The Use of HL7 CDA in the National Health Information System NHIS of Turkey

1
The Use of HL7 CDA in the National Health
Information System (NHIS) of Turkey

• Yildiray KABAK, Asuman DOGAC, Ilker KÖSE, Nihat
  AKPINAR, Murat GÜREL, Yakup ARSLAN, Hakan ÖZER,
  Nihat YURT, Ahmet ÖZÇAM, Soner KIRICI, Mustafa
  Yüksel and Erdinç SABUR

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NHIS, Turkey (Saglik-Net) Infrastructure

• Turkeys 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

3
Saglik-Net Infrastructure
Doctor Data Bank
National Citizenship No Server
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Saglik-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.tr7750/USVSBrowse
  r/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_Mer
  nis.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/SKRS25FListesi/
• 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

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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
• 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

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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

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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

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Transporting EHRs

• HL7 Web Service Profile is used
• 25 HL7 Web Services

12
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

13
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//212.175.169.508443/testexecution/TestExec
  utionGUI.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

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The Main Differences Between the Transmission
Schemas and HL7 CDA

• In an HL7 CDA R2 compliant EHR, the
  ltClinicalDocumentgt is the root element
• In the Transmission Schemas the root of the
  document is the name of the transmission schema,
  e.g., ltexaminationgt
• In HL7 CDA, the dataset sections should start
  with ltsectiongt 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., ltexaminationDatasetgt

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The Main Differences Between the Transmission
Schemas and HL7 CDA

• In the Transmission Schemas, data elements
  sections do not start with ltsectiongt tag the
  tag name is the name of the data element
  concatenated with Section keyword, e.g.,
  ltdiagnosisSectiongt
• In the Level One CDA Schema, the body is composed
  of ltsectiongt elements combined with
  ltcomponentgt elements
• In the NHIS implementation, the components are
  numbered sequentially

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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

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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

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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
ltexamination classCode"DOCCLIN" moodCode"EVN"gt
CDA Header ltcomponent typeCode"COMP"
contextConductionInd"true"gt ltstructuredBody
classCode"DOCBODY" moodCode"EVN"gt
ltcomponent1 typeCode"COMP" contextConductionInd"
true"gt lttestResultDataset
classCode"DOCSECT" moodCode"EVN"gt
... lt/testResultDatasetgt
lt/component1gt ltcomponent2 typeCode"COMP"
contextConductionInd"true"gt
ltdischargeDataset classCode"DOCSECT"
moodCode"EVN"gt ...
lt/dischargeDatasetgt lt/component2gt
ltcomponent3 typeCode"COMP" contextConductionInd"
true"gt ltexaminationDataset
classCode"DOCSECT" moodCode"EVN"gt
... lt/examinationDatasetgt
lt/component3gt ... lt/structuredBodygt
lt/componentgt lt/examinationgt
ltClinicalDocument classCode"DOCCLIN"
moodCode"EVN"gt CDA Header ltcomponent
typeCode"COMP" contextConductionInd"true"gt
ltstructuredBody classCode"DOCBODY"
moodCode"EVN"gt ltcomponent typeCode"COMP"
contextConductionInd"true"gt ltsection
classCode"DOCSECT" moodCode"EVN"gt
... lt/sectiongt lt/componentgt
ltcomponent typeCode"COMP" contextConductionInd"t
rue"gt ltsection classCode"DOCSECT"
moodCode"EVN"gt ... lt/sectiongt
lt/componentgt ltcomponent
typeCode"COMP" contextConductionInd"true"gt
ltsection classCode"DOCSECT" moodCode"EVN"gt
... lt/sectiongt
lt/componentgt ... lt/structuredBodygt
lt/componentgt lt/examinationgt
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An example XSL Transformation Rule
ltxsltemplate name"dischargeDataset-component1"gt
ltxslelement name"component"gt ltxslcopy-of
select"_at_" copy-namespaces"no"/gt
ltxslelement name"section"gt ...
ltxslfor-each select"hl7dischargeDiagnosisSectio
n/hl7component"gt ltxslcall-template
name"dischargeDataset-component1-component"/gt
lt/xslfor-eachgt lt/xslelementgt
lt/xslelementgt lt/xsltemplategt ltxsltemplate
name"dischargeDataset-component1-component"gt
ltxslelement name"entry"gt ltxslcopy-of
select"_at_" copy-namespaces"no"/gt
ltxslelement name"observation"gt
ltxslattribute name"classCode"gtOBSlt/xslattribute
gt ltxslattribute name"moodCode"gtEVNlt/xslat
tributegt ltxslcopy-of select"hl7dischargeD
iagnosis/hl7code" copy-namespaces"no"/gt
ltxslelement name"value"gt
ltxslattribute name"xsitype"gtCVlt/xslattributegt
ltxslcopy-of select"hl7dischargeDiagnosi
s/hl7value/_at_" copy-namespaces"no"/gt
lt/xslelementgt lt/xslelementgt
lt/xslelementgt lt/xsltemplategt
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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

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Demo and Questions

• Thank you for your attention...