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Bemmel, M.A. Musen, 1997]

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and Telemedicine by ENRICO COIERA, 1997].
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86

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paper-based .
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information systems in health care: an approach to classifying evaluative studies,
Computer Methods and programs in Biomedicine, R.P. van der Loo, E.M. van Gennip,
A.R. Bakker, A. Hasman, F.F. Rutten, 1995].

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IM The Computer-based Patient Record: An
Essential Technology for Health Care:
A computer-based patient record (CPR) is an electronic patient record that resides in
a system specifically designed to support users by providing accessibility to complete and
accurate data, alerts, reminders, clinical decision support systems, links to medical
knowledge, and other aids.
Future patient records should support patient care and improve its quality, enhance
productivity and reduce administrative costs, support clinical and health services research,
accommodate future developments, and ensure patient data confidentiality.
Electronic Health(Care) Record,
Citizen Health Record (CHR).
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,
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1987, 1994 ANSI HL7 Standards Developing
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92

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:
Patient William A. Jones, III was admitted on July 18, 1988 at 11:23 a.m. by doctor
Sidney J. Lebauer (#004777) for surgery (SUR). He has been assigned to room
2012, bed 01 on nursing unit 2000.
The message was sent from system ADT1 at the MCM site to system LABADT, also
at the MCM site, on the same date as the admission took place, but three minutes
after the admit.
:
MSH|^~\&|ADT1|MCM|LABADT|MCM|198808181126|SECURITY|ADT^A01|MSG00001
|P|2.4|<cr> EVN|A01|198808181123||<cr>
PID|1||PATID1234^5^M11^ADT1^MR^MCM~123456789^^^USSSA^SS||JONES^
WILLIAM^A^III||19610615|M||C|1200NELM
STREET^^GREENSBORO^NC^27401-1020|GL|(919)379-1212|(919)271-3434||S||
PATID12345001^2^M10^ADT1^AN^A|123456789|987654^NC|<cr>
NK1|1|JONES^BARBARA^K|WI^WIFE||||NK^NEXT OF KIN<cr>
PV1|1|I|2000^2012^01||||004777^LEBAUER^SIDNEY^J.|||SUR||||ADM|A0|<cr>

HL7 Version 3, ,
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HL7,
.
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(Reference
Information Model - RIM) UML

.
,
, .

93

HL7.
XML . XML, ,
HL7 2.4.

3, Clinical Document
Architecture (CDA), Patient Record Architecture (PRA),

. 2000, CDA
ANSI. XML
HL7 RIM, CDA
, .
XMLaware browsers, PDAs, .

3.2

.
150
:
3.2.1 - International Classification of Diseases
(ICD)
ICD 9 (ICD-9):
(WHO)
. ... (National Center
for Health Statistics-NCHS)
(Health Care Financing Administration-HCFA)
ICD-9
ICD-9-CM. WHO ICD-10 HCFA

(Procedure Coding System ICD-10-PCS). HCFA
ICD-10 .
, ICD-9-CM
,
,
.

.
3.2.2 Read Codes
Read Codes
.

.
Read Codes

94

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87%
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, Read Codes
.
Royal Colleges and Associations,
.
3.2.3 Systematized Nomenclature of Human & Veterinary Medicine (SNOMED)
Systematized Nomenclature of Human and
Veterinary Medicine (SNOMED) College of American Pathologists
(CAP)
. - ( )
ICD
. CAP SNOMED
HL7 ACR-NEMA. SNOMED
.
3.2.4 Diagnosis Related Group (DRG)
DRG
.
DRG ( 500)
(grouper)
ICD-9-CM , ,
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( )
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95

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3.3.1
(Social Security Number-SSN)
. ,

SSN SSN

.
E31.12 ASTM (American Society for Testing
and Materials) Guide for the properties of a Universal Healthcare
Identifier (UHID). CPRI (Computer-Based Patient Record Institute)

.
3.3.2
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Administration-HCFA)
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UPIN .
, HCFA
National Provider File-NPF.
3.3.3
-
. Health Industry Number-HIN,
Health Industry Business Communications Council-HIBCC. HIN
. HCFA

(Medicare).
3.3.4
.
Labeler Identification Code-LIC
HIBCC.

96

LIC bar codes

.
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Council
.

3.4
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97

NHS Data Protection Act Computer Misuse Act.

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Data Protection Act.

American Society for Testing and Materials-ASTM

. :

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(Computer-based Patient Records) "Guidelines for Minimal
Data Security Measures for the Protection of Computer-based Patient Records."
E31.17 ASTM
.
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.

4.
4.1 -

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( ), -
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98

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99

4.3
XML, XML-Schema, XSL, XSLT, X-Path, X-Query, Web Services:
.
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,
(
SOAP Win-XP).
, ,
.
, (
) . web sites
, , .
section MSDN Microsoft (http://msdn.microsoft.com ). ,
.
...

100

5.

5.1 XML
5.1.1
1998
W3C (World Wide Web Consortium)
XML 1.0
Internet, ,
, ,

XML,
XML,
" " XML.
,

. ,

,




.

XML
W3C XML
1996 n
1998
XML 1.0 Recommendation.
,

Namespaces in XML, 1999,
XML
(namespaces),

,
style-sheets.
16 1999
W3C XSLT
(XSL Transformations) XML Path
(XPath),


XML.
1999
XML Query,

XML,
2000
XML (XML Protocol)

XML
.
SOAP
(Simple Object Access Protocol),
(2 2001)
(Working Draft)
1.2 SOAP.

5.1.2 XML
XML (eXtensible Markup Language)
. ,
.
, SGML (Standard Generalized Markup Language),
Internet XML
. XML ()
SGML, HTML! XML
. XML

Italic 12 ,
.

, ,
, cross-platform
.

 -


(
)

vectors,
, Meta-data, , ,


[http://www.xml.com, What is XML?].
XML markup
.
tags
. tags,
html.
tag <body> </body>
html

html ,
<header> </header>

( Meta-data, ..).
html XML
html
tags ,
XML

.
XML
. , ,
tag
<Tag>
</Tag>
:
tags
.
<tag1><tag2><tag3>
</tag3></tag2></tag1>

<tag1><tag2><tag3>
</tag2></tag3></tag1>
XML metalanguage markup
. XML

1.1.1..a.1.1

101

XML in 10 points

1. XML is for structuring data. Structured data

includes things like spreadsheets, address books,
configuration parameters, financial transactions,
and technical drawings. XML is a set of rules (you
may also think of them as guidelines or
conventions) for designing text formats that let you
structure your data. XML is not a programming
language, and you don't have to be a programmer
to use it or learn it. XML makes it easy for a
computer to generate data, read data, and ensure
that the data structure is unambiguous. XML avoids
common pitfalls in language design: it is extensible,
platform-independent, and it supports
internationalization and localization. XML is fully
Unicode-compliant.
2. XML looks a bit like HTML. Like HTML, XML
makes use of tags (words bracketed by '<' and '>')
and attributes (of the form name="value"). While
HTML specifies what each tag and attribute means,
and often how the text between them will look in a
browser, XML uses the tags only to delimit pieces
of data, and leaves the interpretation of the data
completely to the application that reads it. In other
words, if you see "<p>" in an XML file, do not
assume it is a paragraph. Depending on the
context, it may be a price, a parameter, a person,
a p... (and who says it has to be a word with a
"p"?).
3. XML is text, but isn't meant to be read.
Programs that produce spreadsheets, address
books, and other structured data often store that
data on disk, using either a binary or text format.
One advantage of a text format is that it allows
people, if necessary, to look at the data without the
program that produced it; in a pinch, you can read
a text format with your favorite text editor. Text
formats also allow developers to more easily debug
applications. Like HTML, XML files are text files that
people shouldn't have to read, but may when the
need arises. Less like HTML, the rules for XML files
are strict. A forgotten tag, or an attribute without
quotes makes an XML file unusable, while in HTML
such practice is tolerated and is often explicitly
allowed. The official XML specification forbids
applications from trying to second-guess the
creator of a broken XML file; if the file is broken, an
application has to stop right there and report an
error.
4. XML is verbose by design. Since XML is a text
format and it uses tags to delimit the data, XML
files are nearly always larger than comparable
binary formats. That was a conscious decision by
the designers of XML. The advantages of a text
format are evident (see point 3), and the
disadvantages can usually be compensated at a
different level. Disk space is less expensive than it
used to be, and compression programs like zip and
gzip can compress files very well and very fast. In
addition, communication protocols such as modem
protocols and HTTP/1.1, the core protocol of the
Web, can compress data on the fly, saving
bandwidth as effectively as a binary format.

102

tags
.

tags, (
)

XML document stylesheet

( ).
XML :
1:
<?xml version="1.0"?>
<purchase id="p001">
<customer db="cust123"/>
<product db="prod345">
<amount>23.45</amount>
</product>
</purchase>
XML 1.0
,
Document Type Definition (DTD),


(markup)
XML. To



DTD .


.
5.1.3 XML-Schema

DTD. O

,

XML.


,

.

3
5. XML is a family of technologies. XML 1.0 is the
specification that defines what "tags" and
"attributes" are. Beyond XML 1.0, "the XML family"
is a growing set of modules that offer useful
services to accomplish important and frequently
demanded tasks. Xlink describes a standard way to
add hyperlinks to an XML file. XPointer and
XFragments are syntaxes in development for
pointing to parts of an XML document. An XPointer
is a bit like a URL, but instead of pointing to
documents on the Web, it points to pieces of data
inside an XML file. CSS, the style sheet language, is
applicable to XML as it is to HTML. XSL is the
advanced language for expressing style sheets. It is
based on XSLT, a transformation language used for
rearranging, adding and deleting tags and
attributes. The DOM is a standard set of function
calls for manipulating XML (and HTML) files from a
programming language. XML Schemas 1 and 2 help
developers to precisely define the structures of
their own XML-based formats. There are several
more modules and tools available or under
development. Keep an eye on W3C's technical
reports page.
6. XML is new, but not that new. Development of
XML started in 1996 and has been a W3C
Recommendation since February 1998, which may
make you suspect that this is rather immature
technology. In fact, the technology isn't very new.
Before XML there was SGML, developed in the early
'80s, an ISO standard since 1986, and widely used
for large documentation projects. The development
of HTML started in 1990. The designers of XML
simply took the best parts of SGML, guided by the
experience with HTML, and produced something
that is no less powerful than SGML, and vastly
more regular and simple to use. Some evolutions,
however, are hard to distinguish from revolutions...
And it must be said that while SGML is mostly used
for technical documentation and much less for
other kinds of data, with XML it is exactly the
opposite.
7. XML leads HTML to XHTML. There is an
important XML application that is a document
format: W3C's XHTML, the successor to HTML.
XHTML has many of the same elements as HTML.
The syntax has been changed slightly to conform to
the rules of XML. A document that is "XML-based"
inherits the syntax from XML and restricts it in
certain ways (e.g, XHTML allows "<p>", but not
"<r>"); it also adds meaning to that syntax
(XHTML says that "<p>" stands for "paragraph",
and not for "price", "person", or anything else).
8. XML is modular. XML allows you to define a new
document format by combining and reusing other
formats. Since two formats developed
independently may have elements or attributes
with the same name, care must be taken when
combining those formats (does "<p>" mean
"paragraph" from this format or "person" from that
one?). To eliminate name confusion when
combining formats, XML provides a namespace
mechanism. XSL and RDF are good examples of
XML-based formats that use namespaces. XML
Schema is designed to mirror this support for
modularity at the level of defining XML document
structures, by making it easy to combine two
schemas to produce a third which covers a merged
document structure.

103

, 1999
9. XML is the basis for RDF and the Semantic Web.
W3C's Resource Description Framework (RDF) is an

XML text format that supports resource description
XML Schema
and metadata applications, such as music playlists,
photo collections, and bibliographies. For example,

RDF might let you identify people in a Web photo
XML Schema, 2
album using information from a personal contact
2001 (W3C
list; then your mail client could automatically start
a message to those people stating that their photos
Recommendation). To XML Schema
are on the Web. Just as HTML integrated

documents, menu systems, and forms applications
to launch the original Web, RDF integrates
(built-in datatypes),
applications and agents into one Semantic Web.

Just like people need to have agreement on the
meanings of the words they employ in their
(usercommunication, computers need mechanisms for
defined datatypes).
agreeing on the meanings of terms in order to
,
communicate effectively. Formal descriptions of
terms in a certain area (shopping or manufacturing,

for example) are called ontologies and are a
XML
necessary part of the Semantic Web. RDF,
ontologies, and the representation of meaning so

that computers can help people do work are all
.
topics of the Semantic Web Activity.

10. XML is license-free, platform-independent and
DTD
well-supported. By choosing XML as the basis for a
,
project, you gain access to a large and growing
community of tools (one of which may already do

what you need!) and engineers experienced in the
,
technology. Opting for XML is a bit like choosing
SQL for databases: you still have to build your own

database and your own programs and procedures
,
that manipulate it, and there are many tools
available and many people who can help you. And
since XML is license-free, you can build your own
,
software around it without paying anybody
,
anything. The large and growing support means
that you are also not tied to a single vendor. XML
..
isn't always the best solution, but it is always worth
(
considering.
) XML Schema
--------------------------------------------------------
W3C Communications Team, w3t-comm@w3.org
Revised 13 Nov. 2001 (last update: 2001/12/20
XML,
10:34:31)
XML,
Created 27 Mar 1999 by Bert Bos

.
, XML Schema
(
XML Schema). , W3C
, XML Schema,
XML,
.

5.2 XSL-XSLT
XML
,
XML, . ,
1998 XSL (eXtensible Stylesheet Language),
,
.

104

CCS (Cascading Style Sheets),

Web. XSL ,
, .
, XML (),
XSL .
5,
( ),
.

.
, ,
.
, XML
,
()
.
(
) W3C draft
Recommendations: .
: XSL
Microsoft ( XSL-T)
XSL ,
XML HTML, browser.
W3C 1999, working
draft.

XSL Transformations (XSLT) 1.0 Recommendation

XSLT processor
( ).
Extensible Stylesheet Language (XSL) Working Draft
(rendering agents)
( XML)
( 1)
<customer>
XSL :
<fo:block space-before.optimum="20pt" font-size="20pt">From:
<fo:inline-sequence font-style="italic">(Customer Reference)
<fo:inline-sequence font-weight="bold">cust123</fo:inline-sequence>
</fo:inline-sequence>
</fo:block>
( PDF, HTML format)
semantics XSL italics bold,
.
5

, rendering

105

XSL,
(.. Javascript). XSL
XML,
.

5.3 Web Services

Web Services Internet, XML
. , -
(modular) , ,
.
,
Internet
.
SOAP (Simple Object Access
Protocol), XML. SOAP
W3C o o XML Protocol
Working Group, ( 2000)
1.2 SOAP,
W3C. , Working Draft (WD), SOAP
Microsoft ,
XML Protocol WG XML
Schema,
XML ,
. SOAP, formatting ,
(RPC) HTTP,

, CORBA/IIOP DCOM.
, IBM, Microsoft Ariba XML
web services, WSDL (Web Services Description Language),
W3C Note,
, , .
, , ,
,
. H WSDL XML
, , ,
.
Internet
, Universal
Description, Discovery and Integration Service (UDDI),
. ,
(interoperability)
, web services
XML
.

106

6.

XML

XML
native XML databases,
XML
XML.

6.1 XML
XML ,
, . H XML
, ,
, XML
"" (markup)
. ,
(parsers).
XML
(database management system - DBMS).
XML
DBMS, ,
( XML), (DTD, XML Schema), Query languages - (XQuery, XPath, XQL ..) (SAX,
DOM ..). , XML
,
, , ,
..
XML

, ,
,
.

6.2 XML

XML 3
:
Native XML databases ( XML)
) XML (
) .
(elements), (attributes), PCDATA
. XPath, XML Infoset
, DOM SAX 1.0.
) XML -- ,

-- .

107

) .

XML -.
native XML databases Tamino, dbXML,
eXcelon, X-Hive/DB eXist.
XML Enabled databases ( XML)

XML.
XML.
XML ,
XML XML
format. , , -,
XML, , .
XML (XPath - XSL-T, DOM SAX)
(.. SQL).
XML enabled .
Hybrid XML Databases ( )
native XML databases, XMLenabled, .
Ozone (. www.ozone-db.org).

6.3 XML
, XML
, ,
. , ,
, native XML
.

6.4 Native XML Databases

,
XML (native XML databases) . ,
(semi-structured). ,
, ,

null, ,
, .
, native
L databases.
.
, native XML database
, .

108

( )
. , (joins)
,
. , , ,

. , native XML databases

.
, , Native XML databases
(document-centric). ,
XML (XML Enabled),
, , .. ,
XML (XML query languages), :
,
bold. ,
SQL.

6.5 Native XML Databases

6.5.1 Text-Based Native XML Databases
Text-Based Native XML Database XML .
, BLOB (Binary Large Object)
, . TextBased Native XML Databases (indexes),
.

.
(index),
,
(read). ,
, Model-Based Native
XML Databases,
. Text-Based Native XML Databases

.


-
- .
6.5.2 Model-Based Native XML Databases
XML ,

. .
. ,
DOM (Document Object Model)
Elements (), Attributes (),
PCDATA, Entities (), EntityReferences ( )

109

,
.
, text-based
, model-based
DOM (Document Object Model),
DOM. , native XML databases

, XML .

6.6 native XML databases

6.6.1
native XML databases (collection).

. ,
, ,

. ,
(manuals) . ,
,
manual.
6.6.2 (Query Languages)
native XML databases
. XPath -
full-text (
eXist xHive/DB)- XQL.
XML XML-QL, YATL, Lorel Quilt.
To , , XML Query Language (XQuery),
W3C (World Wide Web Consortium).
6.6.3 XQuery
H XQuery Quilt,
. H Quilt Xpath 1.0 XQL
. XMLQL (binding)
. SQL
-
( SELECT - FROM - WHERE SQL). H Quilt
OQL, Lorel YATL.
XQuery W3C
. , XML Schema
Xpath,
XPath 2.0 Query . ,
XQuery (data
model) XQuery Xpath 2.0 (XQuery 1.0 and XPath 2.0 Data
Model). Xpath 1.0,

110

. XQuery
XML,
(well-formed) , ,
. To W3C
QueryX, XQuery XML. XQueryX
,
, XML
XML ,
.
XQuery
:

FOR $p IN distinct(document("bib.xml")//publisher)
LET $a:= avg(document("bib.xml")//book[publisher = $p]/price)
RETURN
<publisher>
<name> {$p/text()} </name>
<avgprice> {$a} </avgprice>
</publisher>

100
.

<big_publishers>
{
FOR $p IN distinct(document("bib.xml")//publisher)
LET $b:= document("bib.xml")//book[publisher = $p]
WHERE count($b) > 100
RETURN $p
}
</big_publishers>

111

6.6.4
(update)
(delete) DOM
(Document Object Model). ,
. XQuery
. XML:DB
(www.xmldb.org) XUpdate (XML Update Language),
XML
XML,
, .
6.6.5 XUpdate
XUpdate
XML. Xpath
.
XSL (XSL-T).
XML XUpdate:
:
<addresses>
<address>
<town>Los Angeles</town>
</address>
<address>
<town>San Francisco</town>
</address>
</addresses>
XUpdate:
<xupdate:update select="/addresses/address[2]/town">
New York
</xupdate:update>

112

:
<addresses>
<address>
<town>Los Angeles</town>
</address>
<address>
<town>New York</town>
</address>
</addresses>
Infozone (www.infozone-group.org)
Lexus, XUpdate, ' Java.

6.7 ,
native XML databases . (locking), ,
,
.
,
, (concurrency) ,

. ,
,
. , native
XML databases .

6.8 pplication Programming Interfaces (APIs)

native XML databases (APIs).
, -,
.
XML, DOM . ,

,
.
XML:DB (www.xmldb.org)
XML databases.

,
.

6.9
native XML databases
,
.

113

CDATA (
-markup) , ,
. , ,

, .

114

Guide to Medical Informatics, The Internet and Telemedicine by ENRICO COIERA,

1997
Medical records and other stories: a narratological framework, Methods of
Information in Medicine, 35, 72-87, S. Kay, I.N. Purves, 1996
Handbook of Medical Informatics by J.H. van Bemmel, M.A. Musen, 1997
The paper-based patient record: Is it really so bad? Computer Methods and Programs
in Biomedicine, 48, 127-131, H.J. Tange, 1995
preStandard ENV 13606
The Computer-based Patient Record - An Essential Technology for Health Care,
National Academy Press, Washington, DC, Disk and Steen, 1991
Traditional Hospital records as a Source of Clinical Data in the Outpatient Setting,
proc., SCAMC, 575-9, P.C. Tang, D.Fafchamps, E.H. Shortliffe, 1994
Evaluation of automated information systems in health care: an approach to
classifying evaluative studies, Computer Methods and programs in Biomedicine, 48,
45-52, R.P. van der Loo, E.M. van Gennip, A.R. Bakker, A. Hasman, F.F. Rutten,
1995
The impact of the HELP computer system on the LDS Hospital paper medical
record, Proc., SCAMC, 673-7, G.J. Kuperman, R.M. Gardner, 1990
www.xml.com
XML and Databases, Ronald Bourret,
http://www.rpbourret.com/xml/XMLAndDatabases.htm
XML Database Products, Ronald Bourret,
http://www.rpbourret.com/xml/XMLDatabaseProds.htm
Storing XML in Relational Databases, Igor Dayen
http://www.xml.com/pub/a/2001/06/20/databases.html
XML Enters the DBMS Arena, Edmund X. DeJesus
http://www.computerworld.com
XML:DB FAQ, http://www.xmldb.org/faqs.html
Washed Clean, Washed Up, Edd Dumbill,
http://www.xml.com/pub/a/2001/07/18/taglines.html
A Brief History of SOAP, Don Box
http://www.xml.com/pub/a/2001/04/04/soap.html
The State of XML: Why Individuals Matter, Edd Dumbhill,
http://www.xml.com/pub/a/2001/05/30/stateofxml.html
XML Ain't What It Used To Be, Simon St/ Laurent
http://www.xml.com/pub/a/2001/02/28/eightytwenty.html
XML a cornerstone of new graphics model, Paul Fresta
On Database Theory and XML, Dan Suciu
The Semantic Web, Tim-Berners Lee, James Hendler, Ora Lassila
http://www.sciam.com/2001/0501issue/0501berners-lee.html

115

XML and the Second-Generation Web, Jon Bosak, Tim Bray

http://www.sciam.com/1999/0599issue/0599bosak.html
WSDL for Defining Web Services, Don Kiely,
http://www.xmlmag.com
A Web Services Primer, Venu Vasudevan
http://www.xml.com/pub/a/2001/04/04/webservices/
Web Services: It's So Crazy, It Just Might Not Work, Clay Shirky
http://www.xml.com/pub/a/2001/10/03/webservices.html
The World Wide Web Consortium
http://www.w3.org
XML Software
http://www.xmlsoftware.com
XML tutorial
http://www.w3schools.com

National Electrical Manufacturers Association, Digital imaging and communication in

medicine (DICOM), NEMA Standrds publication, PS 3.6-1993, NEMA: Washinghton,
1993.

Health Level Seven: An application protocol for electronic data exchange in healthcare
environments. Version 2.1 1990. Chicago, Ill.: Health Level Seven, Inc.

Hammond, W.E. 1991. Health Level 7: An application standard for electronic medical
data exchange. Topics in Health Record Management 11:59-66.