Clinical Data Modeling and the HL7 RIMamisha.pragmaticdata.com/~schadow/HAND.pdfTutorial 19 Clinical Data Modeling and the HL7 RIM Gunther Schadow, MD Daniel C. Russler, MD Wesley

Tutorial 19

Clinical Data Modeling and the HL7 RIM

Gunther Schadow, MDDaniel C. Russler, MD

Wesley J. Rishel

American Medical Informatics Association1999 Annual Symposium

Marriott Wardman Park HotelSaturday, November 6, 1999

1:00pm – 4:30pm

Copyright © 1999, Regenstrief Institute for Health Care

Know the Market• HIPAA Regulations

• Privacy & Security

• Administrative--eligibility, claims submission

• Clinical--vocabulary, claims attachments

• Cost and Quality Improvement Needs• Service line methodology

• Condition management orientation

• Risk Management

• Workflow management• Increasing task volume

• Preventing errors

• Decreasing low-value procedures

• Increasing high-value procedures

Knowing the market for healthcare standards means beingable to answer the question of how much customers are willingto pay to upgrade to software incorporating the new standards.

For users, the change to HL7 Version 3 will be expensive. Themain reasons for customers to change to V3 will be eitherneeding to conform with HIPAA or needing to improve cost andquality management.

HIPAA regulations focus on a number of areas, notably,privacy(confidentiality) & security(protection from corruption),basic billing functions, and detailed clinical communication,mostly for billing and reporting purposes.

Cost and quality management have to do with the need tosupport and encourage workers to reduce waste, preventerrors, work quickly, and do the right things.

To accomplish these tasks in an incremental manner,organizations are picking out individual service lines such ascongestive heart failure, knee replacements, or asthma to workon first. Tracking the cost and quality of work and outcomes forthese service lines is a high priority with managers ofhealthcare organizations who are trying to maintain qualitywhile reducing cost. Finally, research demonstrates thatimprovement doesn’t occur unless the workflow can be directlymanaged.

This diagram represents a “mega-use-case,” a use-case with manysmaller use-cases in the course of the larger use-case. This diagramillustrates the course of a condition over time and many settings ofcare. Clinicians know that it is unrealistic to chop a disease up intodifferent, uncoordinated healthcare organizations and expect thetotal outcome of the disease to be optimized. Consequently,organizations are starting to work to improve care from thebeginning of a disease in the outpatient setting, its treatment in thehospital, and to its resolution in the follow-up settings.

For example, when a patient becomes ill, the first contact is usuallywith an office physician. Other contacts with consulting physicians,hospitals and other outpatient therapy settings may follow. In thisdiagram, the patient develops chest pain at home and sees aprimary care physician who suggests angina. The patient is sent to aconsultant who also feels this is angina, performs a stress test andcatheterization and confirms atheroscerotic heart disease. Thepatient is certified for surgery, admitted, and becomes “status postcoronary artery bypass graft.” He is followed by cardiac rehab andfinally is seen back at the physician office. In this case, the episodeof illness that first became apparent with chest pain, nevercompletely resolves.


EnrollmentEpisodeBegins

Doctor'sOffice

Specialist

DiagnosticTesting

Relative HealthHealth

Certification

Admission

Surgery

Discharge

Rehab

Follow-upDoctor'sVisit

Chest Pain

r/o Angina

Angina

ASHD s/p CABG

Modeling the Condition


Perinatal Task Force--Full-Term Delivery

Cardiac Task Force--Congestive Heart Failure

Orthopedics Task Force--Hip Replacement

Pulmonary Task Force--Asthma

Primary Care Task Force--Health Maintenance

Other Task Forces

Chief Medical Officer Chief Information OfficerChief Nursing Officer

Medical Director Clinical Informatics

Nursing Director Clinical Informatics

IS Support Staff

Typical Task Force Organization

In a typical healthcare organization, there is some structure inplace for clinical quality improvement. Someone is in charge ofclinical quality improvement, such as a physician chief-of-staffor chief medical officer as well as a corresponding nursingexecutive. Below the accountable executives is anorganization of committees. Every hospital at least has aPharmacy and Therapeutics Committee, which is responsiblefor the order system prompts and rules. Today, in the mostadvanced organizations, a service-line methodology is evolvingthat places clinicians such as physicians, nurses, andpharmacists, and even cost accounting and marketingpersonnel on a diagnosis-oriented task force that is focused oncost and quality for an individual disease. These service linesthen are marketed to managed care companies or used tomanage DRG costs.

Assigning cost and quality data to these service lines,communicating the data as patients move across settings ofcare, and submitting this data to payors as needed are primarybusiness and clinical needs in today’s environment.


HL7 Mission Statement

To provide standards for the exchange,management and integration of data thatsupport clinical patient care and themanagement, delivery and evaluation ofhealthcare services. Specifically, to createflexible, cost effective approaches, standards,guidelines, methodologies, and relatedservices for interoperability betweenhealthcare information systems.

Traditionally, HL7 has been thought to be simply a messagingstandard for the Level 7 layer of the ISO communicationprotocol. However, a look at the mission statement andactivities of HL7 belies that conception.

I’ve underlined key words in the HL7 Mission Statement andmoved them to the next slide....


Clinical Modeling Goals• Standards for data

• Integration• Reference Information Model(RIM)

• Management• Vocabulary & rule version control

• Exchange• Message formats: Version 2.x; Version 3

• Supporting• Clinical patient care

• Service management--workflow guidelines

• Service delivery--context & relationship tracking

• Service evaluation--cost & quality tracking

Today, HL7 is developing a Reference Information Model thatmay be used by healthcare for many purposes. Vocabularyand decision-rule standards go way beyond simple messageformats. Of course, message standardization is still a primaryproduct of HL7, and the next major version of the messagingstandard is Version 3.


Version 3 Highlights

• New message syntax--XML

• Support for XML document transmission

• Support for an explicit information model

• Support for multiple published vocabularies

• Support for composite datatypes

• Expected V3 message voting in 2000

HL7 Version 3 will have many new and exciting features. Themost difficult feature to implement has been a standardReference Information Model, which underlies theimplementation of all the other features.

Understanding information modeling is key to understandingthe significance of Version 3.


Dog!

HL7/CORBA/DCOM

Importance of Information Model

This slide illustrates the importance of an information model inan alert message. What went wrong in this picture?

An alert message was generated by one biologic computerand transmitted to another. The message was received, butthe alert was not interpreted correctly by the receivingcomputer. Was the sending system wrong or was the receivingsystem wrong? Or was the message format inadequate?

Obviously, in this case, neither system was “wrong.” And allthe messaging standards organizations have discovered theycan generate messages that are misunderstood. The issue inthis example was that the information and vocabulary modelsof the sending and receiving systems were not synchronized.

Although the first system turned the concept of a large, angrydog into an adequately formatted message, the second systemcould not rebuild the same concept from the message format.If both systems interpreted “Dog!” as a warning about large,angry dogs, then this simple message would be adequate.However, if the receiving system is able to substitute othermeanings to the message, the message becomes ambiguous.

An information-model/vocabulary-model shared between twosystems constrains the ambiguity of messages sent betweenthe systems and ensures correct interpretation by the receivingsystem.


Multiple Views of the World

The egg and duck analogy can illustrate the problem(althoughmost analogies can be cracked if worked too hard)...

A duck farmer thinks of the lifecycle of the duck as illustratedabove. The egg produces a duckling which grows into a duckwhich produces more eggs. That view of the duck lifecycle issufficient for raising ducks.


Multiple Views of the World

On the other hand, the cook has no need to recognize therelationship between eggs and ducks. The relationship thecook needs to know is the relationship between raw eggs andfried eggs and the relationship between raw duck and roastduck.


Unified View of the World

A view that accommodates both users of the model doesn’tlook quite like the model that is unique to each user.


HL7 Technical Committees• Orders/Observations

• Ancillary View of the World

• Patient Care• Clinical View of the World

• Modeling & Methodology• Information Model View of the World

• Vocabulary• Linguistic View of the World

In the HL7 Environment, at least four views of the world arerepresented in the HL7 Reference Information Model. Most ofthe examples and concepts used to create the model and thatwill be used to explain the model will come from the fieldsrepresented above. The compromises that were needed tocreate the model from these different views of the world will bediscussed.


Overcoming Isolation throughInformation Modeling


• Islands of data collected in systems and applications• was the primary issue for HL7 v2.x

• continues to be a problem

• Silos of data collected for special interests

Dimensions of Isolation

Ob

serv

atio

ns

Ad

min

istr

atio

n

Kn

ow

led

ge

Pat

ien

t ca

re

• Individualized patient data• no sense of population health, epidemiology

• Data behind technological bars• so many technologies to choose from• “technology independent” architectures?

• Isolated “data elements”


What HL7 version 3 does about it?• The Reference Information Model (RIM) defines and

relates all data that exists for HL7• makes functional Silos obvious

• allows to discover and resolve functional overlap

• allows to integrate additional functionality through• abstraction and reuse

• careful addition of new items

• Strong emphasis on semantics of health careinformation• … rather than on syntax and technology architectures

• offers added value to any technology:• legacy EDI, XML, CORBA, DCOM, Database, ...


The Reference Information Model• is a consensus view on our universe

• nothing exists outside, isolated from the RIM

• provides flexible structures• rather than isolated detail data elements

• melts the vertical silos into a coherent whole

• is work in progress

• wants you to get involved• wants you to wrestle with it,

• wants you to understand it,

• wants you to help improving it

• wants to work for you!


Reference Information Model (RIM)Documents Scheduling Electronic

Medical Record

Payers andCoverage

Encounterand Episode

Provider Location

Stakeholder

Champus_coveragehandicapped_program_cdnon_avail_ cert_on_file_ indretirement_ dttm

station_id

Master_qualitative_observation

abnormal_result_cdcritical_result_ cd

normal_result_ cdpreferred_coding_system_cdvalid_answer_cd

Referral

authorized_visits_qtydescreason_txt

Dietary_intent_or_order

diet_type_cd

instruction_desctray_type_cdservice_period_ cd

Observation_intent_or_orderpatient_hazard_cd

relevant_clinical_information_txtspecimen_action_cd

Treatment_service_eventprescription_id

refills_remaining_nbrPTroutPTcompindication_idsubstance_expiration_dttmsubstance_lot_number_ txtsubstance_manufacturer_cd

dosage_form_ cdstrength_qtyamount_qtyroute_ cdbody_site_cdsubstitution_c d

Treatment_service_administrationadministered_rate_qtycompletion_status_cdsubstance_refusal_reason_cdsystem_entry_ dttmadministration_nbr

administered_per_ timeunit_ cdadministrators_notes_cd

Treatment_service_dispensedispense_package_method_ cddispense_package_size_qtyneeds_human_review_indsuppliers_special_dispensing_instruction_cdtotal_daily_dose_qty

Treatment_service_givegive_per_timeunit_cdqtgive_rate_qtyneeds_human_review_ind

Consent Care_eventAssessment

Advance_directivecompetence_inddirective_cddisclosure_level_ cdlife_quality_descmortuary_preference_ nmnotarization_dttmassessment_dttmemployment_related_ind

Episode

descepisode_type_cdid

list_closed_indoutcome_txtrecurring_service_ind

Clinical_observation

abnormal_result_cdlast_observed_normal_values_dttm

nature_of_abnormal_testing_cdclinically_relevant_ tmrmethod_cdstatus_cd

status_dttmobservation_sub_idvalreferences_range_valuniversal_service_identifier_suffix_txtuser_defined_access_check_cdvalue_datatype_ cd

confirmation_status_cd

Rule_link

priority_ nbr

Conditional_link Judgement_link

type_cd

Master_numeric_range

type_cdcondition_descage_qtygestation_age_qty

value_qtyrace_subspecies_txtgender_cdspecies_ txt

Master_quantitative_observation

corresponding_SI_unit_of_measure_c dunit_of_measure_cddelta_check_change_computation_method_cd

delta_check_change_threshold_qtydelta_check_value_range_qtydelta_check_numeric_low_value_amtdelta_check_retention_period_qtydisplay_length_and_decimal_precision_cd

minimum_meaningful_increment_ nbrsi_conversion_factor_ expr

0..*

1

applies_to 0..*

conforms_to 1

Condition_node

life_cycle_start_dttmlifecycle_status_ cdmanagement_discipline_ cdranking_nbr

employment_related_ind

Episode_of_condition

1

0..1

defines_episode1

links_condition0..1

Master_treatment_service

dea_level_ cddrug_category_cdformulary_status_ cdmedication_form_cdpharmaceutical_class_ cdroute_ cd

therapeutic_class_cd

Treatment_intent_or_order

indication_id

ordering_providers_instruction_ txtrequested_give_strength_qtysubstitution_allowed_ind

Treatment_intent_or_order_revision

dispense_package_method_ cd

dispense_package_size_qtygive_indication_idgive_per_timeunit_cdgive_rate_qtylast_refilled_ dttmmax_give_qtymin_give_qtyneeds_human_review_ind

PTcompPTroutqtprescription_id

refills_allowed_nbrrefills_doses_dispensed_nbrrefills_remaining_nbr

substitution_status_ cdtreatment_suppliers_instruction_cdtotal_daily_dose_qty

0..1

0..*

is_ordered_on0..1

orders0..*

1

1..*

has_parts1

is_part_of

1..*

Master_specimen_requirementadditive_cd

container_ desccontainer_preparation_desccontainer_volume_qty

derived_specimen_c dminimum_collection_volume_qtynormal_collection_volume_qtyspecial_handling_descpriority_ cd

retention_time_qtytype_cd

Goal

expected_achievement_dttmgoal_list_priority_ nbrmanagement_discipline_ cdreview_interval_c d

goal_value_cd

Master_observation_serviceinstrument_ cdpermitted_data_type_cdprocessing_time_qtyspecimen_required_indtypical_turnaround_time_qtyderivation_rule_desc

1

0..*

has 1

is_specified_for 0..*

0..*

0..*

is_basis_for

0..*

has_as_basis

0..*

1..*

1

is_measured_by1..*

measures1Durable_medical_equipment_slot

Durable_medical_equipment_requestquantity_amt

type_cd

Durable_medical_equipmentid

slot_size_increment_qtytype_cd

0..*

1

is_scheduleable_unit_for 0..*

is_scheduled_by 1

0..*

1

requests0..*

is_requested_by1

Durable_medical_equipment_group

id

0..*

0..1

requests 0..*

is_requested_by0..1

1..*

0..*

belongs_to 1..*

contains0..*

Patient_departureactual_discharge_disposition_ cddischarge_ dttmdischarge_location_idexpected_discharge_ disp _cd

Patient_admissionadmission_dttmadmission_reason_c dadmission_referral_ cdadmission_source_cdadmission_type_ cdpatient_valuables_desc

pre_admit_test_ indreadmission_indvaluables_location_desc

Bad_debt_billing_account

bad_debt_recovery_amtbad_debt_transfer_amttransfer_to_bad_debt_ dttm

transfer_to_bad_debt_reason_ cd

Diagnostic_related_group

base_rate_ amtcapital_reimbursement_ amt

cost_weight_amtidmajor_diagnostic_category_cd

operating_reimbursement_ amtreimbursement_amtstandard_day_qtystandard_total_charge_ amt

trim_high_day_qtytrim_low_day_qty

Inpatient_encounter

actual_days_qty

estimated_days_qty

1

0..1

is_terminated_by1

terminates 0..1

1

1

is_preceded_by1

preceded 1

Master_service_relationshiprelationship_type_cdreflex_testing_trigger_rules_ descconstraint_txt

qt

Producer_of_master_service

service_producing_department_type_ cd

Service_intent_or_order_relationship

relationship_type_cdreflex_testing_trigger_rules_ descconstraint_txtqt

Authenticationauthentication_dttm

type_cd

Bad_debt_collection_agency0..*

1

is_assigned_to0..*

is_assigned1

Encounter_drgapproval_indassigned_dttmconfidential_ indcost_outlier_ amtdesc

grouper_review_cdgrouper_version_idoutlier_days_nbroutlier_reimbursement_ amtoutlier_type_cd

1

0..*

is_assigned_as1

is_an_assignment_of0..*

0..*

1

is_assigned_to0..*

is_assigned 1

Real_world_instance_identifiervalue_txt : ST

type_cd : CVqualifier_txt : STvalid_tmr : IVL<TS>

Service_event_relationshiprelationship_type_cd

Service_reason

determination_ dttmdocumentation_ dttmreason_txt

Stakeholder_affiliationaffiliation_type_cddesc

effective_ dttermination_dt

Document_recipient

Healthcare_document_authenticator

1

0..*

created_by 1

is_source_of0..*

Originator

Active_participation

tmrparticipation_type_cd

Stakeholder_affiliate

family_relationship_cd

0..*

1

has_as_secondary_participant0..*

participates_as_secondary_in1

Resource_request

allowable_substitutions_ cd

duration_qtystart_dttmstart_offset_qtystatus_cd

Service_scheduling_request

allowable_substitutions_ cdduration_qtystart_dttm

start_offset_qtystatus_cd

Resource_slotoffset_qtyquantity_amtresource_type_ cd

slot_state_cdstart_dttm

Schedule

id

1

0..*

manages 1

is_managed_by0..*

Insurance_certification_contact

participation_type_cd

Patient_information_recipient

Healthcare_service_providerboard_certification_type_ cdboard_certified_indcertification_dttmeffective_ tmrlicense_idrecertification _dttm

specialty_ cd

1

0..*

participates_as 1

has_as_participant0..*

Accident_information_source

Health_chart_deficiency

assessment_dttmdesc

level_cdtype_cd Patient_service_location_slot

Patient_service_location_group

id

Patient_service_location_request

type_cd

0..1

0..*

is_requested_by0..1

requests0..*

Healthcare_provider_organization

Patient_arrivalacuity_level_c darrival_ dttmmedical_service_idsource_of_arrival_cdmode_ cd

Risk_management_incident

incident_cdincident_dttmincident_severity_ cd

incident_type_cd

Episode_of_care

Location_encounter_roleaccommodation_ cdeffective_ tmrlocation_role_cdstatus_cdtransfer_reason_cdusage_approved_ ind

Preauthorizationauthorized_encounters_qtyauthorized_period_begin_ dtauthorized_period_end_d tidissued_ dttmrequested_ dttmrestriction_desc

status_cdstatus_change_dttm

Master_serviceallowable_processing_priority_ cdallowable_reporting_priority_cd

challenge_information_txtconfidentiality_cdeffective_ tmrfactors_that_may_affect_observation_desc

fixed_canned_message_ cdimaging_measurement_modality_ cd

incompatible_change_dttminterpretation_considerations_desckind_of_quantity_observed_cdlast_update_dttmmethod_cdnature_of_service_cdobservation_id_suffix_ txtorderable_service_ indpatient_preparation_descpoint_versus_interval_cd

portable_device_indreport_display_order_ txtalternate_id

alternate_name_use_cdalternate_n mcontraindication_ descdescperformance_schedule_ cdprimary_nmstandard_time_to_perform_qtytarget_anatomic_site_cd

universal_service_idqtjoin_cdwhen_to_charge_cd

consent_required_ cd

1

0..*

is_source1

has_source 0..*

1

0..*

is_target 1

has_target 0..*

0..* 1..1produces0..* is_produced_by1..1

10..*

is_requested_by1

requests0..*

Billing_information_itemcondition_cdoccurrence_cdoccurrence_dttmoccurrence_span_cdoccurrence_span_from_ dttmoccurrence_span_thru_ dttmquantity_nbrquantity_type_cdvalue_amt

value_c d

Service_intent_or_order

charge_type_cdclarification_phonentering_device_cdescort_required_indexpected_performance_time_qty

filler_order_idstatus_cdstatus_reason_cdorder_effective_ dttmorder_idorder_placed_ dttmqtplacer_order_idecho_back_ txtplanned_patient_transport_ cd

report_results_to_phonresponse_requested_cdservice_body_site_cdservice_body_site_modifier_cdtransport_arranged_indtransport_arrangement_responsibility_cdtransport_mode_cdwhen_to_charge_dttmwhen_to_charge_cdintent_or_order_c djoin_cdstatus_dttm

secondary_identification_t x treporting_priority_ cd

0..*

0..1

is_reason_for0..*

has_as_reason0..1

1

0..*

is_target_for 1

has_as_target0..*

1

0..*

is_source_for 1

has_as_source 0..*

0..*

1

is_an_instance_of0..*

is_instantiated_as1

0..*

0..1participates_in

0..*

has_as_participant 0..1

Guarantor_contract

billing_hold_indbilling_media_cd

charge_adjustment_ cdcontract_duration_cdcontract_type_cdeffective_ tmrinterest_rate_nbrperiodic_payment_amt

priority_ranking_cd

Procedure

anesthesia_ cdanesthesia_ tmrdelay_reason_ txtincision_open_tmrpriority_ nbrprocedure_tmr

functional_type_c dmodifier_cd

Living_subjectbirth_dttmbirthplace_ addrorigin_country_ cd

taxonomic_classification_ cdbreed_txtstrain_txteye_color_ cd

coat_or_feather_coloring_t x tconfidentiality_constraint_cddeceased_ dttm

deceased_ indeuthanasia_indgender_cdgender_status_ cd

primary_name_type_cdprimary_nmimportance_status_txt

qtyproduction_class_cd

Clinical_document_header

availability_status_cd

change_reason_cdcompletion_status_cdconfidentiality_status_cdcontent_presentation_cddocument_header_creation_dttm

file_ nmidlast_edit_dttmorigination_dttmreporting_priority_ cdresults_report_ dttm

storage_status_c dtranscription_dttmtype_cddocument_change_ cd

0..* 1is_related_to0..* is_related_to 1

0..1

0..*

is_parent_document_for

0..1

has_as_a_parent_document0..*

0..1

0..*

is_referred_to_in 0..1

is_related_to0..*

0..1 0..*of0..1 has_been_received_by 0..*

0..*0..1 has_been_originated_by0..*of0..1

Person_employmentaddr

effective_ dthazard_exposure_ txtjob_class_cdjob_title_nmphonprotective_equipment_txtsalary_qtysalary_type_ cdstatus_cd

termination_dtoccupation_ cdjob_status_cd

Master_healthcare_benefit_productassignment_of_benefits_i nd

benefit_product_descidbenefit_product_nm

benefit_product_type_cdbenefits_coordination_cdcob_priority_nbrcombine_baby_bill_indeffective_ tmr

group_benefit_indmail_claim_party_cdrelease_information_cdstatus_cdcoverage_type_ cdagreement_type_cdpolicy_category_ cd

access_protocol_ desc 0..1

0..1

is_child_of

0..1

is_parent_of

0..1

Organizationorganization_name_type_cd

organization_n mstandard_industry_class_cd

0..1

1

is_a_role_of0..1

takes_on_role_of1

0..*

1

is_assigned_by 0..*

assigns1

0..*

0..1

is_issued_by 0..*

issues 0..1

0..*0..1

is_a_subdivision_of0..*

has_as_a_subdivision

0..1

0..1

1

is_role_of

0..1

takes_on_role_of1

Service_event

attestation_dttmtmrcharge_to_practice_qty

charge_to_practice_ cdpatient_sensitivity_cdconsent_cdservice_ descfiller_idfiller_order_status_dttmscheduled_start_ dttmspecimen_received_ dttm

family_awareness_txtindividual_awareness_cdconfidential_ indstatus_cdbilling_priority_nbr

status_reason_cd

1 0..*

is_source_for

1 has_as_source0..*

1 0..*

is_target_for

1 has_as_target0..*

0..*

0..1

is_reason_for

0..*

has_as_reason0..1

0..*

0..1

has_as_evidence

0..*

is_evidence_for0..1

0..*

0..*

is_documented_by 0..*

documents0..*

0..1

0..*

is_fulfilled_by 0..1

fulfills 0..*

1

0..*

is_delivered_during1

delivers 0..*

0..*

0..1

participates_in0..*

has_as_active_participant0..1

Stakeholder

addrcredit_rating_cdemail_address_ txtphontype_cdreal_id : SET<RWII>id : SET<TII>

0..* 1has_as_primary_participant0..* participates_as_primary_in 11

0..1

acts_as1

is_role_of0..1

0..1

1

is_a0..1

takes_on_role_of1

0..1

1

is_role_of0..1

takes_on_role_of1

1

0..1

takes_on_role_of1

is_role_of0..1

0..*

1..1

has_as_participant0..*

participates_in1..1

1

0..1

takes_on_role_of1

is_a_role_of0..1

0..1

1

is_role_of0..1

takes_on_role_of 11

0..1

takes_role_of1is_role_of0..1

Insurer

effective_ tmr

1

0..*

offers1

is_offered_by 0..*

1

0..1

takes_on_role_of1

is_role_of0..1

1

0..*

issues1

is_issued_by0..*

Guarantor

financial_class_cdhousehold_annual_income_amthousehold_size_ nbr 1

1..*

guarantees_payment_under1

has_payment_guaranteed_by

1..*

0..1

1

is_role_of0..1

takes_on_role_of1

Employereffective_ tmr

1

0..*

is_employer_of1

has_as_employer

0..*

0..1

1

is_role_of0..1

takes_on_role_of 1

Health_benefit_product_purchaser

1

0..*

is_the_purchaser_of1

has_as_purchaser

0..*

0..1

1

is_role_of 0..1

takes_on_role_of1

Appointment_requestappointment_rqst_reason_c d

appointment_rqst_type_ cdequip_selection_criteria_ expridlocation_selection_criteria_ exprpriority_ cdrepeating_interval_duration_tmrrepeat_pattern_expr

rqst_event_reason_ cdrqsted_duration_tmrstart_tmrtime_selection_criteria_exprexplicit_time_interval_expr

0..*1 is_requested_by 0..*requests1

1

0..*

requests1

is_requested_by0..*

Appointment

appointment_disposition_ cdappointment_duration_ tmr

appointment_timing_qtcancellation_ dttm

event_reason_ cdexpected_end_ dttmexpected_service_descexpected_start_dttmidoverbook_ indscheduling_begin_dttm

status_cdurgency_cd

visit_type_ cdwait_list_priority_amtscheduling_completed_dttm

0..*

0..*

is_reserved_by0..*

reserves 0..*

1..*

0..*

books 1..*

is_booked_in 0..*

0..1

0..*

is_parent_of

0..1

is_child_of

0..*

Insurance_certification

appeal_reason_cdcertification_duration_qtyeffective_ tmridinsurance_verification_dttm

modification_ dttmnon_concur_cdnon_concur_effective_dttmpenalty_amtreport_of_eligibility_dttmreport_of_eligibility_ind

1

1..*

has_contact1

is_contact_for 1..*

10..* has_coverage_affirmed_by1affirms_insurance_coverage_for0..*

1

0..*

issues1

is_issued_by 0..*

Administrative_patient_death

death_certificate_iddeath_certificate_recorded_ dttmdeath_classification_cddeath_ dttmdeath_location_ txtdeath_notification_source_nmdeath_verification_cddeath_verification_dttmdeath_verification_nm

Patient_information_disclosuredisclosure_dttminfo_disclosed_desc

info_requested_descreason_cdrequested_ dttmurgency_cd

1

0..*

is_the_recipient_of1

is_provided_to 0..*

Disability

effective_ dttmreturn_to_work_auth_dttmtermination_dttmunable_to_work_effective_ dttm

Patient_appointment_request

Patient_slot

Preferred_provider_participationrole_cdeffective_ dttermination_dt

0..*

1

has_as_care_provider 0..*

participates_in 1

Administrative_patient_accident

accident_death_ indaccident_descaccident_dttmaccident_location_descaccident_state_cdaccident_type_cd

job_related_accident_i ndassessment_dttm

1

0..*

identifies

1

is_identified by

0..*

0..1

1..*

is_the_source_of0..1

is_obtained_from

1..*

Health_chart

health_chart_id

health_chart_type_cdstatus_cd

1

0..*

has_an_assessment_of1

is_assessed_against0..*

0..1

0..*

contains 0..1

contained_in 0..*

Master_patient_service_location

addropen_ tmrdescemail_addressid

licensed_bed_nbrnmphonservice_specialty_cdslot_size_increment_qtystatus_cdtype_cdequipment_type_cd

0..*

1

is_scheduleable_unit_for0..*

is_scheduled_by1

1..* 0..*belongs_to1..* contains 0..*

0..*

1

is_housed_at0..*

houses 1

1

0..*

is_requested_by1

requests0..*

1 0..*has1 pertains_to0..*

0..*

0..1

is_included_in 0..*

includes0..1

1..* 0..*provides_patient_services_at1..* provides_services_on_behalf_of0..*

1

0..*

is_entry_location_for1

is_entered_at0..*

0..*

0..1

expects_patient_located_at0..*

expected_patient_location_for0..1

0..*

0..1

is_performed_at 0..*

is_location_for0..1

Patient_encounter

administrative_outcome_txtcancellation_reason_ cddescencounter_classification_cdend_dttm

expected_insurance_plan_qtyfirst_similar_illness_ dttmfollow_up_type_c did

patient_classification_cdpurpose_c drecord_signing_dttmspecial_courtesies_cdstart_dttmstatus_cdtransport_requirement_cdurgency_cd

triage_classification_cdmedical_service_ cdconfidentiality_constraint_cd

0..1

1

precedes0..1

is_preceded_by

1

0..*

1

pertains_to0..*

has1

1..*

1is_part_of

1..* has_parts

1

1..*0..*

has1..*is_present_in0..*

1..*

1

pertains_to 1..*

has1 0..*

0..1

precedes0..*

follows

0..1

0..*0..1 is_assigned_to0..*has_assigned_to_it0..1

1..*

0..1

is_authorized_by 1..*

authorizes 0..1

1..*

0..*

is_scheduled_by1..*

schedules 0..*

Target_participationtmr

participation_type_cd

0..1

0..*

is_target_for0..1

has_as_target0..* 1..*

0..1

is_target_of

1..*

has_as_target 0..1

0..*

0..1

is_target_of0..*

has_as_target0..1

0..1

0..*

is_target_of0..1

+has_as_target0..*

Coverage_itemservice_category_cdservice_ cdservice_modifier_ cd

authorization_ind

network_indassertion_cdcovered_parties_cdqtyquantity_qualifier_cdtime_period_qualifier_cdrange_low_qtyrange_high_qtyrange_units_cdassertion_effective_tmreligibility_ cdpolicy_source_cdeligibility_source_ cdcopay_limit_i nd

non_covered_insurance_cd

0..*

0..1 is_governed_by

0..*

governs0..1

0..1

0..*

has_as_components

0..1

is_a_component_of0..*

0..*

1

provides_validation_for0..*

is_validated_by1

0..*

1

has 0..*

is_associated_with1

1..*

0..*

is_covered_by1..*

provides_coverage_for

0..*

Patient_billing_accountaccount_idadjustment_ cdauthorization_information_txtbilling_status_ cdcertification_required_ind

current_unpaid_balance_qtydelete_ dttm

deleted_account_reason_cdexpected_insurance_plan_qtyexpected_payment_source_cdnotice_of_admission_ dttmnotice_of_admission_ indpatient_financial_class_ cdprice_schedule_id

purge_status_cdpurge_status_dttmreport_of_eligibility_dttmretention_indsignature_on_file_dttmspecial_program_cd

stoploss_limit_ indsuspend_charges_ind

total_adjustment_qtytotal_charge_qtytotal_payment_qtyseparate_bill_i nd

0..*

1

pertains_to0..*

has 1

0..1

0..1

is_the_prior_account_for

0..1

has_as_a_prior_account0..1

0..1

0..*

is_billed_from 0..1

is_billed_to0..*

0..1

0..*

has_charges_for0..1

is_charged_to0..*

0..*

0..*

has_payment_guaranteed_by0..*

provides_payment_guarantee_for

0..*

Collected_specimen_samplebody_site_cd

collection_body_site_modifier_ cdcollection_tmrcollection_method_modifier_cd

collection_scheduled_ dttmcollection_volume_qty

collectors_comment_cdhandling_c didcollection_method_descnumber_of_sample_containers_qtyadditive_descdanger_cdsource_ cdtransport_logistics_cdaction_ cd

type_cd

0..1

0..*

is_target_of0..1

has_as_target 0..*

0..*

1

is_collected_by 0..*

collects1

0..*

0..1

is_collected_during0..*

collects 0..1

0..*

0..1

is_sourced from0..*

is_source_for 0..1Notary_public

effective_interval_ tmr

notary_county_cdnotary_state_cd

Transcriptionist0..1

0..*

transcribes0..1

is_transcribed_by0..*

Insured

Administrative_birth_event

baby_detained_indbirth_certificate_idbirth_method_ cdbirth_recorded_county_ cdbirth_recorded_dttmnewborn_days_ nbrstillborn_ind

1

0..*

has_parts 1

is_part_of0..*

Employee

1

0..*

is_employee_in1

has_as_employee0..*

Entering_person0..*

1..*

represents 0..*

is_represented_by1..*

0..1

0..*

enters 0..1

is_entered_by0..*

0..*

1

is_entered_by 0..*

enters1

Financial_transaction

alternate_descdescextended_ amtfee_schedule_cdinsurance_ amtposting_dt

qtytransaction_batch_idtransaction_ cd

transaction_ dttmtransaction_id

transaction_type_ cdunit_amtunit_cost_amt

0..*

0..1

is_associated_with0..*

is_associated_with 0..1

0..1

0..*

categorizes0..1

is_categorized_by

0..*

1

0..*

is_associated_with 1

pertains_to0..*

0..*

1

is_associated_with0..*

has 1

Person_nameeffective_ dtcdnm

purpose_c dtermination_dttype_cd

0..*

0..*

refers_to_person_by0..*

is_used_by 0..*

Contact_person

contact_reason_ cd

0..*

0..1

is_contact_for 0..*

provides_contact0..1

0..*

0..1

is_contact_for0..*


0..1

0..*


is_contact_for0..*

0..1

0..*


is_contact_for 0..*

0..*

0..1

has_as_contact0..*

is_contact_for0..1

0..*

0..1

has_as_a_contact0..*

is_a_contact_for0..1

Individual_healthcare_practitioner_slot

Certification_second_opinioneffective_ dttm

status_cd

0..*

1

provides_opinion_on0..*

includes 1

Encounter_practitioner

participation_type_cd1..*

1

is_associated_with

1..*

has_as_participant

1

Patientambulatory_status_cdbirth_order_nbr

living_arrangement_cdliving_dependency_c dmultiple_birth_i ndnewborn_baby_indorgan_donor_indpreferred_pharmacy_idstatus_cd

0..1 1pertains_to0..1 has 1

0..*

1

pertains_to

0..*

has 1

0..*

1

pertains_to0..*

has1

1

0..*

is_requested_by1

requests 0..*

1

0..*

is_scheduled_by

1

is_a_scheduleable_unit_for0..*

1

0..*

participates_in1

has_as_care_recipient

0..*

1

0..*

has1

pertains_to0..*

0..*

1

belongs_to0..*

has 1

0..1

0..*

is_primary_facility_for

0..1

has_as_primary_facility0..*

0..*

1

involves 0..*

is_involved_in1

0..1 0..*is_target_of0..1 has_as_target 0..*

1

0..*

has 1

is_for0..*

0..*

1

belongs_to0..*

has 1

0..*

0..1

is_a_contact_for0..*

has_as_a_contact0..1

0..*

0..1

is_sourced_from0..*

is_source_for0..1

Personbirth_dttmbirthplace_ addrcitizenship_country_cdconfidentiality_constraint_cddeceased_ dttmdeceased_ ind

disability_ cdeducation_level_ cdethnic_group_ cdgender_cd

language_ cdmarital_status_cdmilitary_branch_of_service_cd

military_rank_nmmilitary_status_cdnationality_cd

race_cdreligious_affiliation_cd

student_cdvery_important_person_ cdstatus_cd

0..1

1

is_a_role_of0..1

takes_on_role_of1

0..1

1

is_role_of0..1

acts_in_role_of

1

0..1

1

is_role_of0..1

takes_on_role_of1

0..1

1

pertains_to0..1

has1

1

0..1

takes_on_role_of1

is_role_of0..1

1

0..1

takes_on_role_of1

is_a_role_of 0..1

0..*

1

is_entered_by

0..*

enters 1

0..11 is_a_role_of 0..1takes_on_role_of1

1

0..*

has 1

is_for 0..*

1

0..1

takes_on_role_of1

is_a_role_of0..1

Individual_healthcare_practitioner_group

id

Individual_healthcare_practitionerdescfellowship_field_cdgraduate_school_n mgraduation_dttmposition_cd

practitioner_type_cdprimary_care_ ind

residency_field_c dslot_size_increment_qty

1

0..*

is_scheduled_by1

is_scheduleable_unit_for0..*

1..*

0..*

belongs_to1..*

contains0..*

0..*

1

is_provided_by0..*

provides 1

0..*

1

is_participant_for0..*

participates_as1

0..*

0..1

has_a_primary_provider0..*

is_the_primary_provider_for0..1

1

0..1

takes_on_role_of1

is_role_of

0..1

Individual_healthcare_practitioner_request

practitioner_type_cd

0..1

0..*

is_requested_by0..1

requests 0..*

1

0..*

is_requested_by1

requests 0..*


Electronic Medical Record

• Service event• record of service performed

• records actual parameters used

• includes results of observations

• Service order (or “intent”)• request or plan to do a service

• specifies the service parameter• dose, site, timing, …

• contains rationale and context

• Master service• defines every service

• defines service parameters• method, site, answers, ...

• contains medical knowledgeMaster_qualitative_observation

abnormal_result_cdcritical_result_cdnormal_result_cdpreferred_coding_system_cdvalid_answer_cd

Referral



diet_type_cdinstruction_ desctray_type_cdservice_period_cd

Observation_intent_or_orderpatient_hazard_cdrelevant_clinical_information_ txtspecimen_action_cd


refills_remaining_nbrPTroutPTcompindication_idsubstance_expiration_dttmsubstance_lot_number_ txtsubstance_manufacturer_cddosage_form_cdstrength_qtyamount_qtyroute_cdbody_site_ cdsubstitution_ cd

Treatment_service_administrationadministered_rate_qtycompletion_status_cdsubstance_refusal_reason_ cdsystem_entry_dttmadministration_ nbradministered_per_ timeunit_cdadministrators_notes_ cd

Treatment_service_dispensedispense_package_method_cddispense_package_size_qtyneeds_human_review_indsuppliers_special_dispensing_instruction_cdtotal_daily_dose_qty

Treatment_service_givegive_per_ timeunit_cdqtgive_rate_qtyneeds_human_review_ind



Clinical_observationabnormal_result_cdlast_observed_normal_values_dttmnature_of_abnormal_testing_cdclinically_relevant_tmrmethod_cdstatus_cdstatus_dttmobservation_sub_idvalreferences_range_ valuniversal_service_identifier_suffix_txtuser_defined_access_check_cdvalue_datatype _cd


Rule_link

priority_ nbr


type_cd


type_cdcondition_ descage_qtygestation_age_qtyvalue_qtyrace_subspecies_txtgender_cdspecies_txt


corresponding_SI_unit_of_measure_ cdunit_of_measure_cddelta_check_change_computation_method_ cddelta_check_change_threshold_qtydelta_check_value_range_qtydelta_check_numeric_low_value_amtdelta_check_retention_period_qtydisplay_length_and_decimal_precision_cdminimum_meaningful_increment_nbrsi_conversion_factor_expr

0..*

1

applies_to 0..*

conforms_to1

Condition_node

life_cycle_start_dttmlifecycle_status_cdmanagement_discipline_ cdranking_nbremployment_related_ind

1defines_episode1


dea_level_cddrug_category_ cdformulary_status_cdmedication_form_cdpharmaceutical_class_cdroute_cdtherapeutic_class_cd

Treatment_intent_or_orderindication_idordering_providers_instruction_txtrequested_give_strength_qtysubstitution_allowed_ ind


dispense_package_method_cddispense_package_size_qtygive_indication_idgive_per_ timeunit_cdgive_rate_qtylast_refilled_dttmmax_give_qtymin_give_qtyneeds_human_review_indPTcompPTroutqtprescription_idrefills_allowed_ nbrrefills_doses_dispensed_ nbrrefills_remaining_nbrsubstitution_status_ cdtreatment_suppliers_instruction_cdtotal_daily_dose_qty

0..1

0..*

is_ordered_on0..1

orders0..*

1

1..*

has_parts1

is_part_of

1..*

Master_specimen_requirementadditive_cdcontainer_ desccontainer_preparation_desccontainer_volume_qtyderived_specimen_cdminimum_collection_volume_qtynormal_collection_volume_qtyspecial_handling_ descpriority_ cdretention_time_qtytype_cd

Goal

expected_achievement_dttmgoal_list_priority_ nbrmanagement_discipline_ cdreview_interval_cdgoal_value_ cd

Master_observation_serviceinstrument_cdpermitted_data_type_ cdprocessing_time_qtyspecimen_required_indtypical_turnaround_time_qtyderivation_rule_desc

1

0..*

has1

is_specified_for0..*

0..*

0..*

is_basis_for

0..*

has_as_basis

0..*

1..*

1

is_measured_by1..*

measures1

Master_service_relationshiprelationship_type_ cdreflex_testing_trigger_rules_ descconstraint_txtqt

Service_intent_or_order_relationshiprelationship_type_ cdreflex_testing_trigger_rules_ descconstraint_txtqt

Service_event_relationshiprelationship_type_ cd

Service_reason


Active_participationtmrparticipation_type_ cd


Master_serviceallowable_processing_priority_ cdallowable_reporting_priority_cdchallenge_information_txtconfidentiality_ cdeffective_ tmrfactors_that_may_affect_observation_descfixed_canned_message_cdimaging_measurement_modality_cdincompatible_change_dttminterpretation_considerations_desckind_of_quantity_observed_ cdlast_update_dttmmethod_cdnature_of_service_cdobservation_id_suffix_txtorderable_service_indpatient_preparation_descpoint_versus_interval_cdportable_device_ indreport_display_order_ txtalternate_idalternate_name_use_cdalternate_nmcontraindication_descdescperformance_schedule_ cdprimary_nmstandard_time_to_perform_qtytarget_anatomic_site_ cduniversal_service_idqtjoin_ cdwhen_to_charge_ cdconsent_required_ cd

1

0..*

is_source1

has_source0..*

1

0..*

is_target 1

has_target0..*

1..1is_produced_by1..1

1is_requested_by1


charge_type_cdclarification_phonentering_device_ cdescort_required_indexpected_performance_time_qtyfiller_order_idstatus_cdstatus_reason_cdorder_effective_dttmorder_idorder_placed_dttmqtplacer_order_idecho_back_txtplanned_patient_transport_ cdreport_results_to_ phonresponse_requested_cdservice_body_site_ cdservice_body_site_modifier_ cdtransport_arranged_ indtransport_arrangement_responsibility_cdtransport_mode_ cdwhen_to_charge_ dttmwhen_to_charge_ cdintent_or_order_cdjoin_ cdstatus_dttmsecondary_identification_txtreporting_priority_cd

0..*

0..1

is_reason_for0..*

has_as_reason0..1

1

0..*

is_target_for1

has_as_target0..*

1

0..*

is_source_for1

has_as_source0..*

0..*

1


is_instantiated_as1

0..*

0..1participates_in

0..*

has_as_participant0..1

Procedure

anesthesia_cdanesthesia_tmrdelay_reason_txtincision_open_ tmrpriority_ nbrprocedure_tmrfunctional_type_ cd

modifier_cd

0..1is_referred_to_in0..1

Service_event

attestation_dttmtmrcharge_to_practice_qtycharge_to_practice_ cdpatient_sensitivity_cdconsent_cdservice_descfiller_idfiller_order_status_dttmscheduled_start_ dttmspecimen_received_dttmfamily_awareness_ txtindividual_awareness_ cdconfidential_indstatus_cdbilling_priority_ nbrstatus_reason_cd

1 0..*

is_source_for

1 has_as_source0..*

1 0..*

is_target_for

1 has_as_target0..*

0..*

0..1

is_reason_for0..*

has_as_reason0..1

0..*

0..1

has_as_evidence0..*

is_evidence_for0..1

0..*is_documented_by0..*

0..1

0..*

is_fulfilled_by0..1

fulfills 0..*

1

0..*


delivers 0..*

0..*

0..1

participates_in0..*


0..* has_as_participant0..*

requests

0..*is_entered_at0..*

0..*expects_patient_located_at0..*

0..*is_performed_at0..*

0..*is_assigned_to0..*

Target_participationtmrparticipation_type_ cd0..*has_as_target0..* 1..*

0..1

is_target_of

1..*

has_as_target0..1

0..*

0..1

is_target_of0..*

has_as_target0..1

0..* +has_as_target0..*

1..*is_covered_by1..*

0..* is_billed_to0..*

0..*is_charged_to0..*

0..*has_as_target0..*

0..1collects 0..1



Unified Modeling Language



Patient

name : PNDOB : TSaddress : AD

• Class defines things• represents important concepts

of your domain

• concepts = things and ideasthat exist in your business

• important = subject of multipletransactions

• like the definition of a database “record”

Name “compartment” of class

Attribute “compartment” of class• attributes are the data we record about

the things of interest• attributes are values that exist only with

with respect to their containing object• attributes have a name and a data type• like the definition of a data field in a data

base record


Patient

name : PNDOB : TSaddress : AD Patient

name = John DoeDOB = 10-Apr-1966address = Calgary

Patientname = Jane SmithDOB = 1-Oct-1956address = Toronto

Patientname = Bart SimpsonDOB = 5-Sep-1975address = Springfield

Unified Modeling Language• Class defines things

• Objects are instances• individuals of which classes

are a definition• have values assigned to

attributes

• have identity that’s invariantwhen other values change

• like the “records” of a database


Patient


Doctor

name : PNspecialty : CDphone : TEL

seeks care at

provides care for0..*

1..*


• Objects are instances

• Associations relate things• describe the way things relate

to other things“Association role name”

cardinality or “multiplicity”• specifies how many such association instances

each object instance can/must have


Patient


Doctor


seeks care at


1..*



• Associations relate things• describe the way things relate

to other things

“Every Patient … seeks care at … 1 to many … Doctors”

“Reading” associations in plain English:

“Every Doctor … provides care for ... zero to many … Patients”


• Class defines things


• Associations relate things

• Associative classes addproperties to relationships• attributes about association


Patient


Doctor


seeks care at


1..*

Encounter

type : CVtime : IVL⟨TS⟩reason : CD



Patient


Doctor


1

1..*

Encounter





• Associative classes addproperties to relationships• attributes about association

1

0..*


Patient

gender : CDdonor : BLV.I.P. : BL

Doctor

specialty : CDphone : TELprivileges: CV

Person


1

1..*

Encounter


1

0..*




• Associative classes

• Generalization classes

• Generalization classes can simplify the model• through reuse of common concepts• express logical truths of the application domain

• work the other way as “specialization classes”


Patient

gender : CDdonor : BLV.I.P. : BL

Doctor

specialty : CDphone : TELprivileges: CV

Person

name : PNDOB : Dateaddress : AD

1

1..*

Encounter


1

0..*

0..10..1

follow-up




• Associative classes

• Generalization classes

• Reflexive associations

• Reflexive associations structure instances of one class• chain (predecessor-successor,) hierarchy (parent-child,) or

network


Modeling Patterns andStereotypes


Association and roles

Personname : STdate_of_birth : TSaddr : ADphone : TEL

0..*

0..*

patient

physician

Encounter


Role class

Personid : IIname : STdate_of_birth : TSaddr : AD

0..*

0..*

«substance»

PatientMRN : IIinsurance : STnewborn_ind : ST

«role»

Physicianprovider_id : IIspecialty : CDDEA_nmb : II

«role»

0..1

1

0..1

1

Encounter


Association class


0..*

0..*

patient

physician

«substance»

Encounterid : IItime : IVL⟨TS⟩reason : CD

«event»


«role»


«role»

0..1

1

0..1

1


Associative class


0..*

«substance»

0..*Encounterid : IItime : IVL⟨TS⟩reason : CD

«event»


«role»


«role»

0..1

1

0..1

1 1

1

0..*


Encounter participants


0..*

0..*Encounter

id : IItime : IVL⟨TS⟩reason : CD

«substance»

«event»


«role»


«role»

0..1

1

0..1

1 1

1 Attending

0..*

* Consulting

0..*

* Referring


Participation class• attending

• consulting

• referring

• resident• assistant

• ...


0..*0..*


«substance»

«event»


«role»


«role»

0..1

1

0..1

1

1

*

enc’practitionertype : CVtime : IVL⟨TS⟩

«participation»


Summary of Stereotypes• Substance

• Information about physical people and things in the real world.• Type code says what kind of thing it is.

• Role almost like substance• Special information for the role (e.g., specialty, DEA number)

• Typical multiplicity: Substance-1--0..1-Role (inclusive, stable)

• Event associative class 1°• Fundamental information about the event (when, where, …)

• Type code says what happened.

• Participation associative class 2°• Special information about participants relative to the event

• Type code identifies function of the participant in the event

• Associative classes may subsume multiple associations betweenthe same classes.


Encounter revisited


0..*0..*


«substance»

«event»


«role»


«role»

0..1

1

0..1

1

1

*


«participation»

Primary care physician1

0..*

Primary care physician1

0..*


Encounter revisited


0..*0..*

Encounterid : IItype : CVtime : IVL⟨TS⟩

«substance»

0..1

0..*

super-

sub-

Hierarchy

«event»


«role»


«role»

0..1

1

0..1

1

1

*


«participation»

0..1

0..1

follow-up

predecessor

Sequence

• inpatient

• outpatient

• primary care

• specialist

• Ob. encounter

• immunization

• ...


0..*

0..*

source

target

network

Relationship class


0..*0..*

Encounterid : IItype : CVtime : IVL⟨TS⟩

«substance»

«event»


«role»


«role»

0..1

1

0..1

1

1

*


«participation»

enc’relationshiptype : CV

«relationship»

• follow-up

• super-encounter

• referring

• ...


Encounter and Services

0..*

0..*

source

target

network

Person

id : IIname : STdate_of_birth : TSaddr : AD

0..*

0..*Encounter

id : IItype : CVtime : IVL⟨TS⟩

«substance»

«event»

Patient

MRN : IIinsurance : STnewborn_ind : ST

«role»

Physician

provider_id : IIspecialty : CDDEA_nmb : II

«role»

0..1

1

0..1

1

1

*

enc’practitioner

type : CVtime : IVL⟨TS⟩

«participation»

enc’relationship

type : CV

«relationship»

0..*

Serviceid : IItype : CDtime : IVL⟨TS⟩

«event»

1

provider1

0..*

subject

1

0..*


0..*

source

network

srv’relationship

type : CV

«relationship»

Encounter, Service, Observation

0..*

target

Person


0..*0..*

Encounter


«substance»

«event»

Patient


«role»

Physician


«role»

0..1

1

0..1

1

1

*

enc’practitioner


«participation»

0..*

source

network

enc’relationship

type : CV

«relationship»

0..*


«event»

1

*

1

0..*

0..*

*

0..*

0..*0..*

Observationid : IItype : CDvalue : ANYtime : IVL⟨TS⟩

1«event»

srv’practitioner


«participation»

obs’practitioner


«participation»

0..*

source

network

obs’relationship

type : CV

«relationship»


0..*

source

network

srv’relationship

type : CV

«relationship»

Encounter, Service, Observation

0..*

target

Person


0..*0..*

Encounter


«substance»

«event»

Patient


«role»

Physician


«role»

0..1

1

0..1

1

1

*

enc’practitioner


«participation»

0..*

source

network

enc’relationship

type : CV

«relationship»

0..*


«event»

1

*

1

0..*

0..*

Observation

value : ANY

«event»

srv’practitioner


«participation»


Observation — Service and Result• An observation is:

• 2 a : an act of recognizing and noting a fact or occurrence ofteninvolving measurement with instruments

• b : a record or description so obtained.

• 3 : a judgement or inference from what one has observed.Webster’s Dictionary

• act, action, service• the service or procedure of observing

• obtained answer, result value• physical quantity (number with units)

• quality or nominal (coded) result

• images, waveforms, movies, …

• judgement or inference• diagnosis! (coded observation)

• any observation is inference from more basic measurments.


Service Action Oriented View


The Service Action Oriented View• Covers all health care related services.

• Unifies all services in a common “super-class.”

• Models the detail in specializations of the service.• observation: value

• medication: dose, form, route

• Relates to actors, targets, and other servicesthrough the super-class.• tracking of responsibilities

• tracking of resources

• tracking of reason, etc.


Health Care Services are:• what patients seek, to improve or maintain health

• what physicians, nurses, and other providers offer

• what produces information (observation!)

• what produces costs (accounting!)

• what requires resources (scheduling!)

• what influences/produces outcome (studying!)

• what quality management is about (controlling!)

• The service brings patient, provider, resources,outcome, and cost together.

• The Service is the center of our universe.


Service and Context• who is the actor?

• provider, individual or organization

• patient, relative, neigbors in home health

• what is the service?• observation, judgement, medication, surgery, physiotherapy

• consents, advanced directives, education, consultation

• on whom or what (recipient)?• people: patient, relative, neighbor (caring person), community

• things: specimen, food, environmental samples

• indirect recipient, beneficiary (“for whom”)• patient, community (population)

• when?

• where? (facilitiy, location)

• with what? (material resources)


Clinical Modeling Assumptions• Healthcare is a series of service actions

• Each action contributes to cost and quality

• All actions have a context of:• Prior actions

• Current actors, things, & contracts

• Future goals

• Each action consists of:• Action name

• Action values

• Action descriptions will change over time andmust be versioned

Any information model describes a view of the world. In thehealthcare arena, where care is a hands-on service, thelargest cost is the cost of labor. Labor also is majordeterminant of the quality of healthcare delivery. As aconsequence, in order to fulfill the needs of the healthcareindustry, the information model must highlight the importanceof the actions which deliver service.

Other industries have embraced the focus on action as thecenter of cost and quality management. The whole Demingphilosophy taught in Japan and responsible for the restorationof the American auto industry is based on statistical analysis ofaction.

The discussion of the clinical classes of the RIM will focus onthe analysis and modeling of actions in healthcare whichcontribute to the cost and quality of care.


Service Event

Action Name:

When?

Who?

Whom?Why?

Where?

How?

Context of an Action

In HL7, the current action class is named the “Service Event.” Aprimary attribute of the Service Event class is the name of the action.

As discussed by many writers, each action occurs in a context of“Who does it?” “To whom is it done?” “Why is it done?” “Where is itdone?” “How is it done?” and “When is it done?”

The information about when an action occurs is simply a dateattribute of the action class. How an action occurs is oftenincorporated into the action name in a vocabulary like LOINC.Alternatively, it may be stored in a methodology attribute. However,the other items of context are stored as associations from the actionclass to other classes. Who? is answered by the Active Participantclass. Whom? is answered by the Target Participant class. Where? isanswered by the Service Location class. And Why? is answered bythe Reason class.


Service

ServiceRelationship

Action Name:Dates:Cost:Privacy Level:Other ActionValues:

Observation

UniqueAction Values:

Transport-ation


Procedure


ConditionNode


Future classes


Service Action Class Hierarchy

As mentioned earlier, HIPAA, cost and quality management need tobe addressed by the model as well. A privacy attribute on the actionclass allows the level of confidentiality of any action to be explicitlyestablished. In addition, every service action has a cost(as opposedto a charge), since it consumes resources of the healthcare system.

A Unified Modeling Language technique for grouping items into acollection is to create a recursive relationship class. When modeledin this way, a list includes not only the atomic items, but also theitems that have been grouped into collections. For example, if theatomic item is a coin, a grouping of coins is a bag of coins. Throughthis recursive structure, the list is able to represent both the individualcoins and the bags of coins.

One kind of action is the observation. Different kinds of actions haveunique sets of action values. The row of classes along the bottom ofthe slide represent the UML subclass structure for different kinds ofactions in healthcare.

Note that the action name and action value are combined into thesame class hierarchy. In this way, actions and their results aretreated like two sides of the same coin and represented in an objectmodel as one object. The Service Event hierarchy in the RIMrepresents both the doing of the action and the documentation of theaction.


Servicehas Parts

ServiceRelationship


Observation

UniqueAction Value:

Action Relationships

Observation is a class that represents all kinds of observations fromlab tests to diagnoses. One kind of grouping of observations is thelaboratory battery or panel. The individual tests of a battery representthe atoms or coins. The groupings represent the molecules or bags.For example, the traditional Chem 12 is a battery of twelve individualchemistry tests. A CBC is a battery as is a urinalysis.


Servicehas Plan

ServiceRelationship


Observation

UniqueAction Value:

Timeline

CBC U/A X-Ray Diagnosis


A temporal collection, is a collection of tests along a timeline. Thesetests could be individual atoms or batteries of tests. The diagrambelow the UML structure demonstrates four actions including a CBC,urinalysis, and an X-Ray as tests along a timeline. When bundled intoa temporal collection, these tests form an ordered list along a timelinethat can be made as complex as a care path or a guideline.


Servicehas Reason

ServiceRelationship


Observation

UniqueAction Value:

hasReason



In the same way, a current action, X-Ray, may have as it’s reasonthe abnormal white blood count(WBC) in a complete bloodcount(CBC). In this case, the reason for the X-Ray isn’t the value ofthe “charge” for the complete blood count, as in the last example.The reason for the X-Ray is the value of the WBC of the CBC.

As can be seen from these examples, money issues cannot be easilyseparated from clinical issues, and the modeling should recognizethe close relationship between action, cost, and quality.


Servicehas Support

ServiceRelationship


Observation

UniqueAction Value:

Timeline

has Support



Judgement collections bundle past actions into a group united by ajudgement relationship. For example, saying the current action has areason that relates to a past action is like saying I am making thiscurrent payment because of two debts in the past. The money for thepayment in this example is allocated to two actions in the past thatcost money.


Flowsheet Diagnosis

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6Crtn 1.1 1.0 1.0 1.0 Pend OrdBUN 40 30 25 20 Pend OrdI/0 3000

/2003000/500

3000/1000

3000/2000

Ord Ord

Wt 142 144 146 146 Ord OrdADL None Feed All All Ord Ord

Certainly, the many years of experience in ancillary messaging atHL7 were helpful in creating the first versions of the ReferenceInformation Model. However, the early models “hard-coded”relationships that were specific to the ancillary environmentssuch as lab and imaging and didn’t extend to other clinicalenvironments.

One of the helpful techniques for extending the model was theextensive development of use cases. The Flowsheet Diagnosisuse case illustrates some basic principles of medicine andnursing.


Flowsheet Diagnosis


/2003000/500

3000/1000

3000/2000

Ord Ord


• DX: Stable Creatinine

Extending the Flowsheet Diagnosis use case a little furtherallows us to examine how clinicians make observations aboutobservations. In 1991, Rector called these observations aboutobservations, meta-observations. 100 years earlier, Peircedefined two kinds of comparisons. The first is comparingindividual observations across the same type of observation.Above, an observation about a series of creatinines on thesame patient yields the result, “stable creatinine.”


Flowsheet Diagnosis


/2003000/500

3000/1000

3000/2000

Ord Ord


• DX: Improving BUN

Next, the same kind of observation has a result of “improvingBUN.”


Flowsheet Diagnosis


/2003000/500

3000/1000

3000/2000

Ord Ord


• DX: Improving Output

Similarly, the result across time is “improving output.” Note thatthese observations or diagnoses are of the type expectedwhen a physician on the telephone asks the nurse, “How is theoutput?” The response or result is the nursing diagnosis, “Theoutput is improving.”

The clinician puts these multiple diagnoses together to assessa patient.


Flowsheet Diagnosis


/2003000/500

3000/1000

3000/2000

Ord Ord


• DX: Renal insufficiency w/ weakness

possibly secondary to dehydration

Peirce noted that another type of comparison is comparingobservations of different types to make an observation. Above,one possible diagnosis from comparing multiple values acrossobservation types in the first column is renal insufficiency.

Other inferences can be made from the data in column one.Weakness and dehydration are additional inferences that canbe made from column one.


Flowsheet Diagnosis


/2003000/500

3000/1000

3000/2000

Ord Ord


• DX: Renal insufficiency

possibly secondary to dehydration

Analysis of another column leads to a slightly differentconclusion. In this column, no evidence for weakness exists.


Flowsheet Diagnosis


/2003000/500

3000/1000

3000/2000

Ord Ord


• DX: Normal renal function and

activities

Finally, the last column reveals a normal profile across multiplekinds of observations.

So far, we have created a series of diagnoses from analyzingdifferent rows and columns. All of these diagnoses are correctat the same time. However, neither a column nor row by itselfreveals the whole picture.


Flowsheet Diagnosis


/2003000/500

3000/1000

3000/2000

Ord Ord


• DX: Renal insufficiency and weakness

resolving with re-hydration

The clinician who is able to compare the same observationsacross time and compare different kinds of observationsacross time is able to make a more profound observation.


Flowsheet Diagnosis


/2003000/500

3000/1000

3000/2000

Ord Ord


The flowsheet above illustrates some important similaritiesbetween lab results and physical exam results. Of course theBUN and creatinine are lab results. The intake/output, weight,and activities of daily living are physical exam results. Both canbe ordered. Both can be statused as ordered, pending orresulted. If resulted, the result itself can be used to indicate theresulted status. Therefore, the result and the status are bothvalues of the procedure that can be displayed in the samesemantic space. This indicates a close semantic relationshipbetween these two attributes and suggests they could berepresented in the same class.

Other procedures have parallel similarities. Medication ordersand administration, imaging, and consultations all can berepresented in a similar flowsheet.

This recognition of the similarities between all procedures alongwith the multiple attribute values of those procedures which haveclose semantic relationships to each other led to the migrationfrom more traditional, ancillary representations to the UnifiedService Action Model.

Later, as we explore the model as expressed in Unified ModelingLanguage, we will return to these use cases to link the model toreal medicine.


Robotic Arm Discussion• To Grasp Object:

• Locate Object

• Find Distance

• Calculate Move

• Move Arm Closer

• Relocate Object......

• All Events are Divisible• Bill for large event

• Account for small events

• Model recursion(nesting)

Ever have the desire to wring a doctor’s neck? Robots need toperform a specific series of actions to accomplish such a task.

The larger service, To Grasp an Object, can be divided into aseries of smaller services that bring the robotic arm closer andcloser to the target of the action. Every action can be dividedinto smaller and smaller pieces. For example, in the flowsheet,the smallest action recorded on the flowsheet was theperformance of an individual lab test. However, the lab testrequires smaller actions such as drawing blood, transportingthe blood to the lab, putting the blood in the the lab machine,etc.

In healthcare, we need to express actions at multiple levels ofgranularity. For billing purposes, we may only need tomessage on the largest unit....the lab test or even a wholehospitalization as is done with DRG’s. However, to provide thehealthcare, we need to divide the large actions into smalleractions and assign those actions to individual people. Theimportant point is that although actions are infinitely divisible,the practical point-of-view is to only represent actions to thegranularity required by the business needs of healthcare.

In HL7, we have come to call this concept of reductionism asapplied to actions and the corresponding levels of granularity,“The Robotic Arm Discussion.”

Later, we will refer to the robotic arm discussion in reference to“recursion” or “nesting” in the model.


Required Studies PRE- Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk WkPHYSICAL Study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

History & Physical Exam X X X X XWeight & Performance Status X X X X XToxicity Notation X X X X X X X X X X XEstimation of Tumor Mass X X X X

LABORATORYWBC/Diff/Hgb/Hct/Platelets X X X X X X X X XBM aspirate, parffin block, serum XBM slides XNa/KCl/HCO3/Ca/PO4/Mg/Gluc X XUric Acid X X X XSerum creatinine/SGOT/LDH X X X XAlk Phos/Bilirubin(total) X X X XSerum Protein Electrophoresis XSerum Microglobulin X X X X24Hour Urine for total protein, X X X X protein electrophoresis, X immunofix electrophoresis XSerum Pregnancy Test X

X-RAYS & SCANSChest X-ray, PA and Lateral XCardiac EF by MUGA or Echo XRadiographic bone survey XPulmonary Function(DLCO, FEV-1, FVC X

TREATMENTVincristine X X X XDoxorubicin X X X XDexamethasone X X X X X X X X X X X

Clinical Trial Flowsheet

This flowsheet was taken from a clinical trial in Boston. Therelationships found in flowsheets underlie the conclusionsreached both in clinical research and quality improvementprotocols and guidelines. The Unified Service Action Modelillustrated in the Unified Modeling Language helps describe tosoftware developers the relationships that underlie clinicalmedicine and which are now expressed in the larger HL7Reference Information Model.


Business Cycle


Electronic Medical Record

• Service event• record of service performed

• records actual parameters used

• includes results of observations

• Service order (or “intent”)• request or plan to do a service

• specifies the service parameter• dose, site, timing, …

• contains rationale and context

• Master service• defines every service

• defines service parameters• method, site, answers, ...

• contains medical knowledgeMaster_qualitative_observation

abnormal_result_cdcritical_result_cdnormal_result_cdpreferred_coding_system_cdvalid_answer_cd

Referral



diet_type_cdinstruction_ desctray_type_cdservice_period_cd

Observation_intent_or_orderpatient_hazard_cdrelevant_clinical_information_ txtspecimen_action_cd


refills_remaining_nbrPTroutPTcompindication_idsubstance_expiration_dttmsubstance_lot_number_ txtsubstance_manufacturer_cddosage_form_cdstrength_qtyamount_qtyroute_cdbody_site_ cdsubstitution_ cd

Treatment_service_administrationadministered_rate_qtycompletion_status_cdsubstance_refusal_reason_ cdsystem_entry_dttmadministration_ nbradministered_per_ timeunit_cdadministrators_notes_ cd

Treatment_service_dispensedispense_package_method_cddispense_package_size_qtyneeds_human_review_indsuppliers_special_dispensing_instruction_cdtotal_daily_dose_qty

Treatment_service_givegive_per_ timeunit_cdqtgive_rate_qtyneeds_human_review_ind



Clinical_observationabnormal_result_cdlast_observed_normal_values_dttmnature_of_abnormal_testing_cdclinically_relevant_tmrmethod_cdstatus_cdstatus_dttmobservation_sub_idvalreferences_range_ valuniversal_service_identifier_suffix_txtuser_defined_access_check_cdvalue_datatype _cd


Rule_link

priority_ nbr


type_cd


type_cdcondition_ descage_qtygestation_age_qtyvalue_qtyrace_subspecies_txtgender_cdspecies_txt


corresponding_SI_unit_of_measure_ cdunit_of_measure_cddelta_check_change_computation_method_ cddelta_check_change_threshold_qtydelta_check_value_range_qtydelta_check_numeric_low_value_amtdelta_check_retention_period_qtydisplay_length_and_decimal_precision_cdminimum_meaningful_increment_nbrsi_conversion_factor_expr

0..*

1

applies_to 0..*

conforms_to1

Condition_node

life_cycle_start_dttmlifecycle_status_cdmanagement_discipline_ cdranking_nbremployment_related_ind

1defines_episode1


dea_level_cddrug_category_ cdformulary_status_cdmedication_form_cdpharmaceutical_class_cdroute_cdtherapeutic_class_cd

Treatment_intent_or_orderindication_idordering_providers_instruction_txtrequested_give_strength_qtysubstitution_allowed_ ind


dispense_package_method_cddispense_package_size_qtygive_indication_idgive_per_ timeunit_cdgive_rate_qtylast_refilled_dttmmax_give_qtymin_give_qtyneeds_human_review_indPTcompPTroutqtprescription_idrefills_allowed_ nbrrefills_doses_dispensed_ nbrrefills_remaining_nbrsubstitution_status_ cdtreatment_suppliers_instruction_cdtotal_daily_dose_qty

0..1

0..*

is_ordered_on0..1

orders0..*

1

1..*

has_parts1

is_part_of

1..*

Master_specimen_requirementadditive_cdcontainer_ desccontainer_preparation_desccontainer_volume_qtyderived_specimen_cdminimum_collection_volume_qtynormal_collection_volume_qtyspecial_handling_ descpriority_ cdretention_time_qtytype_cd

Goal

expected_achievement_dttmgoal_list_priority_ nbrmanagement_discipline_ cdreview_interval_cdgoal_value_ cd

Master_observation_serviceinstrument_cdpermitted_data_type_ cdprocessing_time_qtyspecimen_required_indtypical_turnaround_time_qtyderivation_rule_desc

1

0..*

has1

is_specified_for0..*

0..*

0..*

is_basis_for

0..*

has_as_basis

0..*

1..*

1

is_measured_by1..*

measures1

Master_service_relationshiprelationship_type_ cdreflex_testing_trigger_rules_ descconstraint_txtqt

Service_intent_or_order_relationshiprelationship_type_ cdreflex_testing_trigger_rules_ descconstraint_txtqt

Service_event_relationshiprelationship_type_ cd

Service_reason


Active_participationtmrparticipation_type_ cd


Master_serviceallowable_processing_priority_ cdallowable_reporting_priority_cdchallenge_information_txtconfidentiality_ cdeffective_ tmrfactors_that_may_affect_observation_descfixed_canned_message_cdimaging_measurement_modality_cdincompatible_change_dttminterpretation_considerations_desckind_of_quantity_observed_ cdlast_update_dttmmethod_cdnature_of_service_cdobservation_id_suffix_txtorderable_service_indpatient_preparation_descpoint_versus_interval_cdportable_device_ indreport_display_order_ txtalternate_idalternate_name_use_cdalternate_nmcontraindication_descdescperformance_schedule_ cdprimary_nmstandard_time_to_perform_qtytarget_anatomic_site_ cduniversal_service_idqtjoin_ cdwhen_to_charge_ cdconsent_required_ cd

1

0..*

is_source1

has_source0..*

1

0..*

is_target 1

has_target0..*

1..1is_produced_by1..1

1is_requested_by1


charge_type_cdclarification_phonentering_device_ cdescort_required_indexpected_performance_time_qtyfiller_order_idstatus_cdstatus_reason_cdorder_effective_dttmorder_idorder_placed_dttmqtplacer_order_idecho_back_txtplanned_patient_transport_ cdreport_results_to_ phonresponse_requested_cdservice_body_site_ cdservice_body_site_modifier_ cdtransport_arranged_ indtransport_arrangement_responsibility_cdtransport_mode_ cdwhen_to_charge_ dttmwhen_to_charge_ cdintent_or_order_cdjoin_ cdstatus_dttmsecondary_identification_txtreporting_priority_cd

0..*

0..1

is_reason_for0..*

has_as_reason0..1

1

0..*

is_target_for1

has_as_target0..*

1

0..*

is_source_for1

has_as_source0..*

0..*

1


is_instantiated_as1

0..*

0..1participates_in

0..*

has_as_participant0..1

Procedure

anesthesia_cdanesthesia_tmrdelay_reason_txtincision_open_ tmrpriority_ nbrprocedure_tmrfunctional_type_ cd

modifier_cd

0..1is_referred_to_in0..1

Service_event

attestation_dttmtmrcharge_to_practice_qtycharge_to_practice_ cdpatient_sensitivity_cdconsent_cdservice_descfiller_idfiller_order_status_dttmscheduled_start_ dttmspecimen_received_dttmfamily_awareness_ txtindividual_awareness_ cdconfidential_indstatus_cdbilling_priority_ nbrstatus_reason_cd

1 0..*

is_source_for

1 has_as_source0..*

1 0..*

is_target_for

1 has_as_target0..*

0..*

0..1

is_reason_for0..*

has_as_reason0..1

0..*

0..1

has_as_evidence0..*

is_evidence_for0..1

0..*is_documented_by0..*

0..1

0..*

is_fulfilled_by0..1

fulfills 0..*

1

0..*


delivers 0..*

0..*

0..1

participates_in0..*


0..* has_as_participant0..*

requests

0..*is_entered_at0..*

0..*expects_patient_located_at0..*

0..*is_performed_at0..*

0..*is_assigned_to0..*

Target_participationtmrparticipation_type_ cd0..*has_as_target0..* 1..*

0..1

is_target_of

1..*

has_as_target0..1

0..*

0..1

is_target_of0..*

has_as_target0..1

0..* +has_as_target0..*

1..*is_covered_by1..*

0..* is_billed_to0..*

0..*is_charged_to0..*


0..1collects 0..1



Event, intent, master• Any service event is an intentional action and

can potentially be ordered.

• An event has a number of parameters• when, how, how much, how long, etc.

• An intent or order specifies some or all of theservice parameters as desired values.

• The master service defines each of theparameters

• the allowable values, or• the preferred defaults


Master, intent, event• Master specifies

• what can potentially be done,

• how it’s usually done,

• what the possible outcomes are.

• Intent or order specifies• what one is supposed to do,

• how one is supposed to do it.

• Event specifies• what has actually been done,

• how it has actually been done,

• what the actual outcomes are.


Service: Master, Order, Event

MasterService

MasterTreatment

MasterObservation

relation-ship

ServiceIntent o.O.

TreatmentIntent o.O.

ObservationIntent o.O.

relation-ship

ServiceEvent

TreatmentServ. Event

ObservationServ. Event

relation-ship


Analyzing

MasterService

MasterTreatment

MasterObservation

relation-ship

ServiceIntent o.O.

TreatmentIntent o.O.

ObservationIntent o.O.

relation-ship

ServiceEvent

TreatmentServ. Event

ObservationServ. Event

relation-ship


Unifying

Service

Treatmentservice

Observationservice

relation-ship

mood_cd

The mood codetells whether aservice instance isa master service,an order, or anevent, or ...


In the mood?• Mood (2) etymology: alteration of mode.

• “Distinction of form […] of a verb

• to express whether the action […] it denotesis conceived

• as fact, or in some other manner (

• as command,

• possibility,

• or wish)

EVENT

ORDER

MASTER

GOAL!


Analysis of moods (and tense)• Indicative / actual

• present perfect “we have done” (report)• past “someone did” (history)

• Imperative & future tense• order: please do!

• Plan (intent): I will do.

• Infinitive “to do”• dictionary form

• 1000+1 Subjunctive moods• potential

• goal,risk

• conditional (for PRN orders, guidelines, alerts)

Service

Define plansand guidelines

Master Services Care plan for a patient

Ordering

Scheduling

Performing

Documenting& reporting

Reviewing

Business Cycle


Constructing the Model


Modeling vs. Assembling

• Modeling• designing a system from scratch

• like pottery begins with a glob of clay

• working from the big picture to the detail

• Assembling• putting together pre-built pieces

• concepts and data elements defined elsewhere

• the pieces do not always fit, need adaptation

The World ActionSubstance

Action

Things

People

Action

OrganizationIndividual

Things

OrganizationIndividual

Action

Things

Facilit

ies


The Universe

type

Object


Node and Arc

type

Object

type

relationship


Attributes are special relationships

type

Object

type

relationship

type

attribute


Attributes are special relationships

typeattribute1

attribute2

...attributei

Object

type

relationship


Substance and Action

type

Substance

type

S’rel’ship

type

Action

type

A’rel’ship

type

S-A’rel’ship

• People

• Things

• Actors

• Object of actions

• Actions, Activities

• generateknowledge

• change the stateof things

• actors

• objects

• location

Stakeholder

affiliation

Service

serv’rel’ship

actor

targetMaterial

mat’rel’ship

responsibility

VerbVerb

SubjectSubject

ObjectObject

StoryStory

People &People &ThingsThings


typetype type / nameiddescriptionmoodstatustime

Service

Core attributes

type

serv’rel’ship

type

actor

type

target

type / nameiddescriptionformextent

Material

type

mat’rel’ship

type

responsibility

Service

id : SET<II> mood_cd : SET<CV> type_cd : CD descr : ED total_time : GTS critical_time : GTS status_cd : CV method_cd : CD body_site_cd : CD interpretation_cd : SET<CV> confidentiality_cd : CV max_repeat_nmb : INT = 1 interruptible_ind : BL = true substitution_cd : CV priority_cd : CV orderable_ind : BL = true

0..n

1..1

target

has

is

1..1

0..n

source

is

has

target

type_cd : SET<CV> tmr : IVL<TS> awareness_cd : CV

0..n

1

0..n

1

Procedure

entry_site_cd : CD

Observation

value : ANY derivation_expr : ST property_cd : CV

Condition Node

Medication

doseform_cd : CV route_cd : CV dosis_qty : PQ strength_qty : PQ rate_qty : PQ ~ 1s check_dose_qty : PQ

actor

type_cd : SET<CV> tmr : IVL<TS> note_txt : ED signature_cd : CV

to stakeholder

to patient / person

Diet

energy_qty : PQ ~ 1 kcal/d carbohydrate_qty : PQ ~ 1 g/d

0..1

0..n

0..n

1

source

has

is

Material

id : SET<II> type_cd : CD form_cd : CV descr : ED status_cd : CV extent_tmr : IVL<TS> lot_nmb : ST handling_cd : CD danger_cd : CD qty : SET<PQ> = {1}

0..n

1

target

has

is

service list

id : II type_cd : CV name : ST descr : ED

owner

0..n

1

represents

to stakeholder

Consent

Device

Therapeutic agent

Food

preference_cd : CDContainer

capacity_qty : PQ height_qty : PQ diameter_qty : PQ barrier_delta_qty : PQ bottom_delta_qty : PQ separator_type_cd : CD cap_type_cd : CD

to location

responsibility

type_cd : SET<CV> tmr : IVL<TS> material_id : SET<II>

to stakeholder

0..*

0..*

1

to financialtransaction

1

0..1

1

0..1

1

0..1

1 0..11

list item

sequence_nmb : REAL priority_nmb : REAL note_txt : ED

0..n

role

Specimen

body_site_cd : CD

0..1

1

to patient

0..*

Access

gauge_qty : PQ body_site_cd : CD entry_site_cd : CD

0..1

1

to patient 0..*

Transportation

Supply

qty : PQ

one-

of

material relationship

type_cd : CV inversion_ind : BL = false tmr : IVL<TS> position_nmb : LIST<NM> qty : PQ

service relationship

type_cd : CV inversion_ind : BL = false sequence_nmb : INT = 1 priority_nmb : INT = 1 pause_qty : PQ ~ 1s = 0s checkpoint_cd : CV = B split_cd : CV = I1 join_cd : CV = W negation_ind : BL = false conjunction_cd : CV = AND

0..*

0..1

about

one-of

to patient / person

Material Service

Roles!Specializations


typetype type / nameiddescriptionmoodstatustime

Service

Core attributes

type

serv’rel’ship

type

actor

type

target

type / nameiddescriptionformextent

Material

type

mat’rel’ship

type

responsibility

Ser

vice

id : S

ET

<II>

mood_cd

: C

V ty

pe_cd

: C

D d

esc

r : E

D tota

l_tim

e : G

TS

critic

al_

time : G

TS

sta

tus_

cd : C

V m

eth

od_cd

: C

D b

ody_

site

_cd

: C

D in

terp

reta

tion_cd

: S

ET

<C

V>

confid

entia

lity_

cd : C

V m

ax_

repeat_

nm

b :

INT

= 1

inte

rruptib

le_in

d :

BL =

true

subst

itutio

n_cd

: C

V p

riorit

y_cd

: C

V o

rdera

ble

_in

d :

BL =

true

0..n

1..1 ta

rgethas

is 1..1

0..n

sourc

e

is

has

targ

et

type_cd

: S

ET

<C

V>

tm

r : IV

L<

TS

> a

ware

ness

_cd

: C

V

0..n

1

0..n

1

Pro

ced

ure

entr

y_si

te_cd

: C

D

Ob

serv

atio

n

valu

e :

AN

Y d

eriv

atio

n_exp

r : S

T p

ropert

y_cd

: C

V

Co

nd

itio

n N

od

e

Me

dic

ati

on

dose

form

_cd

: C

V r

oute

_cd

: C

V d

osi

s_qty

: P

Q s

trength

_qty

: P

Q r

ate

_qty

: P

Q ~

1s

check

_dose

_qty

: P

Q

acto

r

type_cd

: S

ET

<C

V>

tm

r : IV

L<

TS

> n

ote

_tx

t : E

D s

ignatu

re_cd

: C

V

to s

take

hold

er

to p

atie

nt / pers

on

Die

t

energ

y_qty

: P

Q ~

1 k

cal/d

carb

ohyd

rate

_qty

: P

Q ~

1 g

/d

0..1

0..n

0..n

1

sourc

e

has

is

Mat

eria

l

id : S

ET

<II>

type_cd

: C

D form

_cd

: C

V d

esc

r : E

D s

tatu

s_cd

: C

V e

xtent_

tmr

: IV

L<

TS

> lo

t_nm

b : S

T h

andlin

g_cd

: C

D d

anger_

cd :

CD

qty

: S

ET

<P

Q>

= {

1}

0..n

1

targ

et

has

is

serv

ice

list

id : II

type_cd

: C

V n

am

e : S

T d

esc

r : E

D

owne

r

0..n

1

repre

sents

to s

take

hold

er

Co

nse

nt

Dev

ice

Th

erap

euti

c ag

ent

Fo

od

pre

fere

nce

_cd

: C

DC

on

tain

er

capaci

ty_qty

: P

Q h

eig

ht_

qty

: P

Q d

iam

ete

r_qty

: P

Q b

arr

ier_

delta

_qty

: P

Q b

otto

m_delta

_qty

: P

Q s

epara

tor_

type_cd

: C

D c

ap_ty

pe_cd

: C

D

to lo

catio

n

resp

on

sib

ility

type_cd

: S

ET

<C

V>

tm

r : IV

L<

TS

> m

ate

rial_

id : S

ET

<II>

to s

take

hold

er

0..*

0..*

1

to financialtransaction

1

0..1

1

0..1

1

0..1

10..1

1

list

item

sequence

_nm

b :

RE

AL

prio

rity_

nm

b :

RE

AL

note

_tx

t : E

D

0..n

role

Sp

ecim

en

body_

site

_cd

: C

D

0..1

1

to p

atie

nt

0..*

Acc

ess

gauge_qty

: P

Q b

ody_

site

_cd

: C

D e

ntr

y_si

te_cd

: C

D0..1

1

to p

atie

nt

0..*

Tra

nsp

ort

atio

n

Su

pp

ly

qty

: P

Q

one-of

mat

eria

l rel

atio

nsh

ip

type_cd

: C

V in

vers

ion_in

d :

BL =

fals

e tm

r : IV

L<

TS

> p

osi

tion_nm

b :

LIS

T<

NM

> q

ty : P

Q

serv

ice

rela

tio

nsh

ip

type_cd

: C

V in

vers

ion_in

d :

BL =

fals

e s

equence

_nm

b :

INT

= 1

prio

rity_

nm

b : IN

T =

1 p

ause

_qty

: P

Q ~

1s

= 0

s c

heck

poin

t_cd

: C

V =

B s

plit

_cd

: C

V =

I1

join

_cd

: C

V =

W n

egatio

n_in

d :

BL =

fals

e c

onju

nct

ion_cd

: C

V =

AN

D

0..*

0..1

about

one-of

to p

atie

nt / pers

on

The

Uni

fied

2 S

ervi

ce A

ctio

n M

odel

Gu

nth

er

Sch

ad

ow

,D

an

Ru

ssle

r,C

ha

rlie

Me

ad

,Ji

m C

ase

,C

lem

McD

on

ald

.

Co

pyr

igh

t 1

99

9,

Re

ge

nst

rie

f In

stitu

te.

All

rig

hts

re

serv

ed

.R

evi

sio

n 2

.2;

Se

pte

mb

er

29

, 1

99

9.


Service Material• What happens?

• Actions

• Procedure

• Measurements

• Medication

• Outcome

• Change

• With what, where?

• Subjects of actions

• Devices, tools

• Specimen

• Pharmaceutical product

• Product

• Persistence• add orders to specimen

• maintain access/drain


Types of actors Actor.type_cd• performer: principle actor

• e.g., surgeon, anesthesist

• supervisor: responsible actor• e.g., head of department, attending surgeon,

anesthesiologist.

• placer / filler• placer: the orderer

• filler: the performer of the ordered service

• lots more …• all CN/CX-es of HL7 v2.3


Types of targets Target.type_cd• direct vs. indirect target

• direct: who/what is acted on?• subject, recipient

• device, consumable, product

• indirect: on behalf of whom?• patient in teaching the spouse

• patient• what’s a patient anyway?

• mother–baby; donor

• location• service location

• remote location

• origin, destination, via


Responsibility type_cd• A party responsible for defects (someone to sue for)

• owner, holder, manufacturer, distributor, retailer, …

• A party responsible for caring about the “thing”• holder, trainer (of animals)

• mother/father of unborn child


Service Relationship type_cd• composition

• whole - part

• genus - species

• conditioning• precondition, trigger

• outcome, goal, risk

• knowledge• conclusion - evidence

• cause - effect

• recommendation

• revision• amendment, order revision

• condition thread

• options and defaults


Material Relationship type_cd• composition

• whole - part• mixture - ingredient

• base, additive

• active ingredient

• preservative, stabilizer

• flavor, color

• presence• thing “located” at thing

• e.g., book in shelve

• generalization• and specialization


How it works ...


Observation 1/5• Master (OM1-OM6) mood: DEF

• Laboratory to physician.

• Order (ORC+OBR) mood: ORD• Physician to laboratory.

• Result (OBR+OBX) mood: EVN• Laboratory to physician.


Containercapacity: 20 mlcap-type: white

Materialtype: serum tube

M’Rel’shiptype: contains

Specimen

Materialtype: bloodqty: 10 ml

Targettype: specimen

Observationid: [email protected] (ChemLab)mood: DEFtype: Potassium, sK+

value: [0.5; 59.7] mmol/Lpriority: {A, S, R}

Observation Master 2/5

Observationmood: REFvalue: [3.5; 5.5] mmol/L

S’Rel’shiptype: REFV

Actortype: performer

Organizationname: ChemLab

Serum Potassium Master• alternative name: “sK+”

• unit: mmol/L

• absolute range 0.5 - 59.7

• precision 0.1

• available priorities: A, S, and R

• producer of service• ChemLab, an Organization

• specimen requirement• minimum 10 ml blood

• in 20 ml serum tube

• reference ranges• 3.5 to 5.5 mmol/L


Patient

Personname: John DoeDOB: 19690219

Targettype: subject

Actortype: filler

Containercapacity: 20 mlcap-type: white



Specimen

Materialtype: bloodqty: 10 ml




Observation Order 3/5

Specimenbody_site: r. hand

Materialtype: blood serum


Containerid: 12345-9capacity: 20 ml



Organizationname: ChemLabActor

type: performer

IHCPspecialty: internist

Personname: Dr. Smithphone: 630-7960

Actortype: placer

S’Rel’shiptype: instantates

Observationmood: ORDtype: sK+

priority: A


Patient

Personname: John DoeDOB: 19690219

Targettype: subject

IHCPspecialty: internist

Personname: Dr. Smithphone: 630-7960

Actortype: filler



Observation Order 4/5


Specimenbody_site: r. hand



Containerid: 12345-9capacity: 20 ml




Actortype: placer

Observationmood: ORDtype: sK+

priority: A


Personname: T. Shakerphone: 240-9678

Actortype: technician

Observationmood: REFvalue: [3.5; 5.5] mmol/L




Observation Result 5/5








Observationmood: EVNtype: sK+

value: 4.2 mmol/L


Medication 1/5• Order (RXO) mood: ORD

• Physician to pharmacy.

• Administration (RXA) mood: EVN• Nursing into medical record.

• Encoding (RXE) revision of order• Pharmacy to physician.

• Dispense (RXD) supply of material• Pharmacy to physician, nursing, and billing.

• Give notice (RXG) scheduling reminder• Pharmacy to nursing.


Medication order 2/5

Order to dispense

Medicationmood: DEFtype: Ergotaminetartrat + Caffeine

S’Rel’shiptype: INST

Medicationmood: ORDtype: Ergotaminedose_qty: 2 mgdoseform: tabroute: POpriority: PRN

Medicationmood: EVN,CRTtype: Migraine attack

S’Rel’shiptype: PRCN

Materialid: 0078-0034-42 NDCtype: Cafergotqty: 30

Targettype: product

Order to administer

S’Rel’shiptype: DISPinversion_ind: true

Supplymood: ORDtype: Cafergotqty: 1max_rep’_nmb: 3

Locationaddr: 109 12th Street

Materialid: A7 northtype: Care unit

Targettype: destination


Routing options (RXR) 3/5

Medicationmood: ORDtype: Glucose 50%strength: 500 g/Ldose: 500 mLdoseform: fluidroute_cd: IVcrtitical_time: D/1

Materialtype: CVC-Bdescr: blue line

Targettype: DEV Medication

mood: OPT

S’Rel’shiptype: OPTN

Medicationmood: OPT

S’Rel’shiptype: OPTN

M’Rel’shiptype: PART

Accessentry: V. subclaviatarget:V. cava sup.

Materialtype: CVC M’Rel’ship

type: PART

Materialtype: CVC-Rdescr: red line

Targettype: DEV

• Order Glucose 50% (=500 g/L) 500 mL i.v. once per day through centralvenous catheter (CVC, v. subclavia catheter) either the blue or the redline.


Materialtype: Ergotamine tartrat

M’Rel’shiptype: ACTIqty: 1 mg

Compounds (RXC) 4/5

Medicationmood: DEFtype: Cafergotstrength: 1 mgdoseform: tabletroute_cd: PO

Materialtype: carton

M’Rel’shiptype: CONTqty: 5

Materialtype: Caffeine

M’Rel’shiptype: ACTIqty: 100 mg

Targettype: CSM

Materialtype: tablet

M’Rel’shiptype: CONTqty: 30

Materialtype: package

containshas ingredient

• Cafergot ® 1 mg tablet contains 1 mg Ergotamine tartrat and 100 mgCaffeine as active ingredients. Packaged in 30 tabs, and shipped in acarton of 5 packs



Targettype: product

Supplymood: ORDtype: Cafergotqty: 1max_rep’: 3

S’Rel’shiptype: DISPinversion: true

Medicationmood: ORDtype: Ergotaminedose: 2 mgdoseform: tabroute: POpriority: PRN


Targettype: product

Materialid: 0078-0034-42 NDClot’nmb: 123456type: Cafergotqty: 30

Targettype: product

Responsibilitytype: manufacturer

Organizationname: Sandoz

Supplymood: EVNtype: Cafergotqty: 1

S’Rel’shiptype: DISPseq’nmb: 1

Supplymood: EVNtype: Cafergotqty: 1

S’Rel’shiptype: DISPseq’nmb: 2

Dispense and Refill 5/5

How manymore refills?

3 - 2 = 1 !


Observationtype: symptomvalue: belly painsite: lower right

assi

gns

nam

e

Condition Thread

1

• problem represented by a condition thread

• condition node is one contribution (revision) to the thread• condition nodes may contribute a name to a conditionCondition Node

Observationtype: McBurneyvalue: positive

revision2

Proceduretype: appendectomyvalue: no finding

4

has

reas

on

revision

Observationtype: diagnosisvalue: Appendicitis

3

assi

gns

nam

e

revision

Condition Thread


Condition Thread• name of condition may change as new evidence is found

• each condition node is attributed to a provider• condition threads may branch or join to form a network

...

Observationtype: histologyvalue: Lymphoma

5assigns name

revision

Observationtype: symptomvalue: belly painsite: lower right

assi

gns

nam

e

1

Condition Node

Observationtype: McBurneyvalue: positive

revision2

Proceduretype: appendectomyvalue: no finding

4

has

reas

on

revision


3

assi

gns

nam

e

revision

Condition Thread

Prioritized Problem List

Observationtype: diagnosisvalue: HOCM

assigns name

Surgeon

Cardiologist

Psychiatrist


assigns name

Observationtype: diagnosisvalue: Schizophrenia

assigns name

12

3

1

2

3

1

2

3

Each provider mayassign differentpriorities among thesame set ofcondition nodes.

Person-orientedproblem threads

Provider-orientedproblem lists


Problem, Condition, Problem ListTraditional approach

• problem is a diagnosis• medical or nursing diagnosis

• problems are sorted on one list• requires to decide one sort order

for everyone

• requires to different parties tokeep their own problem lists

• isolation, vertical silos to avoidinterference

• problem lists as snapshots• updated with loss of history

• useful only for short termepisodes

HL7 version 3’s approach

• problem is a thread• associating observations and

diagnoses

• each provider/team has its ownproblem list• each may have different sort

order

• but list items reference sharedcondition nodes

• collaboration without interference

• problem threads• connected through history

• useful for long term care andfollow-up


Medicationtype: prednisolone

Medicationtype: dexamethasone

Medicationtype: budensonide

Medicationtype: glucocorticoids

has-species

has-species

has-species

Generic Drugs

Medicationtype: DEA schedule Vhas-species

Drug Classification

Categorical Knowledge• Categories are defined dynamically in the master file.

• Can be shared, and updated timely and correctly.• Categories include regulatory and reimbursement groups.


Medicationtype: budensonide

Medicationtype: glucocorticoids

has-species

More Medical Knowledge• Medical knowledge represented through knowledge links

• Timely distribution through master file transactions• Allows reminders to be delivered at time of order entry

• Condition criteria defined in the form of observations

• Interoperable sharing of knowledge• everything that can be reported can serve as a criterion

Observationtype: diagnosisvalue: asthma bronchiale

Observationtype: diagnosisvalue: herpes viridae infection

has-indication

has-contraindication


Workflow Management• Invented in the manufacturing industry

• Defines processes and dependencies among them• e.g., the output of one process is the input of another

• A structure for timed and conditioned plans.

• Plans• A Service may be composed of plan components,• arranged sequentially, in branches, and loops.

• Branches may be exclusive or parallel.

• Conditions• Branches can have entry conditions,

• Loops can have exit conditions.

• Timing• A unifying approach to the phenomenon of time.


Sequential plans

plan-componentsequence: 5

mood: DEFtype: retraction oflaparoscope


mood: DEFtype: sutures & bandages


mood: DEFtype: preparation of gall-bladder

mood: DEFtype: excision & extraction ofgall bladder



mood: DEFtype: incisions & insertion oftrocars & laparoscope

mood: DEFtype: laparoscopiccholecystectomy


mood: DEFtype: ligature of vessels


mood: DEFtype: ligature of V.cystica


mood: DEFtype: ligature of A.cystica


mood: DEFtype: ligature ofductus cysticus


splitjoin

Branches

A 1

1

3 A 3.3

A 2

2

3 A 3.2

3 A 3.1

A

A 4

4


Medicationmood: ORDtype: Acetaminophendose: 1000 mgroute: p.o.form: tab

Conditional criteria

Observationmood: CRT, EVNtype: dx&complaintsvalue: pain

S’Rel’shiptype: precondition

Acetaminophen 1000 mg tab p.o., PRN pain


D

OR

null

Boolean logic with criteria

A

OR

B

OR

E

OR

IF ((A or B) and C) xor (D or E) THEN X

null

XOR

X

XOR

C

AND


Unified Approach to Timing• Duration

• A physical quantity, e.g., 10 min, 8 h, 16 a.

• Point in time• A date of arbitrary precision (yet never exact)

• 19690219, 19690219185710.001002

• Interval of time• Begin, end date 19690219–19990929

• and width: 30 a

• Uncertain point in time• A date with fuzz: 199909291400 ± 30 min

• Periodic point and interval in Time• Time of day 8 AM every day

• 8 AM to 5 PM = 8 AM for 8 hours.

• July 14: month of year, day of month

• May 15 to September 15 = May 15 for 4 months


• No matter how complex the problem, it always resolves to an outerbound interval and sequence of occurrence intervals.

outer bound interval

1 2 43 5 6

8:00-10:00

Mo We Fr Tu Th Mo

2 4 6 8 10 12 140 16

Mo Tu We Th Fr Mo Tu We Th Fr Mo Tu

Example for complex timing

Mo–Monday–Friday Monday–Friday

Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu

• Every other day from Monday to Friday 8:00 AM to 10:00 AMfor six consecutive times: “J1-5 D/2 H08-10”


Vocabulary – ModelingCompromises


Pre-coordination e.g. LOINC

Composition(Code Phrase datatype)e.g. SNOMED Conceptual Graphs

Information ModelingExtreme--Value = Present/

Not Present

Vocabulary ModelingExtreme--

One Class/One Attribute

Vocabulary vs. Class Modeling


Pre-coordination e.g. LOINC

Composition(Code Phrase)e.g. SNOMED Conceptual Graphs

Diabetes

Asthma

CHF

Value:Not

Present

PneumoniaValue:Any

SNOMEDCode

HealthcareThing



Precoordinated:(chest pain radiating to left arm)

Postcoordinated:(pain (bodysite chest)

(radiating-to (arm (laterality left))))

Diabetes

Asthma

CHF

Value:Not

Present

PneumoniaValue:Any

SNOMEDCode

HealthcareThing



Pat ID Name Admit Anemic HBP # units Bypass Chol

1234-5 Doe Jane 12May95 Yes Yes 3 80 180

9999-3 Jones T 1Aug95 No No 2 90 230

8888-3 Doe Sam 4June95 No Yes 0 80 205

Analytic Data Conceptualization

• Kind of structure used for statistics

• One record per case• Contains abstract summary data

• Smaller size traded for loss of information

• Categorical questions (yes/no) hard to compare, bias?


Patient Date Observation Name Value Units Normal Facility Responsible Range Observer

Doe J 12-May-95 Hemoglobin 13 mg/dl 12.5-15 St Francis Dr Smith

Doe J 13-May-95 Hemoglobin 11.5 mg/dl 12.5-15 St Francis Dr Smith

Doe J 12-May-95 Dias BP 95 mmHg 80-140 St Francis Dr Smith

Doe J 13-May-95 Dias BP 110 mmHg 80-140 St Francis Dr Smith

Doe J 13-May-95 Time on bypass 80 min St Francis Dr Sleepwell

Doe J 13-May-95 Serial # of blood unit 351021 St Francis Dr Bloodbank

Doe J 13-May-95 Serial # of blood unit 351022 St Francis Dr Bloodbank

Kae M 12-May-95 Hemoglobin 10 mg/dl 12.5-15 St Vincent Dr Jones

Kae M 13-May-95 Hemoglobin 9.5 mg/dl 12.5-15 St Vincent Dr Jones

Kae M 12-May-95 Dias BP 95 mmHg 80-140 St Vincent Dr Jones

Kae M 13-May-95 Dias BP 70 mmHg 80-140 St Vincent Dr Jones

• Kind of structure used for laboratory, pharmacy, billing and electronicmedical record system

• One record per observation, multiple records per case

Operational Data Conceptualization


Analytical versus Operational DataAnalytical conceptualization

• Flat File• patient case in one record

• one observation per kind

• Answers often derived• Easy to analyze

• Limit to one purpose

• Question definitions buriedin field definitions• Hard to extend or modify

• Limits on numbers ofobservations

Operational conceptualization

• One Record per Question• observations can repeat,

• can have context attributes• who, when, modifiers, ...

• Answers carry raw data• More complex, more work to

analyze

• Data mining opportunities

• Questions defined in masterfile• Easy to extend and modify

• No limits on numbers ofobservations


Creating Messages


Tracking the Exam• =(molecule) Protocol Fever after Knee

Replacement• -(atom) Oral Temperature

• -(atom) Pain Question

• -(molecule) Wound redness exam

• -(molecule) CBC

• -(molecule) Infectious Disease(ID) consult

• -(molecule) Review session with patient


Point of Care:declarer; recipient

Lab:declarer; recipient

Consultation Service:declarer; recipient

Data Repository:recipient

Trig #1:CommitProgressNote

Progress Note

CBC OrderID Consult Order

Review to Scheduling

Deletion VarianceProtocol Assignment

2. Progress Note > send to data repository

3. Protocol assigned to patient > send to case management system

4. Deletion variance > send to case management system

Tracking the Exam


Tracking the CBC• =(molecule) Protocol Fever after Knee

Replacement• -(atom) Oral Temperature

• -(atom) Pain Question

• -(molecule) Wound redness exam

• -(molecule) CBC

• -(molecule) Infectious Disease(ID) consult

• -(molecule) Review session with patient






Trig #8:Acknow-ledge CBC

CBC Acknowledged

Trig #1:CommitProgressNote

Progress Note

CBC OrderID Consult Order

Review to Scheduling

Deletion VarianceProtocol Assignment

2. Protocol assigned to patient > send to case management system

3. CBC Order > send to lab

4. CBC acknowledged by lab > send back to orderer

Tracking the CBC






5. CBC performed > send to all parties

6. CBC completed > send to all parties

7. CBC viewed by orderer > send back to lab

Trig #9:CBCperform-ed

CBC Performed

Trig #10:CBCComplet-ed

CBC Completed

Trig #11:ViewCBC

CBC Viewed

Tracking the CBC






8. Patient viewed CBC > send to repository

Trig #26:PatientViewedResults

Patient Viewing

Tracking the CBC


InteractionModel

Order

Choice of

Drug

Nursing

Pharmacy

1,1

1,m

1,m

1,m

1,1

1,m

1,m

1,m

Format #2 Format #1 Data

HierarchicalMessage

Description

ReferenceInformation

Model

DomainInformation

Model

MessageInformation

Model

TriggerEvent

SenderApplication

Role

ReceiverApplication

Role

MessageObject

Diagram

Work Products