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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 Y üksel and Er d inç SABUR. NHIS, Turkey ( Sağlık-Net ) Infrastructure. - PowerPoint PPT Presentation
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October 10, 2008 IHIC 2008
The Use of HL7 CDA in the National Health Information System (NHIS) of TurkeyYildiray 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
NationalCitizenship No
Server
Doctor Data Bank
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) 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
October 10, 2008 IHIC 2008
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
Address Name Main Diagnosis Vaccination Treatment Method Diastolic Blood Pressure Healthcare Institution Marital Status
Citizen/Foreigner Registration MHDS
Medical Examination MHDS Prescription MHDS Pregnant Monitoring MHDS Cancer MHDS Inpatient MHDS
Some data elements Some MHDSs
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, 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
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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
October 10, 2008 IHIC 2008
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 <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>” tag
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"> [CDA Header] <component typeCode="COMP" contextConductionInd="true"> <structuredBody classCode="DOCBODY" moodCode="EVN"> <component1 typeCode="COMP" contextConductionInd="true"> <testResultDataset classCode="DOCSECT" moodCode="EVN"> ... </testResultDataset> </component1> <component2 typeCode="COMP" contextConductionInd="true"> <dischargeDataset classCode="DOCSECT" moodCode="EVN"> ... </dischargeDataset> </component2> <component3 typeCode="COMP" contextConductionInd="true"> <examinationDataset classCode="DOCSECT" moodCode="EVN"> ... </examinationDataset> </component3> ... </structuredBody> </component></examination>
<ClinicalDocument classCode="DOCCLIN" moodCode="EVN"> [CDA Header] <component typeCode="COMP" contextConductionInd="true"> <structuredBody classCode="DOCBODY" moodCode="EVN"> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> ... </section> </component> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> ... </section> </component> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> ... </section> </component> ... </structuredBody> </component></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:for-each> </xsl:element> </xsl:element></xsl:template><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" copy-namespaces="no"/> <xsl:element name="value"> <xsl:attribute name="xsi:type">CV</xsl:attribute> <xsl:copy-of select="hl7:dischargeDiagnosis/hl7:value/@*" copy-namespaces="no"/> </xsl:element> </xsl:element> </xsl:element></xsl:template>
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...
