Belgian Healthcare Telematics Commission - Working Group Data - Recommendation 19

Tutorial on Kmehr

The tutorial explains, step by step, the Kmehr structure, using a simple case study.

Case study
Let's consider that we want to send the following contact report:

Dear Dr Jean-Pierre Rochet,
Your patient Jean Dubois came on our emergency unit on 01/10/2001.
He presented a serious infection of the left hand caused by a tropical insect bite.
I have performed a Tevax injection 0,5ml IM and prescribed Augmentin 3*500mg daily for 5 days.
Sincerely yours,
Dr Alain Juvenois

We will now see how to send this report according to the recommendation 4.

Use of XML
The Commission recommends to use XML because of its widespread acceptance by the industry and by all international healthcare standardisation bodies. You can learn more about XML at the official web site of the W3 consortium or on the following commercial site xml.com.

An XML file is a simple text file that you can write with any text processor like Notepad. An XML file is a set of elements. An element has a name (for example 'patient'). The element is limited by a begin tag (for example <patient>) and an end tag (for example </patient>). Between the begin and the end tags, you find the content of the element (for example <patient>Jean Dubois</patient>). The content can be a character string (PCDATA) or a set of other elements. The name of the element describes its content. Therefore an XML message can be auto descriptive (the element names are metadata, data about the data). This is one of the major benefits of XML.

Other attributes than the name can contribute to the description of the element. In the following example, the value of the attribute S of the element <id> specifies that the content of the element <id> is a SIS card number.

The syntax of XML is derived from SGML and is described in a specification document edited by the W3 consortium. It is a very stable specification. The current version is version 1.0.

Example XML

<?xml version="1.0" encoding="ISO-8859-1"?>

<patient>
   <id S="SIS">32031011931</id>
   <firstname>Jean</firstname>
   <familyname>Dubois</familyname>
</patient>

The first line specifies the version of the XML specification to which it complies. The encoding attribute specifies the character set that is used. The ISO-8859-1 supports French accents.

This is a valid XML file. I invite you to copy the text and paste it into Notepad. Save it with an .xml extension. Double click on it from your file manager. You will see that latest versions of web browsers like IE6 recognise its XML structure. An XML document that complies with the w3 specification is said well formed.

Use of XSchema
Anybody can invent elements and attributes to create an XML document. The principle of healthcare message standardisation will be to agree on a definite set of such elements and attributes to be used within the Belgian healthcare community.

An XSchema is a facility to place validation constraints on XML files. It specifies

mandatory or optional elements,
mandatory or optional attributes,
datatype's,
enumeration of allowed values,
cardinalities,
etc...

To place the constraint on the XML file, you have to refer to the XSchema within the XML file (see example below). An XML message that complies with its related XSchema is said valid.

Example XML

Example XSchema

<?xml version="1.0" encoding="ISO-8859-1"?>
<patient xmlns="http://www.health.fgov.be/telematics/kmehr/schema"
                  xmlns:PATIENT="http://www.health.fgov.be/telematics/kmehr/PATIENT"
                  xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
                  xsi:schemaLocation="http://www.health.fgov.be/telematics/kmehr ..\xsd\patient.xsd">
   <id S="SIS">32031011931</id>
   <firstname>Jean</firstname>
   <familyname>Dubois</familyname>
</patient>

<xsd:schema targetNamespace="http://www.health.fgov.be/telematics/kmehr" xmlns:xsd="http://www.w3.org/2001/XMLSchema" xmlns:PATIENT="http://www.health.fgov.be/telematics/kmehr/PATIENT" xmlns="http://www.health.fgov.be/telematics/kmehr/schema" elementFormDefault="qualified" attributeFormDefault="unqualified">
   <xsd:element name="patient">
      <xsd:complexType>
         <xsd:sequence>
            <xsd:element ref="id"/>
            <xsd:element ref="firstname"/>
            <xsd:element ref="familyname"/>
         </xsd:sequence>
      </xsd:complexType>
   </xsd:element>
   <xsd:element name="firstname" type="xsd:string"/>
   <xsd:element name="familyname" type="xsd:string"/>
   <xsd:element name="id" type="ID"/>
   <xsd:complexType name="ID">
      <xsd:simpleContent>
         <xsd:extension base="xsd:string">
            <xsd:attribute name="S" type="IDvalues" use="required"/>
         </xsd:extension>
      </xsd:simpleContent>
   </xsd:complexType>
   <xsd:simpleType name="IDvalues">
      <xsd:restriction base="xsd:string">
         <xsd:enumeration value="SIS"/>
         <xsd:enumeration value="IDENTITY"/>
      </xsd:restriction>
   </xsd:simpleType>
</xsd:schema>

The second line of the XML message specifies the XSchema file to which it should comply with.
On the right side you can discover how an XSchema looks like. Do not try to understand it !
The role of the standardisation bodies is to define such reference XSchema.
The example XML is valid according to its XSchema.

Generic message structure
The Commission has defined a simple, minimal and practical framework for the exchange of clinical data. We have translated our case study to this generic structure. We will first focus on key elements.

A <kmehrmessage> contains one <header> and at least one <folder>. A <folder> gathers the information about a same patient. In our example, we have only one <folder> because the message deals with only one patient.

A <folder> contains one <patient> element and at least one <transaction>. In our example, we have only one <transaction> which is a contact report. In the demonstration material you will find folders with several transactions.

A <transaction> contains at least one <item> or one <heading>. In our example, we can identify several <item>s (type of encounter, date of encounter, diagnosis, drug delivery, drug prescription). They could be sorted between 2 <heading>s (assessment and treatment).

A <heading> contains at least one <item> or one <heading>. In our example, we do not have nested headings.

Example XML

<?xml version="1.0" encoding="ISO-8859-1"?>

<kmehrmessage ... link to XSchema ... >
   <header>
   </header>
   <folder>
      <patient> ... identification of the patient ...       </patient>
      <transaction>
         <item> ... type of encounter ...          </item>
         <item> ... date of encounter ...          </item>
         <heading>
            <item> ... diagnosis ...             </item>
         </heading>
         <heading>
            <item> ... drug delivery ...             </item>
            <item> ... drug prescription ...             </item>
         </heading>
      </transaction>
   </folder>
</kmehrmessage>

This illustrates the skeleton of the message. At this stage, <header> and <item> are still character strings.

Other key elements are required. We will discuss each of them in the next paragraphs.

Unique identifiers
The commission recommends one <id> element to uniquely identify each key element of a message (<header>, <folder>, <transaction>, <heading>, <item>).

The element <id> has 2 mandatory attributes:

S: specifies the identifying system from which the <id> is derived.
- this can be a national registry of patients or healthcare parties, maintained by the appropriate organisations.
- this can be a calculated value applying conventions like sequential numbers.
SV: specifies the version of the identifying system to which the value refers.

The names of those attributes are derived from the Concept Descriptor (CD) element of the HL7-CDA.

Each element of the Kmehr message should be identified by an id that is compliant with the ID-KMEHR identifying system.

element to identify name of the identifying system rule to apply

header ID-KMEHR The <id> must contain a value that identifies uniquely the message within the emitting organisation. We recommend to concatenate the id of the first sender healthcare party of the message followed by a dot and a local unique identifier (see later).

folder ID-KMEHR <id S="ID-KMEHR"> must contain the sequential number of the <folder> within the current message starting from 1

transaction ID-KMEHR <id S="ID-KMEHR"> must contain the sequential number of the <transaction> within the parent folder starting from 1

heading, item ID-KMEHR <id S="ID-KMEHR"> must contain a shared sequential number of the <heading> or <item> within the parent transaction or heading starting from 1.

In addition to the official ID-KMEHR, it is allowed to associate multiple <id>'s for each of those elements. In that case, S="LOCAL" and a third SL attribute specifies the local identifying system (see example).

Example XML

<?xml version="1.0" encoding="ISO-8859-1"?>

<kmehrmessage ... link to XSchema ... >
   <header>
      <id S="ID-KMEHR" SV="1.0">71971801.1234</id>
   </header>
   <folder>
      <id S="ID-KMEHR" SV="1.0">1</id>
      <patient> ... identification of the patient ...       </patient>
      <transaction>
         <id S="ID-KMEHR" SV="1.0">1</id>
         <id S="LOCAL" SL="MyADTSystem" SV="19">6754312</id>
         <item>
            <id S="ID-KMEHR" SV="1.0">1</id>
         ... type of encounter ...
         </item>
         <item>
            <id S="ID-KMEHR" SV="1.0">2</id>
         ... date of encounter ...
         </item>
         <heading>
            <id S="ID-KMEHR" SV="1.0">3</id>
            <item>
               <id S="ID-KMEHR" SV="1.0">1</id>
            ... diagnosis ...
            </item>
         </heading>
         <heading>
            <id S="ID-KMEHR" SV="1.0">4</id>
            <item>
               <id S="ID-KMEHR" SV="1.0">1</id>
            ... drug delivery ...
            </item>
            <item>
               <id S="ID-KMEHR" SV="1.0">2</id>
            ... drug prescription ...
            </item>
         </heading>
      </transaction>
   </folder>
</kmehrmessage>

One element <id> has been added in the example in each of the key elements. The value of the <id> is a string of characters.

In the XML example, the drug prescription item is uniquely identified as the second element of the fourth item/heading elements within the first transaction of the first folder of the message 1234567 of that emitting organisation (will be specified later on within this tutorial). Note that a local identifier has also been sent to identify the transaction.

In the XSchema, we have forced at least one <id> element for <header>, <folder>, <transaction>, <heading> and <item>. The element <id> must have 2 attributes: S, SV. The attribute S must have one of the official values listed in the XSchema. The attribute SL is optional and should be used when S="LOCAL".

Type of the key elements
The Commission recommends to standardise the <type> of the elements <transaction>, <heading> and <item>.

We suggest to extend the previous <id> element concept to code the value of the <type> element, using the following additional standard identifying systems:

element reference table code meaning

transaction CD-TRANSACTION contact
admission
discharge
... contact report
admission notification
discharge notification
...please refer to the recommendation 4 for the full list

heading CD-HEADING ...
assessment
treatment
... ...
assessment
treatment
...

item CD-ITEM ...
encounterdatetime
encountertype
healthissue
medication
... ...
date of encounter
type of encounter
diagnosis
drug delivery or prescription
...

These codes should be placed within the element <cd> using the same attributes as for <id>:

S to specify the reference table
SV to specify the version of the reference table
SL to specify a local reference table when S='LOCAL'

It is allowed to transfer multiple <cd>s and to use local reference tables in addition to the national ones.

Two optional additional attributes are available for the element <cd>:

DN: used in HL7-CDA to possibly transfer the meaning of the code
L: specifies the language used in the DN attribute

Applying those rules to our case study will give:

Example XML

<?xml version="1.0" encoding="ISO-8859-1"?>

<message ... link to XSchema ... >
   <header>
      <id S="ID-KMEHR" SV="4.0">71071801.1234</id>
   </header>
   <folder>
      <id S="ID-KMEHR" SV="1.0">1</id>
      <patient> ... identification of the patient ...       </patient>
      <transaction>
         <id S="ID-KMEHR" SV="1.0">1</id>
         <cd S="CD-TRANSACTION" SV="1.0">contact</cd>
         <item>
            <id S="ID-KMEHR" SV="1.0">1</id>
            <cd S="CD-ITEM" SV="1.0">encountertype</cd>
            ... value of the type of encounter ...
         </item>
         <item>
            <id S="ID-KMEHR" SV="1.0">2</id>
            <cd S="CD-ITEM" SV="1.0">encounterdatetime</cd>
            ... value of the date of encounter ...
         </item>
         <heading>
            <id S="ID-KMEHR" SV="1.0">3</id>
            <cd S="CD-HEADING" SV="1.0">assessment</cd>
            <item>
               <id S="ID-KMEHR" SV="1.0">1</id>
               <cd S="CD-ITEM" SV="1.0">healthissue</cd>
               ... value of diagnosis ...
            </item>
         </heading>
         <heading>
            <id S="ID-KMEHR" SV="1.0">4</id>
            <cd S="CD-HEADING" SV="1.0">treatment</cd>
            <item>
               <id S="ID-KMEHR" SV="1.0">1</id>
               <cd S="CD-ITEM" SV="1.0">medication</cd>
               ... value of drug delivery ...
            </item>
            <item>
               <id S="ID-KMEHR" SV="1.0">2</id>
               <cd S="CD-ITEM" SV="1.0">medication</cd>
               ... value of drug prescription ...
            </item>
         </heading>
      </transaction>
   </folder>
</kmehrmessage>

One element <cd> has been added in the example in <transaction>, <heading> and <item>. The value of the <cd> is a code from one of the reference tables.

In the XSchema, we have forced at least one <cd> element for <transaction>, <heading> and <item>.
We have added the new reference tables to the XSchema. We have created a list of languages. We have added the optional attributes DN and L to the <cd> element.

We will see later that this concept of <cd> will be applied to any other coded concept.

Healthcare Parties
The Commission recommends several elements related to healthcare parties :

Sender and Recipients at the header level
Author at the transaction level

We know that many other healthcare parties can be referenced in healthcare messages: prescribers, performers, transcriptionists, ... These could also be referenced at lower levels (within headings, items or even content).

The <hcparty> element will be used to identify any of those healthcare parties. It has 2 fundamental elements:

<id>: to identify the hcparty uniquely using typically the RIZIV-INAMI identifier
<cd>: to identify the kind of hcparty: organisation, medical specialty, physician, nurse, software application...

This introduces the following additional identifying systems:

element name of the identifying system rule to apply

hcparty ID-HCPARTY RIZIV:INAMI number of the organisation or the healthcare professional

hcparty CD-HCPARTY This combines healthcare party types including official medical specialties ...
hospital
deptlaboratory
physician
nurse
deptcardiology
deptdermatology
deptpharmacy
... ...
Hospital
Laboratory
Physician
Nurse
Cardiology
Dermatology
Pharmacy
...

You can send a message to an organisation, a person or a medical specialty. When <cd> is a specialty, <id> can be null.

The <hcparty> element also supports the following elements:

<familyname> + <firstname> OR <name>
<address>
<telecom>

The role played by the hcparty is derived from its parent element (author, sender, recipient, transcriptionist, prescriber, ...).

Let's now add the missing <hcparty> elements to our example:

Example XML

<?xml version="1.0" encoding="ISO-8859-1"?>

<kmehrmessage ... link to XSchema ... >
   <header>
      <id S="ID-KMEHR" SV="4.0">71071801.1234</id>
      <sender>
         <hcparty>
            <id S="ID-HCPARTY" SV="1.0">71071801</id>
            <cd S="CD-HCPARTY" SV="1.0">hospital</cd>
            <name>CHU de Charleroi</name>
         </hcparty>
         <hcparty>
            <id S="ID-HCPARTY" SV="1.0">1.58585.58.580</id>
            <cd S="CD-HCPARTY" SV="1.0">physician</cd>
            <firstname>Alain</firstname>
            <familyname>Juvenois</familyname>
         </hcparty>
      </sender>
      <recipient>
         <hcparty>
            <id S="ID-HCPARTY" SV="1.0">1.64646.46.004</id>
            <cd S="CD-HCPARTY" SV="1.0">physician</cd>
            <firstname>Jean-Pierre</firstname>
            <familyname>Rochet</familyname>
         </hcparty>
      </recipient>
   </header>
   <folder>
      <id S="ID-KMEHR" SV="1.0">1</id>
      <patient> ... identification of the patient ...       </patient>
      <transaction>
         <id S="ID-KMEHR" SV="1.0">1</id>
         <cd S="CD-TRANSACTION" SV="1.0">contact</cd>
         <author>
            <hcparty>
               <id S="ID-HCPARTY" SV="1.0">1.58585.58.580</id>
               <cd S="CD-HCPARTY" SV="1.0">physician</cd>
               <firstname>Alain</firstname>
               <familyname>Juvenois</familyname>
            </hcparty>
         </author>
         <item>
            <id S="ID-KMEHR" SV="1.0">1</id>
            <cd S="CD-ITEM" SV="1.0">encountertype</cd>
            ... value of the type of encounter ...
         </item>
         <item>
            <id S="ID-KMEHR" SV="1.0">2</id>
            <cd S="CD-ITEM" SV="1.0">encounterdatetime</cd>
            ... value of the date of encounter ...
         </item>
         <heading>
            <id S="ID-KMEHR" SV="1.0">3</id>
            <cd S="CD-HEADING" SV="1.0">assessment</cd>
            <item>
               <id S="ID-KMEHR" SV="1.0">1</id>
               <cd S="CD-ITEM" SV="1.0">healthissue</cd>
               ... value of diagnosis ...
            </item>
         </heading>
         <heading>
            <id S="ID-KMEHR" SV="1.0">4</id>
            <cd S="CD-HEADING" SV="1.0">treatment</cd>
            <item>
               <id S="ID-KMEHR" SV="1.0">1</id>
               <cd S="CD-ITEM" SV="1.0">medication</cd>
               ... value of drug delivery ...
            </item>
            <item>
               <id S="ID-KMEHR" SV="1.0">2</id>
               <cd S="CD-ITEM" SV="1.0">medication</cd>
               ... value of drug prescription ...
            </item>
         </heading>
      </transaction>
   </folder>
</kmehrmessage>

A <sender> and a <recipient> have been added to the <header>. The sender is mandatory and unique. The recipient is mandatory and can be multiple.
An <author> has been added to the <transaction>. The XSchema allows multiple authors for a transaction. At least one author is mandatory.

The XSchema allows to combine <hcparty> elements to specify the person, its organisation and its medical specialty within a <sender>, <recipient> or <author> element.

Other basic elements of the generic message
The Commission recommended originally a few other remaining elements that we have implemented as follows:

At the level of the header
- Date and Time: This is the creation date and time of the message.
- Version: This is the version of the Healthcare Message Specification to which the current XML message complies. It is specified within the element <standard> containing a <cd> referring to a table CD-STANDARD where the successive versions of our specification will be listed. <version> could be misleading. This is why we recommend <standard>.
- Urgency: This is the indication of urgency of the message. It is specified within the element <urgency> containing a <cd> referring to a table CD-URGENCY where the urgency levels are listed.
- Acknowledgment: This indicates if an acknowledgment is required or expected. It is specified within the element <acknowledgment> containing an <cd> referring to a table CD-ACKNOWLEDGMENT where the acknowledgment code are listed.
- Link: This allows to link the message to other messages. It is also useful at other levels (folder, transaction, heading, item and content). Any of those elements can be linked using the same element structure. We propose the element <lnk> with a structure referring to nodes of other messages. The link type refers to a table CD-LNK.
- Confidentiality: To support the concept of distribution rules, we have foreseen a <confidentiality> attribute at the main levels (kmehrmessage, header, folder, transaction, heading, item).
At the level of the folder
- Patient: A <patient> element has been proposed.
At the level of the transaction
- Date and Time: This is the date and time of the medical validation of the transaction.
At the level of the item
- Content: This key issue is discussed in the next paragraph.

Please refer to the detailed specification for the new reference tables CD-URGENCY, CD-STANDARD, CD-LNK, CD-SEX.

The new elements have been added to the examples:

Example XML

<?xml version="1.0" encoding="ISO-8859-1"?>

<kmehrmessage ... link to XSchema ... >
   <header>
      <standard>
         <cd S="CD-STANDARD" SV="1.0">20021205</cd>
      </standard>
      <id S="ID-KMEHR" SV="4.0">71071801.1234</id>
     <date>2001-10-02</date>
     <time>06:03</time>
      <sender>
         <hcparty>
            <id S="ID-HCPARTY" SV="1.0">71071801</id>
            <cd S="CD-HCPARTY" SV="1.0">hospital</cd>
            <name>CHU de Charleroi</name>
         </hcparty>
         <hcparty>
            <id S="ID-HCPARTY" SV="1.0">1.58585.58.580</id>
            <cd S="CD-HCPARTY" SV="1.0">physician</cd>
            <firstname>Alain</firstname>
            <familyname>Juvenois</familyname>
         </hcparty>
      </sender>
      <recipient>
         <hcparty>
            <id S="ID-HCPARTY" SV="1.0">1.64646.46.004</id>
            <cd S="CD-HCPARTY" SV="1.0">physician</cd>
            <firstname>Jean-Pierre</firstname>
            <familyname>Rochet</familyname>
         </hcparty>
      </recipient>
      <acknowledgment>
         <cd S="CD-ACKNOWLEDGMENT" SV="1.0">onerror</cd>
      </acknowledgment>
   </header>
   <folder>
      <id S="ID-KMEHR" SV="1.0">1</id>
      <patient>
         <id S="ID-PATIENT" SV="1.0">32031011931</id>
         <firstname>Jean</firstname>
         <familyname>Dubois</familyname>
         <birthdate>
           <date>1932-03-10</date>
         </birthdate>
         <sex>
            <cd S="CD-SEX" SV="1.0">male</cd>
         </sex>
         <address>
         <cd S="CD-ADDRESS" SV="1.0">home</cd>
            <country>
            <cd S="CD-COUNTRY" SV="1.0">be</cd>
            </country>
            <zip>6044</zip>
            <city>ROUX</city>
            <street>Rue du coucou</street>
            <housenumber>6</housenumber>
         </address>
      </patient>
      <transaction>
         <id S="ID-KMEHR" SV="1.0">1</id>
         <cd S="CD-TRANSACTION" SV="1.0">contact</cd>
        <date>2001-10-01</date>
        <time>15:25</time>
         <author>
            <hcparty>
               <id S="ID-HCPARTY" SV="1.0">1.58585.58.580</id>
               <cd S="CD-HCPARTY" SV="1.0">physician</cd>
               <firstname>Alain</firstname>
               <familyname>Juvenois</familyname>
            </hcparty>
         </author>
         <item>
            <id S="ID-KMEHR" SV="1.0">1</id>
            <cd S="CD-ITEM" SV="1.0">encountertype</cd>
            <content>... value of the type of encounter ...</content>
         </item>
         <item>
            <id S="ID-KMEHR" SV="1.0">2</id>
            <cd S="CD-ITEM" SV="1.0">encounterdatetime</cd>
            <content>... value of the date of encounter ...</content>
         </item>
         <heading>
            <id S="ID-KMEHR" SV="1.0">3</id>
            <cd S="CD-HEADING" SV="1.0">assessment</cd>
            <item>
               <id S="ID-KMEHR" SV="1.0">1</id>
               <cd S="CD-ITEM" SV="1.0">healthissue</cd>
               <content>... value of diagnosis ...</content>
            </item>
         </heading>
         <heading>
            <id S="ID-KMEHR" SV="1.0">4</id>
            <cd S="CD-HEADING" SV="1.0">treatment</cd>
            <item>
               <id S="ID-KMEHR" SV="1.0">1</id>
               <cd S="CD-ITEM" SV="1.0">medication</cd>
               <content>... value of drug delivery ...</content>
            </item>
            <item>
               <id S="ID-KMEHR" SV="1.0">2</id>
               <cd S="CD-ITEM" SV="1.0">medication</cd>
               <content>... value of drug prescription ...</content>
            </item>
         </heading>
      </transaction>
   </folder>
</kmehrmessage>

Proposed extensions to the original recommendation 4

At the level of the header
- Note: It seems interesting to allow the usage of free text (<text>) at each of the key elements of the message. This can be used for comments.
At the level of the transaction
- Iscomplete: This status is useful for laboratory results for example. We suggest the element <iscomplete> containing a boolean.
- Isvalidated: This status is useful for laboratory results for example. We suggest the element <isvalidated> containing a boolean.
At the level of the item
- Content: Multiple contents are allowed. This can be useful when the value of an item is expressed in different units. Lymphocytes (in % and number/mm3).
- Author: A transaction can report information provided by different authors. In that case, it can be interesting to overwrite the author at the level of the item. This element contains an <hcparty> element.
- BeginMoment: It can be interesting to attach a medical begin datetime to an item.
- EndMoment: It can be interesting to attach a medical end datetime to an item.
- Iscomplete: This represents the completeness status of an item (partial, complete). It contains a boolean.
- Lifecycle: This represents the evolution status of an item (requested, planned, performed, cancelled...). It contains a <cd> referring to the table CD-LIFECYCLE.
- Isvalidated: This represents the validity status of an item. It contains a boolean.
- Severity: This represents the severity of an item. It contains a <cd> referring to the table CD-SEVERITY.
- Certainty: This represents the certainty of an item. It contains a <cd> referring to the table CD-CERTAINTY.
- Temporality: This represents the temporality of an item (useful for a drug treatment for example: acute, chronic, ...). It contains a <cd> referring to the table CD-TEMPORALITY.
- Quantity: This represents the quantity of an item (useful for act prescription).
- Frequency: This represents the frequency of an item (useful for drug / act prescription). For example 3 times a day. It contains a combination of a <decimal> and a <unit>.
- Period of the day: This represents a period like noon, morning, ... It contains a <cd> referring to the table CD-DAYPERIOD.
- Site: This represents the location of a lesion, intervention. It contains a <cd> referring to the table CD-SITE.
- Cost: This represents the cost of an item and is composed of a <number> and a coded <unit>. The unit contains a <cd> referring to the table CD-UNIT.
- Duration: This represents the duration of an item and is composed of a <number> and a coded <unit>. (5 days, 10 minutes). The unit contains a <cd> referring to the table CD-UNIT.
At the level of the item content
- Value: The value can be stored using one of the following elements:
  - <cd>: any coding system using our standard cd approach or specified in SL for Local systems.
  - <decimal>
  - <boolean>
  - <date>
  - <time>
  - <hcparty>: the previously defined healthcare party
  - <text>: in that case, the language should be specified in the attribute L
  - <medication>: a structured element as follows:
    - <cd>: using the national coding system CD-DRUG-CNK
    - <tradename> (Augmentin 500 mg)
    - <presentation>: coded with CD-DRUG-PRESENTATION (caps)
    - <strength>: using a quantity and a unit of CD-UNIT (500 mg)
    - <route>: using an administration route from CD-DRUG-ROUTE (per os)
    - <quantityperpackage>: (20) means a box of 20 caps
    - <numberofpackage>: (2) means 2 boxes
    - <package>: using a code from CD-UNIT: (box)
    - <instructionforpatient>: (do not drink milk, ...)
  - <unit>: It contains a <cd> referring to the table CD-UNIT.
  - minimal range: <minref> contains a value representing the minimal value of the normal range.
  - maximal range: <maxref> contains a value representing the maximal value of the normal range.

A few of these elements have been used to finalize the demonstration of our case study:

Example XML

<?xml version="1.0" encoding="ISO-8859-1"?>

<kmehrmessage ... link to XSchema ... >
   <header>
      <standard>
         <cd S="CD-STANDARD" SV="1.0">20021205</cd>
      </standard>
      <id S="ID-KMEHR" SV="4.0">71071801.1234</id>
     <date>2001-10-02</date>
     <time>06:03</time>
      <sender>
         <hcparty>
            <id S="ID-HCPARTY" SV="1.0">71071801</id>
            <cd S="CD-HCPARTY" SV="1.0">hospital</cd>
            <name>CHU de Charleroi</name>
         </hcparty>
         <hcparty>
            <id S="ID-HCPARTY" SV="1.0">1.58585.58.580</id>
            <cd S="CD-HCPARTY" SV="1.0">physician</cd>
            <firstname>Alain</firstname>
            <familyname>Juvenois</familyname>
         </hcparty>
      </sender>
      <recipient>
         <hcparty>
            <id S="ID-HCPARTY" SV="1.0">1.64646.46.004</id>
            <cd S="CD-HCPARTY" SV="1.0">physician</cd>
            <firstname>Jean-Pierre</firstname>
            <familyname>Rochet</familyname>
         </hcparty>
      </recipient>
      <acknowledgment>
         <cd S="CD-ACKNOWLEDGMENT" SV="1.0">onerror</cd>
      </acknowledgment>
   </header>
   <folder>
      <id S="ID-KMEHR" SV="1.0">1</id>
      <patient>
         <id S="ID-PATIENT" SV="1.0">32031011931</id>
         <firstname>Jean</firstname>
         <familyname>Dubois</familyname>
         <birthdate>
           <date>1932-03-10</date>
         </birthdate>
         <sex>
            <cd S="CD-SEX" SV="1.0">male</cd>
         </sex>
         <address>
         <cd S="CD-ADDRESS" SV="1.0">home</cd>
            <country>
            <cd S="CD-COUNTRY" SV="1.0">be</cd>
            </country>
            <zip>6044</zip>
            <city>ROUX</city>
            <street>Rue du coucou</street>
            <housenumber>6</housenumber>
         </address>
      </patient>
      <transaction>
         <id S="ID-KMEHR" SV="1.0">1</id>
         <cd S="CD-TRANSACTION" SV="1.0">contact</cd>
        <date>2001-10-01</date>
        <time>15:25</time>
         <author>
            <hcparty>
               <id S="ID-HCPARTY" SV="1.0">1.58585.58.580</id>
               <cd S="CD-HCPARTY" SV="1.0">physician</cd>
               <firstname>Alain</firstname>
               <familyname>Juvenois</familyname>
            </hcparty>
         </author>
         <item>
            <id S="ID-KMEHR" SV="1.0">1</id>
            <cd S="CD-ITEM" SV="1.0">encountertype</cd>
            <content>
               <cd S="LOCAL" SL="MyADTSYstem" SV="3.4" DN="Consultation en urgence" L="fr">EM</cd>
            </content>
         </item>
         <item>
            <id S="ID-KMEHR" SV="1.0">2</id>
            <cd S="CD-ITEM" SV="1.0">encounterdatetime</cd>
            <content>
               <date>2001-10-01</date>
            </content>
         </item>
         <heading>
            <id S="ID-KMEHR" SV="1.0">3</id>
            <cd S="CD-HEADING" SV="1.0">assessment</cd>
            <item>
               <cd S="CD-ITEM" SV="1.0">healthissue</cd>
               <id S="ID-KMEHR" SV="1.0">1</id>
               <content>
                  <text L="en">infection due to tropical insect bite</text>
               </content>
               <severity>
                  <cd S="CD-SEVERITY" SV="1.0">veryabnormal</cd>
               </severity>
               <site>
                  <text L="en">left hand</text>
               </site>
            </item>
         </heading>
         <heading>
            <id S="ID-KMEHR" SV="1.0">4</id>
            <cd S="CD-HEADING" SV="1.0">treatment</cd>
            <item>
               <id S="ID-KMEHR" SV="1.0">1</id>
               <cd S="CD-ITEM" SV="1.0">medication</cd>
               <content>
                  <medication>
                     <cd S="CD-DRUG-CNK" SV="1999">0135418</cd>
                     <tradename>Tevax amp 0,5ml</tradename>
                     <presentation>
                        <cd S="CD-DRUG-PRESENTATION" SV="V1.0">solution</cd>
                     </presentation>
                     <strength>
                        <decimal>0,5</decimal>
                        <unit>
                           <cd S="CD-UNIT" SV="1.0">ml</cd>
                        </unit>
                     </strength>
                     <route>
                        <cd S="CD-DRUG-ROUTE" SV="V1.0">intramuscular</cd>
                     </route>
                  </medication>
               </content>
               <lifecycle>
               <cd S="CD-LIFECYCLE" SV="1.0">administrated</cd>
               </lifecycle>
               <quantity>
                  <decimal>1</decimal>
               </quantity>
            </item>
            <item>
               <id S="ID-KMEHR" SV="1.0">2</id>
               <cd S="CD-ITEM" SV="1.0">medication</cd>
               <content>
                  <text L="en">prescription of Augmentin 500mg 3x1caps/day during 5 days</text>
               </content>
            </item>
         </heading>
      </transaction>
   </folder>
</kmehrmessage>

Our five items have been filled using the new elements and attributes:

The 'type of encounter' has been qualified using a local code. The meaning of the code has been transferred in French in the DN attribute.
The 'date of encounter' has been put in the date and time elements.
The 'diagnosis' has been transferred as free text but the site and the severity have been placed in appropriate elements.
The 'drug delivery' of Tevax uses the full medication element.
The 'drug prescription' is transferred using pure free text. The fully structured example is given in the demonstration material.

More complete examples
In this tutorial, we have progressively reached the more sophisticated level of structuration. To describe the Tevax delivery, we have made use of many specialised elements and attributes. We remind you that the same information could have been transferred as pure free text.

We provide for demonstration more complete messages as well as the tutorial message:

Tutorial is the XML message that is used by the tutorial.
Level 2 is an XML message where the coding is limited to transaction and heading types. It contains 3 transactions (reports) about one patient (Jean Dubois):
- a contact report
- a laboratory result
- a second contact report
Level 3 is the same XML message, but where item types are also coded.
Level 4 is the same XML message, but where the content of the items is also coded.

These XML messages are displayed using the default presentation of your web browser without any transformation from our part.
To view the raw source code, please use the appropriate function of your browser (right click > Display source for IE6).

You should now read the general specification of the Kmehr message.

element to identify	name of the identifying system	rule to apply
header	ID-KMEHR	The <id> must contain a value that identifies uniquely the message within the emitting organisation. We recommend to concatenate the id of the first sender healthcare party of the message followed by a dot and a local unique identifier (see later).
folder	ID-KMEHR	<id S="ID-KMEHR"> must contain the sequential number of the <folder> within the current message starting from 1
transaction	ID-KMEHR	<id S="ID-KMEHR"> must contain the sequential number of the <transaction> within the parent folder starting from 1
heading, item	ID-KMEHR	<id S="ID-KMEHR"> must contain a shared sequential number of the <heading> or <item> within the parent transaction or heading starting from 1.

element	reference table	code	meaning
transaction	CD-TRANSACTION	contact admission discharge ...	contact report admission notification discharge notification ...please refer to the recommendation 4 for the full list
heading	CD-HEADING	... assessment treatment ...	... assessment treatment ...
item	CD-ITEM	... encounterdatetime encountertype healthissue medication ...	... date of encounter type of encounter diagnosis drug delivery or prescription ...