Coderingen in een HL7v3 RIM EPD. 7 Brachmanoth 2008, kwart over 3 lokale tijd Utrecht Ir. Yeb Havinga

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1 Coderingen in een HL7v3 RIM EPD 7 Brachmanoth 2008, kwart over 3 lokale tijd Utrecht Ir. Yeb Havinga - 1 -

2 Inhoud Waarom een standaard codering? Inleiding Portavita Multidisciplinair EPD HL7 Observation SNOMED CT Drie elementen uit Diabetes dossier - 2 -

3 Leer van geschiedenis Gregoriaanse kalender Vanaf 1582 Next generation Juliaanse kalender Adoptie in europa van 1582 tot 1923 Meten van tijd Metrische systeem Gemeenschappelijke codes handig voor samenwerken 22 mei 2008, 16:00 CET - 3 -

4 Portavita Multidisciplinair EPD ASP based software voor chronic disease management Antistolling, Diabetes, Stroke Service Binnenkort: Hartfalen en COPD Versie 1: HL7 v2 in XML database, tot 2003 Versie 2: HL7 v3 RIM based relationele database Vanaf 2005 dossiers gecodeerd met SNOMED CT concepten voorzover mogelijk

5 SNOMED Clinical Terms Concepten Relaties tussen concepten Link met HL7's CD (concept descriptor) data type snel gelegd De grootste: concepten, 1M relaties Description Logic Post coordination - 5 -

6 SNOMED HL7 Observation Clinical Terms (text from ballot May 08) Code en value Discussion: Structurally, many observations are name-value-pairs, where the Observation.code (inherited from Act) is the name and the Observation.value is the value of the property. Such a construct is also known as a "variable" (a named feature that can assume a value); hence, the Observation class is always used to hold generic namevalue-pairs or variables, even though the variable valuation may not be the result of an elaborate observation method. It may be a simple answer to a question or it may be an assertion or setting of a parameter

7 Drie voorbeelden Hoe ziet het eruit in de website Welke code of value zien we in SNOMED Hoe is het geїmplementeerd? - 7 -

8 Voorbeeld 1: Diagnose - 8 -

9 Diagnoses in SNOMED CT Gevonden Diabetes mellitus type Diabetes mellitus type Maturity onset diabetes mellitus in young Niet gevonden LADA Speciaal geval: overig Diabetes mellitus - 9 -

10 MODY diagnose implementatie in EPD In 2005: Observation: code=intdx (interim diagnosis), value In 2008: Observation: code=assertion, value= Maturity onset diabetes mellitus in young: finding method =??? cognitive process Concern tracker

11 Clinical finding Disease Finding by site Finding of body region Disorder by body site Finding of trunk structure Disorder of body system Digestive system finding General finding of abdomen Disorder of trunk Viscus structure finding Disorder of body cavity Disorder of digestive system Disorder of abdomen Hereditary disease Disorder of endocrine system Metabolic disease Finding of pancreas Abdominal organ finding Disorder of digestive organ Hereditary disorder by system Disorder of carbohydrate metabolism Disorder of pancreas Autosomal hereditary disorder Disorder of glucose metabolism Disorder of endocrine pancreas Disorder of glucose regulation Diabetes mellitus Autosomal dominant hereditary disorder Digestive system hereditary disorder Hereditary disorder of endocrine system Diabetes mellitus associated with genetic syndrome Maturity - 11onset - diabetes mellitus in young

12 Voorbeeld 2: Welbevinden NHG richtlijn diabetes, jaarcontrole De huisarts informeert naar het welbevinden,... SF-36 Gezondheidstoestand vragenlijst 11 multiple choice vragen Vrije tekst veld

13 Welbevinden op scherm Portavita EPD

14 Welbevinden in SNOMED CT General well being finding

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16 Welbevinden implementatie in EPD Uitstekend Observation: code = , value = Uitstekend Goed Observation: code = , value = Goed Redelijk Observation: code = , value = Redelijk Matig Observation: code = , value = Matig Slecht Observation: code = , value = Slecht

17 Voorbeeld 3: Zwangerschap

18 Zwangerschap in SNOMED CT Pregnancy finding: patient currently pregnant not pregnant Finding of fertility: trying to conceive

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21 Zwangerschap implementatie in EPD Zwanger Observation: code = , value = Y Niet zwanger Observation: code = , value = N Wens Observation: code = , value = Y

22 SNOMED HL7 impl. handleiding 1.4 Zwanger Observation code=assertion, value = patient_currently_pregnant Niet zwanger Observation code=assertion, value = patient_currently_pregnant, negationind = Y Observation code=assertion, value = situation with explicit context : associated finding = patient_currently_pregnant, finding context = known absent Wens Observation code=assertion, value = trying to conceive

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24 Toekomstplannen Uitbouwen Portavita Multidisciplinair EPD COPD Hartfalen HL7 ondersteuning door database HL7 datatypes (zoals CD), vertalingen met UMLS, SNOMED post-coordination, HL7 CTS API Portavita Medical Grid Doe mee