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

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IIBA_Latvia_Chapter

Technologie Business

Medical Document Modeling
and Validation for the Latvian
National Electronic Health
Record System
Andrej Dubrovsky
Datorzinību Centrs
05.11.2013

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 information
• Body
• Section
• Textual (user friendly) section data description
• Entry
• Textual (user friendly) entry data description
• Subentry (if needed)

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>

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)

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

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