Coderingen in een HL7v3 RIM EPD Themami… · CT concepten voorzover mogelijk. Concepten Relaties...
Transcript of Coderingen in een HL7v3 RIM EPD Themami… · CT concepten voorzover mogelijk. Concepten Relaties...
Coderingenin een
HL7v3 RIM EPD
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7 Brachmanoth 2008, kwart over 3 lokale tijd Utrecht
Ir. Yeb Havinga
�Waarom een standaard codering?
� Inleiding� Portavita Multidisciplinair EPD
� HL7 Observation
� SNOMED CT
Inhoud
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�Drie elementen uit Diabetes dossier
�Gregoriaanse kalender � Vanaf 1582
� Next generation Juliaanse kalender
� Adoptie in europa van 1582 tot 1923
�Meten van tijd
Metrische systeem
Leer van geschiedenis
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�Metrische systeem
�Gemeenschappelijke codes� handig voor samenwerken
� 22 mei 2008, 16:00 CET
�ASP based software voor chronic disease management� Antistolling, Diabetes, Stroke Service
� Binnenkort: Hartfalen en COPD
�Versie 1: HL7 v2 in XML database, tot 2003
Portavita Multidisciplinair EPD
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�Versie 2: HL7 v3 RIM based relationele database
�Vanaf 2005 dossiers gecodeerd met SNOMED CT concepten� voorzover mogelijk.
�Concepten
�Relaties tussen concepten
� Link met HL7's CD (concept descriptor) data type snel gelegd
�De grootste: 370000 concepten, 1M relaties
SNOMED Clinical Terms
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�De grootste: 370000 concepten, 1M relaties
�Description Logic
� Post coordination
� Code en value� Discussion: Structurally, many observations are name-value-pairs, where the Observation.code(inherited from Act) is the name and theObservation.value is the value of the property.
� Such a construct is also known as a "variable" (a named
SNOMED Clinical TermsHL7 Observation (text from ballot May’08)
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� 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 name-value-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.
�Hoe ziet het eruit in de website
�Welke code of value zien we in SNOMED
�Hoe is het geїmplementeerd?
Drie voorbeelden
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Voorbeeld 1: Diagnose
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Diagnoses in SNOMED CT
� Gevonden� 44054006|Diabetes mellitus type 2
� 46635009|Diabetes mellitus type 1
� 28453007|Maturity onset diabetes mellitus in young
� Niet gevonden
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� LADA
� Speciaal geval: overig� 73211009|Diabetes mellitus
� In 2005:� Observation: code=INTDX (interim diagnosis), value 28453007
� In 2008:� Observation: code=ASSERTION, value= 28453007|Maturity onset diabetes mellitus in
MODY diagnose implementatie in EPD
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28453007|Maturity onset diabetes mellitus in young:418775008|finding method|=???|cognitive process|
� Concern tracker
Disease
Clinical finding
Disorder of body system
Disorder by body site
Finding by site
Disorder of digestive system
Digestive system finding
Disorder of abdomen
General finding of abdomen
Finding of trunk structure
Finding of body region
Disorder of trunk Viscus structure finding Disorder of body cavity
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Autosomal dominant hereditary disorder
Autosomal hereditary disorder
Hereditary disease
Digestive system hereditary disorder
Hereditary disorder by system
Hereditary disorder of endocrine system
Disorder of endocrine system
Diabetes mellitus associated with genetic
syndrome
Diabetes mellitus
Disorder of glucose metabolism
Disorder of carbohydrate metabolism
Metabolic disease
Disorder of endocrine pancreas
Disorder of pancreas
Finding of pancreas Abdominal organ findingDisorder of digestive
organ
Disorder of glucose regulation
�NHG richtlijn diabetes, jaarcontrole� “De huisarts informeert naar het welbevinden, ...
� SF-36 Gezondheidstoestand vragenlijst� 11 multiple choice vragen
�Vrije tekst veld
Voorbeeld 2: Welbevinden
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�Vrije tekst veld
Welbevinden op scherm Portavita EPD
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Welbevinden in SNOMED CT
� 365275006|General well being finding|
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Welbevinden implementatie in EPD
� Uitstekend� Observation: code = 365275006, value = Uitstekend
� Goed� Observation: code = 365275006, value = Goed
� Redelijk
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� Redelijk� Observation: code = 365275006, value = Redelijk
�Matig� Observation: code = 365275006, value = Matig
� Slecht� Observation: code = 365275006, value = Slecht
Voorbeeld 3: Zwangerschap
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� Pregnancy finding:� 77386006|patient currently pregnant
� 60001007|not pregnant
� Finding of fertility:� 169449001|trying to conceive
Zwangerschap in SNOMED CT
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� Zwanger� Observation: code = 77386006, value = Y
�Niet zwanger� Observation: code = 77386006, value = N
�Wens
Zwangerschap implementatie in EPD
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�Wens� Observation: code = 169449001, value = Y
� Zwanger� Observation code=ASSERTION, value = 77386006|patient_currently_pregnant|
�Niet zwanger� Observation code=ASSERTION, value = 77386006|patient_currently_pregnant|, negationInd = Y
SNOMED HL7 impl. handleiding 1.4
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77386006|patient_currently_pregnant|, negationInd = Y
� Observation code=ASSERTION, value = 24376009|situation with explicit context| :246090004|associated finding|= 77386006|patient_currently_pregnant|,408729009|finding context|= 410516002|known absent|
�Wens� Observation code=ASSERTION, value = 169449001|trying to conceive|
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Toekomstplannen
� Uitbouwen Portavita Multidisciplinair EPD� COPD
� Hartfalen
� HL7 ondersteuning door database� HL7 datatypes (zoals CD), vertalingen met UMLS, SNOMED post-coordination, HL7 CTS API
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SNOMED post-coordination, HL7 CTS API
� Portavita Medical Grid
� Doe mee� http://www.portavita.nl/bedrijf/vacature.html