# WIA-hospital-info-system PHASE 1 — DATA-FORMAT Specification **Standard:** WIA-hospital-info-system **Phase:** 1 — DATA-FORMAT **Version:** 1.0 **Status:** Stable This document defines the canonical data-format layer for WIA-hospital-info-system. The standard covers the persistent record shapes that a hospital information system (HIS) maintains for its admissions, clinical, pharmacy, laboratory, radiology, billing, electronic medical record (EMR), and operational subsystems. Whereas the WIA-healthcare-integration standard governs record exchange between organisations, this standard governs the in-hospital record substrate and the internal-subsystem boundaries within a single organisation. Records are consumed by clinicians at the operating site, by hospital administration for operational and statutory reporting, by the patient through the in-hospital patient-portal, by the payer for claims adjudication, by external auditors, and by the supervisory data-protection authority for inspections. References (CITATION-POLICY ALLOW only): - ISO 8601 (date and time representation) - ISO/IEC 11578 (UUID) and IETF RFC 4122 (UUID URN) - ISO/IEC 27001:2022 (information security management) - ISO 27799:2016 (information security in health using ISO/IEC 27002) - ISO 13606-1:2019 (electronic health record reference model) and ISO 13606-2:2019 (archetype interchange) - HL7 v2.5.1 / v2.8.2 messaging (the operating-site messaging substrate that most hospital information systems still use for ADT, ORM, ORU, BAR, MFN, and SIU message types) - HL7 FHIR Release 5 (the modern resource-shape substrate for the EMR facade and for API integration with external partners) - IHE PCC (Patient Care Coordination) profiles for clinical-document content - IHE LAB profiles (LTW, LCSD, LBL, LCC, LPOCT) for laboratory operations - DICOM PS3 (Digital Imaging and Communications in Medicine; cited for the radiology subsystem) - LOINC (Logical Observation Identifiers Names and Codes), SNOMED CT, and ICD-11 (the World Health Organization's eleventh revision of the International Classification of Diseases) for code-system bindings - IETF RFC 8259 (JSON), RFC 9457 (Problem Details) - US HIPAA Security Rule (45 CFR Part 164, Subpart C) and Privacy Rule (45 CFR Part 164, Subpart E) - KR Medical Service Act (의료법) Article 22 (medical- record curation), Article 23 (electronic medical- record curation discipline) and the KR EMR certification programme (전자의무기록 시스템 인증) operated under Article 23-2 - KR Personal Information Protection Act (PIPA, 개인정보보호법) Article 23 sensitive-information clauses - EU European Health Data Space Regulation (cited where the hospital participates in the EHDS infrastructure) --- ## §1 Scope This PHASE defines persistent shapes for the artefacts the hospital information system maintains: - Admissions, discharges, and transfers (ADT) — bed occupancy, encounter status, ward and unit assignment. - Computerised provider order entry (CPOE) — the orders the clinician places against the patient's encounter. - Pharmacy — the dispense-and-administration cycle paired with the medication order. - Laboratory information system (LIS) — the order- result cycle for laboratory tests. - Radiology information system (RIS) and PACS — the imaging-order, study, and report cycle. - Billing and claims — the charge-master and the claim record. - EMR — the longitudinal clinical record visible to the treating clinician. - Master files — the patient master, provider master, service master, and code-system master. KR Medical Service Act medical-record curation (Article 22) requires ten-year retention for medical records and three-year retention for prescription and nursing records; the discipline is encoded in PHASE-3 §9. ## §2 Hospital and Programme Identifier ``` hospitalProgrammeId : string (uuidv7) hospitalName : string (legal name of the hospital) hospitalKind : enum ("tertiary" | "general" | "specialty" | "primary-care" | "long-term-care" | "psychiatric" | "rehabilitation" | "user- defined") hospitalJurisdiction : string (ISO 3166-1 country code) operatingFrameworks : array of enum ("HL7-V2-5-1" | "HL7-V2-8-2" | "HL7-FHIR-R5" | "DICOM-PS3" | "ISO-13606" | "IHE-PCC" | "IHE-LAB" | "KR-EMR-Certification" | "US-HIPAA-PRIVACY" | "US-HIPAA-SECURITY" | "KR-Medical-Service-Act" | "KR-PIPA-SENSITIVE" | "EU-EHDS" | "user-defined") codeSystemsUsed : array of enum ("LOINC" | "SNOMED-CT" | "ICD-11" | "ICD-10-CM" | "RxNorm" | "ATC" | "KCD-8" | "user-defined") emrCertificationRef : string (URI of the operating jurisdiction's EMR certification record — for KR hospitals this is the 전자의무기록 시스템 인증 record) programmeStatus : enum ("commissioning" | "operating" | "rollout-limited" | "wind-down" | "archived") ``` ## §3 Patient Master Record ``` patientMaster: patientId : string (uuidv7; the hospital's master-patient-index identifier) jurisdictionalIdentifiers : array of object (KR resident registration number, US medical record number, EU Member-State national identifier; the hospital records the issuing- authority OID and the scope of use) givenName : array of string familyName : string birthDate : string (ISO 8601 date) administrativeSex : enum ("female" | "male" | "unknown" | "other") preferredLanguage : string (BCP 47) primaryContact : object (the next-of-kin or authorised contact reference) insuranceCoverage : array of object (per-payer coverage records) ``` ## §4 Encounter and Bed-Occupancy Record (ADT) The ADT discipline is captured per HL7 v2.5.1 ADT message-type semantics; the persistent shape is: ``` encounterRecord: encounterId : string (uuidv7) patientRef : string (PHASE-1 §3) encounterClass : enum ("inpatient" | "outpatient" | "emergency" | "day-surgery" | "observation" | "home-care" | "user-defined") admissionAt : string (ISO 8601) dischargeAt : string (ISO 8601; absent until discharge — corresponds to the v2 A03 message) admittingProvider : string (PHASE-1 §6 reference) attendingProvider : string servicedDepartment : string (e.g. internal-medicine, cardiology, oncology, paediatrics) bedOccupancy: wardCode : string roomCode : string bedCode : string occupancyFrom : string (ISO 8601) occupancyTo : string (ISO 8601; absent until transferred or discharged — corresponds to the v2 A02 transfer message) visitNumber : string (the v2 PV1.19 visit number for legacy interfaces) ``` ## §5 Order and Order-Result Record (CPOE) ``` orderRecord: orderId : string (uuidv7) encounterRef : string (PHASE-1 §4) orderClass : enum ("medication" | "laboratory" | "radiology" | "consultation" | "procedure" | "diet" | "nursing" | "blood-product" | "user- defined") orderingProvider : string orderedAt : string (ISO 8601) serviceCode : object (LOINC for laboratory and most diagnostic orders; SNOMED CT for procedures; the hospital's service-master code as a parallel coding for charge-master mapping) priorityKind : enum ("routine" | "stat" | "urgent" | "asap" | "timing-critical") status : enum ("draft" | "active" | "completed" | "cancelled" | "stopped" | "entered-in-error") resultObservations : array of string (PHASE-1 §7 observation references for laboratory orders; the v2 ORU result message that fulfils the order is referenced here) imagingStudyRef : string (PHASE-1 §8 reference for radiology orders) ``` ## §6 Provider Master Record ``` providerMaster: providerId : string (uuidv7; the hospital's internal provider identifier) jurisdictionalLicence : array of object (KR medical- practitioner licence number, US NPI, EU Member-State licensing- authority registration) givenName : array of string familyName : string practitionerRoles : array of object (per-role assignment — physician, nurse, pharmacist, technician, clinical-research-coordinator) privileges : array of string (the hospital's privilege-and-credentialling record reference; controls what order classes the provider may place) ``` ## §7 Laboratory and Pathology Result Record The laboratory-information-system (LIS) record-shape follows the IHE LAB profile for the hospital's laboratory operations: ``` labResultRecord: resultId : string (uuidv7) orderRef : string (PHASE-1 §5) resultStatus : enum ("preliminary" | "final" | "amended" | "corrected" | "cancelled" | "entered-in-error") performedAt : string (ISO 8601) performingLabRef : string (the hospital's in-house laboratory or the reference laboratory the work was sent to) observationCode : object (LOINC code is required; for LIS-internal bench codes the hospital records both the LOINC code and the bench code) valueQuantity : object (UCUM-quantified value) valueCodeable : object (coded result for categorical observations) referenceRange : array of object abnormalFlag : enum ("normal" | "low" | "high" | "low-low" | "high-high" | "abnormal" | "out-of-range" | "user-defined") pathologyNarrativeRef : string (URI of the pathology-report narrative — absent for non-anatomic-pathology results) ``` ## §8 Imaging-Study Record (RIS / PACS) ``` imagingStudyRecord: studyId : string (uuidv7) patientRef : string encounterRef : string orderRef : string (PHASE-1 §5) studyInstanceUid : string (DICOM Study Instance UID — the canonical study identifier for PACS) modality : enum ("CR" | "CT" | "MR" | "NM" | "PT" | "US" | "MG" | "DX" | "RF" | "XA" | "OT" | "user- defined") performedAt : string (ISO 8601) performingTechnologist : string interpretingProvider : string (radiologist reference) reportObservations : array of string (PHASE-1 §7 observation references for structured findings) reportNarrativeRef : string (URI of the imaging- report narrative) pacsInstanceCount : integer (number of DICOM instances in the study) ``` ## §9 Pharmacy Dispense and Administration Record ``` pharmacyDispense: dispenseId : string (uuidv7) orderRef : string (the medication-order reference) dispensedAt : string (ISO 8601) dispensingPharmacist : string medicationCode : object (RxNorm for US, ATC for EU, KR National Drug Master File for KR) quantity : object (UCUM quantity) lotNumberRef : string expiryDate : string (ISO 8601 date) administrationRefs : array of string (PHASE-1 §10 administration references) ``` ## §10 Medication Administration Record (eMAR) ``` medicationAdministration: administrationId : string (uuidv7) dispenseRef : string administeredAt : string (ISO 8601) administeringNurse : string routeKind : enum ("oral" | "intravenous" | "intramuscular" | "subcutaneous" | "transdermal" | "inhalational" | "rectal" | "topical" | "user-defined") doseGiven : object (UCUM quantity) refusalReason : string (absent unless refused; the hospital's nursing discipline records the reason) ``` ## §11 Billing and Charge Record ``` chargeRecord: chargeId : string (uuidv7) encounterRef : string chargeMasterCode : string (the hospital's chargemaster code — the chargemaster cross-walks to the jurisdictional billing-code system) jurisdictionalBillingCode : object (US CPT or HCPCS, KR EDI procedure code, EU national equivalent) serviceDate : string (ISO 8601 date) performingProvider : string quantity : integer unitPrice : object (the chargemaster's per-unit price in the hospital's reporting currency) payerRef : string (the responsible payer reference; absent for self-pay) ``` ## §12 Audit-and-Access-Log Record ``` auditEvent: eventId : string (uuidv7) occurredAt : string (ISO 8601 instant) actorRef : string (provider or system identity) subjectPatientRef : string (absent for system events) eventKind : enum ("login" | "view-record" | "modify-record" | "place-order" | "result-access" | "break-the-glass" | "consent-capture" | "consent-withdrawal" | "report-print" | "user-defined") outcomeKind : enum ("success" | "minor- failure" | "serious-failure") rationale : string (URI of the rationale narrative for break-the-glass events) ``` ## §13 Conformance Implementations claiming PHASE-1 conformance maintain the master files, encounter, order, result, administration, charge, and audit records described above. The KR EMR certification programme (전자의무기록 시스템 인증, KR Medical Service Act Article 23-2) imposes additional record-shape requirements that the hospital satisfies through its certification-record reference; HIPAA Security Rule 45 CFR 164.312(b) audit controls apply to the audit-event record. --- **Document Information:** - **Version:** 1.0 - **Phase:** 1 — DATA-FORMAT - **Status:** Stable - **Standard:** WIA-hospital-info-system - **Last Updated:** 2026-04-28