The Use of HL7 CDA in the National Health Information System (NHIS) of Turkey

1. The Use of HL7 CDA in the National Health Information System (NHIS) of Turkey Yildiray KABAK, Asuman DOGAC, İlker KÖSE, Nihat AKPINAR, Murat GÜREL, Yakup ARSLAN, Hakan ÖZER, Nihat YURT, Ahmet ÖZÇAM, Soner KIRICI, Mustafa Yüksel and Erdinç SABUR IHIC 2008

2. NHIS, Turkey (Sağlık-Net)Infrastructure • Turkey’s National Health Information System (NHIS) aims to provide a nation-wide infrastructure for sharing the Electronic Health Records (EHRs) • The current implementation supports the transfer of EHRs, called the “Transmission Schema” instances from the field to the NHIS servers at the Ministry of Health (MoH) • During the localization of the “Transmission Schemas”, the rules which are set in the “HL7 Refinement, Constraint and Localization” are applied IHIC 2008

3. Sağlık-Net Infrastructure Doctor Data Bank National Citizenship No Server IHIC 2008

4. Sağlık-Net “Transmission Schemas” • “Transmission Schemas” are HL7 v3 conformant messages; HL7 CDA is used as the EHR content format with some modification • The “Transmission Schemas” are based on the national Minimum Health Data Sets (MHDS) • The MHDSs use the data elements from the National Health Data Dictionary (NHDD) • http://www.sagliknet.saglik.gov.tr:7750/USVSBrowser/All.jsp • CDA sections: Minimum Health Data Sets • Patient Identifiers: Turkish Citizen numbers checked from MERNIS database • http://www.nvi.gov.tr/Hakkimizda/Projeler,Spot_Mernis.html IHIC 2008

5. NHIS “Transmission Schemas” • Healthcare Professional Identifiers: Checked from the Doctor Data Bank • http://sbu.saglik.gov.tr/drBank/drbilgileri2.aspx • Codes used: Checked from the National Health Coding Reference Server • http://sbu.saglik.gov.tr/SKRS2%5FListesi/ • Security and Privacy: Various view mechanisms to hide the patient demographics information • Transport: HL7 Web services Profile with WS-Security over SSL • Business rules: Checked with Schematron rules IHIC 2008

6. The National Health Data Dictionary (NHDD) • The National Health Data Dictionary (NHDD)is developed to enable the parties to share the same meaning of data • 46 Minimum Health Data Sets (MHDS) and 261 data elements Some data elements Some MHDSs • Address • Name • Main Diagnosis • Vaccination • Treatment Method • Diastolic Blood Pressure • Healthcare Institution • Marital Status • Citizen/Foreigner Registration MHDS • Medical Examination MHDS • Prescription MHDS • Pregnant Monitoring MHDS • Cancer MHDS • Inpatient MHDS IHIC 2008

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8. An Example Transmission Schema IHIC 2008

9. Health Coding Reference Server (HCRS) • The data elements within the Minimum Health Data Sets are mostly coded with coding systems in use in Turkey • All these coding systems are available at the Health Coding Reference Server (HCRS) as Web services • If a data element is defined in the National Health Data Dictionary as coded or classified, then within the definition of the data element, the related coding/classification system is given in the “HCRS System Code” field • There are three possibilities for a coded element: • Either the value is gathered from a coding system such as ICD-10, or • Coded values for healthcare institutes, or physicians’ specialties, or • The value is of parametric kind such as “gender” or “marital status” IHIC 2008

10. Healthcare Professional Registry • Ministry of Health is authorized to provide the work licenses to the physicians in Turkey • The diploma/specialty information of the medical professionals is recorded together with their Turkish citizenship numbers in the Doctor Data Bank (DDB) • As of October 2007, there are 162,446 registered doctors in the data bank • The Doctor Data Bank is for checking the validity of the healthcare professional identity in the “Transmission Schema” • Later it will be used authorizing access to the EHRs of the patients IHIC 2008

11. Transporting EHRs • HL7 Web Service Profile is used • 25 HL7 Web Services IHIC 2008

12. Handling Security and Privacy • There are two types of administrators in the system: • Security Administrator is in charge of granting rights to the Database Administrators but they themselves have no right to access the database • Various “View” mechanisms are developed to hide the patient demographics data from the unauthorized users • The MoH has selected Oracle Identity Management System • Access to NHIS data is audited by logging all the user events • Currently the work is going on for determining the legal ground about the access rights of various types of users IHIC 2008

13. Testing the Conformance and the Interoperability of HISs/FMISs to NHIS • The NHIS Web services conveying “Transmission Schemas” from the Family Medicine Information Systems (FMIS) and the Hospital Information Systems (HIS) to the MoH NHIS servers are being tested with test data since February 2008 • The TestBATN (Testing Business Process, Application, Transport and Network Layers) is used for this purpose • TestBATN system customized to NHIS, Turkey with 200 test scenarios categorized under 25 test suites • The TestBATN services with these test scenarios are publicly available from MoH, Turkey servers with more than 60 active users daily: • https://212.175.169.50:8443/testexecution/TestExecutionGUI.html IHIC 2008

14. Deployment… • How ready are the NHIS Web Services? • NHIS Web services are being tested since February 2008 and they are ready • Currently stress tests are being applied • How ready are the vendors of HIS and FMIS? • The call center established is actively supporting the developers • http://cagri.saglik.gov.tr/cagrimerkezi/login_page.php • The major HIS vendors seems to be ready for the integration • Starting with January 1, 2009, all the healthcare institutes in Turkey including the hospitals and healthcare posts are obliged to transmit health related data through NHIS IHIC 2008

15. The Main Differences Between the “Transmission Schemas” and HL7 CDA • In an HL7 CDA R2 compliant EHR, the <ClinicalDocument> is the root element • In the “Transmission Schemas” the root of the document is the name of the transmission schema, e.g., <examination> • In HL7 CDA, the dataset sections should start with “<section>” tag • In the “Transmission Schemas”, the name of the opening tag of a section is the name of the dataset concatenated with “Dataset” keyword, e.g., “<examinationDataset>” IHIC 2008

16. The Main Differences Between the “Transmission Schemas” and HL7 CDA • In the “Transmission Schemas”, data elements’ sections do not start with “<section>” tag; the tag name is the name of the data element concatenated with “Section” keyword, e.g., <diagnosisSection> • In the Level One CDA Schema, the body is composed of “<section>” elements combined with “<component>” elements • In the NHIS implementation, the components are numbered sequentially IHIC 2008

17. The Result of the Modifications • These modifications have greatly facilitated the fast deployment of NHIS Web services • The XML schemas themselves contain the constraints rather than expressing the constraints as a set of rules • The validation of an incoming message is performed by checking it with the corresponding “Transmission Schema” XSD • However, for the syntax validation of an HL7 CDA R2 conformant EHR, an incoming EHR document is • First validated against CDA Level One XSD and then • Against the structural Schematron rules which check the constraints on the entries and the sections IHIC 2008

18. What is the Down Side of the “Transmission Schemas”? • Making modifications in the “Transmission Schemas” is difficult • Rather than changing the Schematron rules, you need to change the schemas themselves and the code that processes them • Since the “Transmission Schemas” are not HL7 CDA conformant, cross border interoperability is reduced • Our Solution: Generating HL7 CDA conformant EHRs from the “Transmission Schemas” IHIC 2008

19. Sharing Electronic Healthcare Records Across Country Borders • Generating both • HL7 CDA R2, and • CEN 13606-1 EHRcom • compliant EHRs from the “Transmission Schemas” are described in • “Sharing Electronic Healthcare Records Across Country Borders”, Mustafa Yuksel, M. S. Thesis, Dept. of Computer Eng., METU, Sept. 2008. IHIC 2008

20. Example transformations <examination classCode="DOCCLIN" moodCode="EVN"> [CDA Header] <component typeCode="COMP" contextConductionInd="true"> <structuredBody classCode="DOCBODY" moodCode="EVN"> <component1 typeCode="COMP" contextConductionInd="true"> <testResultDataset classCode="DOCSECT" moodCode="EVN"> ... </testResultDataset> </component1> <component2 typeCode="COMP" contextConductionInd="true"> <dischargeDataset classCode="DOCSECT" moodCode="EVN"> ... </dischargeDataset> </component2> <component3 typeCode="COMP" contextConductionInd="true"> <examinationDataset classCode="DOCSECT" moodCode="EVN"> ... </examinationDataset> </component3> ... </structuredBody> </component> </examination> <ClinicalDocument classCode="DOCCLIN" moodCode="EVN"> [CDA Header] <component typeCode="COMP" contextConductionInd="true"> <structuredBody classCode="DOCBODY" moodCode="EVN"> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> ... </section> </component> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> ... </section> </component> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> ... </section> </component> ... </structuredBody> </component> </examination> IHIC 2008

21. An example XSL Transformation Rule <xsl:template name="dischargeDataset-component1"> <xsl:element name="component"> <xsl:copy-of select="@*" copy-namespaces="no"/> <xsl:element name="section"> ... <xsl:for-each select="hl7:dischargeDiagnosisSection/hl7:component"> <xsl:call-template name="dischargeDataset-component1-component"/> </xsl:for-each> </xsl:element> </xsl:element> </xsl:template> <xsl:template name="dischargeDataset-component1-component"> <xsl:element name="entry"> <xsl:copy-of select="@*" copy-namespaces="no"/> <xsl:element name="observation"> <xsl:attribute name="classCode">OBS</xsl:attribute> <xsl:attribute name="moodCode">EVN</xsl:attribute> <xsl:copy-of select="hl7:dischargeDiagnosis/hl7:code" copy-namespaces="no"/> <xsl:element name="value"> <xsl:attribute name="xsi:type">CV</xsl:attribute> <xsl:copy-of select="hl7:dischargeDiagnosis/hl7:value/@*" copy-namespaces="no"/> </xsl:element> </xsl:element> </xsl:element> </xsl:template> IHIC 2008

22. Semantic Interoperability • The previous objective accomplished structural interoperability, which is crucial • However, more is needed in order to enable semantic interoperability • Mapping of coded terms from locally developed coding systems to international counterparts to the extend possible • Our solution: Terminology Server based modular architecture for automatic mapping of the local coded terms • Unified Medical Language System (UMLS) Knowledge Source Server (KSS) as the Terminology Server IHIC 2008

23. Demo and Questions Thank you for your attention... IHIC 2008