clinical data modeling and the hl7 rimamisha.pragmaticdata.com/~schadow/hand.pdftutorial 19 clinical...
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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.
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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....
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
Overcoming Isolation throughInformation Modeling
Copyright © 1999, Regenstrief Institute for Health Care
• 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”
Copyright © 1999, Regenstrief Institute for Health Care
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, ...
Copyright © 1999, Regenstrief Institute for Health Care
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!
Copyright © 1999, Regenstrief Institute for Health Care
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..*
provides_contact0..1
0..1
0..*
provides_contact0..1
is_contact_for0..*
0..1
0..*
provides_contact0..1
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..*
Copyright © 1999, Regenstrief Institute for Health Care
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
authorized_visits_qtydescreason_txt
Dietary_intent_or_order
diet_type_cdinstruction_ desctray_type_cdservice_period_cd
Observation_intent_or_orderpatient_hazard_cdrelevant_clinical_information_ txtspecimen_action_cd
Treatment_service_eventprescription_id
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
Consent Care_eventAssessment
Advance_directivecompetence_inddirective_cddisclosure_level_ cdlife_quality_descmortuary_preference_ nmnotarization_dttmassessment_dttmemployment_related_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
confirmation_status_cd
Rule_link
priority_ nbr
Conditional_link Judgement_link
type_cd
Master_numeric_range
type_cdcondition_ descage_qtygestation_age_qtyvalue_qtyrace_subspecies_txtgender_cdspecies_txt
Master_quantitative_observation
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
Master_treatment_service
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
Treatment_intent_or_order_revision
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
determination_ dttmdocumentation_ dttmreason_txt
Active_participationtmrparticipation_type_ cd
Patient_service_location_request
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
Service_intent_or_order
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_an_instance_of0..*
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..*
is_delivered_during1
delivers 0..*
0..*
0..1
participates_in0..*
has_as_active_participant0..1
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
0..*has_as_target0..*
Copyright © 1999, Regenstrief Institute for Health Care
Unified Modeling Language
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
Patient
name : PNDOB : TSaddress : AD
Doctor
name : PNspecialty : CDphone : TEL
seeks care at
provides care for0..*
1..*
Unified Modeling Language• Class defines things
• 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
Copyright © 1999, Regenstrief Institute for Health Care
Patient
name : PNDOB : TSaddress : AD
Doctor
name : PNspecialty : CDphone : TEL
seeks care at
provides care for0..*
1..*
Unified Modeling Language• Class defines things
• Objects are instances
• 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”
Copyright © 1999, Regenstrief Institute for Health Care
• Class defines things
• Objects are instances
• Associations relate things
• Associative classes addproperties to relationships• attributes about association
Unified Modeling Language
Patient
name : PNDOB : TSaddress : AD
Doctor
name : PNspecialty : CDphone : TEL
seeks care at
provides care for0..*
1..*
Encounter
type : CVtime : IVL⟨TS⟩reason : CD
Copyright © 1999, Regenstrief Institute for Health Care
Unified Modeling Language
Patient
name : PNDOB : TSaddress : AD
Doctor
name : PNspecialty : CDphone : TEL
1
1..*
Encounter
type : CVtime : IVL⟨TS⟩reason : CD
• Class defines things
• Objects are instances
• Associations relate things
• Associative classes addproperties to relationships• attributes about association
1
0..*
Unified Modeling Language
Patient
gender : CDdonor : BLV.I.P. : BL
Doctor
specialty : CDphone : TELprivileges: CV
Person
name : PNDOB : TSaddress : AD
1
1..*
Encounter
type : CVtime : IVL⟨TS⟩reason : CD
1
0..*
• Class defines things
• Objects are instances
• Associations relate things
• 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”
Unified Modeling Language
Patient
gender : CDdonor : BLV.I.P. : BL
Doctor
specialty : CDphone : TELprivileges: CV
Person
name : PNDOB : Dateaddress : AD
1
1..*
Encounter
type : CVtime : IVL⟨TS⟩reason : CD
1
0..*
0..10..1
follow-up
• Class defines things
• Objects are instances
• Associations relate things
• Associative classes
• Generalization classes
• Reflexive associations
• Reflexive associations structure instances of one class• chain (predecessor-successor,) hierarchy (parent-child,) or
network
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Modeling Patterns andStereotypes
Copyright © 1999, Regenstrief Institute for Health Care
Association and roles
Personname : STdate_of_birth : TSaddr : ADphone : TEL
0..*
0..*
patient
physician
Encounter
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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
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Association class
Personid : IIname : STdate_of_birth : TSaddr : AD
0..*
0..*
patient
physician
«substance»
Encounterid : IItime : IVL⟨TS⟩reason : CD
«event»
PatientMRN : IIinsurance : STnewborn_ind : ST
«role»
Physicianprovider_id : IIspecialty : CDDEA_nmb : II
«role»
0..1
1
0..1
1
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Associative class
Personid : IIname : STdate_of_birth : TSaddr : AD
0..*
«substance»
0..*Encounterid : IItime : IVL⟨TS⟩reason : CD
«event»
PatientMRN : IIinsurance : STnewborn_ind : ST
«role»
Physicianprovider_id : IIspecialty : CDDEA_nmb : II
«role»
0..1
1
0..1
1 1
1
0..*
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Encounter participants
Personid : IIname : STdate_of_birth : TSaddr : AD
0..*
0..*Encounter
id : IItime : IVL⟨TS⟩reason : CD
«substance»
«event»
PatientMRN : IIinsurance : STnewborn_ind : ST
«role»
Physicianprovider_id : IIspecialty : CDDEA_nmb : II
«role»
0..1
1
0..1
1 1
1 Attending
0..*
* Consulting
0..*
* Referring
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Participation class• attending
• consulting
• referring
• resident• assistant
• ...
Personid : IIname : STdate_of_birth : TSaddr : AD
0..*0..*
Encounterid : IItime : IVL⟨TS⟩reason : CD
«substance»
«event»
PatientMRN : IIinsurance : STnewborn_ind : ST
«role»
Physicianprovider_id : IIspecialty : CDDEA_nmb : II
«role»
0..1
1
0..1
1
1
*
enc’practitionertype : CVtime : IVL⟨TS⟩
«participation»
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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.
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Encounter revisited
Personid : IIname : STdate_of_birth : TSaddr : AD
0..*0..*
Encounterid : IItime : IVL⟨TS⟩reason : CD
«substance»
«event»
PatientMRN : IIinsurance : STnewborn_ind : ST
«role»
Physicianprovider_id : IIspecialty : CDDEA_nmb : II
«role»
0..1
1
0..1
1
1
*
enc’practitionertype : CVtime : IVL⟨TS⟩
«participation»
Primary care physician1
0..*
Primary care physician1
0..*
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Encounter revisited
Personid : IIname : STdate_of_birth : TSaddr : AD
0..*0..*
Encounterid : IItype : CVtime : IVL⟨TS⟩
«substance»
0..1
0..*
super-
sub-
Hierarchy
«event»
PatientMRN : IIinsurance : STnewborn_ind : ST
«role»
Physicianprovider_id : IIspecialty : CDDEA_nmb : II
«role»
0..1
1
0..1
1
1
*
enc’practitionertype : CVtime : IVL⟨TS⟩
«participation»
0..1
0..1
follow-up
predecessor
Sequence
• inpatient
• outpatient
• primary care
• specialist
• Ob. encounter
• immunization
• ...
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0..*
0..*
source
target
network
Relationship class
Personid : IIname : STdate_of_birth : TSaddr : AD
0..*0..*
Encounterid : IItype : CVtime : IVL⟨TS⟩
«substance»
«event»
PatientMRN : IIinsurance : STnewborn_ind : ST
«role»
Physicianprovider_id : IIspecialty : CDDEA_nmb : II
«role»
0..1
1
0..1
1
1
*
enc’practitionertype : CVtime : IVL⟨TS⟩
«participation»
enc’relationshiptype : CV
«relationship»
• follow-up
• super-encounter
• referring
• ...
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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..*
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0..*
source
network
srv’relationship
type : CV
«relationship»
Encounter, Service, Observation
0..*
target
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»
0..*
source
network
enc’relationship
type : CV
«relationship»
0..*
Serviceid : IItype : CDtime : IVL⟨TS⟩
«event»
1
*
1
0..*
0..*
*
0..*
0..*0..*
Observationid : IItype : CDvalue : ANYtime : IVL⟨TS⟩
1«event»
srv’practitioner
type : CVtime : IVL⟨TS⟩
«participation»
obs’practitioner
type : CVtime : IVL⟨TS⟩
«participation»
0..*
source
network
obs’relationship
type : CV
«relationship»
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0..*
source
network
srv’relationship
type : CV
«relationship»
Encounter, Service, Observation
0..*
target
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»
0..*
source
network
enc’relationship
type : CV
«relationship»
0..*
Serviceid : IItype : CDtime : IVL⟨TS⟩
«event»
1
*
1
0..*
0..*
Observation
value : ANY
«event»
srv’practitioner
type : CVtime : IVL⟨TS⟩
«participation»
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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.
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Service Action Oriented View
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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.
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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.
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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)
Copyright © 1999, Regenstrief Institute for Health Care
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.
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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.
Copyright © 1999, Regenstrief Institute for Health Care
Service
ServiceRelationship
Action Name:Dates:Cost:Privacy Level:Other ActionValues:
Observation
UniqueAction Values:
Transport-ation
UniqueAction Values:
Procedure
UniqueAction Values:
ConditionNode
UniqueAction Values:
Future classes
UniqueAction Values:
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.
Copyright © 1999, Regenstrief Institute for Health Care
Servicehas Parts
ServiceRelationship
Action Name:Dates:Cost:Privacy Level:Other ActionValues:
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.
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Servicehas Plan
ServiceRelationship
Action Name:Dates:Cost:Privacy Level:Other ActionValues:
Observation
UniqueAction Value:
Timeline
CBC U/A X-Ray Diagnosis
Action Relationships
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.
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Servicehas Reason
ServiceRelationship
Action Name:Dates:Cost:Privacy Level:Other ActionValues:
Observation
UniqueAction Value:
hasReason
CBC U/A X-Ray Diagnosis
Action Relationships
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.
Copyright © 1999, Regenstrief Institute for Health Care
Servicehas Support
ServiceRelationship
Action Name:Dates:Cost:Privacy Level:Other ActionValues:
Observation
UniqueAction Value:
Timeline
has Support
CBC U/A X-Ray Diagnosis
Action Relationships
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.
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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.
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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
• 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.”
Copyright © 1999, Regenstrief Institute for Health Care
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
• DX: Improving BUN
Next, the same kind of observation has a result of “improvingBUN.”
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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
• 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.
Copyright © 1999, Regenstrief Institute for Health Care
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
• 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.
Copyright © 1999, Regenstrief Institute for Health Care
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
• DX: Renal insufficiency
possibly secondary to dehydration
Analysis of another column leads to a slightly differentconclusion. In this column, no evidence for weakness exists.
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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
• 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.
Copyright © 1999, Regenstrief Institute for Health Care
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
• 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.
Copyright © 1999, Regenstrief Institute for Health Care
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
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.
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
Business Cycle
Copyright © 1999, Regenstrief Institute for Health Care
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
authorized_visits_qtydescreason_txt
Dietary_intent_or_order
diet_type_cdinstruction_ desctray_type_cdservice_period_cd
Observation_intent_or_orderpatient_hazard_cdrelevant_clinical_information_ txtspecimen_action_cd
Treatment_service_eventprescription_id
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
Consent Care_eventAssessment
Advance_directivecompetence_inddirective_cddisclosure_level_ cdlife_quality_descmortuary_preference_ nmnotarization_dttmassessment_dttmemployment_related_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
confirmation_status_cd
Rule_link
priority_ nbr
Conditional_link Judgement_link
type_cd
Master_numeric_range
type_cdcondition_ descage_qtygestation_age_qtyvalue_qtyrace_subspecies_txtgender_cdspecies_txt
Master_quantitative_observation
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
Master_treatment_service
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
Treatment_intent_or_order_revision
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
determination_ dttmdocumentation_ dttmreason_txt
Active_participationtmrparticipation_type_ cd
Patient_service_location_request
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
Service_intent_or_order
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_an_instance_of0..*
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..*
is_delivered_during1
delivers 0..*
0..*
0..1
participates_in0..*
has_as_active_participant0..1
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
0..*has_as_target0..*
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
Analyzing
MasterService
MasterTreatment
MasterObservation
relation-ship
ServiceIntent o.O.
TreatmentIntent o.O.
ObservationIntent o.O.
relation-ship
ServiceEvent
TreatmentServ. Event
ObservationServ. Event
relation-ship
Copyright © 1999, Regenstrief Institute for Health Care
Unifying
Service
Treatmentservice
Observationservice
relation-ship
mood_cd
The mood codetells whether aservice instance isa master service,an order, or anevent, or ...
Copyright © 1999, Regenstrief Institute for Health Care
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!
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
Constructing the Model
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
The Universe
type
Object
Copyright © 1999, Regenstrief Institute for Health Care
Node and Arc
type
Object
type
relationship
Copyright © 1999, Regenstrief Institute for Health Care
Attributes are special relationships
type
Object
type
relationship
type
attribute
Copyright © 1999, Regenstrief Institute for Health Care
Attributes are special relationships
typeattribute1
attribute2
...attributei
Object
type
relationship
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
How it works ...
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
Patient
Personname: John DoeDOB: 19690219
Targettype: subject
Actortype: filler
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 Order 3/5
Specimenbody_site: r. hand
Materialtype: blood serum
M’Rel’shiptype: contains
Containerid: 12345-9capacity: 20 ml
Materialtype: serum tube
Targettype: specimen
Organizationname: ChemLabActor
type: performer
IHCPspecialty: internist
Personname: Dr. Smithphone: 630-7960
Actortype: placer
S’Rel’shiptype: instantates
Observationmood: ORDtype: sK+
priority: A
Copyright © 1999, Regenstrief Institute for Health Care
Patient
Personname: John DoeDOB: 19690219
Targettype: subject
IHCPspecialty: internist
Personname: Dr. Smithphone: 630-7960
Actortype: filler
Observationid: [email protected] (ChemLab)mood: DEFtype: Potassium, sK+
value: [0.5; 59.7] mmol/Lpriority: {A, S, R}
Observation Order 4/5
S’Rel’shiptype: instantates
Specimenbody_site: r. hand
Materialtype: blood serum
M’Rel’shiptype: contains
Containerid: 12345-9capacity: 20 ml
Materialtype: serum tube
Targettype: specimen
Organizationname: ChemLab
Actortype: placer
Observationmood: ORDtype: sK+
priority: A
Copyright © 1999, Regenstrief Institute for Health Care
Personname: T. Shakerphone: 240-9678
Actortype: technician
Observationmood: REFvalue: [3.5; 5.5] mmol/L
S’Rel’shiptype: REFV
Observationid: [email protected] (ChemLab)mood: DEFtype: Potassium, sK+
value: [0.5; 59.7] mmol/Lpriority: {A, S, R}
Observation Result 5/5
Actortype: performer
Materialtype: blood serum
Targettype: specimen
Organizationname: ChemLab
Actortype: performer
S’Rel’shiptype: REFV
S’Rel’shiptype: instantates
Observationmood: EVNtype: sK+
value: 4.2 mmol/L
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
Materialid: 0078-0034-42 NDCtype: Cafergotqty: 30
Targettype: product
Supplymood: ORDtype: Cafergotqty: 1max_rep’: 3
S’Rel’shiptype: DISPinversion: true
Medicationmood: ORDtype: Ergotaminedose: 2 mgdoseform: tabroute: POpriority: PRN
Materialid: 0078-0034-42 NDCtype: Cafergotqty: 30
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 !
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Observationtype: diagnosisvalue: Appendicitis
3
assi
gns
nam
e
revision
Condition Thread
Prioritized Problem List
Observationtype: diagnosisvalue: HOCM
assigns name
Surgeon
Cardiologist
Psychiatrist
Observationtype: diagnosisvalue: Appendicitis
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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.
Copyright © 1999, Regenstrief Institute for Health Care
Sequential plans
plan-componentsequence: 5
mood: DEFtype: retraction oflaparoscope
plan-componentsequence: 6
mood: DEFtype: sutures & bandages
plan-componentsequence: 2
mood: DEFtype: preparation of gall-bladder
mood: DEFtype: excision & extraction ofgall bladder
plan-componentsequence: 4
plan-componentsequence: 1
mood: DEFtype: incisions & insertion oftrocars & laparoscope
mood: DEFtype: laparoscopiccholecystectomy
plan-componentsequence: 3
mood: DEFtype: ligature of vessels
plan-componentsequence: 3
mood: DEFtype: ligature of V.cystica
plan-componentsequence: 2
mood: DEFtype: ligature of A.cystica
plan-componentsequence: 1
mood: DEFtype: ligature ofductus cysticus
Copyright © 1999, Regenstrief Institute for Health Care
splitjoin
Branches
A 1
1
3 A 3.3
A 2
2
3 A 3.2
3 A 3.1
A
A 4
4
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
• 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”
Copyright © 1999, Regenstrief Institute for Health Care
Vocabulary – ModelingCompromises
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
Pre-coordination e.g. LOINC
Composition(Code Phrase)e.g. SNOMED Conceptual Graphs
Diabetes
Asthma
CHF
Value:Not
Present
PneumoniaValue:Any
SNOMEDCode
HealthcareThing
Vocabulary vs. Class Modeling
Copyright © 1999, Regenstrief Institute for Health Care
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
Vocabulary vs. Class Modeling
Copyright © 1999, Regenstrief Institute for Health Care
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?
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
Creating Messages
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
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
Copyright © 1999, Regenstrief Institute for Health Care
Point of Care:declarer; recipient
Lab:declarer; recipient
Consultation Service:declarer; recipient
Data Repository:recipient
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
Copyright © 1999, Regenstrief Institute for Health Care
Point of Care:declarer; recipient
Lab:declarer; recipient
Consultation Service:declarer; recipient
Data Repository:recipient
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
Copyright © 1999, Regenstrief Institute for Health Care
Point of Care:declarer; recipient
Lab:declarer; recipient
Consultation Service:declarer; recipient
Data Repository:recipient
8. Patient viewed CBC > send to repository
Trig #26:PatientViewedResults
Patient Viewing
Tracking the CBC
Copyright © 1999, Regenstrief Institute for Health Care
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