Download Section - Google Project Hosting

CDA Document Profiles for
MOH RHR Basic Data Sets
A Project Proposal
Yongjian Bao
February 2, 2010
Problem
• RHR Basic Data Sets (BDS) … 32 Topics
o What info is collected … 1100+ data elements
o Data Element Identifier (HRnn.nn.nnn)
o Value Set defined in some data element
• BDS data should be shared across organization boundaries
o Public health services, health statistic reporting
o Disease prevention, assessment and other BI applications
o Second use
• Exchange mechanism needed for data sharing
o Information integrity
o Data quality
o Semantic interoperability
• Basically, each Data Set is a document defined in context
2/
Yongjian Bao /
February 2, 2010
Proposed Solution: CDA Document
Templates
• CDA: ISO standard adopted internationally
• Text and structured / coded content in the same data set
o Ready for presentation to human user
o Contain structured, coded data for machine consumption
• Leading SDO’s created a great pool of CDA document templates: HL7,
IHE, HITSP
o Patient Summary, Discharge Summary, Operative Notes, etc.
• Standard document templates defined in an open manner … designed
for extension
• Common template libraries cover a large number of healthcare
information topics, and continue growing
!! Template !!
3/
Yongjian Bao /
February 2, 2010
Standard CDA Document Templates:
C80:
An Overview
Terminology
Consult and History
& Physical Note:
C84
Encounter
Document (XDSMS) : C48
Patient Level
Quality (XDSMS) : C38
Lab Report:
C37
XDS-MS
Emergency
Department
Referral
Basic Patient
Privacy
Consents
Exchange of
Personal Health
Record
CSR*
2005
2006
Summary
Document
(CCD): C32
Emergency Care
Summary
(EDES) : C28
Public Health
Laboratory
Report
Functional
Status
Assessment
Immunization
Content: C78
C83: Content
Modules
Care Report
Pre-Populate:
C76
Healthcare
Associated
Infection: C75
Remote
Monitoring
Obx: C74
IHE PCC
TF Vol. 2
Patient Plan of
Care
Care Registry
Pathology
Report
Labor & Delivery
Record
Immunization
Content
EMS Transfer
Antepartum
Record
Quality Reporting
Document
Architecture
Unstructured
Documents
Emergency
Department
Encounter Summary
History and
Physical Note*
Operative
Note
Procedure
Note
Antepartum
Care
Summary
Personal Health
Management
Report*
Hospital
Associated
Infection*
Neonatal Care
Report*
CCD*
Consultation
Note
Public Health
Case Report*
Consent
Directive
2007
2008
2009
2010
4/
Yongjian Bao /
February 2, 2010
IHE Document
Templates
Document Template
1
CDA
Header
1 .. *
Section
Template
0 .. *
0 .. *
Entry
Template
0 .. *
HITSP-C83
IHE PCC
5/
Yongjian Bao /
February 2, 2010
HL7 CCD
Develop RHR Document Templates
Leveraging Standard Libraries
Mapping BDS to Standard Templates
BDS are conceptually self-categorized
Disease Management
Disease / wellness surveillance
Clinical Summary
…
BDS have “sections” built-in
Inpatient Summary
Patient
Healthcare Providers
Diagnosis
Test Result
Medications
List of Surgeries
Healthcare Service Payment
Gaps in Mapping BDS
BDS must support China specific
concepts
Residence Administrative Committee
(辖区居委会名称)
Citizenship of person (母亲国籍代码)
BDS covers a wider range of information
than the scope of standard templates
Simple but wide
Administration use biased
Proposed Methods to Resolve Gaps
Re-structuring / re-factoring
Essential death cause (根本死因代码)
Creating new template (reuse standard
Most data elements can be mapped to
pattern)
standard templates directly
Cancer TNM Stage Class (肿瘤TNM分期代码)
BDS have identified all data elements,
as well as some code sets in data values General Purpose Observation for NVP
Number of times of hospitalization
(住院患者住院次数)
6/
Yongjian Bao /
February 2, 2010
32 Basic Data Sets in RHR
Disease
Management
Disease
Reporting
Public Health
Surveillance
Health Service
Care Summary
Basic Certificates
7/
Yongjian Bao /
February 2, 2010
RHR Document Template Development
Principles
• Guarantee Compliance to Essential Standard Document Templates
o
At minimum: HL7 CCD, IHE Medical Summary
• Use Standard Section and Entry Templates if Possible
• Use Standard Vocabularies (SNOMED CT, LOINC) if Possible
o
Back-up: BDS data identifiers
• Extend Standard Template within Conformance Frame … Compatible
Template
• Create New Template only necessary and for Well-Understood Concept
• Use Generic Observations (NVP) … Leave True Modeling in Future
Work
• Provide Detailed Guide to Steer Implementation of RHR Document
Templates
8/
Yongjian Bao /
February 2, 2010
Proposed Process
Review
BDS
Divide Data
Elements to
Sections
Map Sections
to Standard
Templates
Need domain expert’s help to resolve
ambiguity in BDS, and clearly define
semantics of data elements, possibly
restructuring
Section classification in standard libraries
can be used as a guide
Map Data
Elements to
Standard
Entries
Need knowledge of
standard libraries to
properly use existing
templates for
expression of BDS
data elements
Develop
New Section
Propose
Extensions
Map Data
Elements to
Standard
Entries
Draft templates for individual BDS topics
Consolidate
Common
Sections &
Entries
Identify
Common
Document
Types
Decide
Document
Spec
Develop
Extensions
Final Spec:
Section Lib
Entry Lib
Doc Spec
Harmonize individual drafts into a common set of templates
9/
Yongjian Bao /
February 2, 2010
Future Work
Development Tools
Interoperability Test and Demonstration
Validation and Certification
10 /
Yongjian Bao /
February 2, 2010
CDA Document
Must Have Narrative
Use Reference, no content duplication
Clinical Statement identifier
RIM semantics
Template as helper
Vocabulary, vocabulary, vocabulary
11 /
Yongjian Bao /
February 2, 2010
CDA Templates
A set of rules to express constraints applied to a tree of RIM elements
Template  XML Scheme
Nested … A template can contain one or more sub-templates
Open … A template allows anything CDA supports if it does not explicitly
disallow them
A template can be inherited from its parent template: apply all constraints
of the parent plus new constraints
A document created using a template conforms to the templates and all of
its parents
A template can be associated with semantic meaning, which must be
consistent with other data elements in the template
12 /
Yongjian Bao /
February 2, 2010
CDA Template
A template is identified with an ISO OID value,
include in <templateId> immediately after an
<element>
CCD Template Id: 2.16.840.1.113883.10.20.1
It declares conformance to ALL constraints in
this template
13 /
Yongjian Bao /
February 2, 2010
Template Structure
W3C XML
HL7 CDA R2 Standard
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension='POCD_HD000040' root='2.16.840.1.113883.1.3'/>
CDA R2 Document Template
CDA R2 Document Template
<ClinicalDocument xmlns='urn:hl7-org:v3'>
CDA R2 Document Template
<ClinicalDocument xmlns='urn:hl7-org:v3'>
CDA R2 Document Template
<typeId
extension='POCD_HD000040'
root='2.16.840.1.113883.1.3'/>
<ClinicalDocument
xmlns='urn:hl7-org:v3'>
<typeId
extension='POCD_HD000040' root='2.16.840.1.113883.1.3'/>
<ClinicalDocument
xmlns='urn:hl7-org:v3'>
<templateId<typeId
root='2.16.840.1.113883.10.20.1'/>
extension='POCD_HD000040' root='2.16.840.1.113883.1.3'/>
<templateId<typeId
root='2.16.840.1.113883.10.20.1'/>
extension='POCD_HD000040' root='2.16.840.1.113883.1.3'/>
…
<templateId
root='2.16.840.1.113883.10.20.1'/>
…
<templateId
root='2.16.840.1.113883.10.20.1'/>
…</ClinicalDocument>
…</ClinicalDocument>
</ClinicalDocument>
</ClinicalDocument>
Section Template
Header Constraint
Clinical Statement (Entry)
Template
14 /
Yongjian Bao /
February 2, 2010
HL7 CDAR2 – An Anatomic
Overview
Document Template
CDA Header:
Structured,
coded data
Component
Template
Level 2 CDA specified with section-level templates
simple viewing (XML style sheet)
Patient
Author
Institute
Service time
:
:
Coded section title
XML narrative content (text, lists,
tables)
Structured body
CDA Body:
Choose one
from two body
definitions
Section
Template
section
section
…
section
…
:
Text Structure Entry
Coded Section Entry
Text Structure Entry
Coded Section Entry
:
:
section
section
section
:
:
:
Text Structure Entry
Entry
Template
Coded Section Entry
Non-structured body
Level 1 CDA does not specify any content template, but Level 3 CDA specified with entryheader is always structured and coded
level templates to create highly
structured text
Structured document meta data
text easy to import/parse
Level 3 entry-level templates may
also specify coded content with
explicit coding scheme
Machine comprehensible content
15 /
Yongjian Bao /
February 2, 2010
Sections in CCD, H&P
and Consultation Notes
CCD
H&P
CONS
Def’ed in
H&P
CONS
Reason for Visit / Chief Complaint (29299-5 / 10154-3 / 46239-0)
Reason for Referral (
CRS
History of Present Illness (10164-2)
H&P
Past Medical History (11348-0)
CCD
Allergies / Alerts (48765-2)
H&P
Physical Examination (29545-1)
H&P
Physical Examination – General Status (10210-3)
H&P/CRS
Review of Systems (10187-3)
CCD
Vital Signs (8716-3)
CCD
Results / Diagnostics Findings (30954-2)
CCD
Family History (10157-6)
CCD
Social History (29762-2)
CCD
Medications (10160-0)
H&P
Assessment / Plan of Care (51848-0 / 18776-5 / 51847-2)
CCD
Problems (11450-4)
CCD
Procedures / Procedure History (47519-4)
CCD
Immunizations (11369-6)
CCD
Functional Status (47420-5)
CCD
Medical Equipment (46264-8)
CCD
Encounters (46240-8)
CCD
Payers (48768-6)
CCD
Advanced Directives (42348-3)
10190-7 MENTAL STATUS
11451-2 PSYCHIATRIC FINDINGS
10199-8 HEAD, PHYSICAL FINDINGS
10197-2 EYE, PHYSICAL FINDINGS
10195-6 EAR, PHYSICAL FINDINGS
10203-8 NOSE, PHYSICAL FINDINGS
11393-6 EARS & NOSE & MOUTH & THROAT, PHYSICAL FINDINGS
10201-2 MOUTH & THROAT & TEETH, PHYSICAL FINDINGS
51850-6 HEAD & EARS & EYES & NOSE & THROAT, PHYSICAL FINDINGS
11411-6 NECK, PHYSICAL FINDINGS
10207-9 THORAX & LUNGS, PHYSICAL FINDINGS
11391-0 CHEST, PHYSICAL FINDINGS
11392-8 CHEST WALL, PHYSICAL FINDINGS
10200-4 HEART, PHYSICAL FINDINGS
10193-1 BREASTS, PHYSICAL FINDINGS
10192-3 BACK, PHYSICAL FINDINGS
10191-5 ABDOMEN, PHYSICAL FINDINGS
10204-6 PELVIS, PHYSICAL FINDINGS
11403-3 GROIN, PHYSICAL FINDINGS
10198-0 GENITOURINARY TRACT, PHYSICAL FINDINGS
11400-9 GENITALIA, PHYSICAL FINDINGS
11401-7 GENITALIA FEMALE, PHYSICAL FINDINGS
11402-5 GENITALIA MALE, PHYSICAL FINDINGS
11388-6 BUTTOCKS, PHYSICAL FINDINGS
10205-3 RECTUM, PHYSICAL FINDINGS
10196-4 EXTREMITIES, PHYSICAL FINDINGS
11413-2 SHOULDER, PHYSICAL FINDINGS
11387-8 AXILLA, PHYSICAL FINDINGS
11386-0 UPPER ARM, PHYSICAL FINDINGS
11394-4 ELBOW, PHYSICAL FINDINGS
11398-5 FOREARM, PHYSICAL FINDINGS
11415-7 WRIST, PHYSICAL FINDINGS
11404-1 HAND, PHYSICAL FINDINGS
11406-6 HIP, PHYSICAL FINDINGS
11414-0 THIGH, PHYSICAL FINDINGS
11407-4 KNEE, PHYSICAL FINDINGS
11389-4 CALF, PHYSICAL FINDINGS
11385-2 ANKLE, PHYSICAL FINDINGS
11397-7 FOOT, PHYSICAL FINDINGS
10209-5 BALANCE+COORDINATION, PHYSICAL FINDINGS
10212-9 STRENGTH PHYSICAL FINDINGS
10211-1 SENSATION, PHYSICAL FINDINGS
10206-1 SKIN, PHYSICAL FINDINGS
10194-9 DEEP TENDON REFLEXES, PHYSICAL FINDINGS
10208-7 VESSELS, PHYSICAL FINDINGS
11384-5 PHYSICAL EXAMINATION BY ORGAN SYSTEMS
11447-0 HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC PHYSICAL FINDING
11390-2 CARDIOVASCULAR SYSTEM, PHYSICAL FINDINGS
11399-3 GASTROINTESTINAL SYSTEM, PHYSICAL FINDINGS 16 /
Yongjian Bao /
10202-0 NEUROLOGIC SYSTEM, PHYSICAL FINDINGS
February
2, 2010
11410-8 MUSCULOSKELETAL SYSTEM, PHYSICAL
FINDINGS
Section-Level Template Library
IHE PCC TF Vol. 2, V3.0, 6.4.3 CDA Section Content Module
Reasons for care
Reasons for Referral Care
Coded Reason for Referral Section
Chief Complaint Section
Reason for Visit Section
Hospital Admission Diagnosis Section
Medications
Medications Section
Admission Medication History Section
Medication Administered Section
Hospital Discharge Medications Section
Immunization Section
Relevant Studies
Results Section
Coded Results Section
Hospital Studies Summary Section
Coded Hospital Studies Summary Section
ED Consultations Section
Plans of Care
Care Plan Section
Assessment and Plan Section
Discharge Disposition Section
Discharge Diet Section
Advance Directive Section
Coded Advance Directives Section
Transport Mode Section
Procedures Performed
Procedures and Interventions Section
Impressions
Visit Summary Section
Progress Note Section
ES diagnosis Section
Assessments Section
Other Condition Histories
History of Present Illness Section
Hospital Course Section
Active Problems Section
Discharge Diagnosis Section
Resolved Problems Section
Encounter Histories Section
History of Outpatient Visits Section
History of Inpatient Visits Section
List of Surgeries Section
Coded List of Surgeries Section
Allergies and Other Adverse Reactions Section
Family Medical History Section
Coded Family Medical History Section
Pre-procedure Family Medical History Section
Social History Section
Functional Status Section
Coded Functional Status Assessment Section
Pain Scale Assessment Section
Braden Score Section
Geriatric Depression Scale Section
Physical Function Section
Constraints
Review of Systems Section
Pre-procedure Review of Systems Section
Hazardous Working Conditions Section
Pregnancy History Section
Estimated Due Dates Section
Medical Devices Section
Foreign Travel Section
History of Tobacco Use Section
Current Alcohol / Substance Abuse Section
Transfusion History Section
Physical Exams
Physical Exam Section
Hospital Discharge Physical Exam Section
Vital Signs Section
Coded Vital Signs Section
General Appearance Section
Visible Implanted Medical Devices Section
Integumentary System Section
Head Section
Eyes Section
Ears, Nose, Mouth and Throat Section
Ears Section
Nose Section
Mouth, Throat and Teeth Section
Neck Section
Endocrine System Section
Thorax and Lungs Section
Chest Wall Section
Breast Section
Heart Section
Respiratory Section
Abdomen Section
Lymphatic Section
Vessels Section
Musculoskeletal System Section
Neurologic System Section
Genitalia Section
Rectum Section
Administrative and Other Information
Payers Section
Referral Source Section
Transport Mode Section
17 /
ED Disposition Section
Yongjian Bao /
February 2, 2010
Entry-Level Template Library
IHE PCC TF Vol. 2, V3.0, 6.4.4 CDA and HL7 Entry Content
Module
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Authors and Informants
Linking Narrative and Coded Entries
Severity
Problem Status Observation
Health Status
Comments
Patient Medication Instructions
Medication Fulfillment Instructions
External References
Internal References
Concern Entry
Problem Concern Entry
Allergy and Intolerance Concern
Problem Entry
Allergies and Intolerances
Medications
Immunizations
Supply Entry
Product Entry
Simple Observation
Vital Signs Organizer
Vital Sign Observations
23. Family History Organizer
24. Family History Observation
25. Social History Observation
26. Pregnancy Observation
27. EDD (estimated delivery date) Observation
28. Advance Directive Observation
29. Blood Type Observation
30. Encounter
31. Update Entry
32. Procedure Entry
33. Encounter Disposition
34. Transport
35. Coverage Entry
36. Payer Entry
37. Pain Scale Observation
38. Braden Score Observation
39. Braden Score Component
40. Geriatric Depression Score Observation
41. Geriatric Depression Score Component
42. Survey Panel
43. Survey Observation
44. Nursing Assessment Battery
18 /
Yongjian Bao /
February 2, 2010
Section Structure of Referral Summary
Document
IHE PCC TF Vol. 2, V3.0, 6.4.1.3 Referral Summary
Specification
1. Reason for Referral (R)
2. History Present Illness (R)
3. Active Problems (R)
4.
5.
6.
7.
8.
Current Meds (R)
Allergies (R)
Resolved Problems (R2)
List of Surgeries (R2)
Immunizations (R2)
9. Social History (R2)
10. Pertinent Review of Systems (O)
11. Vital Signs (R2)
12. Relevant Diagnostic Surgical
Procedures / Clinical Reports
(including links) (R2)
13. Relevant Diagnostic Test and
Reports (Lab, Imaging, ECG, etc.)
including links (R2)
14. Plan of Care (new meds, labs or xrays ordered) (R2)
15. Advance Directives (R2)
16. Patient Administrative Identifiers (R)
17. Pertinent Insurance Information (R2)
18. Data needed for state and local
referral forms, if different than above
(R2)
19 /
Yongjian Bao /
February 2, 2010
Nested Template Structure
20 /
Yongjian Bao /
February 2, 2010
PCC Document Contents
IHE PCC TF Vol. 2, V3.0, 6.4.1 CDA Document Content
Modules
Medial Document
1.3.6.1.4.1.19376.1.5.3.1.1.1
Medial Summary
1.3.6.1.4.1.19376.1.5.3.1.1.2
Triage Note
ED Nursing Note
1.3.6.14.1.19376.1.5.3.1.1.13.1.
1
1.3.6.14.1.19376.1.5.3.1.1.13.1.
2
Referral Summary
Discharge Summary
PHR Extract
1.3.6.1.4.1.19376.1.5.3.1.1.3
1.3.6.1.4.1.19376.1.5.3.1.1.4
1.3.6.1.4.1.19376.1.5.3.1.1.5
ED Referral
1.3.6.1.4.1.19376.1.5.3.1.1.10
Composite Triage
and Nursing Note
1.3.6.14.1.19376.1.5.3.1.1.13.1.
3
Antepartum
Summary
1.3.6.14.1.19376.1.5.3.1.1.11.2
ED Physician Note
1.3.6.14.1.19376.1.5.3.1.1.13.1.
4
PHR Update
1.3.6.1.4.1.19376.1.5.3.1.1.6
All PCC documents largely follow the specifications in the
HL7 Care Record Summary (CRS) and ASTM/HL7
Continuity of Care Document (CCD) Implementation
Guides.
21 /
Yongjian Bao /
February 2, 2010
Section Template Example: Coded
Reason for Referral
22 /
Yongjian Bao /
February 2, 2010
Section Template
HL7 CCD Implementation Guide “Functional Status” Section:
CONF-123: CCD SHOULD contain exactly one and SHALL NOT contain more than one
Functional status section (templateId 2.16.840.1.113883.10.20.1.5). The
Functional statusection SHALL contain a narrative block, and SHOULD contain
clinical statements.
Clinical statements SHOULD include one or more problem acts (templateId
2.16.840.1.113883.10.20.1.27) and/or result organizers (templateId
2.16.840.1.113883.10.20.1.32).
CONF-124: The functional status section SHALL contain Section / code.
CONF-125: The value for “Section / code” SHALL be “47420-5” “Functional status
assessment” 2.16.840.1.113883.6.1 LOINC STATIC. ONF-126:
CONF-127: Section / title SHOULD be valued with a case-insensitive language-insensitive
text string containing “functional status”.
Extension Example:
RHIN-CONF-1:
Section / title SHALL be valued with the fixed text “成人体检功能状态”.
23 /
Yongjian Bao /
February 2, 2010
Entry-Level Template Example:
Problem (1.3.6.1.4.1.19376.1.5.3.1.4.5)
<observation classCode=‘OBS’ modeCode=‘EVN’ negationInd=‘false|true’/>
<templateId root=‘2.16.840.1.113883.10.20.1.28’/>
<templateId root=‘1.3.6.1.4.1.19376.1.5.3.1.4.5’/>
<id root=‘ ‘ extension=‘ ‘/>
<code code=‘ ‘ displayName=‘ ‘ codeSystem=‘2.16.840.1.113883.6.96’
codeSystemName=‘SNOMED’/>
<statusCode code=‘completed’/>
<effectiveTime><low value=‘ ‘/><high value=‘ ‘/></effectiveTime>
<condifentialityCode code=‘ ‘/>
Recommended
<uncerterntyCode code =‘ ‘/>
SNOMED CT
<value xsi:type=‘CD’ code =‘ ‘ codeSystem=‘ ‘ codeSystemName=‘ ‘ displayName=‘ ‘>
Codes:
<originalText><reference value=‘ ‘/></originalText>
Code
Description
<!–- zero or one <entryRelationship typeCode=‘SUBJ’ inversionInd=‘true’>
64572001
Condition
severity 1.3.6.1.4.1.19376.1.5.3.1.4.1 -->
418799008
Symptom
<!–- zero or one <entryRelationship typeCode=‘PEFR’ inversionInd=‘false’>
clinical status 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 -->
404684003
Finding
409586006
Complaint
<!–- zero or one <entryRelationship typeCode=‘PEFR’ inversionInd=‘false’>
health status of concern 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 -->
248536006 Functional limitation
<!–- zero or one <entryRelationship typeCode=‘SUBJ’ inversionInd=‘true’>
55607006
Problem
comment 1.3.6.1.4.1.19376.1.5.3.1.4.2 -->
282291009
Diagnosis
24 /
Yongjian Bao /
February 2, 2010
Entry Template
CONF-154:
CONF-155:
CONF-156/7:
CONF-158:
CONF-159:
CONF-160:
CONF-161:
CONF-161:
CONF-161:
<templateId> = “2.16.840.1.113883.10.20.1.28”
Observation / @moodCode = “EVN”
One and exactly one statusCode. Observation / statusCode = “completed”
One and exactly one effectiveTime, to indicate the biological timing of condition, e.g., onset,
duration, etc.
May use Observation / code value set 2.16.840.1.113883.1.11.20.14. Other value sets
possible and allowed.
May refer to an age observation with entryReationship / @typeCode = “SUBJ”.
SHALL have one or more sources of information.
MAY have exactly one problem status.
MAY have exactly one health status.
IHE Adds More Constraints:
<effectiveTime><low value=‘ ‘/><high value=‘ ‘/></effectiveTime>
<value xsi:type=‘CD’ code=‘ ‘displayName=‘ ‘ codeSystem=‘ ‘ codeSystemName=‘ ‘/> prefer to SNOMED
CT, ICD-9 CM, MEDCIN
Define code for unknown / none-existence of conditions: Past Medical History Unknown
(396782006), Family History Unknown (407559004), No Significant Medical History
(160243008), No Current Problem or Disability (160245001), No Known Drug Allergies
(409137002), No Known Allergies (160244002), Substance Type Unknown (64970000)
MAY have exactly one Condition severity (1.3.6.1.4.1.19376.1.5.3.1.4.1)
MAY have one or more Comment (1.3.6.1.4.1.19376.1.5.3.1.4.2)
25 /
Yongjian Bao /
February 2, 2010
RIM Backbone Classes
Role
Link
0..*
0..*
1
Plays
Entity
0..*
0..*
1
1
1
0..*
0..1
0..*
0..1
Act
Relationship
Role
0..*
1
Participation
1
0..*
Act
Scopes
26 /
Yongjian Bao /
February 2, 2010
RIM
27 /
Yongjian Bao /
February 2, 2010
Entry-Level Template Example:
Simple Observation (1.3.6.1.4.1.19376.1.5.3.1.4.13)
<observation typeCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<id root='' extension=''/>
<code code='' displayName='' codeSystem='' codeSystemName=''/>
<text><reference value='#xxx'/></text>
<statusCode code='completed'/>
<effectiveTime value=''/>
<repeatNumber value=''/>
<value xsi:type='' …/>
<interpretationCode code='' codeSystem='' codeSystemName=''/>
<methodCode code='' codeSystem='' codeSystemName=''/>
<targetSiteCode code='' codeSystem='' codeSystemName=''/>
<author typeCode='AUT'>
<assignedAuthor typeCode='ASSIGNED'><id></assignedAuthor>
</author>
</observation>
28 /
Yongjian Bao /
February 2, 2010
Data Type
29 /
Yongjian Bao /
February 2, 2010
CE Types
<!-- type TS -->
<observation typeCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
……
<code code='38208-5' displayName='Pain severity'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
<translation code='406127006' displayName='Pain intensity'
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED
CT'/>
<originalText><reference value='#yyy'/></originalText>
</code>
……
</observation>
30 /
Yongjian Bao /
February 2, 2010
CE Type – Value Set
A CE Type element is associated with a Value Set to define all permitted
codes.
A Value Set is identified with an ISO OID and a text name for display
purpose
A Value Set is defined to represent a concept domain, and can be specified
with sets of codes selected from different code systems
– For example, we may use a value set defined in CCD for Problem Types (SNOMED
CT), and extend it by adding additional codes from RHIN code system
2.16.840.1.113883.1.11.20.14
(ProblemTypeCode)
64572001
Condition
2.16.840.1.113883.6.96
SNOMED CT
418799008
Symptom
2.16.840.1.113883.6.96
SNOMED CT
404684003
Finding
2.16.840.1.113883.6.96
SNOMED CT
409586006
Complaint
2.16.840.1.113883.6.96
SNOMED CT
248536006
Functional limitation
2.16.840.1.113883.6.96
SNOMED CT
55607006
Problem
2.16.840.1.113883.6.96
SNOMED CT
282291009
Diagnosis
2.16.840.1.113883.6.96
SNOMED CT
31 /
Yongjian Bao /
February 2, 2010
CE Types – Non-coded Value
<observation classCode='OBS' moodCode='EVN'>
<code code='33999-4' displayName='Status'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<statusCode code='completed'/>
<value xsi:type='CE' code='55561003' displayName='Active'
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
</observation>
<observation classCode='OBS' moodCode='EVN'>
<code code='33999-4' displayName='Status'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<statusCode code='completed'/>
<value xsi:type='CE'>
<originalText><reference value='#MyTextIsThere'/></originalText>
</value>
</observation>
32 /
Yongjian Bao /
February 2, 2010
CS Types
<!– Example of CE Type: Acuity Event -->
<entry>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'/>
<id root='' extension=''/>
<statusCode code='completed'/>
<code code='273887006' displayName='Triage index'
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
<originalText><reference value='#(ID of text coded)/></orginalText>
</code>
<text><reference value='#text/></text>
……
</observation>
</entry>
33 /
Yongjian Bao /
February 2, 2010
ASSERTION in Coded Concept
<entry>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'/>
<id root='' extension=''/>
<statusCode code='completed'/>
<code code=‘ASSERTION' displayName='Triage index'
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
<originalText><reference value='#(ID of text coded)/></orginalText>
</code>
<text><reference value='#text/></text>
……
</observation>
</entry>
34 /
Yongjian Bao /
February 2, 2010
PHMR Template (Device Observed Event)
<!– Example of Event Observation template -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<templateId root="2.16.840.1.113883.10.20.9.7"/>
<id root="5d186d6a-40c8-4d2d-9187-069ddf08e288"/>
<code code="MDC_PULS_OXIM_PULS_CHAR" codeSystem="2.16.840.1.113883.6.24"
codeSystemName="MDC" displayName="Pulse characteristics Event"/>
<statusCode code="completed"/>
<effectiveTime value="20071206125500.66"/>
<value xsi:type="ST">Maximal inrush of the pulsatile event has been detected</value>
<participant typeCode="DEV">
<participantRole>
<id root="1.2.840.10004.1.1.1.0.0.1.0.0.1.2680"
assigningAuthorityName="EUI-64" extension="1A-3E-41-78-9A-BC-DE-42"/>
</participantRole>
</participant>
</observation>
35 /
Yongjian Bao /
February 2, 2010
Time Types
<!-- type TS -->
<effectiveTime value=' '/>
<!-- type IVL<TS> -->
<effectiveTime low=' ' high=' ' center=' ' width=' ' operator='I | E | A | H | P'/>
<!-- type PIVL -->
<effectiveTime xsi:type=‘PIVL_TS' alignment=' ' institutionSpecified='true|false' operator=' I |
E | A | H | P'>
<phase value=' ' />
<period width=' ' unit=' '/>
</effectiveTime>
<!-- type EIVL -->
<effectiveTime xsi:type='EIVL_TS' event code=' ' operator='I | E | A | H | P'/>
<offset>
<low value='1' unit ='h'/>
<width value='10' unit='min'/>
</offset>
</effectiveTime>
36 /
Yongjian Bao /
February 2, 2010
HL7 Operator Code
code
name
definition
A
intersect
Form the intersection with the value.
E
exclude
Form the set-difference with this value, i.e., exclude
this element or set from the resulting set.
H
convex hull
Form the convex hull with the value. The convex hull is
defined over ordered domains and is the smallest
contiguous superset (interval) that of all the operand
sets.
I
include
Form the union with this value, i.e., include this
element or set in the resulting set.
periodic hull
Form the periodic hull with the value. The periodic hull
is defined over ordered domains and is the periodic set
that contains all contiguous supersets of pairs of
intervals generated by the operand periodic intervals.
P
37 /
Yongjian Bao /
February 2, 2010
Time Type GTS
GTS is defined a sequence of components of
time types: GTS, IVL_TS, PIVL_TS and
EIVL_TS, combined with the <operator>
attributes.
38 /
Yongjian Bao /
February 2, 2010
GTS Types
<!-- twice a day for 10 days from 2/1/2007 to 2/10/2007 -->
<effectiveTime xsi:type='IVL_TS'>
<low value='20070201'/>
<high value='20070210'/>
</effectiveTime>
<effectiveTime xsi:type='PIVL_TS' institutionSpecified='true'
operator='A'>
<period value='12' unit='h' />
</effectiveTime>
39 /
Yongjian Bao /
February 2, 2010
GTS Types
<!-- Once, on 2005-09-01 at 1:18am. -->
<effectiveTime xsi:type='TS' value='200509010118'/>
<!-- every 8 hours for 10 days from 2/1/07 to 2/10/07 -->
<effectiveTime xsi:type='IVL_TS'>
<low value='20070201'/>
<high value='20070210'/>
</effectiveTime>
<effectiveTime xsi:type='PIVL_TS' institutionSpecified='false'
operator='A'>
<period value='8' unit='h' />
</effectiveTime>
40 /
Yongjian Bao /
February 2, 2010
GTS Types
<!-- in the morning for 10 days from 2/1/07 to 2/10/07 -->
<effectiveTime xsi:type='IVL_TS'>
<low value='20070201'/>
<high value='20070210'/>
</effectiveTime>
<effectiveTime xsi:type='EIVL' operator='A'>
<event code='ACM'/>
</effectiveTime>
41 /
Yongjian Bao /
February 2, 2010
GTS Types
<!-- Every day at 8 in the morning for 10 minutes for 10 days
from 2/1/07 to 2/10/07 -->
<effectiveTime xsi:type='IVL_TS'>
<low value='20070201'/>
<high value='20070210'/>
</effectiveTime>
<effectiveTime xsi:type='PIVL_TS' operator='A'>
<phase>
<low value="198701010800" inclusive="true"/>
<width value="10" unit="min"/>
</phase>
<period value='1' unit='d'/>
</effectiveTime>
42 /
Yongjian Bao /
February 2, 2010
Reference
htmlLink
Dedicated Media
Internal Reference
External Reference
43 /
Yongjian Bao /
February 2, 2010
Reference
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
<templateId root='2.16.840.1.113883.10.20.1.4'/>
<code code="10157-6" displayName="HISTORY OF FAMILY MEMBER DISEASES"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Family History</title>
<text><renderMultiMedia referencedObject="MM1"/></text>
<entry>
<observationMedia classCode="OBS" moodCode="EVN" ID="MM1">
<id root="2.16.840.1.113883.19.2.1"/>
<value xsi:type="ED" mediaType="image/jpeg" representation="B64">
Based 64 encoded data for the image
</value>
</observationMedia>
</entry>
…..
</section>
44 /
Yongjian Bao /
February 2, 2010
Reference
……
<text>
<table border="1" width="100%">
<thead>
<tr><th>Procedure</th><th>Date</th></tr>
</thead>
<tbody>
<tr><td><content ID="Proc1">Total hip replacement, left</content></td><td>1998</td></tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<procedure classCode="PROC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.29"/> <!-- Procedure activity template -->
<id root="e401f340-7be2-11db-9fe1-0800200c9a66"/>
<code code="52734007" codeSystem="2.16.840.1.113883.6.96" displayName="Total hip replacement">
<originalText><reference value="#Proc1"/></originalText>
<qualifier>
<name code="272741003" displayName="Laterality"/>
<value code="7771000" displayName="Left"/>
</qualifier>
</code>
……
45 /
Yongjian Bao /
February 2, 2010
External Reference
<entry>
<act classCode='ACT' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
<id root='' extension=''/>
<code nullFlavor='NA' />
<text><reference value='#study-1'/></text>
<reference typeCode='REFR|SPRT'>
<externalDocument classCode='DOC' moodCode='EVN'>
<id extension='' root=''/>
<text><reference value='http://foo..'/></text>
</externalDocument>
</reference>
</act>
</entry>
46 /
Yongjian Bao /
February 2, 2010
Internal Reference
<entryRelationship typeCode='' inversionInd='true|false'>
<act classCode='' moodCode=''>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
<id root='' extension=''/>
<code code='' displayName='' codeSystem=''
codeSystemName=''/>
</act>
</entryRelationship>
47 /
Yongjian Bao /
February 2, 2010
Nullflavor
<assignedEntity>
<id extension='3' root='2.16.840.1.113883.19'/>
<addr nullFlavor='UNK'/>
<telecom nullFlavor='ASKU' use='WP'/>
<assignedPerson>
<name nullFlavor='NAV'/>
</assignedPerson>
</assignedEntity>
48 /
Yongjian Bao /
February 2, 2010
Nullflavor
Code
Print Name
Definition, Properties, Relationships
NI
NoInformation
Description:The value is exceptional (missing, omitted, incomplete,
improper). No information as to the reason for being an exceptional
value is provided. This is the most general exceptional value. It is also
the default exceptional value.
OTH
..
other
Description:The actual value is not a member of the set of permitted
data values in the constrained value domain of a variable. (e.g.,
concept not provided by required code system).
NA
not applicable
Known to have no proper value (e.g., last menstrual period for a
male).
Concept Relationships:
UNK
.
unknown
A proper value is applicable, but not known.
Concept Relationships:
ASKU
..
asked but
unknown
Information was sought but not found (e.g., patient was asked but
didn't know)
NAV
temporarily
unavailable
Definition:
Information is not available at this time but it is expected that it will be
available later.
NASK
not asked
Definition:
This information has not been sought (e.g., patient was not asked)
49 /
Yongjian Bao /
February 2, 2010
Identifier Not Available
<observation classCode="OBSSER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.9.12"/>
<id root="f37a5e13-aae6-4f9c-8afc-af7a9ab087e0"/>
<code code="277923006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Pulse oximetry
waveform">
<translation code="MDC_PULS_OXIM_PLETH"
codeSystem="2.16.840.1.113883.6.24" codeSystemName="MDC"
displayName="Pulse Oximeter Plethysmograph"/>
</code>
<effectiveTime>
<low value="20071206121000.00"/>
<high value="20071206121000.99"/>
</effectiveTime>
</observation>
50 /
Yongjian Bao /
February 2, 2010
Identifier Not Available
<ClinicalDocument
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xmlns:mif="urn:hl7-org:v3/mif" xmlns="urn:hl7-org:v3">
...
<recordTarget>
<patientRole>
<!-- Patient ID - scoped by facility -->
<id nullflavor=“NA"/>
</recordTarget>
...
</ClinicalDocument>
……
<entry typeCode="DRIV">
<!-- Hep B Actual Blood and/or body fluid exposure observation-->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.15.3.26" />
<id nullFlavor="NI"/>
<code code="55213-3" codeSystem="2.16.840.1.113883.6.1" displayName="Number of male sexual partners in
6
months before symptom onset" />
<statusCode code="completed" />
<value xsi:type="INT" value="2" />
</observation>
</entry>
51 /
Yongjian Bao /
February 2, 2010
CDA Model
dataEnterer
typeCode
time: TS[0..1]
Organizer
classCode
modeCode<=EVN
Id:II[0..*]
code: CD CWE[0..1]
statusCode: CS CNE[0..1]
effectiveTime: IVL<TS>[0..1]
recordTarget
custodian
author
typeCode
typeCode=AUT
unctionCode: CE CWE[0..1] informationRecipient
time: TS[1..1]
typeCode
authenticator
informant
typeCode=AUTHEN
Time: TS[1..1]
typeCode
participant
legalAuthenticator
typeCode
typeCode=AUTHEN
functionCode: CE CWE[0..1]
Time: TS[1..1]
time: TS[1..1]
ClinicalDocument
classCode<=DOCCLIN
modeCode<=EVN
Id:II[1..1]
Code: CE CWE[1..1]
Title:ST[0..1]
Confidentiality:CE CWE[1..1]
languageCode: CS CNE[0..1]
setId: II[0..1]
versionNumber: INT[0..1]
Encounter
Section
classCode<=DOCSECT
modeCode<=EVN
Id:II[1..1]
Code: CE CWE[1..1]
Title:ST[0..1]
Confidentiality:CE CWE[1..1]
languageCode: CS CNE[0..1]
StructuredBody
classCode<=DOCBODY
modeCode<=EVN
Confidentiality:CE CWE[1..1]
languageCode: CS CNE[0..1]
performer
ServiceEvent
id: SET<II>[0..*]
typeCode
unctionCode CE CWE00..1] code: CD CWE[0..1]
effectiveTime: IVL<TS>[0..1]
time: IVL<TS>[0..1]
EncompassingEncounter
encounterParticipant id: SET<II>[0..*]
typeCode
Time: IVL<TS>[0..1]
location
typeCode=LOC
Code: CD CWE[0..1]
responsibleParty
effectiveTime: IVL<TS>[0..1]
dischargeDispositionCode: CE CWE[0..1]
typeCode=RESP
ParentDocument
id: SET<II>[0..*]
Code: CD CWE[0..1]
Order
id: SET<II>[0..*]
Code: CD CWE[0..1]
Consent
id: SET<II>[0..*]
Code: CD CWE[0..1]
classCode<=ENC
modeCode
Id:II[0..*]
code: CD CWE[0..1]
negationInd: BL[0..1]
text: ED[0..1]
statusCode: CS CNE[0..1]
effectiveTime: IVL<TS>[0..1]
priorityCode: CE CWE[0..1]
Act
classCode
modeCode
Id:II[0..*]
code: CD CWE[1..1]
negationInd: BL[0..1]
text: ED[0..1]
statusCode: CS CNE[0..1]
effectiveTime: IVL<TS>[0..1]
priorityCode: CE CWE[0..1]
languageCode CS CNE[0..1]
Supply
classCode<=SPLY
modeCode
Id:II[0..*]
code: CD CWE[1..1]
text: ED[0..1]
statusCode: CS CNE[0..1]
effectiveTime: IVL<TS>[0..1]
priorityCode: CE CWE[0..1]
repeatNumber: IVL<INT>[0..1]
independentInd: BL[0..1]
languageCode CS CNE[0..1]
expectedUseTime: IVL<TS>[0..1]
Observation
classCode<=OBS
modeCode
Id:II[0..*]
code: CE CWE[1..1]
negationInd: BL[0..1]
derivationExpr: ST[1..1]
text: ED[0..1]
statusCode: CS CNE[0..1]
effectiveTime: IVL<TS>[0..1]
priorityCode: CE CWE[0..1]
repeatNumber: IVL<INT>[0..1]
languageCode CS CNE[0..1]
Value: ANY[0..1]
interpretationCode: SET<CE> CNE[0..*]
methodCode: SET<CE> CWE[0..*]
targetSiteCode: SET<CD> CWE[0..*]
SubstabceAdministration
classCode<=SBADM
modeCode
Id:II[0..*]
code: CE CWE[0..1]
negationInd: BL[0..1]
text: ED[0..1]
statusCode: CS CNE[0..1]
effectiveTime: IVL<TS>[0..1]
priorityCode: CE CWE[0..1]
repeatNumber: IVL<INT>[0..1]
routeCode CE CWE[0..1]
approachSiteCode: SET<CD> CWE[0..1]
doseQuantity: IVL<PQ>[0..1]
rateQuantity: IVL<PQ>[0..1]
maxDoseQuantity: RTO<PQ,PQ>[0..1]
administrationUnitCode: CE CWE[0..1]
Procedure
classCode<=PROC
modeCode
Id:II[0..*]
code: CE CWE[0..1]
negationInd: BL[0..1]
text: ED[0..1]
statusCode: CS CNE[0..1]
effectiveTime: IVL<TS>[0..1]
priorityCode: CE CWE[0..1]
languageCode: CS CNE[0..1]
methodCode: SET<CE> CWE[0..1]
targetSiteCode SET<CD> CWE[0..1]
52 /
Yongjian Bao /
February 2, 2010
CCD Constraints on CDA Header
53 /
Yongjian Bao /
February 2, 2010
Medication Model
performer
typeCode
time: TS[0..1]
SubstabceAdministration
typeCode=RSON
classCode<=SBADM
modeCode=EVN|INT
Id:II[1..*]
code: CE CWE[0..1]
typeCode=SUBJ
negationInd: BL[0..1]
text: ED[0..1]
statusCode: CS CNE[1..1]
effectiveTime: IVL<TS>[1..*]
repeatNumber: IVL<INT>[0..1]
typeCode=CAUS
routeCode CE CWE[1..1]
approachSiteCode: SET<CD> CWE[0..1]
doseQuantity: IVL<PQ>[1..1]
rateQuantity: IVL<PQ>[1..1]
maxDoseQuantity: RTO<PQ,PQ>[1..1]
administrationUnitCode: CE CWE[0..1] typeCode=REFR
Concern or
Problem
Medication series
number
observation
Reaction
Concern or
Problem
consumable
typeCode
time: TS[0..1]
Manufactured
Product
Material
54 /
Yongjian Bao /
February 2, 2010
Organizer Model
entryRelationship
Observation
Organizer
classCode=CLUSTER
modeCode<=EVN
Id:II[0..*]
code: CD CWE[0..1]
statusCode: CS CNE[0..1]
effectiveTime: IVL<TS>[0..1]
typeCode=“COMP”
typeCode=“SUBJ”
inversionInd=“true”
Age Observation
classCode<=OBS
modeCode=“EVN”
Id:II[1..*]
code: CE CWE[1..1]
negationInd: BL[0..1]
derivationExpr: ST[1..1]
text: ED[0..1]
statusCode=“completed”
effectiveTime: IVL<TS>[0..1]
55 /
Yongjian Bao /
February 2, 2010
Problem Model
participant
typeCode=SUB
awarenessCode
Observation
1..*
Act
classCode=ACT
modeCode=EVN
Id:II[1..*]
code: NullFlavor=“NA”
statusCode: CS CNE[0..1]
effectiveTime: IVL<TS>[0..1]
entryRelationship
typeCode=“SUBJ”
2.16.840.1.113883.10.20.1.27
entryRelationship
classCode<=OBS
typeCode=“SUBJ”
modeCode<=EVN
inversionInd=“true”
Id:II[1..*]
code: CE CWE[1..1]
negationInd: BL[0..1]
text: ED[0..1]
statusCode<=“completed”
entryRelationship
effectiveTime: IVL<TS>[1..1]
typeCode=“REFR”
priorityCode: CE CWE[0..1]
repeatNumber: IVL<INT>[0..1]
languageCode CS CNE[0..1]
Value: ANY[0..1]
interpretationCode: SET<CE> CNE[0..*]
entryRelationship
methodCode: SET<CE> CWE[0..*]
targetSiteCode: SET<CD> CWE[0..*] typeCode=“REFR”
Age Observation
Clinical Status
Health Status
2.16.840.1.113883.10.20.1.28
Concern
Problem
56 /
Yongjian Bao /
February 2, 2010
Payer
participant
typeCode=“HLD”
Clinical Statement
entryRelationship
participant
typeCode=“COV”
performer
typeCode=“PRF”
Act
classCode=ACT
modeCode=DEF
Id:II[1..*]
Code=48768-6 “LOINC”
statusCode=“completed”
effectiveTime: IVL<TS>[0..1]
1..*
entryRelationship
typeCode=“COMP”
sequenceNumber
2.16.840.1.113883.10.20.1.20
Coverage
1..*
Act
classCode=ACT
modeCode=EVN
Id:II[1..*]
Code CE CWE[0..*]
statusCode=“completed”
effectiveTime: IVL<TS>[0..1]
entryRelationship
typeCode=“REFR”
2.16.840.1.113883.10.20.1.26
Policy
typeCode=“SUBJ”
modeCode=PRMS
Act
classCode=ACT
modeCode=EVN
Id:II[1..*]
code CE CWE[0..*]
statusCode=“completed”
effectiveTime: IVL<TS>[0..1]
CS CNE[0..1]
2.16.840.1.113883.10.20.1.19
Authorization
57 /
Yongjian Bao /
February 2, 2010
Where We Start
Use IHE PCC as
reference for
mapping
C80:
Terminology
IHE PCC
TF Vol. 2
CSR*
CCD*
CSR and CCD to resolve any
issue in your mapping process
C83: Content
Modules
History and
Physical Note*
Public Health
Case Report*
Consultation
Note
Hospital
Associated
Infection*
Neonatal Care
Report*
Find more templates in HL7
CDA4CDT and other
implementation guides
Header
Very useful
documents to find
examples and more
specific
explanations.
Quality Reporting
Document
Architecture
Summarization
Notes
Reporting
58 /
Yongjian Bao /
February 2, 2010
Proposed Process
分析数据标准
将数据元归类成块
映射数据组到标准库中section
需了解标准库中，利用
已有的section模板表达
数据元
健康档案数据标准
电子病历临床文档数据标准
领域专家
参考标准中的分类
提出扩展
开发新的Section
确定业务活动/基础模板
映射数据组到标准库中section
选定section
制作IG
实作
59 /
Yongjian Bao /
February 2, 2010