hl7 v3 教育訓練系列教材

HL7 v3HL7 v3 教育訓練系列教材教育訓練系列教材

HL7 Taiwan 協會秘書長 范士展

sjvann@gmail.com

HL7 Taiwan Google 論壇 :http://groups.google.com/group/hl7-taiwan

教育訓練委員會Education Technical Committees

版權所有：台灣健康資訊交換第七層協定協會

CDA R2CDA R2 說明說明

1. CDA R2 簡介2. 文件與訊息差異3. CDA R2 規範4. CDA R2 詳述

CDA R2簡介

說明 Clinical Document Architecture ANSI/HL7 CDA R1.0-2000 ANSI/HL7 CDA R2.0-2005ANSI/HL7 CDA R2.0-2005 Created & maintained by HL7 Structured Documents

Technical Committee (SDTC) A specification for document exchange using

XML, the HL7 Reference Information Model (RIM) Version 3 methodology and vocabulary (SNOMED, ICD, local,…)

LOINC 此系統由臨床病理學家，化學家和實驗室服務開發商

組成的特別團體 the Community of Scholars of the Regenstrief Institute for Health Care 在哈特福德基金會、美國國立醫學圖書館（ NLM ）和美國醫療法規研究署（ AHCPR ）的支援下發展而成。此專案的目標是産生一個用於 ASTM E1238 和 HL7 第 2.2 版實驗室結果和觀察資訊前後關聯通用的檢驗代碼系統。 LOINC 資料庫包括化學，毒物學，血清學，微生物學和一些臨床變數的實驗室觀察報告的記錄。目前資料庫中大約包含 32,000 觀察術語（ observation terms ），其中 20,000 條於實驗室試驗相關。 LONIC可從 INTERNET 上下載，免費使用

SNOMED 以前稱爲：人類與獸類醫學系統術語（ Systematized

Nomenclature of Human and Veterinary Medicine ）。 1933年 , 紐約醫學院就開始醫學術語資料庫的研究，即所謂標準疾病分類術語（ the Standard Classified Nomenclature of Diseases ）。 1961 年美國醫學協會繼續從事這項工作 , 並於 1965 年由美國病理學家協會（ the American College of Pathologists ）出版了病理學系統術語 (the Systematic Nomenclature of Pathology, SNOP) 編碼系統。 SNOP 奠定了人和動物醫學系統化術語 (the Systematic Nomenclature of Human and Veterinary Medicine, SNOMED) 的基礎 , 成爲專用術語集的範例。 SONMED 于 1975 年發行，最新版本稱爲：國際 SNOMED （ SNOMED International ）

ICD 10 由世界衛生組織（ WHO ）在歐洲早期制定的標準上發展形成的， ICD 編碼是最初是用於疾病率和死亡率的統計。 1900 年出版了第一版，約每十年進行一次修訂。在第六個版本以後逐步拓展到用於醫院臨床診斷與手術操作的分類、檢索、統計方面的應用。在此基礎上衍生出多個其他版本和標準，如 :ICD-9-CM 是 ICD-9 在美國的臨床修訂版本，也是美國 DRG 的基礎。 1992 年出版了第十個版本，這個版本進行了很多的擴展和修改，並開始適應流行病學與保健評估方面的需求

CDA是電子文件交換規範 This is a CDA and this and this and this and this and this and this

CDA是電子文件交換規範 CDA 可以是

Discharge SummaryCare Record SummaryProgress NoteH&PPublic health report

… 任何帶有簽章的內容

What is a document? CDA documents are not birth-to-death

aggregate records CDA documents are defined and complete

information object that can exists outside of a message and can include text, images, sounds and other multimedia content

甚麼是電子文件 從 XML 角度，任何一種都是“ document” 直覺的角度， documents 是 :

表現出歷史醫療記錄格式把分散的資料及片斷病歷敍述整合在一起

CDA給一系列的 healthcare documents 一些規範

A clinical document ... 有以下的特色 : Persistence 永久性 Stewardship管理性 Potential for authentication鑑別性 Context 關連性 Wholeness完整性 Human readability閱讀性

因此 CDA documents 不是 : data 碎片除非已簽核 出生至死亡的記錄已簽章文件的集合

CDA document 定義

CDA的设计

文件與訊息差異

Relationship to HL7 messages CDA補足 HL7 messaging 的規格 CDA 文件是已被定義且完整的資訊物件。他可以存在與訊息本體之外。

CDA 文件可用 MIME 編碼放入 HL7 message 中

Messages

can be the same

differ

Messages

can be the same

differ

Documents

can be the same

differ

Documents

can be the same

differ

Content

Intent & use cases

CDA documents::HL7 messages

CDA documents::HL7 messages

Messages

temporary

system-to-system

... not messages

signed?legally accepted?

designed per use case

Messages

temporary

system-to-system

... not messages

signed?legally accepted?

designed per use case

Documents

persistent

human-to-human

care-givers are trained to create documents ...

have legal standing

defined by precedent

Documents

persistent

human-to-human

care-givers are trained to create documents ...

have legal standing

defined by precedent

Lifetime

Commu-nication

Relationto care-givers

Legalaspects

Source

HL7 V2.x

MSH|...EVN|...PID|...PV1|...TXA|...OBX|1|ED|...

|...

CDA documents are encapsulated as MIME packages within HL7 messages

Relationship to HL7 messages

HL7 V3

<Act.Code code="11488-4" codeSystem="2.16.840.1.113883.6.1" displayName="Consultation note"/>

<Act.text type="multipart/related"> MIME-Version: 1.0 Content-Type: multipart/related; boundary="HL7-CDA-boundary"; type="text/xml"; start="10.12.45567.43" Content-Transfer-Encoding: BASE64

General Relationship to Messaging CDA can be the payload in any kind of

message

And can be passed from one kind to another

V2

V3

X12

XDS

CDA R2規範

CDA R-MIM

CDA Header CDA Body,Section, andNarrative Block

Ext'l Refs CDA Entries

CDA = header + body CDA Header

Metadata required for document discovery, management, retrieval

CDA Body Clinical report

Discharge Summary Care Record Summary Progress Note H&P Public health report

… any content that carries a signature

CDA Header The header describes:

The document itself (unique ID, document type classification, version)

Participants (providers, authors, patients…)Document relationships (to orders, other

documents…) Metadata sufficient for document management

XML Body: two types of markup Human-readable “narrative block”, all that is

required to reproduce the legal, clinical content

Optional machine-readable CDA Entries, which drive automated processes

Header Body

Readable: required Computable: optional

Sample CDA

CDA Header: Metadata

Identify Patient Provider Document type...

Sufficient for Medical records management Document management Registry/repositoryg Record locator service Store, query, retrieve

required

CDA Body: Human-readable report

Any type of clinical document H&P Consult Op note Discharge Summary...

Format: tif, PDF, HTML, XML: Paragraph List Table Caption Link Content Presentation

required

CDA Body: Machine Processible Model-based computable semantics:

Observation Procedure Organizer Supply Encounter Substance Administration Observation Media Region Of Interest Act

Optional

CDA: Incremental Computability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (“semantic interoperability”)

CDA R2詳述

The CDA Spec Itself Prose document (pdf or html) RMIM: Refined model (Visio or gif) HMD: Hierarchical Descriptor (table or

spreadsheet) Data types: abstract and XML NOTE: W3C xsd schemas informative

CDA文件

How the CDA is developed and maintained: just enough HL7 Development FrameworkReference Information Model

RMIM

Hierarchical Description

XML Schema

• linearization• additional constraints

• algorithm

• subset of RIM• tighten constraints

The CDA Hierarchical Descriptor

How the XSDs fit together

Level 1

CDA Header is Described

Document Type(s)

Level 2

Assumes XML Body Content

Prescribes:

the Sections,

their Order

and Section Identifier Codes

Level 3

CDA Entries

Vocabulary [Codes]

Relationships

Semantics

The CDA HeaderDocument identification and classification

Participants

Related documents/events

The CDA Body XML or non-XML

Non-XML body

XML Body

Series of recursive sections

Sections establish context and include narrative and entries

identify

set context

Section Narrative

CDA & V3 Data Types

CDAData type

CDA Revisions & Addenda

R-MIM

CDA Header CDA Body, Section, and Narrative Block

CDA Entries Ext'l Refs

CDA HeaderGood Health Clinic Consultation note Consultant: Robert Dolin, MDDate: April 7, 2000Patient: Henry Levin, the 7th MRN: 12345 Sex: MaleBirthdate: September 24, 1932

<?xml version="1.0"?><ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.ReleaseTwo.CommitteeBallot01.July.2003.xsd"><!-- ******************************************************** CDA Header********************************************************-->

Header ElementsGood Health Clinic Consultation note Consultant: Robert Dolin, MDDate: April 7, 2000Patient: Henry Levin, the 7th MRN: 12345 Sex: MaleBirthdate: September 24, 1932

<id extension="c266" root="2.16.840.1.113883.3.933"/><code code="11488-4“codeSystem="2.16.840.1.113883.6.1“ displayName="Consultation note"/><title>Good Health Clinic Consultation Note</title><effectiveTime value="20000407"/><setId extension="BB35" root="2.16.840.1.113883.3.933"/><versionNumber value="2"/><relatedDocument typeCode="RPLC"> <parentDocument> <id extension="a123" root="2.16.840.1.113883.3.933"/> <setId extension="BB35"root="2.16.840.1.113883.3.933"/> <versionNumber value="1"/> </parentDocument> </relatedDocument>

<documnetationOf><inFulfillmentOf><authorization><componentOf>

R-MIM

CDA Header CDA Body, Section, and Narrative Block

CDA Entries Ext'l Refs

Header ElementsGood Health Clinic Consultation note Consultant: Robert Dolin, MDDate: April 7, 2000Patient: Henry Levin, the 7th MRN: 12345 Sex: MaleBirthdate: September 24, 1932

<recordTarget><patientRole>

<id extension="12345" root="2.16.840.1.113883.3.933"/><patientPatient><name>

<given>Henry</given><family>Levin</family><suffix>the 7th</suffix></name>

<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>

<birthTime value="19320924"/></patientPatient></patientRole>

</recordTarget>

R-MIM

CDA Header CDA Body, Section, and Narrative Block

CDA Entries Ext'l Refs

CDA Body

History of Present IllnessHenry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his twenties teens. He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months. Past Medical HistoryAsthmaHypertension (see HTN.cda for details) Osteoarthritis, right kneeMedicationsTheodur 200mg BIDAlbuterol inhaler 2puffs QID PRNPrednisone 20mg qdHCTZ 25mg qd

<!-- ******************************************************** CDA Body********************************************************-->

<component><StructuredBody>

<!--

R-MIM

CDA Header CDA Body, Section, and Narrative Block

CDA Entries Ext'l Refs

CDA Section Narrative Block

History of Present IllnessHenry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his twenties teens. He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months. Past Medical HistoryAsthmaHypertension (see HTN.cda for details) Osteoarthritis, right kneeMedicationsTheodur 200mg BIDAlbuterol inhaler 2puffs QID PRNPrednisone 20mg qdHCTZ 25mg qd

<!-- ******************************************************** History of Present Illness section********************************************************--><component>

<section><code code="10164-2" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC"/><text>Henry Levin, the 7th is a 67 year old male referred for further asthma

management. Onset of asthma in his <delete>twenties</delete><insert>teens</insert>. He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months. </text>

<title>History of Present Illness</title></section>

</component>

<content> <link><renderMultiMedia> <paragraph> <list> <item> <table> <tr> <th> <td><caption>

CDA Section Narrative BlockPast Medical History•Asthma•Hypertension (see HTN.cda for details) •Osteoarthritis, right kneeMedications•Theodur 200mg BID•Albuterol inhaler 2puffs QID PRNPrednisone 20mg qdHCTZ 25mg qdAllergies & Adverse ReactionsPenicillin - HivesAspirin - WheezingCodeine – Itching and nausea

<component> <section> <code code="10153-2" codeSystem="2.16.840.1.113883.6.1“ codeSystemName="LOINC"/> <text> <list> <item><content ID="a1">Asthma</content></item> <item><content ID="a2">Hypertension (see HTN.cda for details)</content></item> <item><content ID="a3">Osteoarthritis, <content ID="a4">right knee</content></content></item> </list> </text> <title>Past Medical History</title> <component1>

<Observation classCode="COND"><code code="G-1001" codeSystem="2.16.840.1.113883.6.5"

codeSystemName="SNOMED" displayName="Prior dx"/><effectiveTime value="1950"/>

<value xsi:type="CD" code="D2-00036"

CDA Entries

XML File

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