded in XML
When alternative implementations are feasible,
new conformance requirements will be issued
• CDA documents derive their machine
processable meaning from HL7 RIM and
use HL7 V3 Data Types
• CDA specification is richly expressive &
flexible
Templates can be used to constrain generic
CDA specificationsSource: HL7 CDA R2
67
Scope of CDA
• Standardization of clinical documents for
exchange
• Data format of clinical documents outside
of exchange context (such as data format
used to store clinical documents) is
out-of-scope
Source: HL7 CDA R2
68
Scope of CDA
• CDA doesn’t specify creation or
management of documents and messages
related to document management
• Instead, HL7 V3 Structured Documents
WG provides specifications on standards
for document exchange within HL7 V3
messages (where CDA clinical documents
can become contents of the messages)
Source: HL7 CDA R2
69
Scope of CDA
Lab Technician Physician
Lab Report
Create
document
Process &
Store
document
Transmit
document
CDA
70
Scope of document content
• Clinical content of the documents is
defined by the RIM and not by CDA.
• CDA only standardizes the structure and
semantics required to exchange documents.
Slide reproduced/adapted from Dr. Supachai Parchariyanon
71
Goals of CDA (1)
• Give priority to delivery of patient care
• Allow cost effective implementation across
as wide a spectrum of systems as possible
• Support exchange of human-readable
documents between users, including those
with different levels of technical
sophistication
• Promote longevity of all information
encoded according to this architecture
Source: HL7 CDA R2
72
Goals of CDA (2)
• Enable a wide range of post-exchange
processing applications
• Be compatible with a wide range of document
creation applications
• Promote exchange that is independent of the
underlying transfer or storage mechanism
• Prepare the design reasonably quickly
• Enable policy-makers to control their own
information requirements without extension to this
specification
Source: HL7 CDA R2
73
CDA & HL7 Messages
• Documents complement HL7 messaging
specifications
• Documents are defined and complete information
objects that can exist outside of a messaging
context
• A document can be a MIME-encoded payload
within an HL7 message
Source: “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
74
CDA & Message Exchange
• CDA can be payload (or content) in any kind of
message
– 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 to
another
Source: “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
75
CDA & Message Exchange
Clinical Document
(Payload)
HL7 V3 Message
(Message)
HL7 V2 Message
(Message)
Source: Adapted from “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
76
CDA As Payload
Source: From “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
77
MIME
• Multipurpose Internet Mail Extensions
• An Internet standard that extends the format of e-
mail to support
– Text in non-ASCII character sets
– Non-text attachments
– Message bodies with multiple parts
– Etc.
• Often used in e-mails & some HTTP data
• Encoding: e.g. base64 (converting bits into
64 ASCII charactersSource: http://en.wikipedia.org/wiki/MIME
78
Base64 Encoding
• TWFuIGlzIGRpc3Rpbmd1aXNoZWQsIG5vdCBvbmx5IGJ
5IGhpcyByZWFzb24sIGJ1dCBieSB0aGlzIHNpbmd1bG
FyIHBhc3Npb24gZnJvbSBvdGhlciBhbmltYWxzLCB3a
GljaCBpcyBhIGx1c3Qgb2YgdGhlIG1pbmQsIHRoYXQg
YnkgYSBwZXJzZXZlcmFuY2Ugb2YgZGVsaWdodCBpbiB
0aGUgY29udGludWVkIGFuZCBpbmRlZmF0aWdhYmxlIG
dlbmVyYXRpb24gb2Yga25vd2xlZGdlLCBleGNlZWRzI
HRoZSBzaG9ydCB2ZWhlbWVuY2Ugb2YgYW55IGNhcm5h
bCBwbGVhc3VyZS4=
• Man is distinguished, not only by his reason, but by this singular
passion from other animals, which is a lust of the mind, that by a
perseverance of delight in the continued and indefatigable generation of knowledge, exceeds the short vehemence of any carnal pleasure.
Source: http://en.wikipedia.org/wiki/Base64
79
Components of CDA Document
• Header
– Metadata requires for document discovery,
management, retrieval
• Body
– Section
– Entry (machine processable part)
– Narrative Block (human readable part)
Source: HL7 CDA R2
80
Major Components of a CDA
• A CDA document is wrapped by the
<ClinicalDocument> element, and contains a
header and a body.
• The header lies between the <ClinicalDocument>
and the <StructuredBody> elements and identifies
and classifies the document and provides
information on authentication, the encounter, the
patient, and the involved providers.
Slide reproduced/adapted from Dr. Supachai Parchariyanon
81
Major Components of a CDA
Slide reproduced/adapted from Dr. Supachai Parchariyanon
82
CDA Model
Source: From “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
83
A Closer Look at a CDA Document
<ClinicalDocument> ... CDA Header ...
<structuredBody> <section> <text>... Single
Narrative Block ...</text>
<observation>...</observation>
<substanceAdministration>
<supply>...</supply>
</substanceAdministration> <observation>
<externalObservation>...
</externalObservation> </observation>
</section> <section> <section>...</section>
</section> </structuredBody>
</ClinicalDocument>
Source: HL7 CDA R2
Human Readable Part
Machine Processable Parts
84
Body –Structured Body (Human Readable)
<section>
<caption>
<captionCode V="11496-7" S=“LOINC"/>
Allergies and Adverse Reactions
</caption>
<list>
<item><content ID=“A1”>Penicillin - Hives</content></item>
<item><content>Aspirin - Wheezing</content></item>
<item>
<content>Codeine – Itching and nausea</content>
</item>
</list>
<coded_entry>
<coded_entry.value ORIGTXT=“A1” V="DF-10074" S=“SNOMED“ DN=“Allergy to Penicillin”/>
</coded_entry>
</section>
Na
rra
tive
Co
mp
uta
ble
REQUIRED
Slide reproduced/adapted from Dr. Supachai Parchariyanon
85
Body - Structured Body (Machine Processable)
<text>
<list>
<item><content ID="A1">Penicillin – Hives …
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="84100007" codeSystem="2.16.840.1.113883.6.96“
codeSystemName="SNOMED CT" displayName="History taking"/>
<value xsi:type="CD" code="247472004"
codeSystem="2.16.840.1.113883.6.96" displayName="Hives">
<originalText><reference value="#A1"/></originalText>
</value>
<entryRelationship typeCode="MFST">
<observation classCode="OBS" moodCode="EVN">
<code code="84100007" codeSystem="2.16.840.1.113883.6.96"
displayName="History taking"/>
<value xsi:type="CD" code="91936005“ CodeSystem="2.16.84…"
displayName=“PCN Allergy"/>
Narr
ative
Com
puta
ble
OPTIONAL
Slide reproduced/adapted from Dr. Supachai Parchariyanon
86
Rendering CDA Documents (1)
Source: From “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
87
Rendering CDA Documents (2)
Source: From “What is CDA R2? by Calvin E. Beebe
at HL7 Educational Summit in July 2012
88
Rendering CDA Documents (3)
• Different recipients may use different style sheets
to render the same CDA document, and thus may
display it differently (but the same content is
presented)
• This can help facilitate display of CDA documents
with specific preferences or local requirements
89
CDA & Document Management
• CDA focuses on document exchange, not
storage or processing
• Clinical documents are used for various reasons
– Clinical care
– Medico-legal reasons (as evidence)
– Auditing
– Etc.
• Clinical documents may contain errors or need
data updates (e.g. preliminary lab results vs. final
results)
90
Some Possible Use Cases of CDA
Intra-institutional
Exchange of parts of medical records (scanned or
structured 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)
91
Some 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
92
Achieving Interoperability
CDA is a general-purpose, broad standard
Use in each use case or context requires
implementation 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)
93
CDA Summary
CDA is a markup standard for document
exchange
Not message exchange
Not document storage or processing
CDA is a general-purpose standard
Use in specific context requires
Implementation Guides (and possibly
Extensions)
94
CDA Summary
CDA is XML-based and RIM-based
CDA documents can be exchanged as
encapsulated data (payload) in any message
(HL7 V2, HL7 V3, etc.)
CDA is not dependent on using HL7 V3
messages
Most likely early use cases for CDA
Referrals
Claims & Reimbursements
Lab/imaging Reports
Electronic Health Records Documents
95
HL7: Take Home Message
• HL7 is not panacea and so does other standards
• People and processes matter most
• Do not aim to build HIS to comply with HL7
specification but do aim to let it be able to
communicate to another systems via HL7
• Most specifications in standards and
interoperability provide framework but not
implementation guide, at times you need experts
Slide reproduced/adapted from Dr. Supachai Parchariyanon
96
Additional Information
• Health Level Seven http://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
• HL7 v3: – “Driving Interoperability & Transforming Healthcare Information
Management” by Charles Mead, MD, MSc.
– http://www.healthcare-informatics.com/webinars/05_20_04.htm
• FHIR: http://www.hl7.org/implement/standards/fhir/
Slide reproduced/adapted from Dr. Supachai Parchariyanon
97
Q/A
Slide reproduced/adapted from Dr. Supachai Parchariyanon