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Rim derived and influenced hl7 standards

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This tutorial provides an introduction to the major HL7 RIM derived and RIM influenced standards. The student will also learn key aspects of the HL7 V3 Development Framework (HDF). …

This tutorial provides an introduction to the major HL7 RIM derived and RIM influenced standards. The student will also learn key aspects of the HL7 V3 Development Framework (HDF).

Topics Covered:

1. HL7 Development Framework
2. HDF Methodology
3. HL7 V3 Development Artifacts
4. Sample V3 Clients and Projects

Published in: Technology

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  • 1. Your Healthcare Standards Conformance Partner RIM Derived and Influenced HL7 Standards AbdulMalik Shakir President and Chief Informatics Scientist
  • 2. Health Information Integration Infrastructure Solutions Hi3 Solutions is a privately owned Health Information Technology vendor headquartered in Los Angeles, California. We provide health information technology products, education, and consulting services that enable our clients to engage effectively in health information exchange, health data integration, and health care quality measurement . Our mission is to accelerate the adoption and application of standards-based health information exchange as a mean’s of improving healthcare outcomes and facilitating compliance with evidence-based best practices in healthcare. Slide Number: 2 © 2014 All Rights Reserved
  • 3. Electronic Health Information Exchange Claims/Prescriptions Referral Process Eligibility Claim Status Referral Process Eligibility Claim/Status Payors Pharmacies Physicians Public Health Medical Records Medical Society Patient Data Family Planning Lab results Mental Health Hospitals County/Community Entities Enrollment Orders Insurance Updates Health Information Results Images Testing Organizations Lab/Images Slide Number: 3 Employers Government Medicare/Medicaid Patients/Consumers © 2014 All Rights Reserved
  • 4. Instructor • AbdulMalik Shakir, President and Chief Informatics Scientist for Hi3 Solutions. • I have been an active HL7 member since 1991 and I’ve made significant contributions to the development and adoption of the HL7 standard. • I am co-chair of the HL7 Modeling and Methodology work group, former member of the HL7 Board of Directors, and an active participant in many HL7 foundation and domain expert work groups. • I am the author of the original RIM and provided oversight for its maintenance from inception through its first publication as an ANSI and then ISO standard. Slide Number: 4 © 2014 All Rights Reserved
  • 5. Session Overview • This tutorial provides an introduction to the major HL7 RIM derived and RIM influenced standards. The student will also learn key aspects of the HL7 V3 Development Framework (HDF). • Topics Covered: – HL7 Development Framework – HDF Methodology – HL7 V3 Development Artifacts – Sample V3 Clients and Projects • This tutorial will assist in preparation for the HL7 v3 Certification exam. Slide Number: 5 © 2014 All Rights Reserved
  • 6. HL7 Development Framework Slide Number: 6 © 2014 All Rights Reserved
  • 7. HDF Introduction • The Health Level Seven Development Framework (HDF) defines the processes, policies, and artifacts associated with development of HL7 specifications and standards. • The HL7 Development Framework (HDF): – Expands HL7’s modeled-based approach for standards development beyond messaging to its other standards such as structured documents, context management, and standards related to electronic health records; – Facilitates increased participation of HL7 members, subject matter experts, and implementers in the development of HL7 standards. – Enables HL7 to remain the industry leader in model-driven development of comprehensive standards for application interoperability in the Health industry. Slide Number: 7 © 2014 All Rights Reserved
  • 8. HDF Background – Health Level Seven • The mission of HL7 is to provide a comprehensive framework and related standards for the exchange, integration, storage, and retrieval of health information that support clinical practices and the management, delivery and evaluation of health services. • HL7 began developing standards in 1987 with the publication of its messaging specification - the Application Protocol for Electronic Data Exchange in Healthcare Environments. • In the years since its founding, HL7 has evolved beyond traditional messaging protocols to include clinical document architectures, medical logic modules, service component specifications, and standards, guidelines, and related services for the management of electronic health records. Slide Number: 8 © 2014 All Rights Reserved
  • 9. The Family of HL7 Standards • • • • • • • • • • Slide Number: 9 Standardization of knowledge representation (Arden / GELLO) Virtual Medical Record for Clinical Decision Support (vMR-CDS) Specification of components for context management (CMA) Standardization of clinical document structures (CDA) Electronic Health Record System Functional Model (EHR-S) Application protocol for electronic data exchange in healthcare environments (messages) Support for use of healthcare services in a Service Oriented Architecture (SOA) Fast Healthcare Interoperability Resources (FHIR) Specification of robust vocabulary definitions for use in clinical messages and documents Work in the area of security, privacy, confidentiality, and accountability © 2014 All Rights Reserved
  • 10. HDF Background – HL7 V3 Methodology • In 1992 HL7 made a fundamental shift in the method it uses to develop its specifications and standards. • The new methodology, referred to as HL7 Version 3.0 (or V3), is a model-driven standards development methodology based upon object-oriented software development practices. • In January 1996, the HL7 Technical Steering Committee adopted the model-driven approach and the Modeling and Methodology Technical Committee assumed primary responsibility for ongoing development of the V3 methodology. Slide Number: 10 © 2014 All Rights Reserved
  • 11. Slide Number: 11 © 2014 All Rights Reserved
  • 12. HL7 Message Development Framework • The HL7 Message Development Framework (MDF) defines the HL7 V3 message development process. • It identifies the phases, activities, and models used in the process of developing HL7 message specifications. • The HL7 MDF was first published in 1997. It has undergone two major revisions since then; once in 1998 and again in 1999. • The current version of the MDF (v3.3), published in December 1999, has not been maintained. • The HDF is a replacement for and an extension to the HL7 Message Development Framework (MDF) Slide Number: 12 © 2014 All Rights Reserved
  • 13. HL7 V3 Methodology: What and How Application Role Trigger Event Information Modeling Storyboard Sender RIM Derive D-MIM Receiver Triggers Restrict References R-MIM Interaction Example Serialize Interaction Modeling HMD Message Design Storyboard Example Slide Number: 13 Content Use Case Modeling Restrict Message Type © 2014 All Rights Reserved
  • 14. HL7 V3 Design Models RIM RIM Reference Information Model (1) Define a D-MIM D-MIM D-MIM Domain Message Information Model (2) Define a R-MIM R-MIM R-MIM Refined Message Information Model (3) Create an HMD HMD HMD Hierarchical Message Definition Slide Number: 14 © 2014 All Rights Reserved
  • 15. HL7 Development Framework Methodology Slide Number: 15 © 2014 All Rights Reserved
  • 16. Seven Phases of the HDF Methodology 1. Project initiation 2. Requirements Documentation 3. Specification Modeling 4. Specification Documentation 5. Specification Approval 6. Specification Publication 7. Specification Profiling Slide Number: 16 © 2014 All Rights Reserved
  • 17. HDF Workflow Diagram Initiate Project Project Charter Specify Requirements The HDF workflow is not a waterfall methodology. Each phase builds upon the prior and may cause prior activities to be revisited and their deliverables adjusted. Requirement Specification Reference Models Prepare Specification Design Models Specification Design Models Approve Specification Prepare Specification Pre-Approval Specification Conformance Statement Approved Specification Slide Number: 17 Publish Approved Specification Published Specification Prepare Specification Profiles Specification Profile © 2014 All Rights Reserved
  • 18. Project initiation During project initiation the project is defined, a project plan is produced, and project approval is obtained. The primary deliverable produced during project initiation is the project charter. Project Initiation Project Charter 1. Define project scope, objectives, and intended deliverables 2. Identify project stakeholders, participants, and required resources 3. Document project assumptions, constraints, and risk 4. Prepare preliminary project plan and document inter-project dependencies 5. Obtain project approval and launch the project Slide Number: 18 © 2014 All Rights Reserved
  • 19. Requirements Documentation During requirements documentation the problem domain is defined, a model of the domain is produced, and the problem domain model is harmonized with HL7 reference models. The primary deliverable produced during requirements documentation is the requirements specification. Project Charter Requirements Documentation Requirements Specification 1. 2. Capture Process Flow: UML Activity Diagram 3. Capture Structure: Domain Analysis Model and Glossary 4. Capture Business Rules: Relationships, Triggers, and Constraints 5. Slide Number: 19 Document Business Process: Dynamic Behavior and Static Structure Harmonize the Domain Analysis Model with HL7 Reference Models © 2014 All Rights Reserved
  • 20. Specification Modeling During specification modeling reference models are constrained into design models through a process of iterative refinement driven by requirements specifications and following specification design rules, conventions, and guidelines. The primary deliverable produced during specification modeling is a set of specification design models. Requirements Specification Specification Modeling Specification Design Models 1. 2. Construct design models of behavioral views 3. Define reusable design model components 4. Construct design models of collaboration and interaction 5. Slide Number: 20 Build design models of static information views Harmonize design models with HL7 Reference Models © 2014 All Rights Reserved
  • 21. Specification Documentation During specification Documentation the specification design models are packaged into logical units, supplemented with explanatory text, and prepared for approval. The primary deliverable produced during specification documentation is a pre-approval specification. Specification Design Models Specification Documentation Pre-Approval Specification 1. 2. Compose explanatory text, examples, and design rationale 3. Update design models and requirement specifications 4. Assemble a pre-approval specification package 5. Slide Number: 21 Organize design model elements into logical packages Submit specification for approval © 2014 All Rights Reserved
  • 22. Specification Approval During specification approval the pre-approval specification is subjected to a series of approvals steps. The specific approval steps vary by kind of specification, level of approval, and realm of interest. The primary deliverable produced during specification approval is an approved specification. Pre-Approval Specification Specification Approval Approved Specification 1. 2. Form a ballot pool and conduct specification ballot 3. Assess negative ballots and affirmative comments 4. Modify specification in response to ballot comments 5. Slide Number: 22 Obtain TSC and Board approval to ballot specification Resolve negative ballot responses and if necessary reballot © 2014 All Rights Reserved
  • 23. Specification Publication During specification publication the approved specification is prepared for prepared for publication and distribution. The primary deliverable produced during specification publication is a published specification. Approved Specification Specification Publication Published Specification 1. 2. Prepare specification for publication 3. Submit publication to standards authorities (ANSI/ISO) 4. Render the specification in various forms of publication media 5. Slide Number: 23 Obtain TSC and Board approval to publish specification Post and distribute approved specifications © 2014 All Rights Reserved
  • 24. Specification Profiling During specification profiling specification models are further refined and specifications furthered constrained following the same set of design rules, conventions, and guidelines used in the development of the specification to produce a profile of the specification for use in a particular environment by a defined community of users. The primary deliverable produced during specification profiling is a set of specification profiles and conformance statements. Published Specification Specification Profiling Specification Profiles and Conformance Statements 1. 2. Further refine and constrain specification design models 3. Document exceptions, extensions, and annotations to specifications 4. Prepare and publish specification profile 5. Slide Number: 24 Identify community of uses for published specification Prepare and publish conformance statements © 2014 All Rights Reserved
  • 25. HDF Workflow Diagram Initiate Project Project Charter Specify Requirements The HDF workflow is not a waterfall methodology. Each phase builds upon the prior and may cause prior activities to be revisited and their deliverables adjusted. Requirement Specification Reference Models Prepare Specification Design Models Specification Design Models Approve Specification Prepare Specification Pre-Approval Specification Conformance Statement Approved Specification Slide Number: 25 Publish Approved Specification Published Specification Prepare Specification Profiles Specification Profile © 2014 All Rights Reserved
  • 26. HL7 Version 3.0 Development Artifacts Slide Number: 26 © 2014 All Rights Reserved
  • 27. HL7 v3.0 Development Artifacts Reference Models Reference Information Model Datatype Specification Vocabulary Specification Design Models Interaction Model Design Information Model Common Message Type Model Content Specifications Hierarchical Message Definition Message Type Definition Implementation Technology Specification Implementation Profiles Message Profile Specification Localized Message Specification Message Conformance Statements Slide Number: 27 © 2014 All Rights Reserved
  • 28. HL7 v3.0 Development Artifacts Reference Models Reference Information Model The HL7 Reference Information Model is the information model from which all other information models and message specifications are derived. Datatype Specification The HL7 Datatype Specification defines the structural format of the data carried in an attribute and influences the set of allowable values an attribute may assume. Vocabulary Specification The HL7 Vocabulary Specification defines the set of all concepts that can be taken as valid values in an instance of a coded attribute or message element. Slide Number: 28 © 2014 All Rights Reserved
  • 29. HL7 v3.0 Development Artifacts Design Models Interaction Model An Interaction Model is a specification of information exchanges within a particular domain as described in storyboards and storyboard examples. Design Information Model A Domain Information Model is an information structure that represents the information content for a set of messages within a particular domain area. Common Message Type Model Slide Number: 29 A Common Message Type Model is a definition of a set of common message components that can be referenced in various message specifications. © 2014 All Rights Reserved
  • 30. HL7 v3.0 Messaging Artifacts Message Specifications Hierarchical Message Definition Message Type Definition Implementation Technology Specification Slide Number: 30 An Hierarchical Message Definition is a specification of message elements including a specification of their grouping, sequence, optionality, and cardinality. A Message Type Definition is a specification of a collection of message elements and a set of rules for constructing a message instance. An Implementation Technology Specification is a specification that describes how to construct HL7 messages using a specific implementation technology. © 2014 All Rights Reserved
  • 31. HL7 v3.0 Development Artifacts Implementation Profiles Localized Message Specification Message Profile Specification A Message Profile Specification is a description of a particular or desired implementation of an HL7 Message standard or Localized Message specification. Message Conformance Statement Slide Number: 31 A Localized Message Specification is a refinement of a HL7 message specification standard that is specified and balloted by an HL7 International Affiliate. A Message Conformance Statement is a comparison of a particular messaging implementation and an HL7 message standard, localization, or profile. © 2014 All Rights Reserved
  • 32. HL7 V3 Message Design Models TraumaRegistryExport PreHosptialRelatedObservation (IDPH_RM00001) classCode*: <= OBS moodCode*: <= EVN code: <= ExternallyDefinedActCodes value: ANY [0..1] VehicleProvider Data content of HL7 messages used to export data from the IDPH Trauma Registry. pertinentInformation 0..* pertinentPreHosptialRelatedObservation 1..1 owningVehicleProvider typeCode*: <= PERT Organization addr : BAG<AD> standardIndustryClassCode : CE Patient Place confidentialityCode : CE mobileInd : BL veryImportantPersonCode : CE addr : AD directionsText : ED Access LicensedEntity positionText : ED approachSiteCode : CD recertificationTime : TS gpsText : ST targetSiteCode : CD gaugeQuantity : PQ ActRelationship typeCode : CS inversionInd : BL outboundRelationship contextControlCode : CS 0..n contextConductionInd : BL sequenceNumber : INT Person 1 source priorityNumber : INT addr : BAG<AD> pauseQuantity : PQ Act Participation maritalStatusCode : CE checkpointCode : CS classCode : CS Entity educationLevelCode : CE typeCode : CS Role splitCode : CS moodCode : CS raceCode : SET<CE> functionCode : CD classCode : CS player joinCode : CS classCode : CS id : SET<II> disabilityCode : SET<CE> contextControlCode : CS determinerCode : CS negationInd : BL 0..1 0..n id : SET<II> code : CD livingArrangementCode : CE sequenceNumber : INT id : SET<II> 0..n conjunctionCode : CS negationInd : BL playedRolecode : CE 1 religiousAffiliationCode : CE negationInd : BL code : CE localVariableName : ST negationInd : BL 1 derivationExpr : ST ethnicGroupCode : SET<CE> quantity : SET<PQ> 0..n noteText : ED seperatableInd : BL addr : BAG<AD> text : ED time : IVL<TS> name : BAG<EN> telecom : BAG<TEL> 0..n statusCode : SET<CS> modeCode : CE desc : ED statusCode : SET<CS> effectiveTime : GTS inboundRelationship awarenessCode : CE statusCode : SET<CS> scopedRoleeffectiveTime : IVL<TS> LivingSubject activityTime : GTS signatureCode : CE existenceTime : IVL<TS> 0..n certificateText : ED target availabilityTime : TS administrativeGenderCode : CE signatureText : ED telecom : BAG<TEL> quantity : RTO 0..1 priorityCode : SET<CE> birthTime : TS performInd : BL riskCode : CE 1 positionNumber : LIST<INT> scoper deceasedInd : BL substitutionConditionCode : CE confidentialityCode : SET<CE> ... handlingCode : CE repeatNumber : IVL<INT> deceasedTime : TS DeviceTask 1 target 1source interruptibleInd : BL multipleBirthInd : BL 1 parameterValue : LIST<ANY> levelCode : CE inboundLink multipleBirthOrderNumber : INT WorkingList 0..n outboundLink 0..n independentInd : BL Employee organDonorInd : BL ownershipLevelCode : CE RoleLink uncertaintyCode : CE FinancialContract jobCode : CE typeCode : CS reasonCode : SET<CE> paymentTermsCode : CE jobTitleName : SC effectiveTime : IVL<TS> languageCode : CE jobClassCode : CE Material NonPersonLivingSubject salaryTypeCode : CE formCode : CE strainText : ED salaryQuantity : MO InvoiceElement genderStatusCode : CE hazardExposureText : ED SubstanceAdministration modifierCode : SET<CE> protectiveEquipmentText : ED Observation unitQuantity : RTO<PQ,PQ> routeCode : CE 0..n value : ANY unitPriceAmt : RTO<MO,PQ> approachSiteCode : SET<CD> ManufacturedMaterial LanguageCommunication interpretationCode : SET<CE> netAmt : MO doseQuantity : IVL<PQ> Procedure methodCode : SET<CE> factorNumber : REAL rateQuantity : IVL<PQ> lotNumberText : ST languageCode : CE methodCode : SET<CE> targetSiteCode : SET<CD> pointsNumber : REAL doseCheckQuantity : SET<RTO> expirationTime : IVL<TS> modeCode : CE approachSiteCode : SET<CD> maxDoseQuantity : SET<RTO> stabilityTime : IVL<TS> proficiencyLevelCode : CE targetSiteCode : SET<CD> substitutionCode : CE preferenceInd : BL DiagnosticImage subjectOrientationCode : CE Container Device capacityQuantity : PQ manufacturerModelName : SC heightQuantity : PQ softwareName : SC localRemoteControlStateCode : CE ... diameterQuantity : PQ capTypeCode : CE alertLevelCode : CE separatorTypeCode : CE lastCalibrationTime : TS barrierDeltaQuantity : PQ bottomDeltaQuantity : PQ PreHospitalVehicle ManagedParticipation id : SET<II> statusCode : SET<CS> PublicHealthCase PatientEncounter detectionMethodCode : CE preAdmitTestInd : BL transmissionModeCode : CE admissionReferralSourceCode : CE diseaseImportedCode : CE lengthOfStayQuantity : PQ dischargeDispositionCode : CE specialCourtesiesCode : SET<CE> specialAccommodationCode : SET<CE> acuityLevelCode : CE Supply quantity : PQ expectedUseTime : IVL<TS> Diet energyQuantity : PQ carbohydrateQuantity : PQ Account name : ST balanceAmt : MO currencyCode : CE interestRateQuantity : RTO<MO,PQ> allowedBalanceQuantity : IVL<MO> FinancialTransaction amt : MO creditExchangeRateQuantity : REAL debitExchangeRateQuantity : REAL classCode*: <= OWN 1..1 preHospitalVehicle id: II [0..1] (VehiclNum) participant code: <= RoleCode (VehiclLevelID) typeCode*: <= ParticipationType InjuryLocation classCode*: <= PLC determinerCode*: <= INSTANCE 0..1 playingInjuryLocation code: CV CWE [0..1] <= EntityCode (InjuryPlaceID) addr: AD [0..1] (AddressScene) MedicalStaffPerson PreHospitalEncounter MedicalStaff classCode*: <= ENC moodCode*: <= EVN id: II [0..1] (crashNum) activityTime: IVL<TS> Role classCode*: <= PROV id: II [0..1] (MedicalStaffID) performer classCode*: <= ROL predecessor 0..1 priorPreHospitalEncounter 0..1 medicalStaff typeCode*: <= PRF typeCode*: <= PREV 1..1 participant location Procedure 0..1 procedureLocation ProcedureLocation typeCode*: <= LOC classCode*: <= PROC location InjuryRelatedObservation classCode*: <= SDLOC moodCode*: <= EVN 0..* pertinentInjuryRelatedObservation classCode*: <= OBS 0..* pertinentProcedure code: CV CWE <= ActCode (ICDCodeID) typeCode*: <= LOC code: <= RoleCode (ProcedLocateID) Injury pertinentInformation moodCode*: <= EVN PatientIncident pertinentInformation7 activityTime: TS (ProcedDate) classCode*: <= ACT 0..1 pertinentInjury typeCode*: <= PERT code: <= ExternallyDefinedActCodes classCode*: <= ENC typeCode*: <= PERT moodCode*: <= EVN pertinentInformation1 moodCode*: <= EVN priorityCode: CV CWE [0..1] <= ActPriority sequenceNumber: INT [0..1] (InjurySequen) activityTime: TS (InjuryDate) component typeCode*: <= PERT value: [0..1] TraumaParticipant id: [1..*] (RegistNum) typeCode*: <= COMP code: CV CNE [0..1] <= ExternallyDefinedActCodes (PatientType) statusCode: LIST<CS> CNE <= ActStatus (IDPHStatus) 0..* pertinentPatientIncidentRelatedObservation PatientIncidentRelatedObservation PatientPerson activityTime: TS (EDDate) 1..1 patient classCode*: <= OBS pertinentInformation2 classCode*: <= PSN Patient subject moodCode*: <= EVN 0..1 playingTraumaParticipant determinerCode*: <= INSTANCE typeCode*: <= PERT 0..* patientIncidentRelatedObservation classCode*: <= PAT typeCode*: <= SBJ code: <= ActCode name: PN [0..1] (*Name) id: II [0..1] (MedicaRecordNum) reasonCode: CV CWE [0..1] <= ActReason existenceTime: (Age) Choice 1..1 patientPatientPerson value: ANY [0..1] administrativeGenderCode: CV CWE <= AdministrativeGender Facility (GenderID) 1..1 providerTraumaParticipant classCode*: <= ORG birthTime: (DateOfBirth) 0..* aRole aRole VehicleProvider determinerCode*: <= INSTANCE addr: AD [0..1] (AddressHome) TraumaParticipant classCode*: <= ROL origin 1..1 arrivalPatientTransfer id: raceCode: CV CWE [0..1] <= Race (RaceID) classCode*: <= ORG PatientTransfer classCode*: <= ORG typeCode*: <= ORG code*: CS CNE <= EntityCode "FAC" ethnicGroupCode: CV CWE [0..1] <= Ethnicity (EthnicID) arrivedBy determinerCode*: <= INSTANCE determinerCode*: <= INSTANCE classCode*: <= TRNS 1..1 owningVehicleProvider id: II [0..1] (VehiclProvide) name: typeCode*: <= ARR id: [1..1] (HospitNum) moodCode*: <= EVN 1..1 transferVehicle code: <= EntityCode (MaxVehiclLevelID) 0..1 subjectChoice code: CV CWE [0..1] <= EntityCode activityTime: IVL<TS> (DischaDate to ArriveDate) via name: ON [0..1] (VehiclProvidName) TransferVehicle name: ON [0..1] (HospitName) Hospital reasonCode: CV CWE [0..1] <= TransferActReason (REASONTRANSFID) typeCode*: <= VIA statusCode: CS CNE [0..1] <= EntityStatus (ActiveFacili) classCode*: <= OWN classCode*: <= ORG pertinentInformation addr: AD [0..1] (HospitCity) id: II [0..1] (VehiclNum) determinerCode*: <= INSTANCE typeCode*: <= PERT code: <= RoleCode (VehiclLevelID) pertinentInformation3 id: 1..* pertinentTransferRelatedObservation LicensedEntity 0..1 licensedEntity 1..1 pertinentHospitalVisit code*: CS CNE <= EntityCode "HOSP" typeCode*: <= PERT destination classCode*: <= LIC name: pertinentInformation5 TransferRelatedObservation typeCode*: <= DST id: II [0..1] HospitalVisit typeCode*: <= PERT classCode*: <= OBS classCode*: <= ENC moodCode*: <= EVN 1..1 admittingProvider moodCode*: <= EVN AdmittingProvider code: CV CWE <= ExternallyDefinedActCodes code: CV CWE <= ActCode (AdmitServicID) admitter classCode*: <= PROV value: PQ [0..1] activityTime: TS (DischaDate) id: II [0..1] (ADMITMEDICASTAFFID) typeCode*: <= ADM methodCode: CV CWE [0..1] <= ObservationMethod dischargeDispositionCode: CV CWE [0..1] code: CV CWE <= RoleCode (StaffTypeID) 0..* hospitalVisitPhysician <= EncounterDischargeDisposition responsibleParty HospitalVisitPhysician typeCode*: <= RESP classCode*: <= PROV time: TS id: II [0..1] code: CV CWE <= RoleCode (StaffTypeID) EmergencyDepartmentRelatedObservation 0..1 pertinentEmergencyDepartmentEncounter classCode*: <= OBS moodCode*: <= EVN 0..* pertinentEmergencyDepartmentRelatedObservation code: CV CWE <= ExternallyDefinedActCodes pertinentInformation classCode*: <= ENC text: moodCode*: <= EVN typeCode*: <= PERT activityTime: TS activityTime: IVL<TS> reasonCode: <= ActReason dischargeDispositionCode: CV CWE <= EncounterDischargeDisposition value: [0..1] methodCode: CV CWE [0..1] <= ObservationMethod component targetSiteCode: CV CWE [0..1] <= HumanActSite typeCode*: <= COMP pertinentInformation typeCode*: <= PERT EmergencyDepartmentEncounter 0..* pertinentHospitalVisitRelatedObservation HospitalVisitRelatedObservation 0..1 healthCareMedicalStaffPerson MedicalStaffPerson classCode*: <= OBS moodCode*: <= EVN code: CV CWE <= ExternallyDefinedActCodes value: [0..1] 0..1 healthCareMedicalStaffPerson classCode*: <= PSN determinerCode*: <= INSTANCE 0..1 healthCareMedicalStaffPerson name: PN [0..1] (MedicaStaffName) RIM 0..* emergencyDepartmentPhysicianAct EmergencyDepartmentPhysician 0..* emergencyDepartmentPhysician classCode*: <= PROV performer id: II [0..1] typeCode*: <= PRF code: CE CWE [0..1] <= RoleCode (StaffTypeID) EmergencyDepartmentPhysicianAct classCode*: <= ACT moodCode*: <= EVN code: CS CNE [0..1] <= ExternallyDefinedActCodes activityTime*: TS [0..1] D-MIM Design Information Model component typeCode*: <= COMP PatientIncidentRelatedObservation InjuryLocation classCode*: <= PLC determinerCode*: <= INSTANCE 0..1 playingInjuryLocation code: CV CWE [0..1] <= EntityCode (InjuryPlaceID) addr: AD [0..1] (AddressScene) classCode*: <= ROL location 1..1 participant typeCode*: <= LOC InjuryRelatedObservation 0..* pertinentInjuryRelatedObservation classCode*: <= OBS pertinentInformation moodCode*: <= EVN typeCode*: <= PERT code: <= ExternallyDefinedActCodes priorityCode: CV CWE [0..1] <= ActPriority sequenceNumber: INT [0..1] (InjurySequen) value: [0..1] PatientPerson classCode*: <= OBS moodCode*: <= EVN code: <= ActCode reasonCode: CV CWE [0..1] <= ActReason value: ANY [0..1] Role Injury 0..* patientIncidentRelatedObservation pertinentInformation2 0..* pertinentPatientIncidentRelatedObservation typeCode*: <= PERT PatientIncident classCode*: <= ACT 0..1 pertinentInjury classCode*: <= ENC moodCode*: <= EVN pertinentInformation1 moodCode*: <= EVN activityTime: TS (InjuryDate) typeCode*: <= PERT id: [1..*] (RegistNum) code: CV CNE <= ExternallyDefinedActCodes (PatientType) statusCode: LIST<CS> CNE <= ActStatus (IDPHStatus) activityTime: TS (EDDate) 1..1 patient classCode*: <= PSN Patient subject determinerCode*: <= INSTANCE classCode*: <= PAT typeCode*: <= SBJ name: PN [0..1] (*Name) id: II [0..1] (MedicaRecordNum) existenceTime: (Age) 1..1 patientPatientPerson administrativeGenderCode: CV CWE <= AdministrativeGender (GenderID) 1..1 providerTraumaParticipant birthTime: (DateOfBirth) addr: AD [0..1] (AddressHome) TraumaParticipant raceCode: CV CWE [0..1] <= Race (RaceID) classCode*: <= ORG ethnicGroupCode: CV CWE [0..1] <= Ethnicity (EthnicID) determinerCode*: <= INSTANCE id: [1..1] (HospitNum) code: CV CWE [0..1] <= EntityCode name: ON [0..1] (HospitName) statusCode: CS CNE [0..1] <= EntityStatus (ActiveFacili) addr: AD [0..1] (HospitCity) R-MIM Slide Number: 32 HMD © 2014 All Rights Reserved
  • 33. Design Information Model Description • Domain Message Information Models (D-MIMs) and Refined Message Information Models (R-MIMs) are types of Design Information Models. • Design information models are composed of class clones that are a restricted subset of the HL7 RIM. • Class clones contain a subset of the attributes and relationships that are defined for the RIM class upon which the clone is based. • Multiple class clones based upon the same RIM class may be included in a design information model. • Each class clone in a design information model is assigned a unique name. Slide Number: 33 © 2014 All Rights Reserved
  • 34. Sample R-MIM Design Information Model Laboratory Observation Order (POLB_RM002100) Common entry point for laboratory order communication. This includes single one-time typeCode*: <= COMP orders as well as recurring orders. This is contextControlCode*: [1..1] Note: used for recurring orders only if the filler <= ContextControlNonPropagating "AN" Includes both splits recurring orders into their occurrences. contextConductionInd*: [1..1] "true" patient and the sequenceNumber: institution. priorityNumber: pauseQuantity: 0..1 patient * 0..1 roleName CMET: (PAT) splitCode: ObservationOrder recordTarget ManufacturedProduct1 Organization R_Patient joinCode: classCode*: <= OBS typeCode*: <= RCT classCode*: <= MANU [universal] seperatableInd: [1..1] "true" classCode*: <= ORG 0..* observationOrder1 moodCode*: <= ORD contextControlCode*: [1..1] (COCT_MT050000) determinerCode*: <= INSTANCE id*: II [1..1] <= ContextControlPropagating "OP" 0..1 manufacturerOrganization name*: ON [1..1] code: CE CWE <= ObservationType (e.g. LOINC code) 1..1 manufacturedProduct * 0..* specimen * consumable 0..* observationOrder2 * negationInd: [1..1] "false" CMET: (SPEC) subject typeCode*: <= CSM 0..* substanceAdministrationStep * derivationExpr: R_Specimen typeCode*: <= SBJ text: component2 SubstanceAdministrationStep [universal] contextControlCode*: [1..1] statusCode*: CS CNE [1..1] <= ActStatus "active" (COCT_MT080000) <= ContextControlPropagating "OP" typeCode*: <= COMP classCode*: <= SBADM effectiveTime: ("physiologically relevant time" aimed for) contextControlCode*: [1..1] moodCode*: <= x_ActMoodOrdPrmsEvn activityTime: IVL<TS> Note: <= ContextControlNonPropagating "AN" id*: II [1..1] priorityCode: CE CWE [0..1] <= ActPriority "R" For clinical observations that are made directly on the patient contextConductionInd*: [1..1] "true" code*: CE CWE <= SubstanceAdministrationActCode confidentialityCode*: [1..*] <= Confidentiality "N" instead of on some specimen. sequenceNumber*: [1..1] text*: repeatNumber: priorityNumber: statusCode*: CS CNE [0..1] 0..1 roleName 1..1 assignedEntity * interruptibleInd: "true" CMET: (ASSIGNED) pauseQuantity: effectiveTime*: IVL<TS> independentInd: "true" author R_Assigned splitCode: routeCode: <= RouteOfAdministration methodCode: <= ObservationMethod typeCode*: <= AUT [universal] joinCode: doseQuantity: PQ contextControlCode*: [1..1] (COCT_MT090000) targetSiteCode: <= ActSite seperatableInd*: [1..1] "false" rateQuantity: PQ <= ContextControlPropagating "OP" noteText: ST Note: time*: TS [1..1] (time of signature) CMET: (ENC) Includes both, the componentOf1 modeCode*: CE CNE [1..1] <= ParticipationMode A_Encounter individual and the typeCode*: <= COMP signatureCode*: CS CNE [1..1] [universal] contextControlCode*: [1..1] <= ContextControlPropagating "OP" signatureText: provider organization. (COCT_MT010000) contextConductionInd*: [1..1] "false" 0..1 encounter * 0..* assignedEntity Drug classCode*: <= MMAT determinerCode*: <= INSTANCE code*: [1..1] <= DrugEntity (Drug code) quantity: desc: 1..1 manufacturedDrug * CMET: (AGNT) R_Responsible [universal] Note: This is the general almost completely unconstrained ActRelationship. Its use includes composition (COMP), occurrences (OCCR), master file references (INST), fulfillment (FLFS) and replacement (RPLC) as well as normal ranges (REFV), decision ranges (COND) and goals. In the DMIM this is left unconstrained, in the RMIMs these might be more constrained. componentOf2 Accession 1..1 agent * classCode*: <= ACSN moodCode*: <= EVN typeCode*: <= AUT id*: II [1..1] author (COCT_MT040000) 0..1 roleName Note: For Advanced Beneficiary Notices or whenconsents are required for testing (e.g., HIV related tests.) CMET: (CONS) A_Consent [universal] (COCT_MT470000) Note: The author of an ORDer is commonly know as the "placer", the author of an ordered promise or event is commonly known as the "filler". The author owns his Act, meaning that direct status canges on this act can only be issued by the Author. typeCode*: <= COMP contextControlCode*: [1..1] <= ContextControlPropagating "OP" contextConductionInd*: [1..1] "false" 0..* accession subjectOf typeCode*: <= SUBJ contextControlCode*: [1..1] <= ContextControlPropagating "OP" contextConductionInd*: [1..1] "false" 0..* consent 0..* pertinentObservationSupporting CMET: (OBS) A_ObservationSupporting [universal] Note: Identifies the "master" or "service catalog" entry of the observation service being performed. Use this alone or in addition to an observation code to specify what is being observed or what is to be observed. component1 / componentOf3 (COCT_MT120200) 0..1 assignedEntity typeCode*: <= ENT contextControlCode*: [1..1] <= ContextControlPropagating "OP" noteText: ST time: TS (time entered into) modeCode*: [1..1] <= "ELECTRONIC" typeCode*: <= PERT contextControlCode*: [1..1] <= ContextControlNonPropagating "AN" contextConductionInd*: [1..1] "true" 0..1 observationDefinition * definition classCode*: <= OBS moodCode*: <= DEF id: II [1..1] typeCode*: <= INST contextControlCode*: [1..1] <= ContextControlNonPropagating "AN" contextConductionInd*: [1..1] "true" typeCode*: <= VRF contextControlCode*: [1..1] <= ContextControl "OP" noteText: ST time*: TS [1..1] (time of signature) modeCode*: [1..1] <= ParticipationMode signatureCode*: [1..1] <= ParticipationSignature signatureText: dataEnterer pertinentInformation ObservationDefinition verifier 0..1 assignedEntity notificationContact Note: For orders: the designated performer, if known and desired at time of ordering. For intents, the promises and events, the "filler." For individual subtasks, used for the technician, etc. typeCode*: <= NOT contextControlCode*: [1..1] <= ContextControlPropagating "OP" 0..* assignedEntity * performer typeCode*: <= PRF contextControlCode*: [1..1] <= ContextControlPropagating "OP" 0..* participant consumable typeCode*: <= CSM contextControlCode*: [1..1] <= ContextControlNonPropagating "ON" 0..* CMET: (ROL) R_Reagent [universal] (COCT_MT250000) 0..* orderOptions controlVariable typeCode*: <= CTRLV contextControlCode*: [1..1] <= ContextControlNonPropagating "AN" contextConductionInd*: [1..1] "false" CMET: (ACT) A_OrderOptions [universal] (COCT_MT210000) 0..* priorObservation replacementOf typeCode*: <= RPLC contextControlCode*: [1..1] <= ContextControlNonPropagating "ON" contextConductionInd*: [1..1] "true" Slide Number: 34 © 2014 All Rights Reserved
  • 35. Design Information Model Diagram Drug classCode*: <= MMAT determinerCode*: <= INSTANCE code*: [1..1] <= DrugEntity (Drug code) quantity: desc: 1..1 manufacturedDrug * ManufacturedProduct1 classCode*: <= MANU consumable classCode*: <= ORG determinerCode*: <= INSTANCE 0..1 manufacturerOrganization name*: ON [1..1] 1..1 manufacturedProduct * typeCode*: <= CSM SubstanceAdministrationStep classCode*: <= SBADM moodCode*: <= x_ActMoodOrdPrmsEvn id*: II [1..1] code*: CE CWE <= SubstanceAdministrationActCode text*: statusCode*: CS CNE [0..1] effectiveTime*: IVL<TS> routeCode: <= RouteOfAdministration doseQuantity: PQ rateQuantity: PQ Slide Number: 35 Organization • A Design Information Model diagrams used a variety of visual tools to document the design. • Entities, Roles, and Acts are represented by rectangular shapes colored Green, Yellow, and Red respectively. • Participations, Role Links, and Act Relationships are represented by arrow shapes colored blue, gold, and pink respectively. • Bold font is used to denote mandatory attributes. © 2014 All Rights Reserved
  • 36. HL7 V3 Modeling Tools Slide Number: 36 © 2014 All Rights Reserved
  • 37. HL7 V3 Modeling Tools RIM RIM Rational Rose RIM R-MIM R-MIM Designer Reference Model Repository RoseTree HMD HMD R-MIM Schema Generator XSD Slide Number: 37 © 2014 All Rights Reserved
  • 38. HL7 Version 3.0 Hierarchical Message Definition An Hierarchical Message Definition is a specification of message elements including a specification of their grouping, sequence, optionality, and cardinality. Slide Number: 38 © 2014 All Rights Reserved
  • 39. Hierarchical Message Definition Slide Number: 39 © 2014 All Rights Reserved
  • 40. Slide Number: 40 Message Type Specification(S) Common Constraints Message Element Specifications Information Model Mapping HMD Components © 2014 All Rights Reserved
  • 41. Slide Number: 41 Message Type Specification(S) Common Constraints Message Element Specifications Mapping to the Information Model HMD Components © 2014 All Rights Reserved
  • 42. HL7 XML Schema Generator HL7 Vocabulary Specification Hierarchical Message Definition HL7 XML Schema Generator XML Schema Specification HL7 Data Type Specification Slide Number: 42 © 2014 All Rights Reserved
  • 43. Sample HL7 Constrained Information Model A_AbnormalityAssessment (COCT_RM420000UV) Description: assessment of clinical findings, including lab test results, for indications of the presence and severity of abnormal conditions AbnormalityAssessment classCode*: = "OBS" moodCode*: = "EVN" code*: CD CWE [1..1] <= V:ObservationType ("ADVERSE_REACTION") statusCode*: CS CNE [1..1] <= V:ActStatusAbortedCancelledCompleted activityTime*: TS.DATETIME [1..1] value: CD CWE [0..1] <= V:AbnormalityAssessmentValue methodCode: SET<CE> CWE [0..*] <= V:AbnormalityAssessmentMethod outcome typeCode*: = "OUTC" contextConductionInd*: BL [1..1] ="true" 1..* assessmentOutcome * AssessmentOutcome AssessmentException classCode*: = "OBS" moodCode*: = "EVN" code*: CD CWE [1..1] <= V:ObservationType ("ASSERTION") value*: SC CWE [1..1] <= V:AssessmentExceptionValue appendageOf AbnormalityGrade typeCode*: = "APND" contextConductionInd*: BL [1..1] ="true" 0..* assessmentOutcomeAnnotation AssessmentOutcomeAnnotation classCode*: = "OBS" moodCode*: = "EVN" code*: CD CWE [1..1] <= V:ObservationType ("ASSERTION") value*: SC CWE [1..1] <= V:AssessmentOutcomeAnnotationValue classCode*: = "OBS" moodCode*: = "EVN" code*: CD CWE [1..1] <= V:ObservationType ("SEV") uncertaintyCode: CE CNE [0..1] <= V:ActUncertainty value*: CD CWE [1..1] <= V:AbnormalityGradeValue Slide Number: 43 © 2014 All Rights Reserved
  • 44. Example Schema Specification Slide Number: 44 © 2014 All Rights Reserved
  • 45. Core Schema • Our generated schema is used in conjunction with core schema specifications provided by HL7. • The core schema specifications include infrastructure root, datatype base, datatype, and vocabulary. • The core schema specification include no domain content. They are present only to facilitate interpretation of datatypes and validation of structural vocabulary. Core Schema Our Schema Include Datatype.XSD Include Include Voc.XSD Slide Number: 45 Infrastructure Root.XSD Include Include Include Datatypebase.XSD © 2014 All Rights Reserved
  • 46. HL7 V3 Message Implementation Technology XML Schema Specification Data Hierarchical Message Definition HL7 Message Creation HL7-Conformant Application Slide Number: 46 Message Instance HL7 Message Parsing Data HL7-Conformant Application © 2014 All Rights Reserved
  • 47. Questions / Discussion Slide Number: 47 © 2014 All Rights Reserved
  • 48. The Family of HL7 Standards • • • • • • • • • • Slide Number: 48 Standardization of knowledge representation (Arden / GELLO) Virtual Medical Record for Clinical Decision Support (vMR-CDS) Specification of components for context management (CMA) Standardization of clinical document structures (CDA) Electronic Health Record System Functional Model (EHR-S) Application protocol for electronic data exchange in healthcare environments (messages) Support for use of healthcare services in a Service Oriented Architecture (SOA) Fast Healthcare Interoperability Resources (FHIR) Specification of robust vocabulary definitions for use in clinical messages and documents Work in the area of security, privacy, confidentiality, and accountability © 2014 All Rights Reserved
  • 49. RIM Derived and Influenced HL7 Standards •  •  •  •  • • Slide Number: 49 Standardization of knowledge representation (Arden / GELLO) Virtual Medical Record for Clinical Decision Support (vMR-CDS) Specification of components for context management (CMA) Standardization of clinical document structures (CDA) Electronic Health Record System Functional Model (EHR-S) Application protocol for electronic data exchange in healthcare environments (messages) Support for use of healthcare services in a Service Oriented Architecture (SOA) Fast Healthcare Interoperability Resources (FHIR) Specification of robust vocabulary definitions for use in clinical messages and documents Work in the area of security, privacy, confidentiality, and accountability © 2014 All Rights Reserved
  • 50. Sample HL7 V3 Clients and Projects Clinical Trial Registration and Results Message Specification Clinical Trial Registration and Results Message Specification UMTS Project Consolidated Dictionary and IHE Content Profile Slide Number: 50 © 2014 All Rights Reserved
  • 51. Clinical Trial Registration and Results Message Specification Slide Number: 51 © 2014 All Rights Reserved
  • 52. CTRR Development Artifacts Slide Number: 52 © 2014 All Rights Reserved
  • 53. Document Identifiers and Keywords Study Protocol Document, Study Description, Features, and Overall Status Study Outcome Measures and Objectives Study Participants Planned Activities, Study Arms, and References Regulatory Authorities, Application Submissions and Authorizations Slide Number: 53 Study Enrollment Stratification and Targets Target Research Products (devices and substances) Study Sites and Study Site Recruitment Activities © 2014 All Rights Reserved
  • 54. RMIM to XSD Slide Number: 54 © 2014 All Rights Reserved
  • 55. Traversing the CTRR RMIM Entry Point Slide Number: 55 © 2014 All Rights Reserved
  • 56. HMD – the RMIM serialized Slide Number: 56 © 2014 All Rights Reserved
  • 57. Study Protocol Document XSD Slide Number: 57 © 2014 All Rights Reserved
  • 58. Subject XSD Slide Number: 58 © 2014 All Rights Reserved
  • 59. Clinical Trial Intent XSD Slide Number: 59 © 2014 All Rights Reserved
  • 60. National Trauma Registry Submission CDA Document Specification Slide Number: 60 © 2014 All Rights Reserved
  • 61. Clinical Document Architecture (CDA) • The HL7 Clinical Document Architecture (CDA) is a document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange. • A clinical document contains observations and services and has the following characteristics: – Persistence – A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements. – Stewardship – A clinical document is maintained by an organization entrusted with its care. – Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated. – Context - A clinical document establishes the default context for its contents. – Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document. – Human readability – A clinical document is human readable. Slide Number: 61 © 2014 All Rights Reserved
  • 62. Clinical Document Architecture RMIM Participating Entities Slide Number: 62 Clinical Document Structured Document Sections Section Entries © 2014 All Rights Reserved
  • 63. NTDB CDA RMIM Subset Patient +recordTarget EntryRelationship ClinicalDocument isSubjectOf 1..* 1 1 0..* 1 0..* 1 +target 1 communicates +nested 0..* +informer Organization 0..* 1..* DocumentSection +source +clinicalStatement 0..* +nesting 0..1 SectionEntry 1..* 0..1 Act Slide Number: 63 Observ ation Encounter Procedure Organizer © 2014 All Rights Reserved
  • 64. From Data Dict. to CDA Impl. Guide Slide Number: 64 © 2014 All Rights Reserved
  • 65. Scope Slide Number: 65 © 2014 All Rights Reserved
  • 66. Implementation Guide Development Slide Number: 66 © 2014 All Rights Reserved
  • 67. DAM: a UML representation of dictionary elements 2.0 Submission:: RegistrySubmissionTransaction 0..1 PreHospitalEcounter + arrivalDateTime :TS [0..1] departureDateTime :TS [0..1] dispatchDateTime :TS [0..1] preHospitalTransportationMethodCode :TransportationMethod [0..*] 0..1 0..1 PreHospitalCirculatorySystemObserv ation PreHospitalRespiratorySystemObserv ation + + + + heartRateAmount :PQ systolicBloodPressureAmount :PQ arterialOxygenSaturationAmount :PQ respiratoryRateAmount :PQ 0..1 PreHospitalNerv ousSystemObserv ation + + + + Slide Number: 67 glasgowComaEyeResponseValue :INT glasgowComaMotorResponseValue :INT glasgowComaScoreValue :INT glasgowComaVerbalResponseCode :INT © 2014 All Rights Reserved
  • 68. Organization of DAM Classes 1.0 Patients + Patient 3.0 Inj ury Ev ents 2.0 Submission + RegistrySubmissionTransaction 4.0 PreHospital Encounters 5.0 Hospital Care Episodes + InjuryEvent + PreHospitalCirculatorySystemObservation + HospitalCareEpisode + InjurySeverityObservation + PreHospitalEcounter + HospitalCirculatorySystemObservation + PreHospitalNervousSystemObservation + HospitalNervousSystemObservation + PreHospitalRespiratorySystemObservation + HospitalPhysiologicalObservation + HospitalRespiratorySystemObservation + 5.1 Emergency Hospital Encounters + 5.2 InpatientHospitalEncounters Slide Number: 68 © 2014 All Rights Reserved
  • 69. Dictionary to DAM Element ID D_01 D_02 D_03 D_04 D_05 D_06 D_07 D_08 D_09 D_10 D_11 D_12 DG_01 DG_02 DG_03 ED_01 ED_02 ED_03 ED_043 ED_05 ED_06 ED_07 ED_08 ED_09 NTDB Dictionary Element D_01: PATIENT’S HOME ZIP CODE D_02: PATIENT’S HOME COUNTRY D_03: PATIENT’S HOME STATE D_04: PATIENT’S HOME COUNTY D_05: PATIENT’S HOME CITY D_06: ALTERNATE HOME RESIDENCE D_07: DATE OF BIRTH D_08: AGE D_09: AGE UNITS D_10: RACE D_11: ETHNICITY D_12: SEX DG_01: CO-MORBID CONDITIONS DG_02: ICD-9 INJURY DIAGNOSES DG_03: ICD-10 INJURY DIAGNOSES ED_01: ED/HOSPITAL ARRIVAL DATE ED_02: ED/HOSPITAL ARRIVAL TIME ED_03: INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE ED_043: INITIAL ED/HOSPITAL PULSE RATE ED_05: INITIAL ED/HOSPITAL TEMPERATURE ED_06: INITIAL ED/HOSPITAL RESPIRATORY RATE ED_07: INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE ED_08: INITIAL ED/HOSPITAL OXYGEN SATURATION ED_09: INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN Slide Number: 69 DAM Package 2.0 Patients 2.0 Patients 2.0 Patients 2.0 Patients 2.0 Patients 2.0 Patients 2.0 Patients 2.0 Patients 2.0 Patients 2.0 Patients 2.0 Patients 2.0 Patients 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes 5.0 Hospital Care Episodes DAM Class Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient HospitalCareEpisode HospitalCareEpisode HospitalCareEpisode HospitalCareEpisode HospitalCareEpisode HospitalCirculatorySystemObservation HospitalCirculatorySystemObservation HospitalPhysiologicalObservation HospitalRespiratorySystemObservation HospitalRespiratorySystemObservation HospitalRespiratorySystemObservation HospitalRespiratorySystemObservation DAM Attribute postalAddress postalAddress postalAddress postalAddress postalAddress residenceStatusCode birthDate eventRelatedAgeQuantity eventRelatedAgeQuantity raceCode ethnicCode genderCode coMorbidConditionCode injuryDiagnosisCode injuryDiagnosisCode arrivalDateTime arrivalDateTime systolicBloodPressureAmount heartRateAmount temperatureAmount respiratoryRateAmount respiratoryAssistanceIndicator arterialOxygenSaturationAmount supplementalOxygenIndicator © 2014 All Rights Reserved
  • 70. CIM: a CDA influenced UML representation of dictionary elements PreHospitalEncounterDetail:: PreHospitalEncounter 1 CDA RMIM RespiratorySystemEntryRelationship + + typeCode :CS = x_ActRelationsh... contextConductionInd :BL = "true" 0..* RespiratorySystemObserv ation 2 Domain Analysis Model + + classCode :CS = "OBS" moodCode :CS = "EVN" Constrained Information Model ArterialOxygenSaturationObserv ation + - code :CD = ObservationType value :PQ ::RespiratorySystemObservation + classCode :CS = "OBS" + moodCode :CS = "EVN" Slide Number: 70 RespiratoryRateObserv ation + - code :CD = ObservationType value :PQ ::RespiratorySystemObservation + classCode :CS = "OBS" + moodCode :CS = "EVN" © 2014 All Rights Reserved
  • 71. Organization of CIM Classes TraumaRegistrySubmissionDocument + HealthcareFacility Patient + RecordTarget + Patient + PatientRole + PatientDetailSection + RegistryParticipant + StructuredBodyComponent + StucturedBody + Submitter + TraumaRegistrySubmissionDocument + Patient + InjuryEventSection (from TraumaRegistrySubmissionDocument) + PreHospital Encounter Section + Hospital Care Episode Section + EntryPoint Inj uryEv entSection PreHospital Encounter Section Hospital Care Episode Section + InjuryEventSection + PreHospitalEncounterSection + HospitalCareEpisodeSection + StructuredBodyInjuryEventComponent + StructoredBodyPreHospitalEncounterComponent + StructuredBodyHospitalCareEpisodeComponent + InjuryEventDetailEntry + PreHospitalEncounterDetail + HospitalCareEpisodeActivityDetail (from TraumaRegistrySubmissionDocument) Slide Number: 71 (from TraumaRegistrySubmissionDocument) (from TraumaRegistrySubmissionDocument) © 2014 All Rights Reserved
  • 72. DAM to CIM DAM Class Patient Patient Patient Patient Patient Patient Patient Patient Patient InjuryEvent InjuryEvent InjuryEvent InjuryEvent InjuryEvent InjuryEvent InjuryEvent InjuryEvent InjuryEvent InjuryEvent InjuryEvent PreHospitalCirculatorySystemObservation PreHospitalCirculatorySystemObservation PreHospitalEncounter PreHospitalEncounter Slide Number: 72 DAM Attribute birthDate ethnicCode eventRelatedAgeQuantity genderCode industryCode occupationCode postalAddress raceCode residenceStatusCode abbreviatedInjuryCode airbagDeploymentCode bodyInjuryRegionCode injurySeverityScoreValue locationTypeCode occurenceDateTime postalAddress primaryInjuryCauseCode safetyEquipmentUsedCode supplementalInjuryCauseCode workRelatedEventInd heartRateAmount systolicBloodPressureAmount arrivalDateTime departureDateTime CIM Class Patient Patient PatientAgeObservation Patient PatientIndustryObservation PatientOccupationObservation PatientRole Patient PatientResidenceStatusObservation AbreviatedInjuryObservation AirbagDeploymentObservation BodyInjuryObservation SeverityScoreObservation LocationTypeObservation InjuryEventAct PostalAddressObservation PrimaryInjuryCauseObservation SafetyEquipmentUsedObservation SupplementalInjuryCauseObservation WorkRelatedObservation HeartRateObservation SystolicBloodPressureObservation PreHospitalEncounter PreHospitalEncounter CIM Attribute birthTime ethnicGroupCode value administrativeGenderCode value value addr raceCode value value value value value value effectiveTime value value value value value value value effectiveTime effectiveTime © 2014 All Rights Reserved
  • 73. IG: Dictionary elements represented as templated CDA constraints CDA RMIM 3 Constrained Information Model NTDB Implementation Guide EMS Implementation Guide Slide Number: 73 © 2014 All Rights Reserved
  • 74. Organization of IG Templates Slide Number: 74 © 2014 All Rights Reserved
  • 75. Organization of IG Templates Name: Author: Version: Created: Updated: TraumaRegistrySubmissionDocument Salimah Shakir 1.0 2/7/2013 9:30:31 PM 6/14/2013 12:01:15 AM Legend HEADER EntryPoint TraumaRegistrySubmissionDocument Patient::PatientRole 1..1 Act Entity 1 Role + + + + - classCode :CS = "DOCCLIN" moodCode :CS = "EVN" id :II code :CE = DocumentType effectiveTime :TS RegistryParticipant + classCode :CS = "ASSIGNED" 1..1 1 Participation 1 1 ActRelationship Submitter StructuredBodyComponent Foriegn Class + + + + typeCode :CS = "COMP" contextConductionInd :BL = "true" typeCode :CS = "INF" contextControlCode :CS = "OP" 1..1 Patient 1..1 HealthcareFacility StucturedBody + RecordTarget + + + Patient + + - classCode :CS = "DOCBODY" moodCode :CS = "EVN" + PatientRole classCode :CS = "ORG" determinerCode :CS = "INSTANCE" id :II + PatientDetailSection 1 1 1 1 BODY 1..1 1..1 PatientDetailSection::PatientDetailSection PatientDetailSection Inj uryEv entSection::Inj uryEv entSection Inj uryEv entSection 0..1 PreHospital Encounter Section:: PreHospitalEncounterSection PreHospital Encounter Section 1..1 Hospital Care Episode Section:: HospitalCareEpisodeSection Hospital Care Episode Section + PatientDetailSection + InjuryEventSection + PreHospitalEncounterSection + HospitalCareEpisodeSection + StucturedBodyPatientDetailComponent + StructuredBodyInjuryEventComponent + StructoredBodyPreHospitalEncounterComponent + StructuredBodyHospitalCareEpisodeComponent + PatientDemographicObservation + InjuryEventDetailEntry + PreHospitalEncounterDetail + HospitalCareEpisodeActivityDetail + PatientEmploymentObservation (from Patient) Slide Number: 75 ENTRIES © 2014 All Rights Reserved
  • 76. Dict to DAM to CIM to IG NTDB Dictionary Element D_01: PATIENT’S HOME ZIP CODE D_02: PATIENT’S HOME COUNTRY D_03: PATIENT’S HOME STATE D_04: PATIENT’S HOME COUNTY D_05: PATIENT’S HOME CITY D_06: ALTERNATE HOME RESIDENCE D_07: DATE OF BIRTH D_08: AGE D_09: AGE UNITS D_10: RACE D_11: ETHNICITY D_12: SEX DG_01: CO-MORBID CONDITIONS DG_02: ICD-9 INJURY DIAGNOSES DG_03: ICD-10 INJURY DIAGNOSES ED_01: ED/HOSPITAL ARRIVAL DATE ED_02: ED/HOSPITAL ARRIVAL TIME ED_03: INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE ED_043: INITIAL ED/HOSPITAL PULSE RATE ED_05: INITIAL ED/HOSPITAL TEMPERATURE ED_06: INITIAL ED/HOSPITAL RESPIRATORY RATE ED_07: INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE ED_08: INITIAL ED/HOSPITAL OXYGEN SATURATION ED_09: INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN Slide Number: 76 CDA Template 3.1 Trauma Registry Submission Document 3.1 Trauma Registry Submission Document 3.1 Trauma Registry Submission Document 3.1 Trauma Registry Submission Document 3.1 Trauma Registry Submission Document 5.3 Patient Demographic Observations Organizer 3.1 Trauma Registry Submission Document 5.3 Patient Demographic Observations Organizer 5.3 Patient Demographic Observations Organizer 5.3 Patient Demographic Observations Organizer 3.1 Trauma Registry Submission Document 3.1 Trauma Registry Submission Document 6.5 Hospital Care Episode Observation Organizer 6.5 Hospital Care Episode Observation Organizer 6.5 Hospital Care Episode Observation Organizer 5.1 Hospital Care Episode Encounter 5.1 Hospital Care Episode Encounter 6.1 Circulatory System Observation Entry 6.1 Circulatory System Observation Entry 6.7 Hospital Care Physiological Observation 6.16 Respiratory System Observation Entry 6.15 Respiratory System Observation 6.16 Respiratory System Observation Entry 6.15 Respiratory System Observation CDA ITEM CDA Clone 8.c.111 8.c.111 8.c.111 8.c.111 8.c.111 42.c.iv 8.c.iv.4 43.c.iv 43.c.iv.1 44.c.iv 8.c.iv.5 8.c.iv.3 84.c.iv 85.c.iv 85.c.iv 31 31 63.c.iv 62.c.iv 100.c.iv 145.c.iv 140.c.iv 144.c.iv 141.c.iv patientRole patientRole patientRole patientRole patientRole observation patient observation observation observation patient patient observation observation observation encounter encounter observation observation observation observation observation observation observation CDA Attribute CDA CONF addr addr addr addr addr value birthTime value value@unit value ethnicGroupCode administrativeGenderCode value value value effectiveTime effectiveTime value value value value value value value 27773 27773 27773 27773 27773 30000 27776 30008 30455 30508 27778 27775 30385 30397 30397 30341 30341 29639 29633 30431 30092 30437 30085 30441 © 2014 All Rights Reserved
  • 77. Trauma Registry Data Submission IG Slide Number: 77 © 2014 All Rights Reserved
  • 78. Front Matter: Introduction and Specification Overview 78 Slide Number: 78 © 2014 All Rights Reserved
  • 79. Conformance Verbs 79 • The conformance verb keyword at the start of a constraint ( SHALL , SHOULD , MAY, etc.) indicates usage conformance. – SHALL is an indication that the constraint is to be enforced without exception; – SHOULD is an indication that the constraint is optional but highly recommended; and – MAY is an indication that the constraint is optional and that adherence to the constraint is at the discretion of the document creator. Slide Number: 79 © 2014 All Rights Reserved
  • 80. Cardinality 80 • The cardinality indicator (0..1, 0..*, 1..1, 1..*, etc.) specifies the allowable occurrences within an instance. • Thus, " MAY contain 0..1" and " SHOULD contain 0..1" both allow for a document to omit the particular component, but the latter is a stronger recommendation that the component be included if it is known. • The following cardinality indicators may be interpreted as follows: – – – – – 0..1 as contains zero or one 1..1 as contains exactly one 2..2 as contains exactly two 1..* as contains one or more 0..* as contains zero or more • Each constraint is uniquely identified (e.g., "CONF:605") by an identifier placed at or near the end of the constraint. Slide Number: 80 © 2014 All Rights Reserved
  • 81. Value Set Binding • Value set bindings adhere to HL7 Vocabulary Working Group best practices, and include both a conformance verb ( SHALL , SHOULD , MAY, etc.) and an indication of DYNAMIC vs. STATIC binding. • The use of SHALL requires that the component be valued with a member from the cited value set; however, in every case any HL7 "null" value such as other (OTH) or unknown (UNK) may be used. • STATIC binding means that the allowed values of the value set do not change automatically as new values are added to a value set. That is, the binding is to a single version of a value set. • DYNAMIC binding means that the intent is to have the allowed values for a coded item automatically change (expand or contract) as the value set is maintained over time. Slide Number: 81 © 2014 All Rights Reserved
  • 82. Templates Slide Number: 82 © 2014 All Rights Reserved
  • 83. Document Template 83 Slide Number: 83 © 2014 All Rights Reserved
  • 84. Section Templates Slide Number: 84 © 2014 All Rights Reserved
  • 85. Entry Templates Slide Number: 85 © 2014 All Rights Reserved
  • 86. Subentry Templates Slide Number: 86 © 2014 All Rights Reserved
  • 87. Vocabulary Tables Slide Number: 87 © 2014 All Rights Reserved
  • 88. Implementation Guide Development Slide Number: 88 © 2014 All Rights Reserved
  • 89. From Data Dict. to CDA Impl. Guide Slide Number: 89 © 2014 All Rights Reserved
  • 90. UMTS Project Consolidated Dictionary and IHE Content Profile Development Slide Number: 90 © 2014 All Rights Reserved
  • 91. UMTS Project Activities Registry Elements Semantic Analysis 1 00069 Dose Amount 00147 Duration 00070 Start Date Time 00306 Stop Date Time MedicationTypeCode Consolidated Dictionary Initial Bolus 00776 Route 00307 Medication 2 DEI Dictionary Element 00112 REI Cardiac Arrest Indicator Registry Element Name Action.4135 RE Section Coding Instructions Context Timing Action.4140 Cardiac Arrest Pre-Hospital Action.4145 Cardiac Arrest Outside Facility Cardiac Arrest Indicator Action.9035 Cardiac Arrest H. In-Hospital Clinical Events Indicate if the patient experienced an episode of cardiac arrest in your facility. Cardiac Arrest Indicator CathPCI.5065 Cardiac Arrest w/in 24 Hours D. Cath Lab Visit Indicate if the patient has had an episode of cardiac arrest within 24 hours of procedure. Cardiac Arrest Indicator ICD.4080 Cardiac Arrest Pre-Hospital C. History and Risk Factors Indicate if the patient experienced cardiac arrest due to arrhythmia. History and Risk Factors VTach/VFib Arrest Indicator ICD.4090 VTach/VFib Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of ventricular tachycardia or ventricular fibrillation. History and Risk Factors Bradycardia Arrest Indicator ICD.4095 Bradycardia Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of bradycardia. History and Risk Factors 00112 Cardiac Arrest Indicator ICD.8005 Cardiac Arrest H. Intra or Post Procedure Events Indicate if the patient experienced cardiac arrest. Intra or Post Procedure 00112 Cardiac Arrest Indicator Impact.8000 Cardiac Arrest L. Intra and Post-Procedure Events Indicate if there was a cardiac arrest event that required CPR. Intra or Post Procedure 00112 q24hr Within 2 weeks Cause Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode First Medical Contact of cardiac arrest. Cardiac Arrest Indicator 00102 00238 Frequency MedicationAdministration Cardiac Arrest Indicator 00112 00800 q12hr 00112 00112 Initial Infusion 00112 00112 MedicationClassCode Standard Clinical Code Systems Location C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was First Medical Contact prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility. C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest First Medical Contact occurred at the outside facility. Cardiac Arrest Indicator TVT.5035 D. Pre-Procedure Status Indicate if the patient has had an episode of cardiac arrest within 24 hours of the procedure. within 24 hours of the procedure First 24 Hours PreHospital Outside Facility In Hospital within 24 hours of procedure Pre-Hospital Administered Pre-Encounter Timing Intra-Encounter 00423 Status Not Administered Blinded 00303 Dose Code Pre-Procedure Intra-Procedure ventricular tachycardia or ventricular fibrillation bradycardia Contraindicated At Discharge Full Reduced Cardiac Arrest w/in 24 Hours Other During Follow-up 3 Conceptual Data Model HL7 Reference Models 01.0 Submissions::ParticipantIdentifier + 01.0 Submissions::SourceSystem identifierValue :ST identifierTypeCode :ParticipantIdentifier - versionIdentifier :ST - 1 identifies originates from 01.0 Submissions::Submission 01.0 Submissions::Participant - submited by name :ST - 1..* + + trialTypeCode :CD researchStudyName :ST 1 identifier :ST submissionTimePeriod :TS.DATE (IVL) 1..* submissionDateTime :TS 01.0 Submissions::Registry submited to 1 - 05.0 Ev ents::Ev entEv entRelation identifier :ST {id} versionIdentifier :ST {id} + Name: Author: Version: Created: Updated: has target 0..* + 0..* + 1 is part of 1 - 0..* 1 Procedure methodCode : SET<CE> approachSiteCode : SET<CD> targetSiteCode : SET<CD> has subject name :EN.PN birthDate :TS.DATE sexCode :CD hispanicIndicator :BL = No ethnicityDetailCode :CD [0..*] (SET) postalZoneIdentifier :II residenceCountryCode :CD indicationCode :CD [0..1] abortedReasonCode :CD [0..*] + ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is a type of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 1 1 1..* InvoiceElement modifierCode : SET<CE> unitQuantity : RTO<PQ,PQ> unitPriceAmt : RTO<MO,PQ> netAmt : MO factorNumber : REAL pointsNumber : REAL is part of 0..* 1 - identifier :II typeCode :CD manufacturerName :EN.ON deviceName :ST universalDeviceIdentifier :II [0..1] 0..1 is part of administers - deviceCounter :INT is part of 0..* 06.0 Lesions::LesionTreatmentDetail - 1..* 0..* - identifierValue :II identifierTypeCode :PatientIdentifier ::ObservationEvent + observationTypeCode :CD 10.0 Medication Administration Ev ents:: Medication 02.0 Patients::PatientRace 02.0 Patients::PatientIdentifier + raceCode :CD raceDetailCode :CD [0..*] (SET) + - 09.0 Procedures::ProcedureVascularAssessment previouslyTreatedIndicator :BL = No culpritLesionIndicator :BL = No - vesselNotAvailableIndicator :BL = No 09.0 Procedures::ArterialAccess 09.0 Procedures::ArterialClosure is part of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 0..1 1 0..* ::ObservationEvent + observationTypeCode :CD ::ObservationEvent + observationTypeCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] medicationCode :CD name :ST - siteCounter :INT directionalityTypeCode :CD [0..1] vesselCode :CD 1..* {ordered} - arterialClosureCounter :INT {id} methodCode :CD [0..1] undocumentedIndicator :BL = No 0..* 0..* 0..* has target is part of is treatment of 1 06.0 Lesions::LesionTreatmentDev ice Account name : ST balanceAmt : MO currencyCode : CE interestRateQuantity : RTO<MO,PQ> allowedBalanceQuantity : IVL<MO> 1 1 06.0 Lesions::Lesion 06.0 Lesions::LesionAffectedVesselSegment deviceCounter :INT - lesionCounter :INT {id} 0..* 04.0 Observ ations::Inv olv edAnatomicSite is located in 0..* - 1 lesionLocationCode :CD segmentCounter :INT involved 1 - 0..* typeCode :CD lateralityCode :CD 1 0..* is a type of + involvementTypeCode :InvolvementType is a type of is a type of Refers to (1..1) 07.0 Devices :: Device 1 08.0 AnatomicSites::AnatomicSite affecting - 0..* 06.0 Lesions::LesionDescriptor 08.0 AnatomicSites::VesselSegment Primary Class FinancialTransaction amt : MO creditExchangeRateQuantity : REAL debitExchangeRateQuantity : REAL - ::ObservationEvent + observationTypeCode :CD - is part of ::AnatomicSite - typeCode :CD - lateralityCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] Dependant Classes Value Sets 08.0 AnatomicSites::AnatomicRegion cardiovascularVesselCode :CD {id} vesselTypeCode :CD is part of ::AnatomicSite - typeCode :CD - lateralityCode :CD 0..* anotomicRegionCode :CD 0..1 ::AnatomicSite - typeCode :CD - lateralityCode :CD 0..* +subsection 0..* graftTypeCode :CD 4 Constrained Information Model (Observ ation) ParticipantIdentifierObserv ation (Section) RegistryParticipantDetailSection (Patient) Patient + + + + # classCode :CS = "PSN" determinerCode :CS = "INSTANCE" (Patient.name) name :EN.PN (Patient.sexCode) administrativeGenderCode :CD (Patient.birthDate) birthTime :TS.DATE (Patient.hispanicIndicator) ethnicGroupCode :CD classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "RegistryPartic... # + 1..* 1 classCode :CS = "OBS" moodCode :CS = "EVN" (ParticipantIdentifier.typeCode) code :CD (ParticipantIdentifier.identifierValue) value :CD (Entry) ParticipantIdentifierObserv ationEntry 1..1 - ii. This observationThe entryRelationship, one [1..1] @moodCode="EVN" b. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31970). @contextConductionInd="true" (CONF:31967). (CONF:31969). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 5 iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972). ::CardiovascularVessel - cardiovascularVesselCode :CD {id} - vesselTypeCode :CD ::AnatomicSite - typeCode :CD - lateralityCode :CD HL7 Clinical Document Architecture RMIM iii. This observationThe entryRelationship, one [1..1] code (CONF:31971). one [1..1] observation c. SHALL contain exactly if present, SHALL contain exactly iv. This observation(CONF:31968). exactly one [1..1] value with @xsi:type="CD" SHALL contain (CONF:31972). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970). 08.0 AnatomicSites::Cardiov ascularGraft - Contains: 6. SHALL contain zeroSHALL containeffectiveTime (CONF:31963). Table 1: ClincalEventObservationSubEntry Contexts 1. or one [0..1] exactly one [1..1] @classCode="OBS" (CONF:31958). 7. SHALL contain exactly one [1..1] value (CONF:31964). 2. SHALL containContained By: exactly one [1..1] @moodCode="EVN" (CONF:31959). Contains: 8. MAY contain zero or more [0..*] zero or one [0..1] @negationInd (CONF:31960). 3. MAY contain entryRelationship (CONF:31965). a. The entryRelationship, if present,one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 4. SHALL contain exactly SHALL contain exactly one [1..1] This @typeCode="OPTN" (CONF:31966). template is used to collect clinical event observations made within the scope of the (CONF:31961). encounter. Observations may be modified by observational semantic qualifiers. b. The entryRelationship, if present,one [1..1] code exactly one [1..1] 5. SHALL contain exactly SHALL contain (CONF:31962). @contextConductionInd="true" SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). 1. (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). c. The entryRelationship, if present,one [1..1] valueexactlyone [1..1] observation 2. SHALL contain (CONF:31964). 7. SHALL contain exactly SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). (CONF:31968). 3. MAY contain zero or one [0..1] @negationInd 8. MAY contain zero or more [0..*] entryRelationship (CONF:31965). (CONF:31960). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 4. SHALL if present, SHALL contain exactly one [1..1] a. The entryRelationship, contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31969). (CONF:31961). @typeCode="OPTN" (CONF:31966). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" 5. SHALL if present, SHALL contain exactly one [1..1] b. The entryRelationship, contain exactly one [1..1] code (CONF:31962). (CONF:31970). @contextConductionInd="true" (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). c. The entryRelationship, contain exactly one [1..1] value (CONF:31964). if present, SHALL contain exactly one [1..1] observation 7. SHALL iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31968). MAY contain zero or more [0..*] entryRelationship (CONF:31965). 8. (CONF:31972). i. This observationThe entryRelationship, one [1..1] @classCode="OBS" a. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31969). @typeCode="OPTN" (CONF:31966). (CONF:31969). is grouped by is a type of Foreign Classes 08.0 AnatomicSites::Cardiov ascularVessel vesselSegmentCode :CD {id} Contained By: ii. This observationThe entryRelationship, one [1..1] @moodCode="EVN" b. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31970). @contextConductionInd="true" (CONF:31967). iii. This observationThe entryRelationship, one [1..1] code (CONF:31971). one [1..1] observation c. SHALL contain exactly if present, SHALL contain exactly iv. This observation(CONF:31968). exactly one [1..1] value with @xsi:type="CD" SHALL contain (CONF:31972). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 0..* is treated by Contains: 1 3. MAY contain zero or one [0..1] @negationInd (CONF:31960). 4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 1.1 ClincalEventObservationSubEntry (CONF:31961).This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 5. SHALL contain exactly one [1..1] code (CONF:31962). Contains: 7. SHALL contain exactly one [1..1] value (CONF:31964). 2. SHALL containContained By: exactly one [1..1] @moodCode="EVN" (CONF:31959). Contains: 8. MAY contain zero or more [0..*] zero or one [0..1] @negationInd (CONF:31960). 3. MAY contain entryRelationship (CONF:31965). a. The entryRelationship, if present,one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 4. SHALL contain exactly SHALL contain exactly one [1..1] This @typeCode="OPTN" (CONF:31966). template is used to collect clinical event observations made within the scope of the (CONF:31961). encounter. Observations may be modified by observational semantic qualifiers. b. The entryRelationship, if present,one [1..1] code exactly one [1..1] 5. SHALL contain exactly SHALL contain (CONF:31962). @contextConductionInd="true" SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). 1. (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). c. The entryRelationship, if present,one [1..1] valueexactlyone [1..1] observation 2. SHALL contain (CONF:31964). 7. SHALL contain exactly SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). (CONF:31968). 3. MAY contain zero or one [0..1] @negationInd 8. MAY contain zero or more [0..*] entryRelationship (CONF:31965). (CONF:31960). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 4. SHALL if present, SHALL contain exactly one [1..1] a. The entryRelationship, contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31969). (CONF:31961). @typeCode="OPTN" (CONF:31966). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" 5. SHALL if present, SHALL contain exactly one [1..1] b. The entryRelationship, contain exactly one [1..1] code (CONF:31962). (CONF:31970). @contextConductionInd="true" (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). c. The entryRelationship, contain exactly one [1..1] value (CONF:31964). 7. SHALL if present, SHALL contain exactly one [1..1] observation iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31968). MAY contain zero or more [0..*] entryRelationship (CONF:31965). 8. (CONF:31972). i. This observationThe entryRelationship, one [1..1] @classCode="OBS" a. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31969). @typeCode="OPTN" (CONF:31966). 1 0..* Legend Diet energyQuantity : PQ carbohydrateQuantity : PQ is use of 0..* ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 1 09.0 Procedures::ArterialClosureDev ice identifies Table 1: ClincalEventObservationSubEntry Contexts SUBENTRY 1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 2. SHALL contain exactly one [1..1] @moodCode="EVN" R Y S U B E N T (CONF:31959). 1 6. SHALL contain zeroSHALL containeffectiveTime (CONF:31963). Table 1: ClincalEventObservationSubEntry Contexts 1. or one [0..1] exactly one [1..1] @classCode="OBS" (CONF:31958). 07.0 Dev ices::Dev ice ::ObservationEvent + observationTypeCode :CD is use by ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 1 is part of Supply quantity : PQ expectedUseTime : IVL<TS> procedureTypeCode :CD ::Intervention - indicationCode :CD [0..1] - abortedReasonCode :CD [0..*] is a type of deviceCounter :INT {id} statusCode :CD abortedReasonCode :CD [0..1] is use of 1 + has subject 1..* - ::Intervention - indicationCode :CD [0..1] - abortedReasonCode :CD [0..*] 02.0 Patients::Patient 0..1 0..* 09.0 Procedures::ProcedureDev iceUse 09.0 Procedures::Procedure - 1 1.1 ClincalEventObservationSubEntry This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 3. MAY contain zero or one [0..1] @negationInd (CONF:31960). 4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 1.1 ClincalEventObservationSubEntry (CONF:31961).This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 5. SHALL contain exactly one [1..1] code (CONF:31962). Contained By: involving 0..* 02.0 Patients::ResearchStudyEnrollment [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] Contained By: Contains: 2. SHALL contain exactly one [1..1] @moodCode="EVN" R Y S U B E N T (CONF:31959). 0..* is part of 0..* enrolledIndicator :BL = No SUBENTRY 1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is referred to by (0..*) 06.0 Lesions :: LesionTreatmentDevice 1 - 1 1.1 ClincalEventObservationSubEntry This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 1 05.0 Events::Intervention 0..* DiagnosticImage subjectOrientationCode : CE Contained By: observationResultTypeCode :CD conditionOnsetDateTime :TS [0..1] +child estimatedOnsiteDateIndicator :BL = No 0..* missingOnsetTimeIndicator :BL = No observationValue :ANY observationValueNegationIndicator :BL = No 07.0 Dev ices::Dev iceDescriptor ::ObservationEvent + observationTypeCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 09.0 Procedures::ProcedureLesion Observation value : ANY interpretationCode : SET<CE> methodCode : SET<CE> targetSiteCode : SET<CD> 0..* + is part of ::ObservationEvent + observationTypeCode :CD 10.0 Medication Administration Ev ents:: MedicationAdministrationEv ent SUBENTRY ClincalEventObservationSubEntry Table 1: ClincalEventObservationSubEntry Contexts is grouped by +parent 0..1 04.0 Observ ations::Observ ationResult 04.0 Observ ations:: Observ ationEv ent observationTypeCode :CD 0..* relationshipTypeCode :RelationshipType is a type of 1 1 1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] name :EN.PN identifier :II isCertifiedIndicator :BL = No 0..* + ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is a type of 09.0 Procedures::ProcedureDescriptor 0..* 03.0 CareEpisodes::Ev entEpisodeRelation + SUBENTRY performed by 0..* methodCode :CD [0..*] (SET) classificationCode :Clasification contextCode :Context eventDateTime :TS [0..1] (IVL) statusCode :CD = Completed eventDuration :PQ.TIME [0..1] has source has target within context of 1 SubstanceAdministration routeCode : CE approachSiteCode : SET<CD> doseQuantity : IVL<PQ> rateQuantity : IVL<PQ> doseCheckQuantity : SET<RTO> maxDoseQuantity : SET<RTO> substitutionCode : CE PublicHealthCase PatientEncounter detectionMethodCode : CE preAdmitTestInd : BL transmissionModeCode : CE admissionReferralSourceCode : CE diseaseImportedCode : CE lengthOfStayQuantity : PQ dischargeDispositionCode : CE specialCourtesiesCode : SET<CE> specialAccommodationCode : SET<CE> acuityLevelCode : CE 1.1 NCDR DAM Classes Salimah Shakir 1.0 11/12/2012 7:02:00 PM 8/26/2013 1:05:44 PM 1 05.0 Ev ents::Ev ent arrivalDateTime :TS dischargeDate :TS.DATE payorTypeCode :CD [1..*] (SET) admissionSourceCode :CD dischargeDispositionCode :CD 1 has source is grouped by 0..* - 05.0 Ev ents::Ev entPerformer relationshipTypeCode :RelationshipType 0..* 03.0 CareEpisodes::CareEpisode 02.0 Patients::ClinicalTrial Registry Specific Business Rules identifier :ST {id} is used by salaryTypeCode : CE salaryQuantity : MO hazardExposureText : ED protectiveEquipmentText : ED 0..n LanguageCommunication languageCode : CE modeCode : CE proficiencyLevelCode : CE preferenceInd : BL 1 has subject formCode : CE ManufacturedMaterial lotNumberText : ST expirationTime : IVL<TS> stabilityTime : IVL<TS> Container Device capacityQuantity : PQ manufacturerModelName : SC heightQuantity : PQ softwareName : SC localRemoteControlStateCode : CE ... diameterQuantity : PQ capTypeCode : CE alertLevelCode : CE separatorTypeCode : CE lastCalibrationTime : TS barrierDeltaQuantity : PQ bottomDeltaQuantity : PQ HL7 & IHE Content Profiles 01.0 Submissions::SourceSystemProv ider provided by 1..* 1 is part of ActRelationship typeCode : CS inversionInd : BL outboundRelationship contextControlCode : CS Access LicensedEntity 0..n contextConductionInd : BL approachSiteCode : CD recertificationTime : TS sequenceNumber : INT targetSiteCode : CD 1 source priorityNumber : INT gaugeQuantity : PQ pauseQuantity : PQ Act Participation checkpointCode : CS classCode : CS Entity typeCode : CS Role splitCode : CS moodCode : CS functionCode : CD classCode : CS player joinCode : CS classCode : CS id : SET<II> contextControlCode : CS determinerCode : CS negationInd : BL 0..1 code : CD 0..n id : SET<II> sequenceNumber : INT id : SET<II> 0..n conjunctionCode : CS negationInd : BL 1 playedRolecode : CE negationInd : BL code : CE localVariableName : ST negationInd : BL 1 derivationExpr : ST quantity : SET<PQ> 0..n noteText : ED seperatableInd : BL addr : BAG<AD> text : ED time : IVL<TS> name : BAG<EN> telecom : BAG<TEL> 0..n statusCode : SET<CS> modeCode : CE desc : ED statusCode : SET<CS> effectiveTime : GTS inboundRelationship awarenessCode : CE statusCode : SET<CS> scopedRole effectiveTime : IVL<TS> activityTime : GTS signatureCode : CE existenceTime : IVL<TS> 0..n certificateText : ED target availabilityTime : TS signatureText : ED telecom : BAG<TEL> quantity : RTO 0..1 priorityCode : SET<CE> performInd : BL riskCode : CE 1 positionNumber : LIST<INT> scoper substitutionConditionCode : CE confidentialityCode : SET<CE> ... handlingCode : CE repeatNumber : IVL<INT> DeviceTask 1 target 1source interruptibleInd : BL 1 parameterValue : LIST<ANY> levelCode : CE inboundLink WorkingList 0..n outboundLink 0..n independentInd : BL Employee ownershipLevelCode : CE RoleLink uncertaintyCode : CE FinancialContract jobCode : CE typeCode : CS reasonCode : SET<CE> paymentTermsCode : CE jobTitleName : SC effectiveTime : IVL<TS> languageCode : CE jobClassCode : CE Material treated NonPersonLivingSubject strainText : ED genderStatusCode : CE ManagedParticipation id : SET<II> statusCode : SET<CS> assigns LivingSubject administrativeGenderCode : CE birthTime : TS deceasedInd : BL deceasedTime : TS multipleBirthInd : BL multipleBirthOrderNumber : INT organDonorInd : BL Patient confidentialityCode : CE veryImportantPersonCode : CE is a trait of Person addr : BAG<AD> maritalStatusCode : CE educationLevelCode : CE raceCode : SET<CE> disabilityCode : SET<CE> livingArrangementCode : CE religiousAffiliationCode : CE ethnicGroupCode : SET<CE> Place mobileInd : BL addr : AD directionsText : ED positionText : ED gpsText : ST 1..* 1 0..* Organization addr : BAG<AD> standardIndustryClassCode : CE iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972). UMTS CDA Template Library 6 Registry Specific Content Profiles 1 SUBENTRY 1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] 1 (StructuredBodyComponent) RegistryParticipantDetailComponent Entry Point (ClinicalDocumentComponent) DocumentComponent (RecordTarget) RecordTarget - isPlayedBy classCode :CS = "PAT" (PatientIdentifier.identifierValue) id :II - typeCode :CS = "RCT" contextControlCode :CS = "OP" - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" Table 1: ClincalEventObservationSubEntry Contexts (Entry) PatientIdentifierObserv ationEntry typeCode :CS = "COMP" contextConductionIndicator :BL = "true" - Contained By: typeCode :CS = "COMP" contextConductionIndicator :BL = "true" (ClinicalDocument) CathPCIRegistryDocument 1..1 1 + # + classCode :CS = "DOCCLIN" moodCode :CS = "EVN" id :II code :CE = "CATHPCI" effectiveTime :TS - 1..1 (Observ ation) PatientIdentifierObserv ation (Section) PatientDetailSection (StructuredBody) DocumentBody 1 classCode :CS = "DOCBODY" moodCode :CS = "EVN" 1..1 1 # classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "PatientDetail" 1 0..* # + classCode :CS = "OBS" moodCode :CS = "EVN" (PatientIdentifier.typeCode) code :CD (PatientIdentifier.identifierValue) value :CD 1 1 1 (StructuredBodyComponent) PatientDetailComponent (StructuredBodyComponent) SubmissionDetailComponent (Custodian) Custodian - - typeCode :CS = "CST" - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" (Entry) PatientRaceObserv ationEntry typeCode :CS = "COMP" contextConductionIndicator :BL = "true" - 1..1 typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1..1 1..1 (CustodianOrganization) Participant + + classCode :CS = "ORG" determinerCode :CS = "INSTANCE" (ParticipantIdentifier.identifierValue) id :II (Participant.name) name :EN.ON (Section) SubmissionDetailSection (AssignedCustodian) ParticipantRole isScopedBy 1 1..1 - # classCode :CS = "ASSIGNED" (Observ ation) PatientRaceObserv ation classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "SubmissionDetail" # + 1 classCode :CS = "OBS" moodCode :CS = "EVN" code :CD = "PatientRace" (PatientRace.raceCode) value :CD [1..*] (SET) (Entry) SubmissionActEntry - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1..1 (Act) SubmissionAct + + classCode :CS = "ACT" moodCode :CS = "EVN" (Submission.identifier) id :II (Submission.submissionTimePeriod) effectiveTime :TS (IVL) (ParticipantRole) TargetRegistry 1 1..1 - classCode :CS = "MMAT" 1..1 1 (ClinicalStatementParticipant) Author - (ClinicalStatementParticipant) Receiv er typeCode :CS = "AUT" contextControlCode :CS = "OP" - isPlayedBy typeCode :CS = "RCV" contextControlCode :CS = "OP" 1..1 1 (Dev ice) DataCollectionSystem + classCode :CS = "DEV" determinerCode :CS = "INSTANCE" (SourceSystem.versionIdentifier) id :II (ParticipantRole) SourceSystem isPlayedBy 1 1..1 - 1 SUBENTRY Contains: 1.1 ClincalEventObservationSubEntry This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 1 1..1 (PatientRole) PatientRole + (Dev ice) RegistrySystem classCode :CS = "MMAT" + + isScopedBy classCode :CS = "DEV" determinerCode :CS = "INSTANCE" (Registry.identifier) id.root :II.root (RegistryVersionIdentifier) id.extension :II.extension 1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 1 2. SHALL contain exactly one [1..1] @moodCode="EVN" R Y S U B E N T (CONF:31959). Contained By: Contains: 3. MAY contain zero or one [0..1] @negationInd (CONF:31960). 4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 1.1 ClincalEventObservationSubEntry (CONF:31961).This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 5. SHALL contain exactly one [1..1] code (CONF:31962). 6. SHALL contain zeroSHALL containeffectiveTime (CONF:31963). Table 1: ClincalEventObservationSubEntry Contexts 1. or one [0..1] exactly one [1..1] @classCode="OBS" (CONF:31958). 7. SHALL contain exactly one [1..1] value (CONF:31964). 2. SHALL containContained By: exactly one [1..1] @moodCode="EVN" (CONF:31959). Contains: 8. MAY contain zero or more [0..*] zero or one [0..1] @negationInd (CONF:31960). 3. MAY contain entryRelationship (CONF:31965). a. The entryRelationship, if present,one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 4. SHALL contain exactly SHALL contain exactly one [1..1] This @typeCode="OPTN" (CONF:31966). template is used to collect clinical event observations made within the scope of the (CONF:31961). encounter. Observations may be modified by observational semantic qualifiers. b. The entryRelationship, if present,one [1..1] code exactly one [1..1] 5. SHALL contain exactly SHALL contain (CONF:31962). @contextConductionInd="true" SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). 1. (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). c. The entryRelationship, if present,one [1..1] valueexactlyone [1..1] observation 2. SHALL contain (CONF:31964). 7. SHALL contain exactly SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). (CONF:31968). 3. MAY contain zero or one [0..1] @negationInd 8. MAY contain zero or more [0..*] entryRelationship (CONF:31965). (CONF:31960). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 4. SHALL if present, SHALL contain exactly one [1..1] a. The entryRelationship, contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31969). (CONF:31961). @typeCode="OPTN" (CONF:31966). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" 5. SHALL if present, SHALL contain exactly one [1..1] b. The entryRelationship, contain exactly one [1..1] code (CONF:31962). (CONF:31970). @contextConductionInd="true" (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). c. The entryRelationship, contain exactly one [1..1] value (CONF:31964). 7. SHALL if present, SHALL contain exactly one [1..1] observation iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31968). MAY contain zero or more [0..*] entryRelationship (CONF:31965). 8. (CONF:31972). i. This observationThe entryRelationship, one [1..1] @classCode="OBS" a. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31969). @typeCode="OPTN" (CONF:31966). ii. This observationThe entryRelationship, one [1..1] @moodCode="EVN" b. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31970). @contextConductionInd="true" (CONF:31967). iii. This observationThe entryRelationship, one [1..1] code (CONF:31971). one [1..1] observation c. SHALL contain exactly if present, SHALL contain exactly iv. This observation(CONF:31968). exactly one [1..1] value with @xsi:type="CD" SHALL contain (CONF:31972). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972). (Entity) SourceSystemProv ider + Slide Number: 91 classCode :CS = "ORG" determinerCode :CS = "INSTANCE" (SourceSystemProvider.identifier) id :II © 2014 All Rights Reserved
  • 92. 1. Semantic Analysis Registry Elements Topic Area Mind Map 00069 Dose Amount 00147 Duration 00070 Start Date Time 00306 Stop Date Time MedicationTypeCode Initial Bolus 00776 Route MedicationClassCode 00307 Medication Initial Infusion q12hr 00238 Frequency MedicationAdministration q24hr Within 2 weeks First 24 Hours Administered Pre-Encounter Intra-Encounter Timing 00423 Status Intra-Procedure At Discharge Not Administered Blinded 00303 Dose Code Pre-Procedure Contraindicated Full Reduced Other During Follow-up Decompose composite registry elements Into interrelated atomic concepts Slide Number: 92 © 2014 All Rights Reserved
  • 93. 2. Terminology Definition Topic Area Mind Map 00069 Dose Amount 00147 Duration 00070 Start Date Time 00306 Stop Date Time MedicationTypeCode Consolidated Dictionary DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context 00112 Cardiac Arrest Indicator Action.4135 Cardiac Arrest Indicator Action.4140 Cardiac Arrest Pre-Hospital 00112 Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility 00112 Cardiac Arrest Indicator Action.9035 Cardiac Arrest 00112 Cardiac Arrest Indicator 00112 Cardiac Arrest Indicator 00800 00102 Timing Location Cause Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode First Medical Contact of cardiac arrest. 00112 Initial Bolus Standard Clinical Code Systems 00776 Route MedicationClassCode 00307 Medication Initial Infusion C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was First Medical Contact prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility. C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest First Medical Contact occurred at the outside facility. PreHospital Outside Facility q12hr q24hr Indicate if the patient experienced an episode of cardiac arrest in your facility. CathPCI.5065 Cardiac Arrest w/in 24 Hours D. Cath Lab Visit Indicate if the patient has had an episode of cardiac arrest within 24 hours of procedure. ICD.4080 Cardiac Arrest Pre-Hospital C. History and Risk Factors Indicate if the patient experienced cardiac arrest due to arrhythmia. VTach/VFib Arrest Indicator ICD.4090 VTach/VFib Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result History and Risk Factors of ventricular tachycardia or ventricular fibrillation. Bradycardia Arrest Indicator ICD.4095 Bradycardia Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result History and Risk Factors of bradycardia. 00112 Cardiac Arrest Indicator ICD.8005 Cardiac Arrest H. Intra or Post Procedure Events Indicate if the patient experienced cardiac arrest. Cardiac Arrest Indicator Impact.8000 Cardiac Arrest L. Intra and Post-Procedure Events Indicate if there was a cardiac arrest event that required CPR. Intra or Post Procedure 00112 MedicationAdministration Within 2 weeks H. In-Hospital Clinical Events 00112 00238 Frequency Cardiac Arrest Indicator TVT.5035 D. Pre-Procedure Status Indicate if the patient has had an episode of cardiac arrest within 24 hours of the procedure. within 24 hours of the procedure First 24 Hours In Hospital within 24 hours of procedure History and Risk Factors Pre-Hospital Administered Pre-Encounter Intra-Encounter Timing 00423 Status Blinded 00303 Dose Code Pre-Procedure Intra-Procedure At Discharge Not Administered ventricular tachycardia or ventricular fibrillation bradycardia Intra or Post Procedure Contraindicated Full Reduced Other Cardiac Arrest w/in 24 Hours During Follow-up Map atomic concepts to controlled clinical terminologies Slide Number: 93 © 2014 All Rights Reserved
  • 94. 3. Conceptual Data Modeling Consolidated Dictionary DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context Timing 00112 Action.4135 Action.4140 Cardiac Arrest Pre-Hospital Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility 00112 Cardiac Arrest Indicator Action.9035 Cardiac Arrest 00112 Cardiac Arrest Indicator 00112 Cardiac Arrest Indicator 00800 VTach/VFib Arrest Indicator ICD.4090 00102 00112 C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was First Medical Contact prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility. C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest First Medical Contact occurred at the outside facility. CathPCI.5065 Cardiac Arrest w/in 24 Hours D. Cath Lab Visit Indicate if the patient has had an episode of cardiac arrest within 24 hours of procedure. ICD.4080 Cardiac Arrest Pre-Hospital C. History and Risk Factors Indicate if the patient experienced cardiac arrest due to arrhythmia. History and Risk Factors VTach/VFib Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of ventricular tachycardia or ventricular fibrillation. History and Risk Factors Bradycardia Arrest Indicator ICD.4095 Bradycardia Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of bradycardia. History and Risk Factors Cardiac Arrest Indicator Cardiac Arrest H. Intra or Post Procedure Events Indicate if the patient experienced cardiac arrest. Intra or Post Procedure within 24 hours of the procedure ICD.8005 Impact.8000 Cardiac Arrest L. Intra and Post-Procedure Events Cardiac Arrest Indicator TVT.5035 D. Pre-Procedure Status Cardiac Arrest w/in 24 Hours name :ST - 01.0 Submissions::SourceSystem identifierValue :ST identifierTypeCode :ParticipantIdentifier - trialTypeCode :CD researchStudyName :ST - versionIdentifier :ST 01.0 Submissions::SourceSystemProv ider provided by 1..* 1 - identifier :ST {id} 1 originates from identifies 01.0 Submissions::Submission submited by 1 1..* + + identifier :ST submissionTimePeriod :TS.DATE (IVL) 1..* submissionDateTime :TS 01.0 Submissions::Registry submited to 1 - 05.0 Ev ents::Ev entEv entRelation identifier :ST {id} versionIdentifier :ST {id} + has target 1 1 0..* + 0..* + 1 is part of 1 0..* is grouped by +parent 0..1 04.0 Observ ations::Observ ationResult 04.0 Observ ations:: Observ ationEv ent 0..* + methodCode :CD [0..*] (SET) classificationCode :Clasification contextCode :Context eventDateTime :TS [0..1] (IVL) statusCode :CD = Completed eventDuration :PQ.TIME [0..1] observationTypeCode :CD 0..* + is part of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is a type of observationResultTypeCode :CD conditionOnsetDateTime :TS [0..1] +child estimatedOnsiteDateIndicator :BL = No 0..* missingOnsetTimeIndicator :BL = No observationValue :ANY observationValueNegationIndicator :BL = No 1 has source has target 09.0 Procedures::ProcedureDescriptor 0..* 0..* ::ObservationEvent + observationTypeCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] relationshipTypeCode :RelationshipType has subject is part of within context of 07.0 Dev ices::Dev iceDescriptor ::ObservationEvent + observationTypeCode :CD 03.0 CareEpisodes::Ev entEpisodeRelation + is a type of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is referred to by (0..*) 06.0 Lesions :: LesionTreatmentDevice 0..* is part of is part of 0..* 1 10.0 Medication Administration Ev ents:: MedicationAdministrationEv ent 0..* name :EN.PN birthDate :TS.DATE sexCode :CD hispanicIndicator :BL = No ethnicityDetailCode :CD [0..*] (SET) postalZoneIdentifier :II residenceCountryCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 1 1 09.0 Procedures::ProcedureDev iceUse 05.0 Events::Intervention 09.0 Procedures::Procedure indicationCode :CD [0..1] abortedReasonCode :CD [0..*] + ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is a type of - procedureTypeCode :CD ::Intervention - indicationCode :CD [0..1] - abortedReasonCode :CD [0..*] is a type of is use by ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] deviceCounter :INT {id} statusCode :CD abortedReasonCode :CD [0..1] 07.0 Dev ices::Dev ice ::ObservationEvent + observationTypeCode :CD is use of 0..* ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 1 0..* 1 - 1 1 1..* identifier :II typeCode :CD manufacturerName :EN.ON deviceName :ST universalDeviceIdentifier :II [0..1] is use of 1 + has subject 1..* - ::Intervention - indicationCode :CD [0..1] - abortedReasonCode :CD [0..*] 02.0 Patients::Patient 0..1 enrolledIndicator :BL = No involving 1 0..* 02.0 Patients::ResearchStudyEnrollment - 0..* is treated by - is part of administers 0..* 0..* 09.0 Procedures::ProcedureLesion 1 06.0 Lesions::LesionTreatmentDetail - 1..* 0..* identifierValue :II identifierTypeCode :PatientIdentifier raceCode :CD raceDetailCode :CD [0..*] (SET) ::ObservationEvent + observationTypeCode :CD 10.0 Medication Administration Ev ents:: Medication 02.0 Patients::PatientRace - + - deviceCounter :INT is part of is used by is a trait of assigns 09.0 Procedures::ArterialClosureDev ice identifies 0..1 02.0 Patients::PatientIdentifier 09.0 Procedures::ProcedureVascularAssessment previouslyTreatedIndicator :BL = No culpritLesionIndicator :BL = No - vesselNotAvailableIndicator :BL = No 09.0 Procedures::ArterialAccess ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 09.0 Procedures::ArterialClosure is part of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 0..1 1 0..* ::ObservationEvent + observationTypeCode :CD ::ObservationEvent + observationTypeCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] medicationCode :CD name :ST - siteCounter :INT directionalityTypeCode :CD [0..1] vesselCode :CD 1..* {ordered} - arterialClosureCounter :INT {id} methodCode :CD [0..1] undocumentedIndicator :BL = No 0..* 0..* 0..* is part of is treatment of 1 06.0 Lesions::LesionTreatmentDev ice has subject has target treated 1 1 06.0 Lesions::Lesion 06.0 Lesions::LesionAffectedVesselSegment Refers to (1..1) 07.0 Devices :: Device - lesionCounter :INT {id} 1 0..* - lesionLocationCode :CD segmentCounter :INT 0..* 04.0 Observ ations::Inv olv edAnatomicSite involved 1 - 0..* typeCode :CD lateralityCode :CD 1 0..* is a type of + involvementTypeCode :InvolvementType is a type of is a type of deviceCounter :INT is located in is part of - 1 08.0 AnatomicSites::AnatomicSite affecting 0..* Legend Primary Class Dependant Classes Value Sets Foreign Classes ::ObservationEvent + observationTypeCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 08.0 AnatomicSites::VesselSegment - 08.0 AnatomicSites::Cardiov ascularVessel vesselSegmentCode :CD {id} ::AnatomicSite - typeCode :CD - lateralityCode :CD is part of 0..* - 08.0 AnatomicSites::AnatomicRegion cardiovascularVesselCode :CD {id} vesselTypeCode :CD ::AnatomicSite - typeCode :CD - lateralityCode :CD is part of 0..* anotomicRegionCode :CD ::AnatomicSite - typeCode :CD - lateralityCode :CD +subsection 0..* 0..1 is grouped by is a type of + Account name : ST balanceAmt : MO currencyCode : CE interestRateQuantity : RTO<MO,PQ> allowedBalanceQuantity : IVL<MO> FinancialTransaction amt : MO creditExchangeRateQuantity : REAL debitExchangeRateQuantity : REAL NCDR DAM Classes Salimah Shakir 1.0 11/12/2012 7:02:00 PM 8/26/2013 1:05:44 PM name :EN.PN identifier :II isCertifiedIndicator :BL = No performed by 1 05.0 Ev ents::Ev ent arrivalDateTime :TS dischargeDate :TS.DATE payorTypeCode :CD [1..*] (SET) admissionSourceCode :CD dischargeDispositionCode :CD - 0..* has source is grouped by 0..* - 05.0 Ev ents::Ev entPerformer relationshipTypeCode :RelationshipType 0..* 03.0 CareEpisodes::CareEpisode 02.0 Patients::ClinicalTrial 06.0 Lesions::LesionDescriptor Diet energyQuantity : PQ carbohydrateQuantity : PQ Name: Author: Version: Created: Updated: 1..* 1 01.0 Submissions::Participant 0..* Supply quantity : PQ expectedUseTime : IVL<TS> bradycardia Conceptual Data Model 0..* PublicHealthCase PatientEncounter detectionMethodCode : CE preAdmitTestInd : BL transmissionModeCode : CE admissionReferralSourceCode : CE diseaseImportedCode : CE lengthOfStayQuantity : PQ dischargeDispositionCode : CE specialCourtesiesCode : SET<CE> specialAccommodationCode : SET<CE> acuityLevelCode : CE ventricular tachycardia or ventricular fibrillation Indicate if the patient has had an episode of cardiac arrest within 24 hours of the procedure. 01.0 Submissions::ParticipantIdentifier Container Device capacityQuantity : PQ manufacturerModelName : SC heightQuantity : PQ softwareName : SC localRemoteControlStateCode : CE ... diameterQuantity : PQ capTypeCode : CE alertLevelCode : CE separatorTypeCode : CE lastCalibrationTime : TS barrierDeltaQuantity : PQ bottomDeltaQuantity : PQ Pre-Hospital Intra or Post Procedure Cardiac Arrest Indicator + DiagnosticImage subjectOrientationCode : CE In Hospital within 24 hours of procedure Indicate if there was a cardiac arrest event that required CPR. HL7 Reference Models ActRelationship typeCode : CS inversionInd : BL outboundRelationship contextControlCode : CS 0..n contextConductionInd : BL sequenceNumber : INT Person 1 source priorityNumber : INT addr : BAG<AD> pauseQuantity : PQ Act Participation maritalStatusCode : CE checkpointCode : CS classCode : CS Entity educationLevelCode : CE typeCode : CS Role splitCode : CS moodCode : CS raceCode : SET<CE> functionCode : CD classCode : CS player joinCode : CS classCode : CS id : SET<II> disabilityCode : SET<CE> contextControlCode : CS determinerCode : CS negationInd : BL 0..1 code : CD 0..n id : SET<II> livingArrangementCode : CE sequenceNumber : INT id : SET<II> 0..n conjunctionCode : CS negationInd : BL 1 playedRolecode : CE religiousAffiliationCode : CE negationInd : BL code : CE localVariableName : ST negationInd : BL 1 derivationExpr : ST ethnicGroupCode : SET<CE> quantity : SET<PQ> 0..n noteText : ED seperatableInd : BL addr : BAG<AD> text : ED time : IVL<TS> name : BAG<EN> telecom : BAG<TEL> 0..n statusCode : SET<CS> modeCode : CE desc : ED statusCode : SET<CS> effectiveTime : GTS inboundRelationship awarenessCode : CE statusCode : SET<CS> scopedRole effectiveTime : IVL<TS> LivingSubject activityTime : GTS signatureCode : CE existenceTime : IVL<TS> 0..n certificateText : ED target availabilityTime : TS administrativeGenderCode : CE signatureText : ED telecom : BAG<TEL> quantity : RTO 0..1 priorityCode : SET<CE> birthTime : TS performInd : BL riskCode : CE 1 positionNumber : LIST<INT> scoper deceasedInd : BL substitutionConditionCode : CE confidentialityCode : SET<CE> ... handlingCode : CE repeatNumber : IVL<INT> deceasedTime : TS DeviceTask 1 target 1source interruptibleInd : BL multipleBirthInd : BL 1 parameterValue : LIST<ANY> levelCode : CE inboundLink multipleBirthOrderNumber : INT WorkingList 0..n outboundLink 0..n independentInd : BL Employee organDonorInd : BL ownershipLevelCode : CE RoleLink uncertaintyCode : CE FinancialContract jobCode : CE typeCode : CS reasonCode : SET<CE> paymentTermsCode : CE jobTitleName : SC effectiveTime : IVL<TS> languageCode : CE jobClassCode : CE Material NonPersonLivingSubject salaryTypeCode : CE formCode : CE strainText : ED salaryQuantity : MO InvoiceElement genderStatusCode : CE hazardExposureText : ED SubstanceAdministration modifierCode : SET<CE> protectiveEquipmentText : ED Observation unitQuantity : RTO<PQ,PQ> routeCode : CE 0..n value : ANY unitPriceAmt : RTO<MO,PQ> approachSiteCode : SET<CD> ManufacturedMaterial LanguageCommunication interpretationCode : SET<CE> netAmt : MO doseQuantity : IVL<PQ> Procedure methodCode : SET<CE> factorNumber : REAL rateQuantity : IVL<PQ> lotNumberText : ST languageCode : CE methodCode : SET<CE> pointsNumber : REAL doseCheckQuantity : SET<RTO> targetSiteCode : SET<CD> expirationTime : IVL<TS> modeCode : CE approachSiteCode : SET<CD> maxDoseQuantity : SET<RTO> stabilityTime : IVL<TS> proficiencyLevelCode : CE targetSiteCode : SET<CD> substitutionCode : CE preferenceInd : BL Outside Facility Indicate if the patient experienced an episode of cardiac arrest in your facility. 00112 Patient ManagedParticipation Place confidentialityCode : CE id : SET<II> mobileInd : BL veryImportantPersonCode : CE statusCode : SET<CS> addr : AD directionsText : ED Access LicensedEntity positionText : ED approachSiteCode : CD recertificationTime : TS gpsText : ST targetSiteCode : CD gaugeQuantity : PQ Cause PreHospital H. In-Hospital Clinical Events 00112 Organization addr : BAG<AD> standardIndustryClassCode : CE Location Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode First Medical Contact of cardiac arrest. Cardiac Arrest Indicator 00112 Construct a UML model representation of normalized terminology concepts Cardiac Arrest Indicator 00112 08.0 AnatomicSites::Cardiov ascularGraft - graftTypeCode :CD ::CardiovascularVessel - cardiovascularVesselCode :CD {id} - vesselTypeCode :CD ::AnatomicSite - typeCode :CD - lateralityCode :CD Slide Number: 94 © 2014 All Rights Reserved
  • 95. 4. CDA Constraint Modeling Conceptual Data Model 01.0 Submissions::ParticipantIdentifier + name :ST - 01.0 Submissions::SourceSystem identifierValue :ST identifierTypeCode :ParticipantIdentifier - trialTypeCode :CD researchStudyName :ST - versionIdentifier :ST 01.0 Submissions::SourceSystemProv ider provided by 1..* 1 - identifier :ST {id} 1 identifies originates from 0..* Name: Author: Version: Created: Updated: 1..* 1 01.0 Submissions::Submission 01.0 Submissions::Participant submited by 1 1..* + + identifier :ST submissionTimePeriod :TS.DATE (IVL) 1..* submissionDateTime :TS 01.0 Submissions::Registry submited to 1 - 05.0 Ev ents::Ev entEv entRelation identifier :ST {id} versionIdentifier :ST {id} + has target 1 1 0..* + 0..* + 1 is part of 1 NCDR DAM Classes Salimah Shakir 1.0 11/12/2012 7:02:00 PM 8/26/2013 1:05:44 PM name :EN.PN identifier :II isCertifiedIndicator :BL = No 0..* performed by is grouped by 1 05.0 Ev ents::Ev ent arrivalDateTime :TS dischargeDate :TS.DATE payorTypeCode :CD [1..*] (SET) admissionSourceCode :CD dischargeDispositionCode :CD - 0..* has source is grouped by 0..* - 05.0 Ev ents::Ev entPerformer relationshipTypeCode :RelationshipType 0..* 03.0 CareEpisodes::CareEpisode 02.0 Patients::ClinicalTrial +parent 0..1 04.0 Observ ations::Observ ationResult 04.0 Observ ations:: Observ ationEv ent 0..* + methodCode :CD [0..*] (SET) classificationCode :Clasification contextCode :Context eventDateTime :TS [0..1] (IVL) statusCode :CD = Completed eventDuration :PQ.TIME [0..1] observationTypeCode :CD 0..* + is part of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is a type of observationResultTypeCode :CD conditionOnsetDateTime :TS [0..1] +child estimatedOnsiteDateIndicator :BL = No 0..* missingOnsetTimeIndicator :BL = No observationValue :ANY observationValueNegationIndicator :BL = No 1 has source has target 09.0 Procedures::ProcedureDescriptor 0..* 0..* ::ObservationEvent + observationTypeCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] relationshipTypeCode :RelationshipType has subject is part of + within context of 07.0 Dev ices::Dev iceDescriptor ::ObservationEvent + observationTypeCode :CD 03.0 CareEpisodes::Ev entEpisodeRelation is a type of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is referred to by (0..*) 06.0 Lesions :: LesionTreatmentDevice 0..* is part of is part of 0..* 1 1 1 09.0 Procedures::ProcedureDev iceUse 05.0 Events::Intervention 09.0 Procedures::Procedure indicationCode :CD [0..1] abortedReasonCode :CD [0..*] + ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is a type of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] - procedureTypeCode :CD ::Intervention - indicationCode :CD [0..1] - abortedReasonCode :CD [0..*] is a type of deviceCounter :INT {id} statusCode :CD abortedReasonCode :CD [0..1] 07.0 Dev ices::Dev ice ::ObservationEvent + observationTypeCode :CD is use by ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is use of 0..* ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 1 0..* 1 - identifier :II typeCode :CD manufacturerName :EN.ON deviceName :ST universalDeviceIdentifier :II [0..1] 1 1 1..* involving 0..* name :EN.PN birthDate :TS.DATE sexCode :CD hispanicIndicator :BL = No ethnicityDetailCode :CD [0..*] (SET) postalZoneIdentifier :II residenceCountryCode :CD is use of 1 + has subject 1..* - ::Intervention - indicationCode :CD [0..1] - abortedReasonCode :CD [0..*] 02.0 Patients::Patient 0..1 enrolledIndicator :BL = No 0..* is treated by - is part of deviceCounter :INT is part of 0..* is used by identifies administers is a trait of 09.0 Procedures::ArterialClosureDev ice assigns 0..* 09.0 Procedures::ProcedureLesion 1 0..1 + 06.0 Lesions::LesionTreatmentDetail - 1..* 0..* - identifierValue :II identifierTypeCode :PatientIdentifier ::ObservationEvent + observationTypeCode :CD 10.0 Medication Administration Ev ents:: Medication 02.0 Patients::PatientRace 02.0 Patients::PatientIdentifier raceCode :CD raceDetailCode :CD [0..*] (SET) + - ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] medicationCode :CD name :ST 09.0 Procedures::ProcedureVascularAssessment previouslyTreatedIndicator :BL = No culpritLesionIndicator :BL = No - vesselNotAvailableIndicator :BL = No 09.0 Procedures::ArterialAccess 09.0 Procedures::ArterialClosure is part of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 0..1 1 0..* ::ObservationEvent + observationTypeCode :CD ::ObservationEvent + observationTypeCode :CD - siteCounter :INT directionalityTypeCode :CD [0..1] vesselCode :CD 1..* {ordered} - arterialClosureCounter :INT {id} methodCode :CD [0..1] undocumentedIndicator :BL = No 0..* 0..* 0..* is treatment of 1 06.0 Lesions::LesionTreatmentDev ice has subject treated has target is part of 0..* 1 1 06.0 Lesions::Lesion 06.0 Lesions::LesionAffectedVesselSegment deviceCounter :INT - lesionCounter :INT {id} 0..* 04.0 Observ ations::Inv olv edAnatomicSite is located in 0..* - 1 lesionLocationCode :CD segmentCounter :INT involved 1 - 0..* typeCode :CD lateralityCode :CD 1 0..* is a type of + involvementTypeCode :InvolvementType is a type of is a type of Refers to (1..1) 07.0 Devices :: Device 1 08.0 AnatomicSites::AnatomicSite affecting - is part of Map UMTS Conceptual Data Model to the HL7 Clinical Document Architecture 10.0 Medication Administration Ev ents:: MedicationAdministrationEv ent 1 0..* 02.0 Patients::ResearchStudyEnrollment - 0..* 06.0 Lesions::LesionDescriptor 08.0 AnatomicSites::VesselSegment Legend - ::ObservationEvent + observationTypeCode :CD Primary Class 08.0 AnatomicSites::Cardiov ascularVessel - is part of 08.0 AnatomicSites::AnatomicRegion cardiovascularVesselCode :CD {id} vesselTypeCode :CD is part of ::AnatomicSite - typeCode :CD - lateralityCode :CD 0..* anotomicRegionCode :CD 0..1 ::AnatomicSite - typeCode :CD - lateralityCode :CD 0..* +subsection 0..* is grouped by is a type of Foreign Classes vesselSegmentCode :CD {id} ::AnatomicSite - typeCode :CD - lateralityCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] Dependant Classes Value Sets 08.0 AnatomicSites::Cardiov ascularGraft - graftTypeCode :CD ::CardiovascularVessel - cardiovascularVesselCode :CD {id} - vesselTypeCode :CD ::AnatomicSite - typeCode :CD - lateralityCode :CD HL7 Clinical Document Architecture RMIM Constrained Information Model (Observ ation) ParticipantIdentifierObserv ation (Section) RegistryParticipantDetailSection (Patient) Patient + + + + # classCode :CS = "PSN" determinerCode :CS = "INSTANCE" (Patient.name) name :EN.PN (Patient.sexCode) administrativeGenderCode :CD (Patient.birthDate) birthTime :TS.DATE (Patient.hispanicIndicator) ethnicGroupCode :CD classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "RegistryPartic... # + 1..* 1 classCode :CS = "OBS" moodCode :CS = "EVN" (ParticipantIdentifier.typeCode) code :CD (ParticipantIdentifier.identifierValue) value :CD (Entry) ParticipantIdentifierObserv ationEntry 1..1 - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1 (StructuredBodyComponent) RegistryParticipantDetailComponent Entry Point (ClinicalDocumentComponent) DocumentComponent (RecordTarget) RecordTarget - isPlayedBy classCode :CS = "PAT" (PatientIdentifier.identifierValue) id :II - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" (Entry) PatientIdentifierObserv ationEntry typeCode :CS = "COMP" contextConductionIndicator :BL = "true" - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1 (ClinicalDocument) CathPCIRegistryDocument (PatientRole) PatientRole + - typeCode :CS = "RCT" contextControlCode :CS = "OP" 1..1 1..1 1 + # + classCode :CS = "DOCCLIN" moodCode :CS = "EVN" id :II code :CE = "CATHPCI" effectiveTime :TS 1 - 1..1 (Observ ation) PatientIdentifierObserv ation (Section) PatientDetailSection (StructuredBody) DocumentBody classCode :CS = "DOCBODY" moodCode :CS = "EVN" 1..1 1 # classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "PatientDetail" 1 0..* # + classCode :CS = "OBS" moodCode :CS = "EVN" (PatientIdentifier.typeCode) code :CD (PatientIdentifier.identifierValue) value :CD 1 1 1 - (StructuredBodyComponent) PatientDetailComponent (StructuredBodyComponent) SubmissionDetailComponent (Custodian) Custodian - typeCode :CS = "CST" - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" (Entry) PatientRaceObserv ationEntry typeCode :CS = "COMP" contextConductionIndicator :BL = "true" - 1..1 typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1..1 1..1 (CustodianOrganization) Participant + + classCode :CS = "ORG" determinerCode :CS = "INSTANCE" (ParticipantIdentifier.identifierValue) id :II (Participant.name) name :EN.ON (Section) SubmissionDetailSection (AssignedCustodian) ParticipantRole isScopedBy 1 1..1 - # classCode :CS = "ASSIGNED" (Observ ation) PatientRaceObserv ation classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "SubmissionDetail" # + 1 classCode :CS = "OBS" moodCode :CS = "EVN" code :CD = "PatientRace" (PatientRace.raceCode) value :CD [1..*] (SET) (Entry) SubmissionActEntry - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1..1 (Act) SubmissionAct + + classCode :CS = "ACT" moodCode :CS = "EVN" (Submission.identifier) id :II (Submission.submissionTimePeriod) effectiveTime :TS (IVL) (ParticipantRole) TargetRegistry 1 1..1 - classCode :CS = "MMAT" 1..1 1 (ClinicalStatementParticipant) Author - (ClinicalStatementParticipant) Receiv er typeCode :CS = "AUT" contextControlCode :CS = "OP" - isPlayedBy typeCode :CS = "RCV" contextControlCode :CS = "OP" 1..1 1 (Dev ice) DataCollectionSystem + classCode :CS = "DEV" determinerCode :CS = "INSTANCE" (SourceSystem.versionIdentifier) id :II (ParticipantRole) SourceSystem isPlayedBy 1 1..1 - (Dev ice) RegistrySystem classCode :CS = "MMAT" + + classCode :CS = "DEV" determinerCode :CS = "INSTANCE" (Registry.identifier) id.root :II.root (RegistryVersionIdentifier) id.extension :II.extension isScopedBy (Entity) SourceSystemProv ider + Slide Number: 95 classCode :CS = "ORG" determinerCode :CS = "INSTANCE" (SourceSystemProvider.identifier) id :II © 2014 All Rights Reserved
  • 96. 5. UMTS CDA Template Construction HL7 & IHE Content Profiles 1 1.1 SUBENTRY ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] Table 1: ClincalEventObservationSubEntry Contexts Contained By: Specify registry agnostic CDA element usage, cardinality, and value constraints 1 SUBENTRY Contains: 1.1 ClincalEventObservationSubEntry This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 1 2. SHALL contain exactly one [1..1] @moodCode="EVN" R Y S U B E N T (CONF:31959). Contained By: Contains: 3. MAY contain zero or one [0..1] @negationInd (CONF:31960). 4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 1.1 ClincalEventObservationSubEntry (CONF:31961).This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 5. SHALL contain exactly one [1..1] code (CONF:31962). 6. SHALL contain zeroSHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 1. or one [0..1] effectiveTime (CONF:31963). 7. SHALL contain exactly one [1..1] value (CONF:31964). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). Contained By: Contains: 8. MAY contain zero or more [0..*] zero or one [0..1] @negationInd (CONF:31960). 3. MAY contain entryRelationship (CONF:31965). a. The entryRelationship, if present,one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 4. SHALL contain exactly SHALL contain exactly one [1..1] This @typeCode="OPTN" (CONF:31966). template is used to collect clinical event observations made within the scope of the (CONF:31961). encounter. Observations may be modified by observational semantic qualifiers. b. The entryRelationship, if present,one [1..1] code exactly one [1..1] 5. SHALL contain exactly SHALL contain (CONF:31962). @contextConductionInd="true" SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). 1. (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). c. The entryRelationship, if present,one [1..1] value exactlyone [1..1] observation 2. SHALL contain (CONF:31964). 7. SHALL contain exactly SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). (CONF:31968). 8. MAY contain zero or 3. MAY contain zero or one [0..1](CONF:31965). (CONF:31960). more [0..*] entryRelationship @negationInd i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 4. SHALL if present, SHALL contain exactly one [1..1] a. The entryRelationship, contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31969). (CONF:31961). @typeCode="OPTN" (CONF:31966). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" 5. SHALL if present, SHALL contain exactly one [1..1] b. The entryRelationship, contain exactly one [1..1] code (CONF:31962). (CONF:31970). @contextConductionInd="true" (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). c. The entryRelationship, contain exactly one [1..1] value (CONF:31964). 7. SHALL if present, SHALL contain exactly one [1..1] observation iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31968). MAY contain zero or more [0..*] entryRelationship (CONF:31965). 8. (CONF:31972). i. This observationThe entryRelationship, one [1..1] @classCode="OBS" a. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31969). @typeCode="OPTN" (CONF:31966). ii. This observationThe entryRelationship, one [1..1] @moodCode="EVN" b. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31970). @contextConductionInd="true" (CONF:31967). iii. This observationThe entryRelationship, one [1..1] code (CONF:31971). one [1..1] observation c. SHALL contain exactly if present, SHALL contain exactly iv. This observation(CONF:31968). exactly one [1..1] value with @xsi:type="CD" SHALL contain (CONF:31972). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972). Constrained Information Model (Observ ation) ParticipantIdentifierObserv ation (Section) RegistryParticipantDetailSection (Patient) Patient + + + + # classCode :CS = "PSN" determinerCode :CS = "INSTANCE" (Patient.name) name :EN.PN (Patient.sexCode) administrativeGenderCode :CD (Patient.birthDate) birthTime :TS.DATE (Patient.hispanicIndicator) ethnicGroupCode :CD UMTS CDA Template Library classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "RegistryPartic... # + 1..* 1 classCode :CS = "OBS" moodCode :CS = "EVN" (ParticipantIdentifier.typeCode) code :CD (ParticipantIdentifier.identifierValue) value :CD (Entry) ParticipantIdentifierObserv ationEntry 1..1 - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1 (StructuredBodyComponent) RegistryParticipantDetailComponent Entry Point (ClinicalDocumentComponent) DocumentComponent (RecordTarget) RecordTarget - isPlayedBy classCode :CS = "PAT" (PatientIdentifier.identifierValue) id :II - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" (Entry) PatientIdentifierObserv ationEntry typeCode :CS = "COMP" contextConductionIndicator :BL = "true" - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1 (ClinicalDocument) CathPCIRegistryDocument (PatientRole) PatientRole + - typeCode :CS = "RCT" contextControlCode :CS = "OP" 1..1 1..1 1 + # + classCode :CS = "DOCCLIN" moodCode :CS = "EVN" id :II code :CE = "CATHPCI" effectiveTime :TS 1 - 1..1 (Observ ation) PatientIdentifierObserv ation (Section) PatientDetailSection (StructuredBody) DocumentBody classCode :CS = "DOCBODY" moodCode :CS = "EVN" 1..1 1 # classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "PatientDetail" 1 0..* # + classCode :CS = "OBS" moodCode :CS = "EVN" (PatientIdentifier.typeCode) code :CD (PatientIdentifier.identifierValue) value :CD 1 1 1 (Custodian) Custodian - (StructuredBodyComponent) PatientDetailComponent (StructuredBodyComponent) SubmissionDetailComponent - typeCode :CS = "CST" - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" (Entry) PatientRaceObserv ationEntry typeCode :CS = "COMP" contextConductionIndicator :BL = "true" - 1..1 typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1..1 1..1 (CustodianOrganization) Participant + + classCode :CS = "ORG" determinerCode :CS = "INSTANCE" (ParticipantIdentifier.identifierValue) id :II (Participant.name) name :EN.ON (Section) SubmissionDetailSection (AssignedCustodian) ParticipantRole isScopedBy 1 1..1 - # classCode :CS = "ASSIGNED" (Observ ation) PatientRaceObserv ation classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "SubmissionDetail" # + 1 classCode :CS = "OBS" moodCode :CS = "EVN" code :CD = "PatientRace" (PatientRace.raceCode) value :CD [1..*] (SET) (Entry) SubmissionActEntry - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1..1 (Act) SubmissionAct + + classCode :CS = "ACT" moodCode :CS = "EVN" (Submission.identifier) id :II (Submission.submissionTimePeriod) effectiveTime :TS (IVL) (ParticipantRole) TargetRegistry 1 1..1 - classCode :CS = "MMAT" 1..1 1 (ClinicalStatementParticipant) Author - (ClinicalStatementParticipant) Receiv er typeCode :CS = "AUT" contextControlCode :CS = "OP" - isPlayedBy typeCode :CS = "RCV" contextControlCode :CS = "OP" 1..1 1 (Dev ice) DataCollectionSystem + classCode :CS = "DEV" determinerCode :CS = "INSTANCE" (SourceSystem.versionIdentifier) id :II (ParticipantRole) SourceSystem isPlayedBy 1 1..1 - (Dev ice) RegistrySystem classCode :CS = "MMAT" + + classCode :CS = "DEV" determinerCode :CS = "INSTANCE" (Registry.identifier) id.root :II.root (RegistryVersionIdentifier) id.extension :II.extension isScopedBy (Entity) SourceSystemProv ider + Slide Number: 96 classCode :CS = "ORG" determinerCode :CS = "INSTANCE" (SourceSystemProvider.identifier) id :II © 2014 All Rights Reserved
  • 97. 6. Registry Content Profile Specification Registry Specific Business Rules 1 SUBENTRY 1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] Table 1: ClincalEventObservationSubEntry Contexts Contained By: 1 SUBENTRY Contains: 1.1 ClincalEventObservationSubEntry This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. Specify registry specific CDA element usage, cardinality, and value constraints 1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 2. SHALL contain exactly one [1..1] @moodCode="EVN" R Y S U B E N T (CONF:31959). Contained By: 1 Contains: 3. MAY contain zero or one [0..1] @negationInd (CONF:31960). 4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 1.1 ClincalEventObservationSubEntry (CONF:31961).This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 5. SHALL contain exactly one [1..1] code (CONF:31962). 6. SHALL contain zeroSHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 1. or one [0..1] effectiveTime (CONF:31963). 7. SHALL contain exactly one [1..1] value (CONF:31964). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). Contained By: Contains: 8. MAY contain zero or more [0..*] zero or one [0..1] @negationInd (CONF:31960). 3. MAY contain entryRelationship (CONF:31965). a. The entryRelationship, if present,one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 4. SHALL contain exactly SHALL contain exactly one [1..1] This @typeCode="OPTN" (CONF:31966). template is used to collect clinical event observations made within the scope of the (CONF:31961). encounter. Observations may be modified by observational semantic qualifiers. b. The entryRelationship, if present,one [1..1] code exactly one [1..1] 5. SHALL contain exactly SHALL contain (CONF:31962). @contextConductionInd="true" SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). 1. (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). c. The entryRelationship, if present,one [1..1] value exactlyone [1..1] observation 2. SHALL contain (CONF:31964). 7. SHALL contain exactly SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). (CONF:31968). 8. MAY contain zero or 3. MAY contain zero or one [0..1](CONF:31965). (CONF:31960). more [0..*] entryRelationship @negationInd i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 4. SHALL if present, SHALL contain exactly one [1..1] a. The entryRelationship, contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31969). (CONF:31961). @typeCode="OPTN" (CONF:31966). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" 5. SHALL if present, SHALL contain exactly one [1..1] b. The entryRelationship, contain exactly one [1..1] code (CONF:31962). (CONF:31970). @contextConductionInd="true" (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). c. The entryRelationship, contain exactly one [1..1] value (CONF:31964). 7. SHALL if present, SHALL contain exactly one [1..1] observation iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31968). MAY contain zero or more [0..*] entryRelationship (CONF:31965). 8. (CONF:31972). i. This observationThe entryRelationship, one [1..1] @classCode="OBS" a. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31969). @typeCode="OPTN" (CONF:31966). ii. This observationThe entryRelationship, one [1..1] @moodCode="EVN" b. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31970). @contextConductionInd="true" (CONF:31967). iii. This observationThe entryRelationship, one [1..1] code (CONF:31971). one [1..1] observation c. SHALL contain exactly if present, SHALL contain exactly iv. This observation(CONF:31968). exactly one [1..1] value with @xsi:type="CD" SHALL contain (CONF:31972). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972). UMTS CDA Template Library Registry Specific Content Profiles 1 SUBENTRY 1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] Table 1: ClincalEventObservationSubEntry Contexts Contained By: 1 SUBENTRY Contains: 1.1 ClincalEventObservationSubEntry This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 2. SHALL contain exactly one [1..1] @moodCode="EVN" R Y S U B E N T (CONF:31959). Contained By: 1 Contains: 3. MAY contain zero or one [0..1] @negationInd (CONF:31960). 4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 1.1 ClincalEventObservationSubEntry (CONF:31961).This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 5. SHALL contain exactly one [1..1] code (CONF:31962). 6. SHALL contain zeroSHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 1. or one [0..1] effectiveTime (CONF:31963). 7. SHALL contain exactly one [1..1] value (CONF:31964). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). Contained By: Contains: 8. MAY contain zero or more [0..*] zero or one [0..1] @negationInd (CONF:31960). 3. MAY contain entryRelationship (CONF:31965). a. The entryRelationship, if present,one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 4. SHALL contain exactly SHALL contain exactly one [1..1] This @typeCode="OPTN" (CONF:31966). template is used to collect clinical event observations made within the scope of the (CONF:31961). encounter. Observations may be modified by observational semantic qualifiers. b. The entryRelationship, if present,one [1..1] code exactly one [1..1] 5. SHALL contain exactly SHALL contain (CONF:31962). @contextConductionInd="true" SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). 1. (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). c. The entryRelationship, if present,one [1..1] value exactlyone [1..1] observation 2. SHALL contain (CONF:31964). 7. SHALL contain exactly SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). (CONF:31968). 8. MAY contain zero or 3. MAY contain zero or one [0..1](CONF:31965). (CONF:31960). more [0..*] entryRelationship @negationInd i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 4. SHALL if present, SHALL contain exactly one [1..1] a. The entryRelationship, contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31969). (CONF:31961). @typeCode="OPTN" (CONF:31966). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" 5. SHALL if present, SHALL contain exactly one [1..1] b. The entryRelationship, contain exactly one [1..1] code (CONF:31962). (CONF:31970). @contextConductionInd="true" (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). c. The entryRelationship, contain exactly one [1..1] value (CONF:31964). 7. SHALL if present, SHALL contain exactly one [1..1] observation iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31968). MAY contain zero or more [0..*] entryRelationship (CONF:31965). 8. (CONF:31972). i. This observationThe entryRelationship, one [1..1] @classCode="OBS" a. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31969). @typeCode="OPTN" (CONF:31966). ii. This observationThe entryRelationship, one [1..1] @moodCode="EVN" b. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31970). @contextConductionInd="true" (CONF:31967). iii. This observationThe entryRelationship, one [1..1] code (CONF:31971). one [1..1] observation c. SHALL contain exactly if present, SHALL contain exactly iv. This observation(CONF:31968). exactly one [1..1] value with @xsi:type="CD" SHALL contain (CONF:31972). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972). Slide Number: 97 © 2014 All Rights Reserved
  • 98. UMTS Project Activities Registry Elements Semantic Analysis 1 00069 Dose Amount 00147 Duration 00070 Start Date Time 00306 Stop Date Time MedicationTypeCode Consolidated Dictionary Initial Bolus 00776 Route 00307 Medication 2 DEI Dictionary Element 00112 REI Cardiac Arrest Indicator Registry Element Name Action.4135 RE Section Coding Instructions Context Timing Action.4140 Cardiac Arrest Pre-Hospital Action.4145 Cardiac Arrest Outside Facility Cardiac Arrest Indicator Action.9035 Cardiac Arrest H. In-Hospital Clinical Events Indicate if the patient experienced an episode of cardiac arrest in your facility. Cardiac Arrest Indicator CathPCI.5065 Cardiac Arrest w/in 24 Hours D. Cath Lab Visit Indicate if the patient has had an episode of cardiac arrest within 24 hours of procedure. Cardiac Arrest Indicator ICD.4080 Cardiac Arrest Pre-Hospital C. History and Risk Factors Indicate if the patient experienced cardiac arrest due to arrhythmia. History and Risk Factors VTach/VFib Arrest Indicator ICD.4090 VTach/VFib Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of ventricular tachycardia or ventricular fibrillation. History and Risk Factors Bradycardia Arrest Indicator ICD.4095 Bradycardia Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of bradycardia. History and Risk Factors 00112 Cardiac Arrest Indicator ICD.8005 Cardiac Arrest H. Intra or Post Procedure Events Indicate if the patient experienced cardiac arrest. Intra or Post Procedure 00112 Cardiac Arrest Indicator Impact.8000 Cardiac Arrest L. Intra and Post-Procedure Events Indicate if there was a cardiac arrest event that required CPR. Intra or Post Procedure 00112 q24hr Within 2 weeks Cause Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode First Medical Contact of cardiac arrest. Cardiac Arrest Indicator 00102 00238 Frequency MedicationAdministration Cardiac Arrest Indicator 00112 00800 q12hr 00112 00112 Initial Infusion 00112 00112 MedicationClassCode Standard Clinical Code Systems Location C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was First Medical Contact prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility. C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest First Medical Contact occurred at the outside facility. Cardiac Arrest Indicator TVT.5035 D. Pre-Procedure Status Indicate if the patient has had an episode of cardiac arrest within 24 hours of the procedure. within 24 hours of the procedure First 24 Hours PreHospital Outside Facility In Hospital within 24 hours of procedure Pre-Hospital Administered Pre-Encounter Timing Intra-Encounter 00423 Status Not Administered Blinded 00303 Dose Code Pre-Procedure Intra-Procedure ventricular tachycardia or ventricular fibrillation bradycardia Contraindicated At Discharge Full Reduced Cardiac Arrest w/in 24 Hours Other During Follow-up 3 Conceptual Data Model HL7 Reference Models 01.0 Submissions::ParticipantIdentifier + 01.0 Submissions::SourceSystem identifierValue :ST identifierTypeCode :ParticipantIdentifier - versionIdentifier :ST - 1 identifies originates from 01.0 Submissions::Submission 01.0 Submissions::Participant - submited by name :ST - 1..* + + trialTypeCode :CD researchStudyName :ST 1 identifier :ST submissionTimePeriod :TS.DATE (IVL) 1..* submissionDateTime :TS 01.0 Submissions::Registry submited to 1 - 05.0 Ev ents::Ev entEv entRelation identifier :ST {id} versionIdentifier :ST {id} + Name: Author: Version: Created: Updated: has target 0..* + 0..* + 1 is part of 1 - 0..* 1 Procedure methodCode : SET<CE> approachSiteCode : SET<CD> targetSiteCode : SET<CD> has subject name :EN.PN birthDate :TS.DATE sexCode :CD hispanicIndicator :BL = No ethnicityDetailCode :CD [0..*] (SET) postalZoneIdentifier :II residenceCountryCode :CD indicationCode :CD [0..1] abortedReasonCode :CD [0..*] + ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is a type of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 1 1 1..* InvoiceElement modifierCode : SET<CE> unitQuantity : RTO<PQ,PQ> unitPriceAmt : RTO<MO,PQ> netAmt : MO factorNumber : REAL pointsNumber : REAL is part of 0..* 1 - identifier :II typeCode :CD manufacturerName :EN.ON deviceName :ST universalDeviceIdentifier :II [0..1] 0..1 is part of administers - deviceCounter :INT is part of 0..* 06.0 Lesions::LesionTreatmentDetail - 1..* 0..* - identifierValue :II identifierTypeCode :PatientIdentifier ::ObservationEvent + observationTypeCode :CD 10.0 Medication Administration Ev ents:: Medication 02.0 Patients::PatientRace 02.0 Patients::PatientIdentifier + raceCode :CD raceDetailCode :CD [0..*] (SET) + - 09.0 Procedures::ProcedureVascularAssessment previouslyTreatedIndicator :BL = No culpritLesionIndicator :BL = No - vesselNotAvailableIndicator :BL = No 09.0 Procedures::ArterialAccess 09.0 Procedures::ArterialClosure is part of ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 0..1 1 0..* ::ObservationEvent + observationTypeCode :CD ::ObservationEvent + observationTypeCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] medicationCode :CD name :ST - siteCounter :INT directionalityTypeCode :CD [0..1] vesselCode :CD 1..* {ordered} - arterialClosureCounter :INT {id} methodCode :CD [0..1] undocumentedIndicator :BL = No 0..* 0..* 0..* has target is part of is treatment of 1 06.0 Lesions::LesionTreatmentDev ice Account name : ST balanceAmt : MO currencyCode : CE interestRateQuantity : RTO<MO,PQ> allowedBalanceQuantity : IVL<MO> 1 1 06.0 Lesions::Lesion 06.0 Lesions::LesionAffectedVesselSegment deviceCounter :INT - lesionCounter :INT {id} 0..* 04.0 Observ ations::Inv olv edAnatomicSite is located in 0..* - 1 lesionLocationCode :CD segmentCounter :INT involved 1 - 0..* typeCode :CD lateralityCode :CD 1 0..* is a type of + involvementTypeCode :InvolvementType is a type of is a type of Refers to (1..1) 07.0 Devices :: Device 1 08.0 AnatomicSites::AnatomicSite affecting - 0..* 06.0 Lesions::LesionDescriptor 08.0 AnatomicSites::VesselSegment Primary Class FinancialTransaction amt : MO creditExchangeRateQuantity : REAL debitExchangeRateQuantity : REAL - ::ObservationEvent + observationTypeCode :CD - is part of ::AnatomicSite - typeCode :CD - lateralityCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] Dependant Classes Value Sets 08.0 AnatomicSites::AnatomicRegion cardiovascularVesselCode :CD {id} vesselTypeCode :CD is part of ::AnatomicSite - typeCode :CD - lateralityCode :CD 0..* anotomicRegionCode :CD 0..1 ::AnatomicSite - typeCode :CD - lateralityCode :CD 0..* +subsection 0..* graftTypeCode :CD 4 Constrained Information Model (Observ ation) ParticipantIdentifierObserv ation (Section) RegistryParticipantDetailSection (Patient) Patient + + + + # classCode :CS = "PSN" determinerCode :CS = "INSTANCE" (Patient.name) name :EN.PN (Patient.sexCode) administrativeGenderCode :CD (Patient.birthDate) birthTime :TS.DATE (Patient.hispanicIndicator) ethnicGroupCode :CD classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "RegistryPartic... # + 1..* 1 classCode :CS = "OBS" moodCode :CS = "EVN" (ParticipantIdentifier.typeCode) code :CD (ParticipantIdentifier.identifierValue) value :CD (Entry) ParticipantIdentifierObserv ationEntry 1..1 - ii. This observationThe entryRelationship, one [1..1] @moodCode="EVN" b. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31970). @contextConductionInd="true" (CONF:31967). (CONF:31969). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 5 iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972). ::CardiovascularVessel - cardiovascularVesselCode :CD {id} - vesselTypeCode :CD ::AnatomicSite - typeCode :CD - lateralityCode :CD HL7 Clinical Document Architecture RMIM iii. This observationThe entryRelationship, one [1..1] code (CONF:31971). one [1..1] observation c. SHALL contain exactly if present, SHALL contain exactly iv. This observation(CONF:31968). exactly one [1..1] value with @xsi:type="CD" SHALL contain (CONF:31972). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970). 08.0 AnatomicSites::Cardiov ascularGraft - Contains: 6. SHALL contain zeroSHALL containeffectiveTime (CONF:31963). Table 1: ClincalEventObservationSubEntry Contexts 1. or one [0..1] exactly one [1..1] @classCode="OBS" (CONF:31958). 7. SHALL contain exactly one [1..1] value (CONF:31964). 2. SHALL containContained By: exactly one [1..1] @moodCode="EVN" (CONF:31959). Contains: 8. MAY contain zero or more [0..*] zero or one [0..1] @negationInd (CONF:31960). 3. MAY contain entryRelationship (CONF:31965). a. The entryRelationship, if present,one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 4. SHALL contain exactly SHALL contain exactly one [1..1] This @typeCode="OPTN" (CONF:31966). template is used to collect clinical event observations made within the scope of the (CONF:31961). encounter. Observations may be modified by observational semantic qualifiers. b. The entryRelationship, if present,one [1..1] code exactly one [1..1] 5. SHALL contain exactly SHALL contain (CONF:31962). @contextConductionInd="true" SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). 1. (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). c. The entryRelationship, if present,one [1..1] valueexactlyone [1..1] observation 2. SHALL contain (CONF:31964). 7. SHALL contain exactly SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). (CONF:31968). 3. MAY contain zero or one [0..1] @negationInd 8. MAY contain zero or more [0..*] entryRelationship (CONF:31965). (CONF:31960). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 4. SHALL if present, SHALL contain exactly one [1..1] a. The entryRelationship, contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31969). (CONF:31961). @typeCode="OPTN" (CONF:31966). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" 5. SHALL if present, SHALL contain exactly one [1..1] b. The entryRelationship, contain exactly one [1..1] code (CONF:31962). (CONF:31970). @contextConductionInd="true" (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). c. The entryRelationship, contain exactly one [1..1] value (CONF:31964). if present, SHALL contain exactly one [1..1] observation 7. SHALL iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31968). MAY contain zero or more [0..*] entryRelationship (CONF:31965). 8. (CONF:31972). i. This observationThe entryRelationship, one [1..1] @classCode="OBS" a. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31969). @typeCode="OPTN" (CONF:31966). (CONF:31969). is grouped by is a type of Foreign Classes 08.0 AnatomicSites::Cardiov ascularVessel vesselSegmentCode :CD {id} Contained By: ii. This observationThe entryRelationship, one [1..1] @moodCode="EVN" b. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31970). @contextConductionInd="true" (CONF:31967). iii. This observationThe entryRelationship, one [1..1] code (CONF:31971). one [1..1] observation c. SHALL contain exactly if present, SHALL contain exactly iv. This observation(CONF:31968). exactly one [1..1] value with @xsi:type="CD" SHALL contain (CONF:31972). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 0..* is treated by Contains: 1 3. MAY contain zero or one [0..1] @negationInd (CONF:31960). 4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 1.1 ClincalEventObservationSubEntry (CONF:31961).This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 5. SHALL contain exactly one [1..1] code (CONF:31962). Contains: 7. SHALL contain exactly one [1..1] value (CONF:31964). 2. SHALL containContained By: exactly one [1..1] @moodCode="EVN" (CONF:31959). Contains: 8. MAY contain zero or more [0..*] zero or one [0..1] @negationInd (CONF:31960). 3. MAY contain entryRelationship (CONF:31965). a. The entryRelationship, if present,one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 4. SHALL contain exactly SHALL contain exactly one [1..1] This @typeCode="OPTN" (CONF:31966). template is used to collect clinical event observations made within the scope of the (CONF:31961). encounter. Observations may be modified by observational semantic qualifiers. b. The entryRelationship, if present,one [1..1] code exactly one [1..1] 5. SHALL contain exactly SHALL contain (CONF:31962). @contextConductionInd="true" SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). 1. (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). c. The entryRelationship, if present,one [1..1] valueexactlyone [1..1] observation 2. SHALL contain (CONF:31964). 7. SHALL contain exactly SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). (CONF:31968). 3. MAY contain zero or one [0..1] @negationInd 8. MAY contain zero or more [0..*] entryRelationship (CONF:31965). (CONF:31960). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 4. SHALL if present, SHALL contain exactly one [1..1] a. The entryRelationship, contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31969). (CONF:31961). @typeCode="OPTN" (CONF:31966). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" 5. SHALL if present, SHALL contain exactly one [1..1] b. The entryRelationship, contain exactly one [1..1] code (CONF:31962). (CONF:31970). @contextConductionInd="true" (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). c. The entryRelationship, contain exactly one [1..1] value (CONF:31964). 7. SHALL if present, SHALL contain exactly one [1..1] observation iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31968). MAY contain zero or more [0..*] entryRelationship (CONF:31965). 8. (CONF:31972). i. This observationThe entryRelationship, one [1..1] @classCode="OBS" a. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31969). @typeCode="OPTN" (CONF:31966). 1 0..* Legend Diet energyQuantity : PQ carbohydrateQuantity : PQ is use of 0..* ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 1 09.0 Procedures::ArterialClosureDev ice identifies Table 1: ClincalEventObservationSubEntry Contexts SUBENTRY 1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 2. SHALL contain exactly one [1..1] @moodCode="EVN" R Y S U B E N T (CONF:31959). 1 6. SHALL contain zeroSHALL containeffectiveTime (CONF:31963). Table 1: ClincalEventObservationSubEntry Contexts 1. or one [0..1] exactly one [1..1] @classCode="OBS" (CONF:31958). 07.0 Dev ices::Dev ice ::ObservationEvent + observationTypeCode :CD is use by ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 1 is part of Supply quantity : PQ expectedUseTime : IVL<TS> procedureTypeCode :CD ::Intervention - indicationCode :CD [0..1] - abortedReasonCode :CD [0..*] is a type of deviceCounter :INT {id} statusCode :CD abortedReasonCode :CD [0..1] is use of 1 + has subject 1..* - ::Intervention - indicationCode :CD [0..1] - abortedReasonCode :CD [0..*] 02.0 Patients::Patient 0..1 0..* 09.0 Procedures::ProcedureDev iceUse 09.0 Procedures::Procedure - 1 1.1 ClincalEventObservationSubEntry This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 3. MAY contain zero or one [0..1] @negationInd (CONF:31960). 4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 1.1 ClincalEventObservationSubEntry (CONF:31961).This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 5. SHALL contain exactly one [1..1] code (CONF:31962). Contained By: involving 0..* 02.0 Patients::ResearchStudyEnrollment [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] Contained By: Contains: 2. SHALL contain exactly one [1..1] @moodCode="EVN" R Y S U B E N T (CONF:31959). 0..* is part of 0..* enrolledIndicator :BL = No SUBENTRY 1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is referred to by (0..*) 06.0 Lesions :: LesionTreatmentDevice 1 - 1 1.1 ClincalEventObservationSubEntry This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 1 05.0 Events::Intervention 0..* DiagnosticImage subjectOrientationCode : CE Contained By: observationResultTypeCode :CD conditionOnsetDateTime :TS [0..1] +child estimatedOnsiteDateIndicator :BL = No 0..* missingOnsetTimeIndicator :BL = No observationValue :ANY observationValueNegationIndicator :BL = No 07.0 Dev ices::Dev iceDescriptor ::ObservationEvent + observationTypeCode :CD ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] 09.0 Procedures::ProcedureLesion Observation value : ANY interpretationCode : SET<CE> methodCode : SET<CE> targetSiteCode : SET<CD> 0..* + is part of ::ObservationEvent + observationTypeCode :CD 10.0 Medication Administration Ev ents:: MedicationAdministrationEv ent SUBENTRY ClincalEventObservationSubEntry Table 1: ClincalEventObservationSubEntry Contexts is grouped by +parent 0..1 04.0 Observ ations::Observ ationResult 04.0 Observ ations:: Observ ationEv ent observationTypeCode :CD 0..* relationshipTypeCode :RelationshipType is a type of 1 1 1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] name :EN.PN identifier :II isCertifiedIndicator :BL = No 0..* + ::Event - methodCode :CD [0..*] (SET) + classificationCode :Clasification + contextCode :Context - eventDateTime :TS [0..1] (IVL) - statusCode :CD = Completed - eventDuration :PQ.TIME [0..1] is a type of 09.0 Procedures::ProcedureDescriptor 0..* 03.0 CareEpisodes::Ev entEpisodeRelation + SUBENTRY performed by 0..* methodCode :CD [0..*] (SET) classificationCode :Clasification contextCode :Context eventDateTime :TS [0..1] (IVL) statusCode :CD = Completed eventDuration :PQ.TIME [0..1] has source has target within context of 1 SubstanceAdministration routeCode : CE approachSiteCode : SET<CD> doseQuantity : IVL<PQ> rateQuantity : IVL<PQ> doseCheckQuantity : SET<RTO> maxDoseQuantity : SET<RTO> substitutionCode : CE PublicHealthCase PatientEncounter detectionMethodCode : CE preAdmitTestInd : BL transmissionModeCode : CE admissionReferralSourceCode : CE diseaseImportedCode : CE lengthOfStayQuantity : PQ dischargeDispositionCode : CE specialCourtesiesCode : SET<CE> specialAccommodationCode : SET<CE> acuityLevelCode : CE 1.1 NCDR DAM Classes Salimah Shakir 1.0 11/12/2012 7:02:00 PM 8/26/2013 1:05:44 PM 1 05.0 Ev ents::Ev ent arrivalDateTime :TS dischargeDate :TS.DATE payorTypeCode :CD [1..*] (SET) admissionSourceCode :CD dischargeDispositionCode :CD 1 has source is grouped by 0..* - 05.0 Ev ents::Ev entPerformer relationshipTypeCode :RelationshipType 0..* 03.0 CareEpisodes::CareEpisode 02.0 Patients::ClinicalTrial Registry Specific Business Rules identifier :ST {id} is used by salaryTypeCode : CE salaryQuantity : MO hazardExposureText : ED protectiveEquipmentText : ED 0..n LanguageCommunication languageCode : CE modeCode : CE proficiencyLevelCode : CE preferenceInd : BL 1 has subject formCode : CE ManufacturedMaterial lotNumberText : ST expirationTime : IVL<TS> stabilityTime : IVL<TS> Container Device capacityQuantity : PQ manufacturerModelName : SC heightQuantity : PQ softwareName : SC localRemoteControlStateCode : CE ... diameterQuantity : PQ capTypeCode : CE alertLevelCode : CE separatorTypeCode : CE lastCalibrationTime : TS barrierDeltaQuantity : PQ bottomDeltaQuantity : PQ HL7 & IHE Content Profiles 01.0 Submissions::SourceSystemProv ider provided by 1..* 1 is part of ActRelationship typeCode : CS inversionInd : BL outboundRelationship contextControlCode : CS Access LicensedEntity 0..n contextConductionInd : BL approachSiteCode : CD recertificationTime : TS sequenceNumber : INT targetSiteCode : CD 1 source priorityNumber : INT gaugeQuantity : PQ pauseQuantity : PQ Act Participation checkpointCode : CS classCode : CS Entity typeCode : CS Role splitCode : CS moodCode : CS functionCode : CD classCode : CS player joinCode : CS classCode : CS id : SET<II> contextControlCode : CS determinerCode : CS negationInd : BL 0..1 code : CD 0..n id : SET<II> sequenceNumber : INT id : SET<II> 0..n conjunctionCode : CS negationInd : BL 1 playedRolecode : CE negationInd : BL code : CE localVariableName : ST negationInd : BL 1 derivationExpr : ST quantity : SET<PQ> 0..n noteText : ED seperatableInd : BL addr : BAG<AD> text : ED time : IVL<TS> name : BAG<EN> telecom : BAG<TEL> 0..n statusCode : SET<CS> modeCode : CE desc : ED statusCode : SET<CS> effectiveTime : GTS inboundRelationship awarenessCode : CE statusCode : SET<CS> scopedRole effectiveTime : IVL<TS> activityTime : GTS signatureCode : CE existenceTime : IVL<TS> 0..n certificateText : ED target availabilityTime : TS signatureText : ED telecom : BAG<TEL> quantity : RTO 0..1 priorityCode : SET<CE> performInd : BL riskCode : CE 1 positionNumber : LIST<INT> scoper substitutionConditionCode : CE confidentialityCode : SET<CE> ... handlingCode : CE repeatNumber : IVL<INT> DeviceTask 1 target 1source interruptibleInd : BL 1 parameterValue : LIST<ANY> levelCode : CE inboundLink WorkingList 0..n outboundLink 0..n independentInd : BL Employee ownershipLevelCode : CE RoleLink uncertaintyCode : CE FinancialContract jobCode : CE typeCode : CS reasonCode : SET<CE> paymentTermsCode : CE jobTitleName : SC effectiveTime : IVL<TS> languageCode : CE jobClassCode : CE Material treated NonPersonLivingSubject strainText : ED genderStatusCode : CE ManagedParticipation id : SET<II> statusCode : SET<CS> assigns LivingSubject administrativeGenderCode : CE birthTime : TS deceasedInd : BL deceasedTime : TS multipleBirthInd : BL multipleBirthOrderNumber : INT organDonorInd : BL Patient confidentialityCode : CE veryImportantPersonCode : CE is a trait of Person addr : BAG<AD> maritalStatusCode : CE educationLevelCode : CE raceCode : SET<CE> disabilityCode : SET<CE> livingArrangementCode : CE religiousAffiliationCode : CE ethnicGroupCode : SET<CE> Place mobileInd : BL addr : AD directionsText : ED positionText : ED gpsText : ST 1..* 1 0..* Organization addr : BAG<AD> standardIndustryClassCode : CE iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972). UMTS CDA Template Library 6 Registry Specific Content Profiles 1 SUBENTRY 1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] 1 (StructuredBodyComponent) RegistryParticipantDetailComponent Entry Point (ClinicalDocumentComponent) DocumentComponent (RecordTarget) RecordTarget - isPlayedBy classCode :CS = "PAT" (PatientIdentifier.identifierValue) id :II - typeCode :CS = "RCT" contextControlCode :CS = "OP" - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" Table 1: ClincalEventObservationSubEntry Contexts (Entry) PatientIdentifierObserv ationEntry typeCode :CS = "COMP" contextConductionIndicator :BL = "true" - Contained By: typeCode :CS = "COMP" contextConductionIndicator :BL = "true" (ClinicalDocument) CathPCIRegistryDocument 1..1 1 + # + classCode :CS = "DOCCLIN" moodCode :CS = "EVN" id :II code :CE = "CATHPCI" effectiveTime :TS - 1..1 (Observ ation) PatientIdentifierObserv ation (Section) PatientDetailSection (StructuredBody) DocumentBody 1 classCode :CS = "DOCBODY" moodCode :CS = "EVN" 1..1 1 # classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "PatientDetail" 1 0..* # + classCode :CS = "OBS" moodCode :CS = "EVN" (PatientIdentifier.typeCode) code :CD (PatientIdentifier.identifierValue) value :CD 1 1 1 (StructuredBodyComponent) PatientDetailComponent (StructuredBodyComponent) SubmissionDetailComponent (Custodian) Custodian - - typeCode :CS = "CST" - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" (Entry) PatientRaceObserv ationEntry typeCode :CS = "COMP" contextConductionIndicator :BL = "true" - 1..1 typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1..1 1..1 (CustodianOrganization) Participant + + classCode :CS = "ORG" determinerCode :CS = "INSTANCE" (ParticipantIdentifier.identifierValue) id :II (Participant.name) name :EN.ON (Section) SubmissionDetailSection (AssignedCustodian) ParticipantRole isScopedBy 1 1..1 - # classCode :CS = "ASSIGNED" (Observ ation) PatientRaceObserv ation classCode :CS = "DOCSECT" moodCode :CS = "EVN" code :CE = "SubmissionDetail" # + 1 classCode :CS = "OBS" moodCode :CS = "EVN" code :CD = "PatientRace" (PatientRace.raceCode) value :CD [1..*] (SET) (Entry) SubmissionActEntry - typeCode :CS = "COMP" contextConductionIndicator :BL = "true" 1..1 (Act) SubmissionAct + + classCode :CS = "ACT" moodCode :CS = "EVN" (Submission.identifier) id :II (Submission.submissionTimePeriod) effectiveTime :TS (IVL) (ParticipantRole) TargetRegistry 1 1..1 - classCode :CS = "MMAT" 1..1 1 (ClinicalStatementParticipant) Author - (ClinicalStatementParticipant) Receiv er typeCode :CS = "AUT" contextControlCode :CS = "OP" - isPlayedBy typeCode :CS = "RCV" contextControlCode :CS = "OP" 1..1 1 (Dev ice) DataCollectionSystem + classCode :CS = "DEV" determinerCode :CS = "INSTANCE" (SourceSystem.versionIdentifier) id :II (ParticipantRole) SourceSystem isPlayedBy 1 1..1 - 1 SUBENTRY Contains: 1.1 ClincalEventObservationSubEntry This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 1 1..1 (PatientRole) PatientRole + (Dev ice) RegistrySystem classCode :CS = "MMAT" + + isScopedBy classCode :CS = "DEV" determinerCode :CS = "INSTANCE" (Registry.identifier) id.root :II.root (RegistryVersionIdentifier) id.extension :II.extension 1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). Table 1: ClincalEventObservationSubEntry Contexts 1 2. SHALL contain exactly one [1..1] @moodCode="EVN" R Y S U B E N T (CONF:31959). Contained By: Contains: 3. MAY contain zero or one [0..1] @negationInd (CONF:31960). 4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 1.1 ClincalEventObservationSubEntry (CONF:31961).This template is used to collect clinical event observations made within the scope of the [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)] encounter. Observations may be modified by observational semantic qualifiers. 5. SHALL contain exactly one [1..1] code (CONF:31962). 6. SHALL contain zeroSHALL containeffectiveTime (CONF:31963). Table 1: ClincalEventObservationSubEntry Contexts 1. or one [0..1] exactly one [1..1] @classCode="OBS" (CONF:31958). 7. SHALL contain exactly one [1..1] value (CONF:31964). 2. SHALL containContained By: exactly one [1..1] @moodCode="EVN" (CONF:31959). Contains: 8. MAY contain zero or more [0..*] zero or one [0..1] @negationInd (CONF:31960). 3. MAY contain entryRelationship (CONF:31965). a. The entryRelationship, if present,one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" 4. SHALL contain exactly SHALL contain exactly one [1..1] This @typeCode="OPTN" (CONF:31966). template is used to collect clinical event observations made within the scope of the (CONF:31961). encounter. Observations may be modified by observational semantic qualifiers. b. The entryRelationship, if present,one [1..1] code exactly one [1..1] 5. SHALL contain exactly SHALL contain (CONF:31962). @contextConductionInd="true" SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958). 1. (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). c. The entryRelationship, if present,one [1..1] valueexactlyone [1..1] observation 2. SHALL contain (CONF:31964). 7. SHALL contain exactly SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959). (CONF:31968). 3. MAY contain zero or one [0..1] @negationInd 8. MAY contain zero or more [0..*] entryRelationship (CONF:31965). (CONF:31960). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" 4. SHALL if present, SHALL contain exactly one [1..1] a. The entryRelationship, contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31969). (CONF:31961). @typeCode="OPTN" (CONF:31966). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" 5. SHALL if present, SHALL contain exactly one [1..1] b. The entryRelationship, contain exactly one [1..1] code (CONF:31962). (CONF:31970). @contextConductionInd="true" (CONF:31967). 6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). c. The entryRelationship, contain exactly one [1..1] value (CONF:31964). 7. SHALL if present, SHALL contain exactly one [1..1] observation iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31968). MAY contain zero or more [0..*] entryRelationship (CONF:31965). 8. (CONF:31972). i. This observationThe entryRelationship, one [1..1] @classCode="OBS" a. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31969). @typeCode="OPTN" (CONF:31966). ii. This observationThe entryRelationship, one [1..1] @moodCode="EVN" b. SHALL contain exactly if present, SHALL contain exactly one [1..1] (CONF:31970). @contextConductionInd="true" (CONF:31967). iii. This observationThe entryRelationship, one [1..1] code (CONF:31971). one [1..1] observation c. SHALL contain exactly if present, SHALL contain exactly iv. This observation(CONF:31968). exactly one [1..1] value with @xsi:type="CD" SHALL contain (CONF:31972). i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969). ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970). iii. This observation SHALL contain exactly one [1..1] code (CONF:31971). iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972). (Entity) SourceSystemProv ider + Slide Number: 98 classCode :CS = "ORG" determinerCode :CS = "INSTANCE" (SourceSystemProvider.identifier) id :II © 2014 All Rights Reserved
  • 99. Questions Slide Number: 99 © 2014 All Rights Reserved
  • 100. Thank You AbdulMalik Shakir President and Chief Informatics Scientist Hi3 Solutions | your healthcare standards conformance partner 3500 West Olive Ave, Suite # 300, Burbank, CA 91505. Direct: +1 626 644 4491 | Toll Free: +1 800 918 6520 www.hi3solutions.com Slide Number: 100 | abdulmalik.shakir@hi3Solutions.com © 2014 All Rights Reserved