Transcript Document

EHR System Function and Information Model
(EHR-S FIM) Release 2.1 Prototype
Executive Summary for
Immunization Capability
and its EHR-S FIM
[email protected] , EHR WG facilitator
[email protected] , DoD Point-of-Contact
February 9, 2012 – Original
February 26, 2012 – Last Update
Call for Participation
This work is being done by the HL7 EHR Interoperability Work-group,
meeting every Tuesday at 4PM ET, dial-in: 1-770-657-9270, Passcode: 510269#
The most current artifacts are at: http://wiki.hl7.org/index.php?title=EHR_Interoperability_WG
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Executive Summary
For EHR-S FIM Release 2.1, this project has the purpose to
1) add core information models for each EHR-S FM function
•
make the EHR-S FM easier to use for analysts and engineers
•
verify and validate EHR-S FM Release 2.0
2) Service Aware Interoperability Framework (SAIF) DSTU demonstration
3) Support specific profiles (e.g., WG project DAMS, DIMS, DCMS).
The plan is to use an architecture modeling tool to represent the EHR-S FIM and
then generate appropriate views, reports, XML and HTML renderings of each
EHR-S function’s scenarios, requirements, actors, actions/activities,
dependencies, business rules, information & data
The DoD-VA Joint Immunization Capability (JIC), HL7 EHR Diabetes project,
ISO 13940 Continuity-of-Care harmonization are proposed as a set of
demonstration prototypes of increasing complexity.
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Immunization Management Capability
Scope, Including Dependent EHR-S Functions
We started with CP6.2 and included its dependencies:
1. CP.6.2 Manage Immunization Administration
2. CP.1.6 Manage Immunization List
3. CP.1.2 Manage Allergy, Intolerance and Adverse Reaction List
4. CP.1.3 Manage Medication List
5. CP.3.3 Manage Clinical Documents and Notes
6. CPS.1.7.2 Manage Patient Advance Directives
7. CPS.3.9 Clinical Decision Support System Guidelines Updates
8. CPS.9.4 Standard Report Generation
9. AS.4.1 Manage Registry Communication
10. Record Infrastructure See separate slide deck for each EHR-S Function for
details, not shown in this slide deck.
All EHR-S Functions are at:
11. Trust Infrastructure
http://wiki.hl7.org/index.php?title=EHR_Interoperability_WG
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EHR-FIM
Legend
class Legend
Perspective
Activ ity associated w ith EHR-S Function
control flow
control flow
Task w ithin Activ ity
End Activity
Start Activity
depends on
EHR-S Component
depends on
Syatem Component 3
System Component
+
-
attribute 2 [SHALL CC]
attribute 1 [SHOULD or MAY CC]
+
-
operation [SHALL CC]()
operation 2 [SHOULD or MAY CC]()
system component 4
has-a
aggregation
is-a (type)
generalization
association
System Component 2
EHR-S Function
«trace»
FEAT URE:
EHR-S Function
depends on
FEAT URE 2
realization
"implements"
REQUIREMENT :
Conformance
Criteria
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Methodology
Sparx Enterprise Architect views were used to create a separate slide set for an
Immunization Management Capability based on the “See Also” Dependencies
of CP.6.2 Manage Immunization Administration (defined on “Prototype Scope”
Slide) following these steps:
1.
Create Component Traceability View for each EHR-S Function
•
•
•
Start with applicable reusable components and their data elements
Based on Conformance Criteria, add additional function-specific components
Based on Conformance Criteria, add additional attributes or operations
–
–
2.
3.
Indicate SHALL attributes or operations as “public”
Indicate SHOULD or MAY attributes or operations as “private”
Create Conceptual Information Model view from step 1.
Create Conceptual Data Model view from step 1.
•
4.
Map EHR-S Components to supporting EHR-S Functions (“See Also” Dependencies)
Create Activity Model for the function.
•
Map Activities to EHR-S Components
This Executive Summary was created from the resultant model.
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Issues
1. What is normative within the EHR-S Information Model.
– Activity Diagrams map operational-activities to system components-and-functions.
• Recommend informative
– Conceptual Information Models
• set of components and their relationships? … recommend informative
– Conceptual Data Models (many-to-many mappings from functions-to-components)
• Set of components and their data elements per EHR-S Function … recommend normative
• Distinguish between elements derived from SHALLs vs. those from SHOULDs and MAYs
2. Criteria to determine the “See Also” Dependencies.
– EHR-S Function dependency with other Functions conformance criteria
– Dependency relationship with derived EHR-S Function’s entities
3. How will we represent the Information Model for Ballot.
–
Tool generated Graphic representation (e.g., same as Immunization Prototype)
•
–
Textural listing of components and data elements similar to
•
•
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Will ISO accept this?
HITSP/C83 CDA Content Modules and
HITSP/C154 Data Dictionary
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Conclusions
• EHR-S FIM can be the conceptual foundation for Interoperability
Specifications, refined into:
– Domain analysis Models (DAMs) and Detailed Clinical Models (DCL)
– Logical Perspective
– Implementable Perspective (Physical or Serialiazable Models)
• Messages, Documents, Services
• EHR-S FIM can be composed into higher level capabilities by functional
analysts and system engineers
– Encourage reuse of EHR-S FIM components
– Avoid duplication and “stovepipe applications”
• EHR-S FIM can populate portions of SAIF for HL7 WGs
– Information and Computational Dimensions
– Conceptual Perspective
• An Enterprise Architecture tool is essential to maintain consistency
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Immunization Management Capability
Models
•
•
•
•
•
•
•
•
•
•
•
•
CP.6.2 Clinician-Activities Mapped-to System-Components
CP.6.2 Conceptual Information Model (CIM) Mapped to EHR-S Functions
CP.6.2 CDM Requirements-Traceability
Immunization Management Capability: CP.6.2 & its Dependencies
CIM for Immunization Management Capability
CDM for Advanced Directive
CDM for Allergy, Intolerance and Adverse Reaction Event
CDM for Clinical Decision Support
CDM for Clinical Document or Note
CDM for Event
CIM is Conceptual Information Model
CDM for Lists
CDM is Conceptual Data Model
CDM for Immunization Event
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Description of Model Diagrams
The “Activities Mapped to System-Components” show
• Row 1: operational activities performed by the clinician, indicating
dependencies on
• Row 2: The EHR System components, which support the clinician’s
activities.
The “CIM Mapped to EHR-S Functions” show
• System Components for the EHR-S Function being analyzed, mapped
to the requisite System Components.
The Conceptual Data Model shows
• Attributes & operations for each System Component.
CDM Requirements-Traceability Shows
• Derivation of attributes and operations for each Component
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CP.6.2 Manage Immunization Administration
Clinician-Activities Mapped-to EHR-S Components
Clinician
act CP.6.2 ACT Manage Immunization Administration
Manage Trusts
Manage Business
Rules
depends on
depends on
depends on
CP.6.2 Manage Immunization Administration
Start
EHR-S Components
Encounter
Manage Records
Manage
Ev ents
Manage
Immunization
Schedules
Ev ent
Immunization
Schedule
Manage
Lists
Manage
Documents &
Notes
Document
or Note
Manage
Terminology
Manage
Regestries
Terminology
Registry
Manage
Reports
End
Report
is-a
is-a
Allergy,
Intolerance and
Adv erse
Reaction Ev ent
is-a
List
Clinical Document or Note
ia-a
Registry Immunization
(Public Health)
is-a
Immunization List
Adv anced Directiv e
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RED:
delete,
Blue:
insert
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CP.6.2 Manage Immunization Administration
Conceptual Information Model (CIM) Mapped to Supporting Functions
class CP.6.2 CIM Manage Immunization Administration
CP, CPS & AS
Registry
List
Clinical Document or Note
Document or Note
Immunization
Registry (Public
Health)
AS.4.1 Manage Registry
Communication
Encounter
Immunization List
Ev ent
Report
Terminology
Adv anced Directiv e
document or note
Immunization
History
CPS.9.4 Standard
Report Generation
Immunization
Ev ent
CPS.1.7.2 Manage Patient
Advance Directives
Allergy, Intolerance and
Adv erse Reaction Ev ent
CP.3.2 Manage Patient
Clinical Measurements
CP.6.2 Manage Immunization Administration
CP.1.6 Manage Immunization List
CP.1.2 Manage Allergy, Intolerance and Adverse Reaction List
Trust Infrastructure
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Record Infrastructure
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CP.6.2 Manage Immunization Administration
Components mapped to Requirements
req CP.6.2 RT Manage Immunization Administration
Encounter
NOTE: SHALL
conformance criteria
have bolded borders
-
differential diagnosis
disposition
follow up activities
follow up needed :boolean
follow up results
type
+
manage()
CP.6.2#03 The system
SHALL provide the ability to
determine and render
required immunizations, and
when they are due, based
on widely accepted
immunization schedules,
when rendering encounter
information.
0..*
List
CP.6.2#12 The system
SHOULD harmonize
Immunization histories with
a public health
immunization registry
according to scope of
practice, organizational
policy and/or jurisdictional
law.
-
define sort restrictions()
define sort criteria()
filter()
link to problem-treatment()
manage()
manage reason for change ()
sort()
+
manage()
depends on
CP.6.2#11 The system
SHOULD exchange
immunization histories with
public health immunization
registries according to scope
of practice, organizational
policy and/or jurisdictional
law.
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CP.1.2 Manage Allergy, Intolerance and
Adverse Reaction List
ia-a
depends
Immunization List
on
Registry Immunization
(Public Health)
+
+
depends on
CP.6.2#14 The system
SHALL conform to function
CP.1.6 (Manage
Immunization List).
analyze()
manage()
is-a
CP.6.2#13 The system
SHOULD capture and render
immunization histories from
a public health
immunization registry.
CP.6.2#07 The system
SHALL provide the ability to
maintain the immunization
schedule.
Immunization
Schedule
Immunization
History
+
-
CP.6.2#15 The system
SHOULD provide the ability
to update immunization
histories at the time of
capturing an immunization
administration.
render()
harmonize()
capture()
exchange()
update()
Allergy, Intolerance and
Adv erse Reaction Ev ent
depends on
CP.1.6 Manage
Immunization List
CP.6.2#08 The system
SHALL provide the ability to
render a patient‘s
immunization history upon
request for appropriate
authorities such as schools or
day-care centers.
CP.6.2#17 The system
SHALL provide the ability to
determine due and overdue
ordered immunizations and
render a notification.
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-
data of review
reaction type
severity
type
+
manage()
CP.6.2#04 The system
SHOULD provide the ability
to capture, in a discrete field,
an allergy/adverse reaction to
a specific unization.
CP.6.2#09 The system
SHALL conform to function
CP.1.2 (Manage Allergy,
Intolerance and Adverse
Reaction List).
12
CP.6.2 Manage Immunization Administration
Components mapped to Requirements
req CP.6.2 RT Manage Immunization Administration
CP.6.2#02 T he system MAY
auto-popul ate the
i mmuni zati on admi ni strati on
record as a by-product of
veri fi cati on of admi ni steri ng
provi der, pati ent,
medi cati on, dose, route and
ti me accordi ng to scope of
practi ce, organi zati onal
pol i cy and/or j uri sdi cti ona
Ev ent
+
+
-
date (occurence)
ti me (occurence)
change j usti fi cati on
ci rcumstances
cl i ni cal i nformati on
date (entry)
date (revi ew)
descri pti on
durati on
i nformati on revi ewed
i nformati on source
i nformati on val i dator
l ocati on
mechani sm
metadata
person-rol e
status
tri gger
type
+
+
+
deacti vate()
j usti fy()
manage()
CP.6.2#21 T he system
SHALL provi de the abi l i ty to
capture the recei vi ng enti ty
(e.g., pati ent, representati ve,
organi zati on) when pati ent
educati on i nformati on i s
provi ded at the ti me of
i mmuni zati on
admi ni strati on.
CP.6.2#06 T he system
SHOULD provi de the abi l i ty
to l i nk standard codes (e.g.
NDC, LOINC, SNOMED or
CPT ) wi th di screte data
el ements associ ated wi th an
i mmuni zati on.
Medi cati on
Admi ni strati on?
Terminology
-
code set
+
manage()
Immunization Ev ent
i s-a
CP.6.2#05 T he system
SHALL conform to functi on
CP.3.2 (Manage Pati ent
Cl i ni cal Measurements) to
capture other cl i ni cal data
perti nent to the
i mmuni zati on admi ni strati on
(e.g., vi tal si gns).
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+
+
+
date (recommended booster)
dose
educati onal i nformati on recei ved :bool ean
encounter
future booster
heal thcare organi zati on
i mmuni zati on order
i mmuni zati on provi der
i mmuni zati on type
j usti fi cati on-i mmuni zati on refusal
l ot
manufacturer
ordered i mmuni zati on due date
recei pt of i mmuni zati on preference
recei vi ng enti ty (educati onal i nformati on)
refusal of vacci ne type
route of admi ni strati on
ti me (admi ni strati on)
type
seri es (i mmuni zati on)
CP.3.2 Manage Pati ent
Cl i ni cal Measurements
NOTE: SHALL conformance
criteria have bolded
borders
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CP.6.2#18 T he system
SHALL provi de the abi l i ty to
render a pati ent educati onal
i nformati on regardi ng the
admi ni strati on (e.g., Vacci ne
Informati on Statement
(VIS)).
CP.6.2#19 T he system
SHALL provi de the abi l i ty to
capture that pati ent
educati onal i nformati on
(e.g., VIS) was provi ded at
the ti me of i mmuni zati on
admi ni strati on.
CP.6.2#01 T he system
SHALL provi de the abi l i ty to
capture, mai ntai n and
render i mmuni zati on
admi ni strati on detai l s as
di screte data, i ncl udi ng:(1)
the i mmuni zati on
name/type, strength and
dose;(2) date and ti me of
admi ni strati on;(3)
manufacturer, l ot numb
CP.6.2#23 T he system
SHOULD provi de the abi l i ty
to capture pati ent
preferences regardi ng
recei pt of i mmuni zati on
(e.g. refusal of certai n
vacci ne types) at ti me of
i mmuni zati on
admi ni strati on.
CP.6.2#22 T he system
SHOULD provi de the abi l i ty
to capture and mai ntai n
i mmuni zati on refusal
reasons as di screte data.
CP.6.2#20 T he system
SHALL provi de the abi l i ty to
capture documentati on that
pati ent educati onal
i nformati on (e.g., VIS) was
provi ded at the ti me of
i mmuni zati on
admi ni strati on.
CP.6.2#16 T he system
SHALL provi de the abi l i ty to
render the i mmuni zati on
order as wri tten (i .e., exact
cl i ni ci an order l anguage)
when renderi ng
admi ni strati on i nformati on.
CP.6.2#10 T he system
SHOULD transmi t requi red
i mmuni zati on admi ni strati on
i nformati on to a publ i c
heal th i mmuni zati on regi stry
accordi ng to scope of
practi ce, organi zati onal
pol i cy and/or j uri sdi cti onal
l aw.
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Immunization Management Capability
CP.6.2 Manage Immunization Administration & Its Dependencies
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Immunization Management Capability
Conceptual Information Model (CIM)
class CIM Immunization Management Capability
Clinical and Clinical Support System Components
Registry Immunization
(Public Health)
is-a
Registry
EHR System
Medical Dev ice
CDS-Clinical
Decision Support
Encounter
Clinical
Information
has-a
0..*
1..*
has-a
Document or Note
is-a
Report
Template
List
Ev ent
Clinical Document
or Note
Adv anced
Directiv e
document or note
0..*
is-a
is-a
Immunization
Ev ent
Medication
Ev ent
is-a
Reminder
or Alert
0..*
has-a
is-a
is-a
Allergy, Intolerance
and Adv erse
Reaction Ev ent
Immunization
List
is-a
Adv anced
Directiv e Ev ent
Immunization
Schedule
Immunization
Witheld Ev ent
is-a
Medication
List
is-a
CDS
Update
Terminology
Allergy, Intolerance
and Adv erse
Reaction List
Immunization
History
Patients Requiring
Follow up List
Problem List
Record Infrastructure
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ia-a
is-a
Trust Infrastructure
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Advanced Directive
Conceptual Data Model (CDM) Traceable to Conformance Criteria (CC)
class RT Adv anced Directiv e
Ev ent
+
+
-
date (occurence)
time (occurence)
change justification
circumstances
clinical information
date (entry)
date (review)
description
duration
information reviewed
information source
information validator
location
mechanism
metadata
person-role
status
trigger
type
SHALL CCs have
bolded borders.
See individual EHR-S
Function’s slide deck
for CC details
CPS.1.7.2#03
CP.3.3#09
CP.3.3#11
Document or Note
has-a
CPS.1.7.2#01
+
+
+
+
+
+
+
authenticator
author
date
facility
patient
type
status
+
+
+
+
render()
capture()
update()
tag()
CP.3.3#10
CP.3.3#02
CP.3.3#03
CP.6.2#02
CP.6.2#06
CP.3.3#08
CP.3.3#05
is-a
CP.3.3#07
+ deactivate()
+ justify()
+ manage()
Adv anced Directiv e Ev ent
CPS.1.7.2#02
CPS.1.7.2#08
CPS.1.7.2#07
CPS.1.7.2#06
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+
+
+
+
+
+
+
+
+
+
+
+
advanced directive captured :boolean
person completing AD
relationship to patient
circumstances (of receipt)
circumstances (of review)
date (received)
date (recinded)
date (review)
0..*
date (signed/completed)
date (updated)
Review
type
Adv anced Directiv e Type Enumeration
-
CP.3.3#14
Do Not Recusitate (DNR) Order
Durable Power of Attorney
Living Will
other
Preferred Interventions for Known Conditions
-
circumstances
date
reviewer
CP.3.3#15
-
CP.3.3#17
disposition
signature
structured :boolean
- manage()
+ render()
+ tag()
Adv anced
Directiv e Rev iew
0..*
Clinical Document or
Note
CP.3.3#04
CP.3.3#12
CP.3.3#01
Adv anced
Directiv e Author
-
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date signed
name
relationship
time signed
is-a
CP.3.3#16
Adv anced
Directiv e
CPS.1.7.2#05
CPS.1.7.2#04
16
Allergy, Intolerance and Adverse Reaction Event
Conceptual Data Model (CDM) Traceable to Conformance Criteria (CC)
class RT Allergy, Intolerance and Adv erse Reaction Ev ent
Ev ent
Clinical
Information
-
type
CP.6.2#09
CP.1.2#04
CP.1.2#16
CP.1.2#17
+
+
-
date (occurence)
ti me (occurence)
change j usti fi cati on
ci rcumstances
cl i ni cal i nformati on
date (entry)
date (revi ew)
descri pti on
durati on
i nformati on revi ewed
i nformati on source
i nformati on val i dator
l ocati on
mechani sm
metadata
person-rol e
status
tri gger
type
+
+
+
deacti vate()
j usti fy()
manage()
CP.1.2#24
CP.1.2#26
CP.1.2#25
CP.1.2#07
CP.1.2#19
CP.1.2#22
SHALL CCs have
bolded borders.
See individual EHR-S
Function’s slide deck
for CC details
i s-a
Allergy, Intolerance
and Adv erse
Reaction Ev ent
CP.1.2#02
CP.1.2#01
CP.1.2#03
-
data of revi ew
reacti on type
severi ty
type
CP.1.2#18
+
manage()
CP.1.2#21
CP.1.2#13
CP.6.2#04
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Clinical Decision Support
Conceptual Data Model (CDM) Traceable to Conformance Criteria (CC)
class RT Clinical Decision Support (CDS)
Ev ent
SHALL CCs have
bolded borders.
See individual EHR-S
Function’s slide deck
for CC details
CPS.3.9#04
CDS-Clinical Decision
Support
CPS.3.9#01
-
m ai ntai n()
+
+
-
date (occurence)
ti m e (occurence)
change j usti fi cati on
ci rcum stances
cl i ni cal i nform ati on
date (entry)
date (revi ew)
descri pti on
durati on
i nform ati on revi ewed
i nform ati on source
i nform ati on val i dator
l ocati on
m echani sm
m etadata
person-rol e
status
tri gger
type
+
+
+
deacti vate()
j usti fy()
m anage()
i s-a
CDS Update
-
date (update)
versi on
-
m anage()
CDS Content
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CPS.3.9#03
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CPS.3.9#02
CDS Rules
18
Clinical Document or Note
Conceptual Data Model (CDM) Traceable to Conformance Criteria (CC)
class RT Clinical Document or Note
CPS.1.7.2#03
Document or Note
Document or Note Type Enumeration
-
addenda
ori gi nal
updated by am endm ent i n order to correct
Document or Note
Status Enumeration
-
fi nal
prel i m i nary
si gned
+
+
+
+
+
+
+
authenti cator
author
date
faci l i ty
pati ent
type
status
CPS.1.7.2#01
+
+
+
+
render()
capture()
update()
tag()
CP.3.3#08
CP.3.3#11
CP.3.3#10
CP.3.3#02
CP.3.3#09
CP.3.3#03
i s-a
Template
Clinical Document or
Note Disposition
Enumeration
-
future fol l ow-up
recal l pati ent
revi ewed and fi l es
Clinical Document or
Note Type Enumeration
«enum »
+
ori gi nal
+
addenda
+
update
-
CP.3.3#04
type
CP.3.3#16
CP.3.3#14
Clinical Document or
Note
CP.3.3#15
-
di sposi ti on
si gnature
structured :bool ean
+
+
m anage()
render()
tag()
CP.6.2#06
CP.6.2#02
CP.3.3#07
CP.3.3#12
i s-a
SHALL CCs have bolded
borders. See individual EHR-S
Function’s slide deck for CC
details
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CP.3.3#05
Adv anced
Directiv e
CP.3.3#17
Unstructured
Document
CP.3.3#01
CPS.1.7.2#04
CPS.1.7.2#05
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Event
Conceptual Data Model (CDM) Traceable to Conformance Criteria (CC)
class RT Ev ent
Terminology
Trigger
Enumeration
-
-
-
date & Time
identifier
location
Demographic
Information
(structured)
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-
Clinical
Information
code set
-
type
+ manage()
drug
environment
food
other
Person-Role
Demographic
Information
SHALL CCs have
bolded borders.
See individual EHR-S
Function’s slide deck
for CC details
person identifier 1..* 1..*
+
role
+
Clinical Document or
Note
- disposition
- signature
- structured :boolean
- manage()
+ render()
+ tag()
Ev ent-Status
Enumeration
- active
- completed
- deactive
+
- erroneously captured
+
- pending
+
CP.1.3#08
CP.1.3#13
date (occurence)
time (occurence)
change justification
circumstances
clinical information
date (entry)
date (review)
description
duration
information reviewed
information source
information validator
location
mechanism
metadata
person-role
status
trigger
type
deactivate()
justify()
manage()
Ev ent Type Enumeration
CP.1.2#15
Ev ent
CP.1.2#25
CPS.3.9#04
CP.1.2#14
CP.1.3#10
CP.1.3#05
AS.4.1#02
-
advanced directive
adverse reaction
allergy
CDS Alerts
CDS reminders
CDS update
clinical document or note
discharge
encounter
intolerance
medication (pharmacist change)
medication (prescription dispensing)
medication (prescription filling)
medication history received (external source)
order
other
procedure
registry
reminders & alerts
report
surgical
transfer
CP.1.6#02
DRAFT WORKING DOCUMENT
20
Lists
Conceptual Data Model (CDM) Traceable to Conformance Criteria (CC)
class RT List
CP.1.2#12
List
CP.1.4#08
-
CP.3.3#06
is-a
define sort restrictions()
define sort criteria()
filter()
link to problem-treatment()
manage()
manage reason for change ()
sort()
ia-a
Allergy, Intolerance
and Adv erse
Reaction List
7/16/2015
CP.1.2#11
SHALL CCs have
bolded borders.
See individual EHR-S
Function’s slide deck
for CC details
is-a
Immunization List
+ analyze()
+ manage()
Medication
List
Patients Requiring
Followup List
DRAFT WORKING DOCUMENT
CP.3.3#18
21
Immunization Event
Conceptual Data Model (CDM) Traceable to Conformance Criteria (CC)
class RT Immunization Ev ent
CP.1.2#13
CP.3.3#12
CP.6.2#03
CP.3.3#19
Encounter
-
differential diagnosis
disposition
follow up activities
follow up needed :boolean
follow up results
type
+ manage()
has-a
CP.3.3#13
CP.3.3#18
CPS.3.9#04
CP.1.2#20
Immunization Future
Booster
-
+
+
1..* -
0..*
date (occurence)
time (occurence)
change justification
circumstances
clinical information
date (entry)
date (review)
description
duration
information reviewed
information source
information validator
location
mechanism
metadata
person-role
status
trigger
type
+ deactivate()
+ justify()
+ manage()
immunization type
recommended date
health care
organisation
Immunization Witheld
Ev ent
+ exception reason
+ withholding provider
7/16/2015
CP.1.6#02
Ev ent
is-a
CP.1.6#03
SHALL CCs have
bolded borders.
See individual EHR-S
Function’s slide deck
for CC details
CP.6.2#17
CP.6.2#16
CP.6.2#21
CP.6.2#22
CP.6.2#06
CP.6.2#02
is-a
Immunization Ev ent
+
0..* +
+
date (recommended booster)
dose
educational information received :boolean
encounter
future booster
healthcare organization
immunization order
immunization provider
immunization type
justification-immunization refusal
lot
manufacturer
ordered immunization due date
receipt of immunization preference
receiving entity (educational information)
refusal of vaccine type
route of administration
time (administration)
type
series (immunization)
DRAFT WORKING DOCUMENT
CP.6.2#23
CP.6.2#18
CP.6.2#10
CP.6.2#20
CP.6.2#05
CP.6.2#19
CP.6.2#01
CP.1.6#05
22
Reference Information
• EHR-S FIM Verb Hierarchy
• Observations by reviewers
7/16/2015
DRAFT WORKING DOCUMENT
23
EHR-S FIM
Action Verb Hierarches
Manage (Data)
Capture
Maintain
AutoStore
Populate
Enter
Archive
Import
Backup
Receive
Decrypt
Encrypt
Recover
Restore
Save
Update
Remove
Annotate
Attest
Edit
Harmonize
Integrate
Link
Tag
Delete
Purge
7/16/2015
Render
Extract
Present
Exchange
Transmit
DRAFT WORKING DOCUMENT
Export
Import
Receive
Transmit
Determine
Analyze
Decide
ManageDataVisibility
De-Identify
Hide
Mask
Re-Identify
Unhide
Unmask
24
Observation [David Baas]
•
•
From where I’m sitting, deriving conceptual information models based on the conformance criteria
could be useful for consuming a functional profile. I would assume it could be used as reference
for developing a domain analysis model for a project, to fill in blanks of conceptual information not
expressed by clinical SMEs, and to shorten the learning curve for projects required to adopt the
conformance criteria. Regardless of how modeling evolved on the project, the CDM would still be
a bridge to validate addressing information needs at a high level. I would not foresee using the
CDM or other artifacts verbatim in modeling for a specific project because some the
relationships/associations expressed appear to be more subjective than explicit representation of
the conformance criteria. I suggest annotating whether the relationships in the CDM represent
explicit conformance criteria or not. For those that are not explicit (SHALL), it should be clear
implementers have no obligation to portray those relationships the way they are expressed
in the model.
In reviewing the other artifacts (activity diagrams, and conceptual information model) I was a little
concerned that the content suggested a more prescriptive view of EHR functionality, which I’m not
sure is a good thing. In the case of the activity diagrams being prototyped, I can see they are not
attempting to sequence how tasks within an activity are executed, but using activity diagrams
suggests that is the intended direction. I think that path would be too restrictive for implementers. I
think the CIM raises more questions than it answers. This is another one where I think it best left
to specific implementation projects. Perhaps other folks will provide a different perspective, but I
think the CDM content is the most useful for understanding the conformance criteria for greater
adoption.
7/16/2015
DRAFT WORKING DOCUMENT
25
Observation [Kevin Coonan, HL7 Patient Care WG Co-chair]
•
•
•
•
•
•
We have been having a lot of discussions in patient care, clinical statement, CIMI and MnM regarding representation of clinical
content. One of the most important is the recognition and separation of dynamic uses / extracts of information one would see in an
EHR-S GUI or CDA v. an information model suited for information exchange, persistence, transformation, analytics, decision
support. A good example of this is the common notions of a “problem list”, “allergy list” or “list of immunizations”. These are artifacts
we are used to seeing in paper charts, since there was no other effective means to address longitudinal data which otherwise would
be scattered in the linear ordering progress notes. In fact, HL7 defines these working lists as ‘..collects a dynamic list of individual
instances of Act via ActRelationship which reflects the need of an individual worker, team of workers, or an organization to manage
lists of acts for many different clinical and administrative reasons. Examples of working lists include problem lists, goal lists, allergy
lists, and to-do lists.’
There are also design patterns well suited for static semantics from the (being revised for May ballot) Patient Care domain, all of
which are different entry points into a common model. These include a pattern for a Care Record, which corresponds best to the
conventional notion of the documentation of an encounter. The Care Record, however, has entries which follow the Health Concern
pattern and the Care Plan pattern.
Health Concerns are anything which affects one’s health which need to be managed/tracked over time. These includes risks,
diseases, problems, allergies/intolerances to medications, social circumstances, and complications.
The Care Plan documents interventions, treatments and orders. Care Plans can have embedded logic, e.g. stating a specific action
should (not) be taken if a specific criterion is met. So things like immunization schedules, insulin sliding scales/sick day rules, or
complex oncology protocols have a common design basis. While we are used to thinking of Concerns and Plans as future looking,
the same pattern is used to document things which have happened (e.g. procedure which has been completed), so the Care Plan
includes not just what is currently being done, what is planned, but also what has been done in the past.
An instance of an encounter’s documentation therefore would have elements from the Care Record (e.g. the signs/symptoms
discovered at the time of the encounter), Health Concerns (in a linear narrative like a CDA these typically are organized into the
familiar ‘lists’, e.g. allergy list, problem list, PMH), and Care Plan (again in ‘lists’—e.g. medication list). An encounter would also
expect to generate new Care Plans and new Health Concerns as part of the clinical decision making. (The A&P in Weed’s POMR).
By separating the model of use (various lists) from model of meaning (the Patient Care Domain Model plus the derived detailed
clinical models which bind terminology, etc.) we can most effectively devise those specifications needed for given use cases.
7/16/2015
DRAFT WORKING DOCUMENT
26
Observation [Kevin Coonan, HL7 Patient Care WG Co-chair]
•
•
•
•
I am coordinating with Richard Savage (now working for CDC) on immunizations with Patient Care. I
don’t know who the modeling facilitator is for the new immunization project, but if it is a void I might fill
in. I am going to start tacking the immunization (JIC) (analysis/conceptual) models and see if I can get
them into something which is a better approximation of a real information model of the clinical content
static semantics.
Do you think this is a good point to start to put together the background and socialization needed to
come to some decision regarding the representation of static semantics for iEHR? I see two related
decisions: #1 what modeling language is going to be used for design, and #2 what is the modeling
language used for the wire format. Obviously, with HL7 v3 there is close traceability between the
graphic format in the Visio based RMIM Designer and the resultant MIF2 representation. I believe that
the UML based SMD also does this. MIF2 è XSD, so there is a close tie between MIF and something
which can be implemented.
Of course, we could also use HL7 templates (whatever those are) on top of a base model, rather than
having all the explicit details in the MIF2. We could even use ADL for this, if we were so inclined. That
still leaves us the question about ‘wire format’. I.e. what one server says to another.
Eventually, I would expect a ‘cleaner’ modeling language to be used for design, with transformation to
arbitrary implementable paradigms. Hopefully CIMI will fill this niche. Not in time to do the modeling for
JIC, Pharmacy, etc. but hopefully just in time to model the core content of an ambulatory documentation
system.
7/16/2015
DRAFT WORKING DOCUMENT
27
CP.6.2 Immunization Management
“See Also” Dependencies
DRAFT WORKING DOCUMENT
7/16/2015
RED: delete, Blue: insert
28
EHR-S FIM Immunization Management Prototype Status
L
A
S
t
C
C
Notional
Scenario
CP.6.2 Manage Immunization Administration
2/11
X
X
X
X
X
X
X
CP.1.6 Manage Immunization List
2/11
X
X
X
X
X
√
X
CP.1.2 Manage Allergy, Intolerance and Adverse
Reaction List
2/11
√
√
√
√
√
√
√
CP.1.3 Manage Medication List
2/11
X
X
X
X
X
X
X
CP.3.3 Manage Clinical Documents and Notes
2/11
√
√
√
√
√
√
√
CPS.1.7.2 Manage Patient Advance Directives
2/11
X
X
X
X
X
X
X
CP.3.3 Manage Clinical Documents and Notes
2/11
√
√
√
√
√
√
√
CPS.3.9 Clinical Decision Support System
Guidelines Updates
2/11
√
√
√
√
√
√
√
CPS.9.4 Standard Report Generation
2/11
√
√
√
√
√
√
√
AS.4.1 Manage Registry Communication
2/11
√
√
√
√
√
√
√
EHR-S Function
Act CIM CDM RT
See
Also
√ = first draft done, X = Peer reviewed by WG
CC=Conformance Criteria, Act=Activity Diagram, CIM=Conceptual Information Model, CDM=Conceptual
7/16/2015 Data Model, RT-A=Requirements Trace to Activities, RT-D=Requirements trace to Data
29