This document provides an overview of a presentation on health information model standards given by Jason Siegel to the Johns Hopkins School of Medicine. The presentation covers Health Level Seven (HL7) standards including the Reference Information Model (RIM), HL7 version 2 and 3 messaging, and HL7 vocabulary. It also discusses the CDC Public Health Information Network (PHIN) and the PHIN Logical Data Model, as well as other health data models.

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Health Information Model Standards
Johns Hopkins School of Medicine
Division of Health Sciences Informatics
Course 600.708 - Health Information
Systems Standards and Interoperability
Information Model Standards Session
Jason Siegel, MD
Chief Medical Informaticist
Public Health Division
Atlas Development Corporation

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Introduction
• Approach: Informal with Slides
– Problem of how to dissect an elephant
– Presentation is dynamic
– Teach how to learn on your own
• Instructor: Jason Siegel, MD
– Internist with Endocrinology training
• Programming since 1969
• Medical Informatics since 1980
– Atlas Development since 2000
• Chief Medical Informaticist
– HIPAA and PHIN Compliance officer
• Public Health Data Model Architect
– Deploying to 7 California counties (est. 18,000,000 people)
– Deploying to Wisconsin state (est. 6,000,00 people)

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Tutorial Topics
• Health Level Seven (HL7)
– History and Purpose
– Messaging Needs
– Version Evolution: v2 and v3
– Reference Information Model (RIM)
– Structure of Core classes
– Data Types: Simple and Complex
– Vocabulary: Basis of specialization
– Building Messages from the RIM
– How to Study the RIM
• CDC Public Health Information Network (PHIN)
– CDC PHIN adoption of RIM
– Public Health Conceptual Data Model
– PHIN Logical Data Model
– NEDSS and OMS Data Models
• Other Medical Data models
– Canadian Data Models
– Atlas Public Health Information Model

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Health Level Seven
www.hl7.org

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HL7 Purpose
• Standardize the structure and format of
the application layer of the Open System
Interconnections for Health data exchange

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Need for Standard Messaging
6 nodes = 15 individual
connections
EMR EMR
PH PH
LAB LAB
EMR EMR
PH PH
LAB LAB
HL7
6 nodes = 6 standard
connections

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HL7 Version 2.x Message
• Defined Message Structure
– Delimited fields
– Standardized term sets
• Adopted widely
– Laboratories and Hospital systems
– Basis of current CDC messages
• Limits
– Not based on general conceptual model
– Difficult to represent hierarchical concepts
MSH|^~&||QUEST DIAGNOSTICS-LOS ANGELES (METRO)^05D0642827^CLIA|NPHSS|54-LA
CNTY|200507081018||ORU^R01|200507041000|P|2.3|||||||
PID||8527292^^^^^L.A JAIL TWIN TOWERS_____|0002255^^^^^QUEST DIAGNOSTICS-LOS ANGELES
(METRO)&05D0642827&CLIA||SKYWALKER^ANAKIN||19650115|M||U|^^^^^^^^^||^^^^^^|||||||||U
OBR|1||WD223962R|^^^7500074554^CULTURE,
MYCOBACT^L|||20050530|||||||20050530|^^&&&&SPUTUM&L|^PILE^|^^^^^213^8935658||||||||F||||
ZLR||L.A JAIL TWIN TOWERS_____|450 BAUCHET ST FL 2,^^LOS ANGELES^CA^90012-
2907|^^^^^213^8935658|^40^Y|||||||||||||||
OBX|1|CE|^^^75407123^MYCOBACTERIUM CULTURE ID^L|1|^^^MTBC^MYCOBACTERIUM TUBERCULOSIS
COMPLEX^L||||||F|||200507010858|05D0642827^^CLIA

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HL7 version 3 Message
• Message Derived from General Model (RIM)
– Standardized structure, data types, vocabularies
– Can be represented in XML format
• Leading Edge
– Infinitely extensible
– Can easily represent hierarchies
– Can build new messages/views from other components
• Limits
– Not widely accepted
– Greater difficulty generating messages
<observation classCode="OBS" moodCode="EVN">
<code code="121961000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
displayName="Clostridium botulinum toxin assay"/>
<effectiveTime value="200504070930"/>
<value xsi:type="CE" code="385333003"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Botulinum toxin type E">
<originalText><reference value="LAB1"/></originalText>
</value>
</observation>

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HL7 version 3 Definition
Version 3 uses an object-oriented
development methodology and a Reference
Information Model (RIM) to create
messages. The RIM is an essential part of
the HL7 Version 3 development
methodology, as it provides an explicit
representation of the semantic and lexical
connections that exist between the
information carried in the fields of HL7
messages.
webstore.ansi.org/ansidocstore/product.asp?sku=ANSI%2FHL7+V3+2006

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Reference Information Model (normative)

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RIM Architecture is a Paradigm Shift
• HL7 version 3 Reference Information Model
– Structure: Defines general classes and specializations
– Data Types: Defines structural format of attribute data
– Vocabulary: Controls possible values in coded attributes
Entity
People
Organizations
Materials
Role
Patient
Provider
Exposed
Participation
Subject
Author
Performer
Act
Observation
Public Health Case
Substance Admin
RoleLink
Authority
Has Part
Replaces
Act
Relationship
Component
Refers to
Sequel

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Common RIM Data Types
Simpler Types
• BL: Boolean
• BN: Boolean non-null
• BIN: Binary
• ST: Character String
• SC: String with Code
• INT: Integer
• REAL: Real
• RTO: Ratio
• QTY: Quantity
Unit Based
• PQ: Physical Quantity
• MO: Monetary Amount
• TS: Point in Time
Identifiers
• OID: Object Identifier
• II: Instance Identifier
• URL: Universal Resource Locator
Coded Attributes
• CD: Concept Descriptor
• CE: Code with Equivalents
• CR: Concept Role
• CS: Coded Simple
• CV: Coded Value
• CO: Coded Ordinal
Collections & Complex
• BAG: Bag (unordered, non-unique)
• SET: Set (unordered, unique)
• LIST: Sequence (ordered, unique)
• ED: Encapsulated Data
• IVL: Interval
• GTS: General Timing Specification
• AD: Address
– ADX: Address Part
• EN: Entity Name
– ENXP: Entity Name Part

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Coded Attributes are the Key to Expandability
Concept Descriptor (CD)
Code with Equivalents (CE)
Coded Value (CV)
Coded Simple (CS)

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Instance Identifiers give Specificity to the RIM

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Object Identifiers are Essential to the RIM
• An Object Identifier is an Ordered List of Integers
– Used to unambiguously identify information instances
– Includes vocabularies, record identifiers
• HL7 OID Tree
– HL7: 2.16.840.1.113883
• iso/itu.country.usa.company.hl7
– Members: 2.16.840.1.113883.3
• Atlas Dev: 2.16.840.1.113883.3.33
– Identifiers: 2.16.840.1.113883.4
• SSN Admin: 2.16.840.1.113883.4.1
– Vocabulary
• Internal: 2.16.840.1.113883.5
– EntityClass: 2.16.840.1.113883.5.41
• External: 2.16.840.1.113883.6
– LOINC: 2.16.840.1.113883.6.1
– SNOMED-CT: 2.16.840.1.113883.6.96

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Object Identifier Examples
• Person is a LivingSubject is an Entity
– administrativeGender attribute : CE data type
• code = M
• codeSystem = 2.16.840.1.113883.5.1
• codeSystemName = HL7
• codeSystemVersion = 2.11
• displayName = male
• originalText = man
– id attribute : II data type (Instance Identifier)
• root = 2.16.840.1.113883.4.1 {Social Security Admin}
• extension = 123-45-6780 {SSN}
• assigningAuthorityName = SS Administration
• displayable = True

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Partial HL7 Vocabulary List

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Class Codes Allow Specialization

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Reference Information Model (billboard)

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Entity Subclasses

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Role and Participation Subclasses

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Act Clinical Subclasses

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Act Relationship is Key to Flexibility
PH Case
Schedule
Visits
Lab
Test
Give
Meds
Triggers
Field
Visit-1
Disease
Dx
Support
Occur
Reason
Compon
Physical
Exam
System
Review
Pulse BP
Field
Visit-2
Occur
Com
pon
Com
pon
Com
pon
Com
pon
Allergy
Com
pon

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RIM Model Download
www.hl7.org/library/data-model/RIM/modelpage_mem.htm

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HL7 v3 is About Messages from the RIM

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HL7 Visio Drawing Template

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Class Instance Requires Linkage to RIM Source

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Class Builder Dialog Defines Message Content

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Common Message Elements are Building Blocks
R_CoveredParty universal (COCT_RM500000)

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Domain Information Model Defines Entire Scope
Public Health Reporting Domain Information Model (PORR_DM100001UV01)

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Refined Message Information Model is Specific
Notifiable Condition Report RMIM (PORR_RM100001UV01)

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How to Study the RIM

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CDC PHIN
www.cdc.gov/phin/

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CDC Adoption of HL7 v3 RIM
• Functional Specifications (2002)
– PHIN_Functions_Specifications_121802.pdf
• Data standards are derived from, and compatible with the Health Level 7
Reference Information Model (RIM).
– 2) The Use of Electronic Clinical Data for Event
Detection
• Data accumulated for this purpose need to be stored in a format compatible
with the NEDSS / HL7-compatible Logical Data Model so that general
analytic and reporting tools can be developed.
• PHIN Logical Data Model (2004)
– PHIN_LDM_User_Guide_v1.0.pdf
– Derived from HL7 v3 RIM
• Many RFPs still require PHIN LDM compatibility
– Even though newer CDC requirements do not

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CDC Model Hierarchy Definitions
1. Subject Area Model (SAM)
A subject area model contains only subject areas and their connections, and usually serves as a
model for a large domain, such as the entire enterprise or a major functional area. It is used for
high-level planning and setting of project scope.
2. Class Relationship Model (CRM)
A class relationship model contains only subject areas, classes, and relationships, and generally
depicts a limited domain, such as a single project or enterprise business area. It is used for high-
level analysis and estimation of project size.
3. Conceptual Data Model (CDM)
A conceptual data model contains subject areas, classes, attributes, datatypes, and relationships,
and generally models a project-specific domain, such as public health, finance, or material
management. It results from a relatively detailed level of analysis and is often a primary project
deliverable.
4. Logical Data Model (LDM)
A logical data model contains subject areas, normalized classes, atomic attributes, relationships,
and candidate/primary keys, and usually serves as a model for an enterprise-specific
implementation of a project-specific domain. It signifies the completion of the most detailed level
of data analysis and the beginning of database design.
5. Database Design Model (DDM)
A database design model contains table spaces, tables, columns, datatypes, and primary/foreign
keys, and generally represents an existing or planned database of a computerized information
system. It indicates the completion of database design and the beginning of database
construction.
6. Physical Database Model (PDM)
A physical database model contains the data definition language (DDL) required to create tables
and indexes, as well as data base management system (DBMS)-enforced constraints. It is a
machine-processable specification of an existing or planned database of a computerized
information system, and corresponds to the final step of database design and construction.
www.cdc.gov/nedss/datamodels/phcdm.pdf

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CDC Public Health Conceptual Data Model
www.cdc.gov/nedss/datamodels/phcdm.pdf

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CDC PHIN Logical Data Model
www.cdc.gov/phin/library/documents/pdf/PHIN_LDM_User_Guide_v1.0.pdf

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PHIN LDM Act Subschema

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Public Health Case Class Differences from RIM
• RIM PH Case
– Includes OBS attributes
– Value can be Anything,
including all other data types
• CDC PH Case
– Adds extra
attributes
– Does not
support CE
– Value is
restricted

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National Electronic Disease Surveillance System

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NEDSS Logical Data Model (partial)

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Outbreak Management System

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OMS Logical Data Model (partial)

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Other Health Data Models

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Some Data Model Definitions
• ANSI (1975)
– Conceptual schema : entity classes and relationships
– Logical schema: descriptions of tables and columns
– Physical schema: physical means for data storage
• Zachman Framework
– Conceptual model: classes of significance
– Contextual model: assertions about associations
– Logical model: descriptions of tables and columns
– Physical model: physical means for data storage
– Data definition: actual coding of the database schema
– Data manipulation: operations applied to the data
en.wikipedia.org/wiki/data_modeling

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Canadian Institute for Health Information
www.cihi.ca/cihiweb/en/downloads/infostand_chdm_e_CHDMv2_31.pdf

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Canada Conceptual Health Data Model
www.cihi.ca/cihiweb/en/downloads/infostand_chdm_e_Visio-CHDMv2_3.pdf

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Pan-Canadian Public Health Surveillance Solution Project

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Atlas Public Health Information Model (APHIM)

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APHIM Physical Data Model Section

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APHIM Data Definition Language

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Questions and Answers
• Jason A. Siegel, MD
Chief Medical Informaticist
RIM Cartographer
Atlas Development Corporation
26679 West Agoura Road
Building C, Suite 200
Calabasas, CA 91307
• Cell : 562-243-7422
Res : 562-598-6997
Ofc : 818-340-7080
Fax : 818-340-7079
Eml : jsiegel@atlasdev.com
Web: www.atlasdev.com