Healthc Inform Res.  2011 Dec;17(4):205-213. 10.4258/hir.2011.17.4.205.

The Development of Clinical Document Standards for Semantic Interoperability in China

• Yang P
• Pan F
• Liu D
• Xu Y
• Wan Y
• Tu H
• Tang X
• Hu J

• KMID: 2284547
• DOI: http://doi.org/10.4258/hir.2011.17.4.205

Abstract

OBJECTIVES
This study is aimed at developing a set of data groups (DGs) to be employed as reusable building blocks for the construction of the eight most common clinical documents used in China's general hospitals in order to achieve their structural and semantic standardization.
METHODS
The Diagnostics knowledge framework, the related approaches taken from the Health Level Seven (HL7), the Integrating the Healthcare Enterprise (IHE), and the Healthcare Information Technology Standards Panel (HITSP) and 1,487 original clinical records were considered together to form the DG architecture and data sets. The internal structure, content, and semantics of each DG were then defined by mapping each DG data set to a corresponding Clinical Document Architecture data element and matching each DG data set to the metadata in the Chinese National Health Data Dictionary. By using the DGs as reusable building blocks, standardized structures and semantics regarding the clinical documents for semantic interoperability were able to be constructed.
RESULTS
Altogether, 5 header DGs, 48 section DGs, and 17 entry DGs were developed. Several issues regarding the DGs, including their internal structure, identifiers, data set names, definitions, length and format, data types, and value sets, were further defined. Standardized structures and semantics regarding the eight clinical documents were structured by the DGs.
CONCLUSIONS
This approach of constructing clinical document standards using DGs is a feasible standard-driven solution useful in preparing documents possessing semantic interoperability among the disparate information systems in China. These standards need to be validated and refined through further study.

Keyword

Electronic Health Records; Standards; Health Level Seven; Information Systems

MeSH Terms

Asian Continental Ancestry Group
China
Delivery of Health Care
Electronic Health Records
Health Level Seven
Hospitals, General
Humans
Information Systems
Semantics

Figure

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  Figure 1 The formulation process of the data groups (DGs) and clinical documents, which includes three steps: development of the DGs' architecture and contents, definition of the structure, content and semantics of each DG, and construction of each clinical document with DGs. HL7: Health Level Seven, IHE: Integrating the Healthcare Enterprise, HITSP: Healthcare Information Technology Standards Panel, CNHDD: Chinese National Health Data Dictionary, CDA: Clinical Document Architecture.

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  Figure 2 The architecture and contents of the data groups (DGs). Altogether, 5 header DGs, 48 section DGs and 17 entry DGs were proposed. Each DG contains one or more data items. A body consists of one or more section DGs. A section DG contains a single narrative block and zero or more entry DGs which represent the narrative block by structured data items.

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  Figure 3 An XML instance of the entry data group (DG) Allergies and Adverse Reactions. The allergy substance-penicillin and allergy symptom-hives were represented by the element observation nested in the element act respectively. Their relationship was connected by the element entryRelationship.

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  Figure 4 Outpatient medical record summary document structured by data groups (DGs) in XML Schema, which is comprised of 3 header DGs (Document Identifier, Patient Information, Healthcare Providers) and 12 section DGs (e.g., Chief Complaint, Physical Exam).

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