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Representing Mock Patient Data in HL7 Standards: A Comprehensive Overview

This document provides a detailed overview of representing mock patient data using HL7 standards, particularly focusing on the Clinical Document Architecture (CDA). It discusses the structure of the CDA, including top-level classes, headers, and body content types such as XML and non-XML. An example case shows a patient with diabetes referred to a hypertension clinic. The content includes essential identifiers, patient information, and medical history while explaining how to construct these elements in accordance with HL7 standards, including RIM V3 and OWL.

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Representing Mock Patient Data in HL7 Standards: A Comprehensive Overview

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  1. COI: Representing Mock Patient Data in HL7 StandardsAn example Helen Chen February 12, 2008

  2. Expressing RIM V3 in OWL • Top-Level Classes

  3. ACT This class hierarchy is constructed according to ACT Type code definition

  4. Entity, Participation, Role These class hierarchies are constructed according to respective type code too

  5. RoleLink and ActRelationship As Properties

  6. HL7 Vocabulary And Code

  7. HL7 Data Type

  8. HL7 CDA For Clinical Document • CDA are used as schemas for recording clinical events in documents • Header: • Global-unique identifiers • Document Type Code • Timestamp • Confidentiality Code • Patient • Author • Custodian • Body: • XML Content (such as tables, lists, etc.) • Non-XML Content (such as sounds, video clips, etc.)

  9. Translation of XDS Schema To OWL Constructs Note: not alll xds constructs used in CDA schema can be translated In OWL constructs, such as “optional” and “include”

  10. HL7 CDA For Clinical Document

  11. COI Mock Up Patient Data in CDA Document -1 • On 19 April, 54-year-old man with diabetes was referred to the Hypertension Clinic in Jichi Medical School Hospital with symptoms of dizziness and orthostatic intolerance • CDA header - where you can find the document <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:mif="urn:hl7-org:v3/mif" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd"> <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/> <id extension = "c266" root="2.16.840.1.113883.3933"/><code code="11488-4" codeSystem="2.16.840.1.113883.6.1" displayName=“ReferNote"/> <Hypertension Clinica in JiChi Medical School Hospital</title><effectiveTime value=“200704"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <setId extension="BB35" root="2.16.840.1.113883.3.933"> <versionNumber value="2"/> <legalAuthenticator> <author> <custodian> ……..

  12. COI Mock Up Patient Data-2 • CDA section - where to find specific patient information: patient <recordTarget> <patientRole> <id extension="12345" root="2.16.840.1.113883.3.933"/> <patient> <name> <given>Henry</given> <family>Levin</family> <suffix>the 7th</suffix> </name> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" /> <birthTime value="19540924"/> </patient> <providerOrganization> <id extension="M345" root="2.16.840.1.113883.3.933"/> </providerOrganization> </patientRole> </recordTarget> ……..

  13. COI Mock Up Patient Data-3 • CDA section - patient present medical condition: debetes <section> <code code=“1234-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Present Medical Condition</title> <text> Patient has <content ID=“d1">Diebetes</content> </text> <entry> <observation classCode="OBS" moodCode="EVN"> <code code=“1234567" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName=“Diebetes"> <originalText> <reference value="#d1"/> </originalText> </code> <statusCode code="completed"/> </observation> </entry> </section>

  14. COI Mock Up Patient Data-3 • CDA section - patient past medical history: Hypertension <section> <code code=“1234-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Present Medical History</title> <text> There is a history of <content ID=“d2">Hypertension</content> </text> <entry> <observation classCode="OBS" moodCode="EVN"> <code code=“1234567" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName=“Hypertension"> <originalText> <reference value="#d2"/> </originalText> </code> <statusCode code="completed"/> <activityTime time=“20050629” /> </observation> </entry> </section>

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