KR100597524B1 - Method for Generation of HL7 Discharge Summary CDA Document, and Hospital Information Management System therefor - Google Patents

Abstract

The present invention relates to a method for generating a HL7 discharge summary CDA document for generating a standardized document for sharing and utilizing a medical information document between medical institutions through a communication network, and a hospital information management system for the same.

The present invention comprises a control unit for controlling the overall operation of the system; A CDA document repository for storing and managing the discharged summary CDA documents generated; A schema generation unit for generating a schema to be included in the discharge summary CDA document according to the analysis of the HL7 RIM and the refined R-MIM, and storing it in the CDA document repository; When the signal to generate the discharge summary CDA document is generated under the control of the control unit, the discharge summary CDA document stored in the CDA document repository and generated by RIM and R-MIM analysis is extracted and parsed, and then discharged according to the HL7 standard. It generates a discharge summary CDA document in accordance with the HL7 standard, including a CDA document generation unit for generating a and a CDA document repository that stores it in the CDA document repository, enabling document sharing among medical institutions, thereby integrating medical information about individuals sequentially It has the advantage of being manageable.

HL7, CDA documents

Description

Method for Generation of HL7 Discharge Summary CDA Document, and Hospital Information Management System therefor}

1 is a diagram showing a connection relationship between a hospital information management system and a communication network according to the present invention;

2 is a view showing in detail the configuration of a hospital information management system according to the present invention;

3 is a diagram showing an example of analysis of HL7 RIM and R-MIM of patient discharge information according to the present invention;

4 is a view showing an element selection example for generating a CDA document according to the present invention;

5 illustrates a CDA document template according to the present invention;

6 is a diagram showing an example of digital signature on a CDA document according to the present invention;

7 illustrates an embodiment of transmitting a CDA document to a CDR by the HL7 transport protocol according to the present invention;

8 is a view showing an embodiment of transmitting a HL7 discharge summary CDA document between medical institutions according to the present invention,

9 is a flowchart illustrating an embodiment of a method for generating a discharge summary CDA document according to the present invention.

<Description of the symbols for the main parts of the drawings>

100: hospital information management system 110: control unit

120: hospital business processing unit 130: schema generation unit

140: CDA document generation unit 150: user authentication unit

160: encryption and decryption processing unit 170: information transmitting and receiving unit

180: Database 190: CDA Document Repository

200: Web service provider 300: communication network

500: CDR system

The present invention relates to a method for generating a HL7 discharge summary CDA document, and more particularly, a method for generating a HL7 discharge summary CDA document for generating a standardized document for sharing and utilizing medical information documents between medical institutions through a communication network, and a hospital for the same. An information management system.

Currently, most hospital information systems are adopting a system operating system based on the order entry & order communication system (OCS). As a management-oriented medical data search and storage method, it is impossible to search and manage data for national disease management, medical support, infectious diseases, cancer, chronic disease management, and lifetime health care.

In the current state of managing patient medical information based on OCS, when a patient moves to or visits another medical department in a medical institution, the medical institution visited by the patient includes information that must be shared among the medical institutions. The previous medical information documents are delivered directly by the patient or the guardian of the patient, or received by FAX, mail, etc. from the medical institution where the patient has previously visited. The reliability of the document was low.

Accordingly, the medical institution repeatedly performed the same test (eg, clinical pathology, radiography, etc.) that the patient had previously performed, thereby increasing the burden on medical expenses.

In addition, application programs built in medical institutions are designed without organic connection with medical data, which unnecessarily increased medical data in medical institutions, and manpower and costs for maintaining, repairing, and managing the medical data are increasing.

In addition, since the systems established in multiple medical institutions are different, it is necessary to use another software to execute the medical information documents generated in the systems of other medical institutions, which causes a problem of mixing costs and medical information documents. have.

Therefore, there is a need for the standardization of medical information documents that can be transmitted by international standard protocols that can be shared between medical institutions at regional or national levels.

SUMMARY OF THE INVENTION The present invention has been made to solve the above problems, and there is a technical problem to provide a method for generating a HL7 discharge summary CDA document and a hospital information management system for generating the discharge summary CDA document according to the HL7 standard.

In order to achieve the above object, the present invention is connected to a communication network, and transmits and receives a medical information document with a CDR system that stores and manages medical information collected from a plurality of medical institutions, and the discharge summary CDA document of patients visiting the medical institution HL7 A hospital information management system created by the standard,

A control unit controlling the overall operation of the system; A CDA document repository for storing and managing the discharged summary CDA documents generated; A schema generation unit for generating a schema to be included in the discharge summary CDA document according to the analysis of the HL7 RIM and the refined R-MIM, and storing the schema in the CDA document repository; When a signal for generating a discharge summary CDA document is generated under the control of the control unit, the discharge summary schema stored in the CDA document repository and generated by RIM and R-MIM analysis is extracted and parsed to discharge discharge summary according to the HL7 standard. And a CDA document generation unit for generating a CDA document and storing it in the CDA document repository.

Another embodiment of the present invention is connected to a communication network, HL7 in the hospital information management system for transmitting and receiving a medical information document with a CDR system for storing and managing medical information collected from a plurality of medical institutions, and manages the medical information of patients visiting the medical institution A method of generating a discharge summary CDA document, the hospital information management system including a repository for storing the CDA document,

A first step of generating a schema to be included in the discharge summary CDA document according to the analysis of the HL7 RIM and the purified R-MIM, and storing it in the CDA document repository; When a signal for generating a discharge summary CDA document is generated, the discharge summary schema is extracted from the schema stored in the CDA document repository, and parsed to generate a discharge summary CDA document according to the HL7 standard, and the CDA document repository is generated. Storing in a second step; And a third step of encrypting and transmitting the HL7 discharge summary CDA document generated in the second step to the CDR system, so that the discharge summary CDA document generated by the HL7 standard can be shared among the systems of multiple medical institutions. do.

The hospital information management system disclosed in the detailed description of the present invention will be described using only the discharge summary CDA document according to the HL7 standard for recording discharge information among a plurality of medical information CDA documents for convenience of description.

Hereinafter, exemplary embodiments of the present invention will be described in detail with reference to the accompanying drawings.

1 is a diagram illustrating a connection relationship between a hospital information management system and a communication network according to the present invention.

The Hospital Information System (100-1 ~ 100-n), which manages patient medical information, stores and manages medical information such as personal information, medical information, and discharge information of patients who have visited medical institutions. The discharge summary CDA document is generated by the HL7 standard, and the HL7 discharge summary CDA document for each user is recorded and transmitted to the CDR (Clinical Data Repository) system 500 through the communication network 300.

Since the HL7 discharge summary CDA document cannot be viewed outside the medical institution, communication between the hospital information management system 100 and the CDR system 500 must be performed according to a predetermined network protocol and a designated message format. And CDR system 500 should be provided with a processing unit capable of encrypting and decrypting the HL7 Discharge Summary CDA document created in accordance with the designated message format.

For example, the protocol and the message format may use a method defined in HL7. The hospital information management system 100 may transmit medical information input by a medical staff to a document generation program according to the HL7 protocol, for example, the HL7 interface engine. Stored in conjunction with the toolkit or using its own Medical Document Architecture (CDA).

In addition, the hospital information management system 100 transmits individual medical information to the CDR system 500 through the communication network 300 using the HL7 interface to be stored.

In the above description, the communication network 300 can be applied to all possible forms that can transmit medical information, such as the Internet, wireless communication network, dedicated network.

The CDR system 500 is a repository for receiving medical information CDA documents generated by the HL7 standard transmitted from a plurality of hospital information management systems 100-1 to 100-n and storing them by index. In response to a request for previous medical information transmitted from the hospital information management system 100 of the patient, the patient's previous medical information (eg, a discharge summary CDA document) is provided with the patient's consent.

FIG. 2 is a diagram showing in detail a configuration of a hospital information management system according to the present invention. FIG. 3 is a diagram illustrating an example of analyzing HL7 RIM and R-MIM of patient discharge information. FIG. 4 is a diagram illustrating an example of selecting elements for generating a CDA document. 5, which illustrates the CDA document template, and FIG. 6, which shows an example of transmitting the CDA document to the CDR by the HL7 transport protocol, will be described.

As shown, the hospital information management system 100 is a control unit 110 for controlling the overall operation of the hospital information management system 100, a hospital that registers and retrieves hospital-related documents resulting from hospitalization or discharge of a patient, etc. Business processing unit 120, schema generation unit 130 for generating a schema for generating a CDA document, CDA document generation unit 140 for generating a discharge summary CDA document reflecting the characteristics of the department treated by the patient according to the HL7 standard And a user authentication unit 150 that performs authentication of a user accessing the hospital information management system 100 for reasons such as medical information registration and retrieval.

In addition, the hospital information management system 100 transmits the medical information CDA document to the encryption and decryption processing unit 160, the CDR system 500 to perform encryption or decryption processing of the CDA document transmitted and received from the hospital information management system 100 or Or an information transmitting / receiving unit 170 for requesting and receiving a medical information CDA document for a specific patient, a database for storing medical information classified according to a predetermined item, a schema, and a HL7 discharge summary CDA document CDA document repository 190 and a web service provider 200 for displaying services such as discharge summary CDA document registration, discharge summary CDA document transmission, etc. on a web screen.

In more detail, the schema generator 130 generates a schema to be included in the discharge summary CDA document according to the analysis of the HL7 Reference Information Model (hereinafter, referred to as RIM) and refined R-MIM. And store it in the CDA Document Repository 190.

Here, RIM is a static model designed based on the approximate elements of health and health care that must be included to generate CDA documents. Classes, State-Machine diagrams, Use Includes Case Model, Interaction Model, Data Type Model, Terminology Model, etc. That is, RIM is an abstract model and consists of six backbone classes Act, Participation, Entity, Role, and RoleLink ActRelationShip.

On the other hand, the R-MIM is designed to refine the elements to be included in the CDA document in more detail compared to the RIM, as shown in FIG.

3, the R-MIM of A is further generated for the domestic discharge summary record according to the HL7 standard, which is discharge condition (Discharge Condition), discharge type (Discharge Type), infection status (Hospital Infection), Death type, and B's R-MIM is derived according to the HL7 standard and includes NonXMLBody, diagnosis name, operation name, surgical record and Consists of a StructureBody that will contain the results of the clinical pathology examination.

When a signal for generating the discharge summary CDA document is generated under the control of the controller 110, the CDA document generation unit 140 is stored in the CDA document repository 190 and is generated through RIM and R-MIM analysis. Schema is extracted and automatically parsed to generate a discharge summary CDA document according to the HL7 standard and stored in the CDA document repository 190.

Here, as shown in FIG. 4, the CDA document generation unit 140 selects or modifies (B) an element corresponding to the characteristics of each department in the discharge summary schema (A) generated through the RIM analysis to summarize the HL7 standard discharge summary. The CDA document is created. Afterwards, the header part of the CDA document is equally applied to the discharge of the CDA document by the same medical department, and the body part is standardized so that only the body part can be modified and added. The header portion of the CDA document is a portion in which the patient's personal information is recorded, and the medical information is recorded according to the characteristics of the department of the body. Detailed description thereof will be described later.

The template of the discharge summary CDA document generated by the CDA document generation unit 140 according to the HL7 standard is clearly distinguished from a header part and a body part as illustrated in FIG. 5. Here, the header part is composed of CDA information, Encounter, Service Actors, and Patient Targets, and the body part is composed of Narrative and Text. Entries. do. The components of the header are patient information (eg, name, date of birth, address, etc.), hospitalization and discharge information, signature, organization information, etc., and the components of the body are chief complaints. ), Personal & Family Hx, Diagnosis, Surgery & Procedure, Lab & Image Data, Progress Note, Discharge Med), Discharge Plan, and Discharge Condition.

In addition, the CDA document generation unit 140 includes information such as diagnosis name, surgery and treatment, surgical record, imaging test and diagnosis, clinical examination and result, discharge prescription, post-discharge plan, discharge status, discharge type, infection status, death type, etc. After confirming, adding, and changing the discharge summary CDA document is generated, and after completion of the doctor's signature is stored in the CDA document repository 190. In this case, the discharge summary CDA document cannot be corrected and added after the completion of the electronic signature of two medical doctors and one medical recorder. The electronic signature can be determined from the legalAuthenticator, authenticator, and author elements of the discharge summary CDA document, and FIG. 6 shows an example of digital signature on the legalAuthenticator.

In addition, when the CDA document generation unit 140 generates the HL7 discharge summary CDA document, the CDA document generation unit 140 includes a code for distinguishing the sex of the patient recorded in the HL7 discharge summary CDA document, thereby providing the medical information of the patient. It can be used when searching and extracting.

The HL7 discharge summary CDA document generated by the CDA document generation unit 140 may be stored in a portable memory device capable of storing information, such as a floppy diskette, a CD, and a chip in a mobile communication terminal, and then delivered to a user. This is a method for patients who refuse to share their medical information with others.

As shown in FIG. 7, the CDA document repository 190 transmits the discharge summary CDA document of a specific patient encrypted by the encryption / decryption processor 160 to the CDR system 500 through the information transceiver 170. In this case, the discharge summary CDA document is transmitted to the CDR system 500 via the communication network 300 using the HL7 interface. The CDR system 500 stores the patient-specific HL7 discharge summary CDA document transmitted from the hospital information management system 100 and then receives the medical information request signal transmitted from the hospital information management system of another medical institution, requesting medical information. The authentication process for the user is performed, and if the user is an authenticated user, the medical information is encrypted and provided.

The web service provider 200 provides a discharge summary CDA document generated by the CDA document generator 140 in the form of a web service.

8 is a diagram illustrating an embodiment of transmitting a HL7 discharge summary CDA document between medical institutions according to the present invention.

For example, if patient A is admitted to Busan ○○ hospital and undergoes gastrectomy, Busan ○○ hospital generates CD A document of patient A's HL7 discharge summary when patient A is discharged after treatment and sent to CDR system. A patient's HL7 discharge summary CDA document is stored in a portable memory device capable of transmitting information (1) and simultaneously storing information such as a CD, a floppy diskette, and a chip in a mobile communication terminal (2).

Then, if patient A visits the emergency room of Daegu ○○ hospital with abdominal pain, symptoms of bleeding, loss of consciousness, etc., Daegu ○○ hospital has a family history for emergency transfusion and reoperation for A patient. Medical information, including medical treatment information, final clinical pathology test results, and image diagnosis results, will be required.In this case, the attending physician of Daegu ○○ Hospital will be responsible for patient A's portable memory device. Check Patient A's medical information by checking the HL7 Discharge Summary CDA document stored at

Alternatively, the hospital information management system of Daegu ○○ Hospital requests and receives the HL7 discharge summary CDA document containing the patient's previous medical information to Busan ○○ Hospital with the consent of Patient A and Guardian (③), or the CDR system. (500) request and receive a HL7 discharge summary CDA document from patient A.

In addition, the hospital information management system of Daegu ○○ Hospital is the same procedure that was performed when the patient was discharged from Busan ○○ Hospital when he finished the treatment of Patient A and created the HL7 discharge summary CDA document. Transfer (4), save the HL7 discharge summary CDA document to a portable memory device and provide it to patient A).

9 is a flowchart illustrating an embodiment of a method for generating a discharge summary CDA document according to the present invention.

The schema generation unit 130 of the hospital information management system 100 generates a schema to be included in the discharge summary CDA document according to the analysis of the HL7 RIM and the refined R-MIM, and the CDA document repository 190. In step S101.

Subsequently, when a signal for generating a discharge summary CDA document is generated under the control of the controller 110, the CDA document generation unit 140 is stored in the CDA document repository 190 and generated through RIM and R-MIM analysis. The discharge summary schema Schema is extracted and automatically parsed to generate a discharge summary CDA document according to the HL7 standard and stored in the CDA document repository 190 (S103, S105).

Here, as shown in FIG. 4, the CDA document generation unit 140 selects or modifies (B) an element corresponding to the characteristics of each department in the discharge summary schema (A) generated through the RIM analysis to summarize the HL7 standard discharge summary. The CDA document is created. Afterwards, the header part of the CDA document is equally applied to the discharge of the CDA document by the same medical department, and the body part is standardized so that only the body part can be modified and added. The header portion of the CDA document records the personal information of the patient, and the medical information is recorded according to the characteristics of each department of the body.

The HL7 discharge summary CDA document generated in step S103 may be stored in a portable memory device capable of storing information, such as a floppy diskette, a CD, and a chip in a mobile communication terminal, and then delivered to a user. This is a method for patients who refuse to share their medical information with others.

Subsequently, the CDA document repository 190 transmits the discharge summary CDA document of the specific patient encrypted by the encryption / decryption processor 160 to the CDR system 500 through the information transceiver 170 (S107). Here, the discharge summary CDA document is transmitted to the CDR system 500 via the communication network 300 using the HL7 interface. The CDR system 500 stores the patient-specific HL7 discharge summary CDA document transmitted from the hospital information management system 100 and then receives the medical information request signal transmitted from the hospital information management system of another medical institution, requesting medical information. The authentication procedure for users is performed, and if the user is an authenticated user, the relevant medical information is encrypted and provided.

In the detailed description of the present invention, only the discharge summary CDA document of the plurality of medical information CDA documents has been described as an example. However, it will be apparent to those skilled in the art that the present invention can be easily applied to other medical information documents except discharge information. will be.

As such, those skilled in the art will appreciate that the present invention can be implemented in other specific forms without changing the technical spirit or essential features thereof. Therefore, the above-described embodiments are to be understood as illustrative in all respects and not as restrictive. The scope of the present invention is shown by the following claims rather than the detailed description, and all changes or modifications derived from the meaning and scope of the claims and their equivalents should be construed as being included in the scope of the present invention. do.

As described above, the method for generating the HL7 discharge summary CDA document of the present invention and the hospital information management system therefor generate the discharge summary CDA document according to the HL7 standard, so that documents can be shared among medical institutions. There is an advantage that can be integrated management sequentially.

In addition, since the present invention generates a CDA document according to the HL7 standard, it is possible to reduce the cost of installing new software for executing different types of medical information documents in a plurality of medical institutions.

Claims (11)

A hospital information management system connected to a communication network, transmitting and receiving a medical information document with a CDR system for storing and managing medical information collected from a plurality of medical institutions, and generating a discharge summary CDA document of a patient visiting the medical institution by the HL7 standard. , A control unit controlling the overall operation of the system; A CDA document repository for storing and managing the discharged summary CDA documents generated; A schema generation unit for generating a schema to be included in the discharge summary CDA document according to the analysis of the HL7 RIM and the refined R-MIM, and storing the schema in the CDA document repository; And When a signal for generating a discharge summary CDA document is generated under the control of the control unit, the discharge summary schema stored in the CDA document repository and generated by RIM and R-MIM analysis is extracted and parsed to discharge discharge summary according to the HL7 standard. A CDA document generation unit for generating a CDA document and storing it in the CDA document repository; Hospital information management system comprising a. The method of claim 1, The hospital information management system, A user authentication unit which authenticates a user accessing the system for registration and retrieval of medical information; An encryption and decryption processing unit for encrypting the HL7 discharge summary CDA document generated by the CDA document generation unit or decoding the HL7 discharge summary CDA document transmitted from the CDR system and another medical institution; An information transmitting / receiving unit which transmits the HL7 discharge summary CDA document to the CDR system or requests and receives the HL7 discharge summary CDA document for a specific patient to a system of another medical institution and / or the CDR system; And A web service providing unit which displays and provides a service provided by the hospital information management system on a web screen; Hospital information management system comprising a further. The method of claim 1, The CDA document generation unit, Hospital information management system, characterized in that to generate the HL7 standard discharge summary CDA document by selecting or modifying the elements according to the characteristics of each department in the schema. The method of claim 1, The HL7 discharge summary CDA document is a hospital information management system, characterized in that it contains an electronic signature of the doctor and medical personnel who treated the patient. The method of claim 1, The HL7 discharge summary CDA document generated by the CDA document generation unit according to the HL7 standard is divided into a header part and a body part. The header portion is composed of CDA information, Encounter, Service Actors, and Patients, and the body portion is composed of narrative and text entities. , The components of the header are the patient's personal information, hospitalization and discharge information, signature, organization information (Organization Information), the components of the body (Chief complaint), personal and family history (Personal & Family Hx) , Diagnosis, Surgery & Procedure, Lab & Image Data, Progress Note, Discharge Med, Discharge Plan, Discharge Hospital information management system, characterized in that the (Discharge Condition). The method of claim 1, The HL7 discharge summary CDA document is stored in a portable memory device consisting of a CD, a floppy diskette, a chip in a mobile communication terminal or a combination thereof. HL7 discharge summary CDA document in a hospital information management system connected to a communication network, transmitting and receiving a medical information document with a CDR system for storing and managing medical information collected from a plurality of medical institutions, and managing medical information of patients visiting the medical institution. As the generation method, the hospital information management system includes a repository for storing CDA documents, A first step of generating a schema to be included in the discharge summary CDA document according to the analysis of the HL7 RIM and the purified R-MIM, and storing it in the CDA document repository; When a signal for generating a discharge summary CDA document is generated, the discharge summary schema is extracted from the schema stored in the CDA document repository, and parsed to generate a discharge summary CDA document according to the HL7 standard, and the CDA document repository is generated. Storing in a second step; And A third step of encrypting and transmitting the HL7 discharge summary CDA document generated in the second step to the CDR system; A method for generating a HL7 discharge summary CDA document, comprising: allowing the discharge summary CDA document generated by the HL7 standard to be shared by a system of a plurality of medical institutions. The method of claim 7, wherein The second step, Selecting or modifying an element suitable for each department in the schema to generate an HL7 standard discharge summary CDA document. The method of claim 7, wherein In the second step, And the HL7 discharge summary CDA document is stored in the CDA document repository, including the digital signatures of the doctors and medical personnel who have treated the patient. The method of claim 7, wherein The HL7 discharge summary CDA document is divided into a header part and a body part, The header portion is composed of CDA information, Encounter, Service Actors, and Patients, and the body portion is composed of narrative and text entities. , The components of the header are the patient's personal information, hospitalization and discharge information, signature, organization information (Organization Information), the components of the body (Chief complaint, personal and family history (Personal & Family Hx) , Diagnosis, Surgery & Procedure, Lab & Image Data, Progress Note, Discharge Med, Discharge Plan, Discharge HL7 discharge summary CDA document generation method characterized in that the (Discharge Condition). The method of claim 7, wherein And storing the HL7 discharge summary CDA document in a portable memory device including a CD, a floppy diskette, a chip in a mobile communication terminal, or a combination thereof.

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