The Use of HL7 CDA in the National Health by ngs20854


									       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

October 10, 2008                 IHIC 2008
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

October 10, 2008                  IHIC 2008
Sağlık-Net Infrastructure

                               Doctor Data

                                 Citizenship No

October 10, 2008   IHIC 2008
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)

    CDA sections: Minimum Health Data Sets

    Patient Identifiers: Turkish Citizen numbers checked from
     MERNIS database

October 10, 2008                     IHIC 2008
NHIS “Transmission Schemas”
    Healthcare Professional Identifiers: Checked from the Doctor
     Data Bank

    Codes used: Checked from the National Health Coding
     Reference Server

    Security and Privacy: Various view mechanisms to hide the
     patient demographics information

    Transport: HL7 Web services Profile with WS-Security over

    Business rules: Checked with Schematron rules

October 10, 2008                      IHIC 2008
The National Health Data Dictionary
    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
         Some data elements                         Some MHDSs
                  Address                               Citizen/Foreigner Registration
                  Name                                   MHDS
                  Main Diagnosis                        Medical Examination MHDS
                  Vaccination                           Prescription MHDS
                  Treatment Method                      Pregnant Monitoring MHDS
                  Diastolic Blood Pressure              Cancer MHDS
                  Healthcare Institution                Inpatient MHDS
                  Marital Status

October 10, 2008                              IHIC 2008
October 10, 2008   IHIC 2008
An Example Transmission Schema

October 10, 2008   IHIC 2008
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,
         Coded values for healthcare institutes, or physicians’ specialties, or
         The value is of parametric kind such as “gender” or “marital status”

October 10, 2008                       IHIC 2008
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

October 10, 2008                  IHIC 2008
Transporting EHRs

    HL7 Web Service Profile is used
         25 HL7 Web Services

October 10, 2008                IHIC 2008
    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

    October 10, 2008                IHIC 2008
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 :

October 10, 2008                     IHIC 2008
    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


      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

October 10, 2008                  IHIC 2008
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>”

    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>”

October 10, 2008                 IHIC 2008
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

October 10, 2008           IHIC 2008
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

October 10, 2008                 IHIC 2008
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”

October 10, 2008                 IHIC 2008
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.

October 10, 2008                       IHIC 2008
     Example transformations
<examination classCode="DOCCLIN" moodCode="EVN">                <ClinicalDocument classCode="DOCCLIN"
 [CDA Header]                                                   moodCode="EVN">
 <component typeCode="COMP" contextConductionInd="true">         [CDA Header]
  <structuredBody classCode="DOCBODY" moodCode="EVN">            <component typeCode="COMP"
    <component1 typeCode="COMP"                                 contextConductionInd="true">
contextConductionInd="true">                                      <structuredBody classCode="DOCBODY"
      <testResultDataset classCode="DOCSECT"                    moodCode="EVN">
moodCode="EVN">                                                     <component typeCode="COMP"
        ...                                                     contextConductionInd="true">
      </testResultDataset>                                            <section classCode="DOCSECT" moodCode="EVN">
    </component1>                                                       ...
    <component2 typeCode="COMP"                                       </section>
contextConductionInd="true">                                        </component>
      <dischargeDataset classCode="DOCSECT"                         <component typeCode="COMP"
moodCode="EVN">                                                 contextConductionInd="true">
        ...                                                           <section classCode="DOCSECT" moodCode="EVN">
      </dischargeDataset>                                               ...
    </component2>                                                     </section>
    <component3 typeCode="COMP"                                     </component>
contextConductionInd="true">                                        <component typeCode="COMP"
      <examinationDataset classCode="DOCSECT"                   contextConductionInd="true">
moodCode="EVN">                                                       <section classCode="DOCSECT" moodCode="EVN">
        ...                                                             ...
      </examinationDataset>                                           </section>
    </component3>                                                   </component>
    ...                                                             ...
  </structuredBody>                                               </structuredBody>
 </component>                                                    </component>
</examination>                                                  </examination>
         October 10, 2008                             IHIC 2008
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: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"
    <xsl:element name="value">
      <xsl:attribute name="xsi:type">CV</xsl:attribute>
      <xsl:copy-of select="hl7:dischargeDiagnosis/hl7:value/@*"

October 10, 2008                                   IHIC 2008
Semantic Interoperability

    The previous objective accomplished structural interoperability,
     which is crucial

    However, more is needed in order to enable semantic
      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

October 10, 2008                  IHIC 2008
Demo and Questions

                   Thank you for your attention...

October 10, 2008              IHIC 2008

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