COI: Representing Mock Patient Data in HL7 Standards An example Helen Chen February 12, 2008

Expressing RIM V3 in OWL Top-Level Classes

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

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

RoleLink and ActRelationship As Properties

HL7 Vocabulary And Code

HL7 Data Type

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.)

Translation of XDS Schema To OWL Constructs XSD OWL Definition xs:schema|targetNamespace rdf:RDF|xml:base Define the namespace. xs:schema|xmlns rdf:RDF|xmlns Define the default namespace. xs:complexType|name owl:Class Defines the class. xs:complexType//element or xs:element|attribute owl:DatatypeProperty owl:ObjectProperty owl:Restriction rdf:OnProperty Defines the properties and restrictions of the class. xs:attribute owl:DatatypeProperty Defines the datatype properties. xs:element@type rdfs:range Defines the range of class. xs:maxOccurs xs:minOccurs owl:maxCardinality owl:minCardinality Defines the number of class’ relationships. Note: not alll xds constructs used in CDA schema can be translated In OWL constructs, such as “optional” and “include”

HL7 CDA For Clinical Document Element Name (rdf:Property) Cardinality (owl:Restriction) RIM Source (rdfs:domain) Data Type (rdfs:range) 1 ClinicalDocument 0..1 Document 2 typeId 1..1 InfrastructureRoot II 3 classCode Act CS 4 moodCode 5 Id 6 code CE 7 title ST 8 effectiveTime TS 9 confidentialityCode 10 languageCode 11 setId ContextStructure 12 versionNumber INT 13 copyTime 14 recordTarget 1..* SET<RecordTarget> 15 typeCode Participation 16 contextControlCode 17 patientRole PatientRole 18 Role 19 SET<II> 20 addr 0..* SET<AD>

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> ……..

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> ……..

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>

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>