Medical Document Modeling
and Validation for the Latvian
National Electronic Health
Record System
Andrej Dubrovsky
Datorzi...
Plan
•
•
•
•

What is EHR
Documents and their format
Problem and approaches
Lessons learned
What is EHR
EHR

Hospital

Medical data
Diagnoses
Allergies
Warnings
Drug use
Disabilities
Implants

Practitioner

Patient
Document format
Clinical Document Architecture
structure
• Header
• Patient information
• Doctor information
• Hospital in...
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...
Problem and approaches
•
•

Problem

•

Validate all documents and entries

Approach

•

•

Business analysis approach:

•...
Lessons learned
•

Technology solutions are working (they only
depend on technology)

•
•

Administrative change at this s...
Questions
Thank You for attention!
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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

  1. 1. Medical Document Modeling and Validation for the Latvian National Electronic Health Record System Andrej Dubrovsky Datorzinību Centrs 05.11.2013
  2. 2. Plan • • • • What is EHR Documents and their format Problem and approaches Lessons learned
  3. 3. What is EHR EHR Hospital Medical data Diagnoses Allergies Warnings Drug use Disabilities Implants Practitioner Patient
  4. 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. 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. 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. 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. 8. Questions
  9. 9. Thank You for attention!

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