1. COI: Representing Mock Patient Data in HL7 Standards An 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
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.
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”

10. 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>

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=" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
<typeId root=" " extension="POCD_HD000040"/>
<id extension = "c266" root=" "/> <code code=" " codeSystem=" " displayName=“ReferNote"/>
<Hypertension Clinica in JiChi Medical School Hospital</title> <effectiveTime value=“200704"/>
<confidentialityCode code="N" codeSystem=" "/>
<setId extension="BB35" root=" ">
<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=" "/>
<patient>
<name>
<given>Henry</given>
<family>Levin</family>
<suffix>the 7th</suffix>
</name>
<administrativeGenderCode code="M" codeSystem=" " />
<birthTime value=" "/>
</patient>
<providerOrganization>
<id extension="M345" root=" "/>
</providerOrganization>
</patientRole>
</recordTarget>
……..

13. COI Mock Up Patient Data-3
CDA section - patient present medical condition: debetes
<section>
<code code=“1234-5"
codeSystem=" "
codeSystemName="LOINC"/>
<title>Present Medical Condition</title>
<text>
Patient has <content ID=“d1">Diebetes</content>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code=“ "
codeSystem=" "
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=" "
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=“ "
codeSystem=" "
codeSystemName="SNOMED CT"
displayName=“Hypertension">
<originalText>
<reference value="#d2"/>
</originalText>
</code>
<statusCode code="completed"/>
<activityTime time=“ ” />
</observation>
</entry>
</section>