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'HL7 CDA modeling and development for Latvian National Electronic Health Record (EHR) Information System by Andrej Dubrovsky, LV
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'HL7 CDA modeling and development for Latvian National Electronic Health Record (EHR) Information System by Andrej Dubrovsky, LV

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  • 1. Medical Document Modeling and Validation for the Latvian National Electronic Health Record System Andrej Dubrovsky Datorzinību Centrs 05.11.2013
  • 2. Plan • • • • What is EHR Documents and their format Problem and approaches Lessons learned
  • 3. What is EHR EHR Hospital Medical data Diagnoses Allergies Warnings Drug use Disabilities Implants Practitioner Patient
  • 4. Document format Clinical Document Architecture structure • Header • Patient information • Doctor information • Hospital information • Body • Section • Textual (user friendly) section data description • Entry • Textual (user friendly) entry data description • Subentry (if needed)
  • 5. Example <section> <templateId root="1.3.6.1.4.1.38760.1.2.2.2.1" /> <code code="1.3.6.1.4.1.38760.1.2.2.2" codeSystem="OID Vocabularry OID" codeSystemName="text that represent OID Vocabularry OID" displayName="text that represent code" /> <title>Diagnosis section title</title> <text>Diagnosis human readable description here</text> <entry> <observation moodCode="EVN" negationInd="false"> <templateId root="1.3.6.1.4.1.38760.1.2.3.2.1" /> <id root="1.3.6.1.4.1.38760.3.4.5.3" extension="1" /> <code code="... code value ..." codeSystem="... code system OID ..." codeSystemName=" ... code system name ..." displayName=" ... user friendly code value ..." /> <effectiveTime> <low value="20111223105917" /> <high value="20111223105917" /> </effectiveTime> <value code="W53.2" codeSystem="1.3.6.1.4.1.38760.2.173" displayName="Žurkas kodums, skolā, citu institūciju un sabiedrisko iestāžu telpās" /> </observation> </entry> </section>
  • 6. Problem and approaches • • Problem • Validate all documents and entries Approach • • Business analysis approach: • • • Perform analysis on documents required Find similar elements (like diagnosis or recommendation) and write validators for them Reuse them and get rid of the rest (if possible) Technology approach • • Use existing legal framework as a document design Use code generation to mass produce validation code (it might be redundant)
  • 7. Lessons learned • Technology solutions are working (they only depend on technology) • • Administrative change at this scale is hard Technology solution might help the project, but allow business as usual and so discourage changes where they are due
  • 8. Questions
  • 9. Thank You for attention!