Transcript Document
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 Erd inç 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 Bank National Citizenship No Server
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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
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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 October 10, 2008 IHIC 2008
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 Citizen/Foreigner Registration 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
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An Example Transmission Schema
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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” 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 patients 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 : https://212.175.169.50:8443/testexecution/TestExecutionGUI.html
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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 October 10, 2008 IHIC 2008
The Main Differences Between the “Transmission Schemas” and HL7 CDA
In an HL7 CDA R2 compliant EHR, the
The Main Differences Between the “Transmission Schemas” and HL7 CDA
In the “Transmission Schemas”, data elements’ sections do not start with “
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.
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Example transformations
<
examination
classCode =" DOCCLIN " moodCode =" EVN "> [CDA Header] < component typeCode =" COMP " < structuredBody classCode =" contextConductionInd DOCBODY " moodCode =" =" true EVN "> "> <
component1
typeCode =" COMP " contextConductionInd =" true "> <
testResultDataset
classCode =" DOCSECT " moodCode =" EVN "> ...
<
component2
typeCode =" COMP " contextConductionInd =" true "> <
dischargeDataset
classCode =" DOCSECT " moodCode =" EVN "> ...
<
component3
typeCode =" COMP " contextConductionInd =" true "> <
examinationDataset
classCode =" DOCSECT " moodCode =" EVN "> ...
...
ClinicalDocument
classCode =" DOCCLIN " moodCode =" EVN "> [CDA Header] < component typeCode =" COMP " contextConductionInd =" true "> < structuredBody moodCode =" EVN "> classCode =" DOCBODY " <
component
typeCode =" COMP " contextConductionInd =" true "> <
section
classCode =" DOCSECT " moodCode =" EVN "> ...
<
component
typeCode =" COMP " contextConductionInd =" true "> <
section
classCode =" DOCSECT " moodCode =" EVN "> ...
<
component
typeCode =" COMP " contextConductionInd =" true "> <
section
classCode =" DOCSECT " moodCode =" EVN "> ...
...
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An example XSL Transformation Rule
< xsl:template name =" dischargeDataset-component1 "> < xsl:element < xsl:copy-of name =" component "> 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 < xsl:element name =" dischargeDataset-component1-component "> name =" entry "> < xsl:copy-of < xsl:element select =" @* " name =" copy-namespaces observation "> =" no "/> < xsl:attribute name =" classCode "> OBS < xsl:attribute < xsl:copy-of name =" moodCode "> EVN select =" hl7:dischargeDiagnosis/hl7:code " copy-namespaces =" no "/> < xsl:element name =" value "> < xsl:attribute name =" xsi:type "> CV < xsl:copy-of select =" hl7:dischargeDiagnosis/hl7:value/@* " copy-namespaces =" no "/> 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 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 October 10, 2008 IHIC 2008
Demo and Questions
Thank you for your attention...
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