Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Republic of Korea.
Data Science Research Institute, Samsung Medical Center, Seoul, Republic of Korea.
Appl Clin Inform. 2022 May;13(3):592-601. doi: 10.1055/s-0042-1749331. Epub 2022 Jun 22.
Health information exchange (HIE) allows healthcare providers to access a patient's medical information to improve patient care continuity. The standardized data realize the HIE values. Since the Health Level 7 Clinical Document Architecture (CDA) is flexible, implementation guides (IG) are needed for use cases. Although many CDA IGs have been developed, they did not describe how these CDA IGs were developed. A national CDA IG that meets the local requirements is demanded since the data differs according to the digital divide and social-cultural background of the country that wants to establish HIE. Due to their localized contents, other countries cannot directly adopt the published CDA IGs.
We developed the national CDA IG, namely, Korean (K)-CDA IG that meets the local requirement, including reusable structured templates, value sets, and object identifiers (OIDs). We present a detailed description of the development process and the technical methods of the national CDA IG in the Korean context.
The K-CDA IG was developed in the following stages: analysis, development, and evaluation. First, we investigated the health information environment and electronic health record (EHR) systems and conducted a gap analysis with published CDA IGs. Second, a templated CDA approach was taken for designing modular. Lastly, we consulted a technical advisory group for comments on the validity of the K-CDA IG.
A total of 35 CDA templates were developed. We improved 28 value sets of which 13 were Korea specific and 15 were based on the ones used in other IGs, and made a set of rules to establish the OID structure.
We presented the development process and the technical specifications of K-CDA IG. We explored how the results can be used as interoperability criteria in the national EHR systems certification program. Finally, we provided recommendations that could guide other entities planning their HIE programs.
健康信息交换（HIE）允许医疗保健提供者访问患者的医疗信息，以提高患者护理的连续性。标准化数据实现了 HIE 的价值。由于 Health Level 7 Clinical Document Architecture（CDA）具有灵活性，因此需要使用案例的实施指南（IG）。尽管已经开发了许多 CDA IG，但它们没有描述这些 CDA IG 是如何开发的。由于数据因想要建立 HIE 的国家的数字鸿沟和社会文化背景而有所不同，因此需要符合当地要求的国家 CDA IG。由于其本地化内容，其他国家无法直接采用已发布的 CDA IG。
我们开发了符合当地要求的国家 CDA IG，即韩国（K）-CDA IG，其中包括可重复使用的结构化模板、值集和对象标识符（OID）。我们详细介绍了在韩国背景下开发国家 CDA IG 的过程和技术方法。
K-CDA IG 的开发分为以下阶段：分析、开发和评估。首先，我们调查了健康信息环境和电子健康记录（EHR）系统，并与已发布的 CDA IG 进行了差距分析。其次，我们采用模板化的 CDA 方法进行模块化设计。最后，我们咨询了技术咨询小组，以征求他们对 K-CDA IG 有效性的意见。
共开发了 35 个 CDA 模板。我们改进了 28 个值集，其中 13 个是韩国特有的，15 个是基于其他 IG 中的值集，还制定了一套规则来建立 OID 结构。
我们介绍了 K-CDA IG 的开发过程和技术规范。我们探讨了如何将这些结果用作国家 EHR 系统认证计划中的互操作性标准。最后，我们提出了一些建议，可以为其他规划 HIE 计划的实体提供指导。
