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Establishing semantic interoperability in the course of clinical document exchange using international standard for metadata registry

Article information

J Korean Med Assoc. 2012;55(8):729-740
Publication date (electronic) : 2012 August 16
doi : https://doi.org/10.5124/jkma.2012.55.8.729
Yu Rang Park, PhD1, Hyehyeon Kim, MS1, Eun Yang An, AB1, Hyung Hoi Kim, MD2,3, Ju Han Kim, MD4, Rae Woong Park, MD5, Dong Kyun Park, MD6, Eun-Young Jung, PhD6, Ju Han Kim, MD1,7
1Seoul National University Biomedical Informatics (SNUBI), Division of Biomedical Informatics, Seoul National University College of Medicine, Seoul, Korea.
2Department of Laboratory Medicine, Pusan National University School of Medicine, Busan, Korea.
3Medical Research Institute, Pusan National University Hospital, Busan, Korea.
4Heart Center of Chonnam National University Hospital, Gwangju, Korea.
5Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea.
6U-Healthcare Center, Gachon University Gil Hospital, Incheon, Korea.
7Systems Biomedical Informatics National Core Research Center, Division of Biomedical Informatics, Seoul National University College of Medicine, Seoul, Korea.
Corresponding author: Ju Han Kim, juhan@snu.ac.kr
Received 2012 July 02; Accepted 2012 July 16.

Abstract

Around the world electronic health records data are being shared and exchanged between two different systems for direct patient care, as well as for research, reimbursement, quality assurance, epidemiology, public health, and policy development. It is important to communicate the semantic meaning of the clinical data when exchanging electronic health records data. In order to achieve semantic interoperability of clinical data, it is important not only to specify clinical entries and documents and the structure of data in electronic health records, but also to use clinical terminology to describe clinical data. There are three types of clinical terminology: interface terminology to support a user-friendly structured data entry; reference terminology to store, retrieve, and analyze clinical data; and classification to aggregate clinical data for secondary use. In order to use electronic health records data in an efficient way, healthcare providers first need to record clinical content using a systematic and controlled interface terminology, then clinical content needs to be stored with reference terminology in a clinical data repository or data warehouse, and finally, the clinical content can be converted into a classification for reimbursement and statistical reporting. For electronic health records data collected at the point of care to be used for secondary purposes, it is necessary to map reference terminology with interface terminology and classification. It is necessary to adopt clinical terminology in electronic health records systems to ensure a high level of semantic interoperability.

Keywords: Metadata; Semantic interoperability; Metadata registry; ISO/IEC 11179; Clinical document exchange

Acknowledgement

This research was supported by the basic science research program through the National Research Foundation of Korea funded by the Ministry of Education, Science and Technology (2010-0028631). YRP's education grant was supported by the Ministry of Health and Welfare, Republic of Korea (A112020).

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Article information Continued

Copyright © 2012 Korean Medical Association

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Figure 1

Figure 1

Creating metadata for clinical document exchange. (A) Basic architecture of ISO/IEC 11179 consists of data element, data element concept (DEC), conceptual domain and value domain. (B) Procedure diagram of metadata extraction vocabulary mapping from clinical documents. UMLS, unified medical language system.

Figure 2

Figure 2

The example of medadata about patient personal medical history asthma occurrence indicator.

Figure 3

Figure 3

Metadata registry (MDR)-based semantic interoperability during clinical document architecture (CDA)-based clinical document exchange. EMR, electronic medical record; OpenEHR, open Electronic Health Record.

Figure 4

Figure 4

Example for (A) HL-7 template and (B) open Electronic Health Record archetype on patient registration number.

Figure 5

Figure 5

Screenshot from clinical document exchange using Health Avatar CCR+.

Table 1

Distribution of metadata served by BMESH server

Table 1

CRF, case report form; CDISC, Clinical Data Interchange Standards Consortium; CDASH, Clinical Data Acquisition Standards Harmonization ; KFDA, Korea Food & Drug Administration. a)Five clinical document types (admission note, initial medical examination note, discharge note, emergency note, and operation note) from five major Korean hospitals (Seoul National University Hospital, Ajou University Medical Center, Pusan National University Hospital, Gachon University Gil Hospital, and Chonnam National University Hospital).

Table 2

Number of metadata instances extracted from five document types from five hospitals

Table 2

Table 3

Number of common metadata between hospitals

Table 3

Table 4

Number of metadata shared in five clinical document types from five hospitals

Table 4

Table 5

Constraint rules for HL-7 template and OpenEHR archetypes

Table 5

OpenEHR, open Electronic Health Record; CDA, clinical document architecture; DE, data element; VD, value domain.