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HL7 v3 教育訓練系列教材

教育訓練委員會 Education Technical Committees. HL7 v3 教育訓練系列教材. 版權所有：台灣健康資訊交換第七層協定協會. 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. CDA R2 說明. CDA R2 簡介 文件與訊息差異 CDA R2 規範 CDA R2 詳述. CDA R2 簡介. 說明. Clinical Document Architecture

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HL7 v3 教育訓練系列教材

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  1. 教育訓練委員會 Education Technical Committees HL7 v3教育訓練系列教材 版權所有：台灣健康資訊交換第七層協定協會 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

  2. CDA R2說明 CDAR2簡介 文件與訊息差異 CDAR2規範 CDA R2詳述

  3. CDAR2簡介

  4. 說明 • Clinical Document Architecture • ANSI/HL7 CDA R1.0-2000 • ANSI/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,…)

  5. 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

  6. 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）

  7. 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

  8. 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

  9. CDA是電子文件交換規範 • CDA 可以是 • Discharge Summary • Care Record Summary • Progress Note • H&P • Public health report • … 任何帶有簽章的內容

  10. 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

  11. 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

  12. CDA document定義 • 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

  13. CDA的设计

  14. 文件與訊息差異

  15. 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

  16. CDA documents::HL7 messages Documents can be the same differ Messages can be the same differ Content Intent & use cases

  17. CDA documents::HL7 messages Documents persistent human-to-human care-givers are trained to create documents ...have legal standing defined by precedent Messages temporary system-to-system ... not messages signed?legally accepted? designed per use case Lifetime Commu-nication Relationto care-givers Legalaspects Source

  18. Relationship to HL7 messages • CDA documents are encapsulated as MIME packages within HL7 messages HL7 V2.x MSH|... EVN|... PID|... PV1|... TXA|... OBX|1|ED|... |... 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

  19. General Relationship to Messaging • CDA can be the payload in any kind of message • And can be passed from one kind to another V2 X12 V3 XDS

  20. CDAR2規範

  21. CDA Body, Section, and Narrative Block CDA Header CDA Entries CDA R-MIM Ext'l Refs

  22. 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

  23. 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

  24. 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

  25. Sample CDA • Header • Body • Readable: required • Computable: optional

  26. CDA Header: Metadata • Identify • Patient • Provider • Document type... • Sufficient for • Medical records management • Document management • Registry/repositoryg • Record locator service • Store, query, retrieve required

  27. 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

  28. CDA Body: Machine Processible • Model-based computable semantics: • Observation • Procedure • Organizer • Supply • Encounter • Substance Administration • Observation Media • Region Of Interest • Act Optional

  29. CDA: Incremental Computability • Standard HL7 metadata • Simple XML for point of care human readability • RIM semantics for reusable computability (“semantic interoperability”)

  30. CDA R2詳述

  31. 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

  32. CDA文件

  33. How the CDA is developed and maintained: just enough HL7 Development Framework RMIM Reference Information Model • subset of RIM • tighten constraints • linearization • additional constraints XML Schema • algorithm Hierarchical Description

  34. The CDA Hierarchical Descriptor

  35. How the XSDs fit together

  36. The CDA Header Document identification and classification Participants Related documents/events

  37. The CDA Body • XML or non-XML

  38. Non-XML body

  39. XML Body identify Sections establish context and include narrative and entries Series of recursive sections set context

  40. Section Narrative

  41. CDA & V3 Data Types Data type CDA

  42. CDA Revisions & Addenda

  43. R-MIM CDA Body, Section, and Narrative Block Ext'l Refs CDA Header CDA Entries

  44. CDA Header Good Health Clinic Consultation note Consultant: Robert Dolin, MD Date: April 7, 2000 Patient: Henry Levin, the 7th MRN: 12345 Sex: Male Birthdate: 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 ******************************************************** -->

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