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RIM Derived and Influenced HL7 Standards AbdulMalik Shakir President and Chief Informatics Scientist Your Healthcare Standards Conformance Partner
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Rim derived and influenced hl7 standards

May 25, 2015

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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).

Topics Covered:

1. HL7 Development Framework
2. HDF Methodology
3. HL7 V3 Development Artifacts
4. Sample V3 Clients and Projects
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Page 1: Rim derived and influenced hl7 standards

RIM Derived and Influenced HL7 Standards

AbdulMalik Shakir

President and Chief Informatics Scientist

Your Healthcare Standards Conformance Partner

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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.

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Electronic Health Information Exchange

Pharmacies

Physicians

Testing OrganizationsLab/Images

Hospitals

Payors

Employers

County/Community Entities

Patients/ConsumersGovernmentMedicare/Medicaid

Lab results

Patient Data

Orders

Results

Images

Eligibility

Referral Process

Claim Status

Claims/Prescriptions

Referral Process

Claim/Status

Health Information

Insurance Updates

Eligibility

Medical Records

Enrollment

Mental Health

Family Planning

Medical Society

Public Health

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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.  

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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.

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HL7 Development Framework

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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.

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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.

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The Family of HL7 Standards

• 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

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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.

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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)

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HL7 V3 Methodology: What and How

Use Case Modeling

Interaction Modeling

Message Design

Information Modeling

RIM

Restrict

R-MIM

Serialize

HMD

Restrict

MessageType

Example

Storyboard

StoryboardExample

D-MIM

Derive

ApplicationRole

Sender Receiver

TriggerEvent

Triggers

Content

InteractionReferences

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HL7 V3 Design ModelsRIM

(1)Define aD-MIM

D-MIM

(2)Define aR-MIM

R-MIM

(3)Create

an HMD

HMD

RIMReference Information Model

D-MIMDomain Message Information Model

R-MIMRefined Message Information Model

HMDHierarchical Message Definition

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HL7 Development Framework

Methodology

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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

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HDF Workflow DiagramInitiateProject

ProjectCharter

SpecifyRequirements

ReferenceModels

RequirementSpecification

Prepare SpecificationDesign Models

SpecificationDesign Models

PrepareSpecification

ApproveSpecification

ApprovedSpecification

PublishApproved

Specification

PublishedSpecification

Prepare SpecificationProfiles

SpecificationProfile

ConformanceStatement

Pre-ApprovalSpecification

The HDF workflow is not a waterfall methodology.Each phase builds upon the prior and may causeprior activities to be revisited and their deliverablesadjusted.

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Project initiationDuring 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.

ProjectInitiation

ProjectCharter

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

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Requirements DocumentationDuring 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.

RequirementsDocumentation

Requirements Specification

1. Document Business Process: Dynamic Behavior and Static Structure

2. Capture Process Flow: UML Activity Diagram

3. Capture Structure: Domain Analysis Model and Glossary

4. Capture Business Rules: Relationships, Triggers, and Constraints

5. Harmonize the Domain Analysis Model with HL7 Reference Models

ProjectCharter

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Specification ModelingDuring 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.

SpecificationModeling

SpecificationDesign Models

1. Build design models of static information views

2. Construct design models of behavioral views

3. Define reusable design model components

4. Construct design models of collaboration and interaction

5. Harmonize design models with HL7 Reference Models

RequirementsSpecification

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Specification DocumentationDuring 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.

SpecificationDocumentation

Pre-ApprovalSpecification

1. Organize design model elements into logical packages

2. Compose explanatory text, examples, and design rationale

3. Update design models and requirement specifications

4. Assemble a pre-approval specification package

5. Submit specification for approval

SpecificationDesign Models

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Specification ApprovalDuring 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.

SpecificationApproval

ApprovedSpecification

1. Obtain TSC and Board approval to ballot specification

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. Resolve negative ballot responses and if necessary reballot

Pre-ApprovalSpecification

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Specification PublicationDuring specification publication the approved specification is prepared for prepared for publication and distribution. The primary deliverable produced during specification publication is a published specification.

SpecificationPublication

PublishedSpecification

1. Obtain TSC and Board approval to publish specification

2. Prepare specification for publication

3. Submit publication to standards authorities (ANSI/ISO)

4. Render the specification in various forms of publication media

5. Post and distribute approved specifications

ApprovedSpecification

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Specification ProfilingDuring 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.

SpecificationProfiling

SpecificationProfiles and

ConformanceStatements

1. Identify community of uses for published specification

2. Further refine and constrain specification design models

3. Document exceptions, extensions, and annotations to specifications

4. Prepare and publish specification profile

5. Prepare and publish conformance statements

PublishedSpecification

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HDF Workflow DiagramInitiateProject

ProjectCharter

SpecifyRequirements

ReferenceModels

RequirementSpecification

Prepare SpecificationDesign Models

SpecificationDesign Models

PrepareSpecification

ApproveSpecification

ApprovedSpecification

PublishApproved

Specification

PublishedSpecification

Prepare SpecificationProfiles

SpecificationProfile

ConformanceStatement

Pre-ApprovalSpecification

The HDF workflow is not a waterfall methodology.Each phase builds upon the prior and may causeprior activities to be revisited and their deliverablesadjusted.

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HL7 Version 3.0 Development Artifacts

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HL7 v3.0 Development ArtifactsReference

InformationModel

ReferenceInformation

Model

DatatypeSpecification

DatatypeSpecification

VocabularySpecificationVocabulary

SpecificationReference

Models

InteractionModel

InteractionModel

DesignInformation

Model

DesignInformation

Model

CommonMessage Type

Model

CommonMessage Type

Model

DesignModels

HierarchicalMessage

Definition

HierarchicalMessage

Definition

MessageType

Definition

MessageType

Definition

ImplementationTechnology

Specification

ImplementationTechnology

Specification

Content Specifications

MessageProfile

Specification

MessageProfile

Specification

LocalizedMessage

Specification

LocalizedMessage

Specification

MessageConformanceStatements

MessageConformanceStatements

ImplementationProfiles

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HL7 v3.0 Development Artifacts

ReferenceInformation

Model

ReferenceInformation

Model

DatatypeSpecification

DatatypeSpecification

VocabularySpecificationVocabulary

Specification

Reference Models

The HL7 Reference Information Model is the information model from which all other information models and message specifications are derived.

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.

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.

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HL7 v3.0 Development Artifacts

InteractionModel

InteractionModel

DesignInformation

Model

DesignInformation

Model

CommonMessage Type

Model

CommonMessage Type

Model

Design Models

An Interaction Model is a specification of information exchanges within a particular domain as described in storyboards and storyboard examples.

A Domain Information Model is an information structure that represents the information content for a set of messages within a particular domain area.

A Common Message Type Model is a definition of a set of common message components that can be referenced in various message specifications.

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HL7 v3.0 Messaging Artifacts

HierarchicalMessage

Definition

HierarchicalMessage

Definition

MessageType

Definition

MessageType

Definition

ImplementationTechnology

Specification

ImplementationTechnology

Specification

Message Specifications

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.

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HL7 v3.0 Development Artifacts

MessageProfile

Specification

MessageProfile

Specification

LocalizedMessage

Specification

LocalizedMessage

Specification

MessageConformance

Statement

MessageConformance

Statement

Implementation Profiles

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 Profile Specification is a description of a particular or desired implementation of an HL7 Message standard or Localized Message specification.

A Message Conformance Statement is a comparison of a particular messaging implementation and an HL7 message standard, localization, or profile.

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HL7 V3 Message Design Models

RIM

Account

name : STbalanceAmt : MOcurrencyCode : CEinterestRateQuantity : RTO<MO,PQ>allowedBalanceQuantity : IVL<MO>

DeviceTask

parameterValue : LIST<ANY>

DiagnosticImage

subjectOrientationCode : CE

Diet

energyQuantity : PQcarbohydrateQuantity : PQ

FinancialContract

paymentTermsCode : CE

FinancialTransaction

amt : MOcreditExchangeRateQuantity : REALdebitExchangeRateQuantity : REAL

InvoiceElement

modifierCode : SET<CE>unitQuantity : RTO<PQ,PQ>unitPriceAmt : RTO<MO,PQ>netAmt : MOfactorNumber : REALpointsNumber : REAL

ManagedParticipation

id : SET<II>statusCode : SET<CS>

Observation

value : ANYinterpretationCode : SET<CE>methodCode : SET<CE>targetSiteCode : SET<CD>

PatientEncounter

preAdmitTestInd : BLadmissionReferralSourceCode : CElengthOfStayQuantity : PQdischargeDispositionCode : CEspecialCourtesiesCode : SET<CE>specialAccommodationCode : SET<CE>acuityLevelCode : CE

Procedure

methodCode : SET<CE>approachSiteCode : SET<CD>targetSiteCode : SET<CD>

PublicHealthCase

detectionMethodCode : CEtransmissionModeCode : CEdiseaseImportedCode : CE

SubstanceAdministration

routeCode : CEapproachSiteCode : SET<CD>doseQuantity : IVL<PQ>rateQuantity : IVL<PQ>doseCheckQuantity : SET<RTO>maxDoseQuantity : SET<RTO>substitutionCode : CE

Supply

quantity : PQexpectedUseTime : IVL<TS>

WorkingList

ownershipLevelCode : CE

Container

capacityQuantity : PQheightQuantity : PQdiameterQuantity : PQcapTypeCode : CEseparatorTypeCode : CEbarrierDeltaQuantity : PQbottomDeltaQuantity : PQ

Device

manufacturerModelName : SCsoftwareName : SClocalRemoteControlStateCode : CE...alertLevelCode : CElastCalibrationTime : TS

LivingSubject

administrativeGenderCode : CEbirthTime : TSdeceasedInd : BLdeceasedTime : TSmultipleBirthInd : BLmultipleBirthOrderNumber : INTorganDonorInd : BL

ManufacturedMaterial

lotNumberText : STexpirationTime : IVL<TS>stabilityTime : IVL<TS>

Material

formCode : CENonPersonLivingSubject

strainText : EDgenderStatusCode : CE

Organization

addr : BAG<AD>standardIndustryClassCode : CE

Person

addr : BAG<AD>maritalStatusCode : CEeducationLevelCode : CEraceCode : SET<CE>disabilityCode : SET<CE>livingArrangementCode : CEreligiousAffiliationCode : CEethnicGroupCode : SET<CE>

Place

mobileInd : BLaddr : ADdirectionsText : EDpositionText : EDgpsText : ST

Access

approachSiteCode : CDtargetSiteCode : CDgaugeQuantity : PQ

Employee

jobCode : CEjobTitleName : SCjobClassCode : CEsalaryTypeCode : CEsalaryQuantity : MOhazardExposureText : EDprotectiveEquipmentText : ED

LicensedEntity

recertificationTime : TS

Patient

confidentialityCode : CEveryImportantPersonCode : CE

ActRelationship

typeCode : CSinversionInd : BLcontextControlCode : CScontextConductionInd : BLsequenceNumber : INTpriorityNumber : INTpauseQuantity : PQcheckpointCode : CSsplitCode : CSjoinCode : CSnegationInd : BLconjunctionCode : CSlocalVariableName : STseperatableInd : BL

Act

classCode : CSmoodCode : CSid : SET<II>code : CDnegationInd : BLderivationExpr : STtext : EDstatusCode : SET<CS>effectiveTime : GTSactivityTime : GTSavailabilityTime : TSpriorityCode : SET<CE>confidentialityCode : SET<CE>repeatNumber : IVL<INT>interruptibleInd : BLlevelCode : CEindependentInd : BLuncertaintyCode : CEreasonCode : SET<CE>languageCode : CE

0..n

1

outboundRelationship

0..n

source1

0..n

1

inboundRelationship

0..n

target

1

LanguageCommunication

languageCode : CEmodeCode : CEproficiencyLevelCode : CEpreferenceInd : BL

Participation

typeCode : CSfunctionCode : CDcontextControlCode : CSsequenceNumber : INTnegationInd : BLnoteText : EDtime : IVL<TS>modeCode : CEawarenessCode : CEsignatureCode : CEsignatureText : EDperformInd : BLsubstitutionConditionCode : CE...

0..n

1

0..n

1

Entity

classCode : CSdeterminerCode : CSid : SET<II>code : CEquantity : SET<PQ>name : BAG<EN>desc : EDstatusCode : SET<CS>existenceTime : IVL<TS>telecom : BAG<TEL>riskCode : CEhandlingCode : CE

1

0..n

1

0..n

RoleLink

typeCode : CSeffectiveTime : IVL<TS>

Role

classCode : CSid : SET<II>code : CEnegationInd : BLaddr : BAG<AD>telecom : BAG<TEL>statusCode : SET<CS>effectiveTime : IVL<TS>certificateText : EDquantity : RTOpositionNumber : LIST<INT>

0..n

1

0..n

10..n0..1

playedRole0..n

player

0..1

0..n0..1

scopedRole

0..n

scoper

0..1

0..n

1

outboundLink 0..n

source1

0..n

1

inboundLink0..n

target1

HMD

Design Information Model

D-MIM

PatientIncidentclassCode*: <= ENCmoodCode*: <= EVNid: [1..*] (RegistNum)code: CV CNE [0..1] <= ExternallyDefinedActCodes (PatientType)statusCode: LIST<CS> CNE <= ActStatus (IDPHStatus)activityTime: TS (EDDate)

InjuryclassCode*: <= ACTmoodCode*: <= EVNactivityTime: TS (InjuryDate)

0..1 pertinentInjury

typeCode*: <= PERTpertinentInformation1

TraumaRegistryExport(IDPH_RM00001)

Data content of HL7messages used to exportdata from the IDPH TraumaRegistry.

PatientPersonclassCode*: <= PSNdeterminerCode*: <= INSTANCEname: PN [0..1] (*Name)existenceTime: (Age)administrativeGenderCode: CV CWE <= AdministrativeGender (GenderID)birthTime: (DateOfBirth)addr: AD [0..1] (AddressHome)raceCode: CV CWE [0..1] <= Race (RaceID)ethnicGroupCode: CV CWE [0..1] <= Ethnicity (EthnicID)

1..1 patientPatientPerson

1..1 providerTraumaParticipant

PatientclassCode*: <= PATid: II [0..1] (MedicaRecordNum)

TraumaParticipantclassCode*: <= ORGdeterminerCode*: <= INSTANCEid: [1..1] (HospitNum)code: CV CWE [0..1] <= EntityCodename: ON [0..1] (HospitName)statusCode: CS CNE [0..1] <= EntityStatus (ActiveFacili)addr: AD [0..1] (HospitCity)

1..1 patient

typeCode*: <= SBJsubject

InjuryLocationclassCode*: <= PLCdeterminerCode*: <= INSTANCEcode: CV CWE [0..1] <= EntityCode (InjuryPlaceID)addr: AD [0..1] (AddressScene)

0..1 playingInjuryLocation

RoleclassCode*: <= ROL

1..1 participant

typeCode*: <= LOC

location

InjuryRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ExternallyDefinedActCodespriorityCode: CV CWE [0..1] <= ActPriorityvalue: [0..1]

0..* pertinentInjuryRelatedObservation

typeCode*: <= PERTsequenceNumber: INT [0..1] (InjurySequen)

pertinentInformation

ProcedureclassCode*: <= PROCmoodCode*: <= EVNcode: CV CWE <= ActCode (ICDCodeID)activityTime: TS (ProcedDate)

0..* pertinentProcedure

typeCode*: <= PERTpertinentInformation7

0..1 medicalStaff

typeCode*: <= PRFperformer

MedicalStaffclassCode*: <= PROVid: II [0..1] (MedicalStaffID)

0..1 procedureLocation

typeCode*: <= LOClocation

ProcedureLocationclassCode*: <= SDLOCcode: <= RoleCode (ProcedLocateID)

PatientIncidentRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ActCodereasonCode: CV CWE [0..1] <= ActReasonvalue: ANY [0..1]

0..* pertinentPatientIncidentRelatedObservation

typeCode*: <= PERTpertinentInformation2

PatientTransferclassCode*: <= TRNSmoodCode*: <= EVNactivityTime: IVL<TS> (DischaDate to ArriveDate)reasonCode: CV CWE [0..1] <= TransferActReason (REASONTRANSFID)

1..1 arrivalPatientTransfer

typeCode*: <= ARRarrivedBy

0..* aRole

typeCode*: <= ORGorigin

0..1 playingTraumaParticipant

aRoleclassCode*: <= ROL

TransferRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: CV CWE <= ExternallyDefinedActCodesvalue: PQ [0..1]methodCode: CV CWE [0..1] <= ObservationMethod

1..* pertinentTransferRelatedObservationtypeCode*: <= PERT

pertinentInformation

1..1 transferVehicle

typeCode*: <= VIAvia

1..1 owningVehicleProvider

TransferVehicleclassCode*: <= OWNid: II [0..1] (VehiclNum)code: <= RoleCode (VehiclLevelID)

VehicleProviderclassCode*: <= ORGdeterminerCode*: <= INSTANCEid: II [0..1] (VehiclProvide)code: <= EntityCode (MaxVehiclLevelID)name: ON [0..1] (VehiclProvidName)

HospitalVisitclassCode*: <= ENCmoodCode*: <= EVNcode: CV CWE <= ActCode (AdmitServicID)activityTime: TS (DischaDate)dischargeDispositionCode: CV CWE [0..1] <= EncounterDischargeDisposition

1..1 pertinentHospitalVisit

typeCode*: <= PERTpertinentInformation5

HospitalVisitRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: CV CWE <= ExternallyDefinedActCodesvalue: [0..1]

0..* pertinentHospitalVisitRelatedObservation

typeCode*: <= PERT

pertinentInformation

1..1 admittingProvider

typeCode*: <= ADMadmitter

0..1 healthCareMedicalStaffPerson

AdmittingProviderclassCode*: <= PROVid: II [0..1] (ADMITMEDICASTAFFID)code: CV CWE <= RoleCode (StaffTypeID)

0..* hospitalVisitPhysician

typeCode*: <= RESPtime: TS

responsibleParty

0..1 healthCareMedicalStaffPerson

HospitalVisitPhysicianclassCode*: <= PROVid: II [0..1]code: CV CWE <= RoleCode (StaffTypeID)

MedicalStaffPersonclassCode*: <= PSNdeterminerCode*: <= INSTANCEname: PN [0..1] (MedicaStaffName)

0..1 licensedEntity

typeCode*: <= DSTdestination

0..1 subjectChoice

LicensedEntityclassCode*: <= LICid: II [0..1]

Choice

FacilityclassCode*: <= ORGdeterminerCode*: <= INSTANCEid:code*: CS CNE <= EntityCode "FAC"name:

HospitalclassCode*: <= ORGdeterminerCode*: <= INSTANCEid:code*: CS CNE <= EntityCode "HOSP"name:

EmergencyDepartmentEncounterclassCode*: <= ENCmoodCode*: <= EVNactivityTime: IVL<TS>dischargeDispositionCode: CV CWE <= EncounterDischargeDisposition

0..1 pertinentEmergencyDepartmentEncounter

typeCode*: <= PERT

pertinentInformation3

EmergencyDepartmentRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: CV CWE <= ExternallyDefinedActCodestext:activityTime: TSreasonCode: <= ActReasonvalue: [0..1]methodCode: CV CWE [0..1] <= ObservationMethodtargetSiteCode: CV CWE [0..1] <= HumanActSite

0..* pertinentEmergencyDepartmentRelatedObservation

typeCode*: <= PERTpertinentInformation

0..* emergencyDepartmentPhysician

typeCode*: <= PRFperformer

0..1 healthCareMedicalStaffPerson EmergencyDepartmentPhysicianclassCode*: <= PROVid: II [0..1]code: CE CWE [0..1] <= RoleCode (StaffTypeID)

PreHospitalEncounterclassCode*: <= ENCmoodCode*: <= EVNid: II [0..1] (crashNum)activityTime: IVL<TS>

0..1 priorPreHospitalEncounter

typeCode*: <= PREV

predecessor

PreHosptialRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ExternallyDefinedActCodesvalue: ANY [0..1]

0..* pertinentPreHosptialRelatedObservation

typeCode*: <= PERTpertinentInformation

1..1 preHospitalVehicle

typeCode*: <= ParticipationTypeparticipant

1..1 owningVehicleProvider

PreHospitalVehicleclassCode*: <= OWNid: II [0..1] (VehiclNum)code: <= RoleCode (VehiclLevelID)

0..* emergencyDepartmentPhysicianActtypeCode*: <= COMP

component

EmergencyDepartmentPhysicianActclassCode*: <= ACTmoodCode*: <= EVNcode: CS CNE [0..1] <= ExternallyDefinedActCodesactivityTime*: TS [0..1]

component

0..* patientIncidentRelatedObservation

typeCode*: <= COMP

VehicleProvider

MedicalStaffPerson

TraumaParticipant

R-MIM

PatientIncidentclassCode*: <= ENCmoodCode*: <= EVNid: [1..*] (RegistNum)code: CV CNE <= ExternallyDefinedActCodes (PatientType)statusCode: LIST<CS> CNE <= ActStatus (IDPHStatus)activityTime: TS (EDDate)

InjuryclassCode*: <= ACTmoodCode*: <= EVNactivityTime: TS (InjuryDate)

0..1 pertinentInjury

typeCode*: <= PERTpertinentInformation1

PatientPersonclassCode*: <= PSNdeterminerCode*: <= INSTANCEname: PN [0..1] (*Name)existenceTime: (Age)administrativeGenderCode: CV CWE <= AdministrativeGender (GenderID)birthTime: (DateOfBirth)addr: AD [0..1] (AddressHome)raceCode: CV CWE [0..1] <= Race (RaceID)ethnicGroupCode: CV CWE [0..1] <= Ethnicity (EthnicID)

1..1 patientPatientPerson

1..1 providerTraumaParticipant

PatientclassCode*: <= PATid: II [0..1] (MedicaRecordNum)

TraumaParticipantclassCode*: <= ORGdeterminerCode*: <= INSTANCEid: [1..1] (HospitNum)code: CV CWE [0..1] <= EntityCodename: ON [0..1] (HospitName)statusCode: CS CNE [0..1] <= EntityStatus (ActiveFacili)addr: AD [0..1] (HospitCity)

1..1 patient

typeCode*: <= SBJsubject

InjuryLocationclassCode*: <= PLCdeterminerCode*: <= INSTANCEcode: CV CWE [0..1] <= EntityCode (InjuryPlaceID)addr: AD [0..1] (AddressScene)

0..1 playingInjuryLocation

RoleclassCode*: <= ROL

1..1 participant

typeCode*: <= LOC

location

InjuryRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ExternallyDefinedActCodespriorityCode: CV CWE [0..1] <= ActPriorityvalue: [0..1]

0..* pertinentInjuryRelatedObservation

typeCode*: <= PERTsequenceNumber: INT [0..1] (InjurySequen)

pertinentInformation

PatientIncidentRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ActCodereasonCode: CV CWE [0..1] <= ActReasonvalue: ANY [0..1]

0..* pertinentPatientIncidentRelatedObservation

typeCode*: <= PERT

pertinentInformation2

component

0..* patientIncidentRelatedObservation

typeCode*: <= COMP

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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.

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Sample R-MIM Design Information Modelcomponent1 / componentOf3

0..* observationOrder1

0..* observationOrder2 *

typeCode*: <= COMPcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "true"sequenceNumber:priorityNumber:pauseQuantity:splitCode:joinCode:seperatableInd: [1..1] "true"

0..* pertinentObservationSupporting

typeCode*: <= PERTcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "true"

pertinentInformation

0..* substanceAdministrationStep *

component2typeCode*: <= COMPcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "true"sequenceNumber*: [1..1]priorityNumber:pauseQuantity:splitCode:joinCode:seperatableInd*: [1..1] "false"

SubstanceAdministrationStepclassCode*: <= SBADMmoodCode*: <= x_ActMoodOrdPrmsEvnid*: II [1..1]code*: CE CWE <= SubstanceAdministrationActCodetext*:statusCode*: CS CNE [0..1]effectiveTime*: IVL<TS>routeCode: <= RouteOfAdministrationdoseQuantity: PQrateQuantity: PQ

ObservationOrderclassCode*: <= OBSmoodCode*: <= ORDid*: II [1..1]code: CE CWE <= ObservationType (e.g. LOINC code)negationInd: [1..1] "false"derivationExpr:text:statusCode*: CS CNE [1..1] <= ActStatus "active"effectiveTime: ("physiologically relevant time" aimed for)activityTime: IVL<TS>priorityCode: CE CWE [0..1] <= ActPriority "R"confidentialityCode*: [1..*] <= Confidentiality "N"repeatNumber:interruptibleInd: "true"independentInd: "true"methodCode: <= ObservationMethodtargetSiteCode: <= ActSite

AccessionclassCode*: <= ACSNmoodCode*: <= EVNid*: II [1..1]

CMET: (ENC) A_Encounter

[universal](COCT_MT010000)

CMET: (ASSIGNED) R_Assigned

[universal](COCT_MT090000)

0..1 roleName

CMET: (PAT) R_Patient[universal]

(COCT_MT050000)

0..1 roleName

CMET: (CONS) A_Consent[universal]

(COCT_MT470000)

CMET: (AGNT) R_Responsible

[universal](COCT_MT040000)

0..1 roleName

0..* participant

typeCode*: <= CSMcontextControlCode*: [1..1] <= ContextControlNonPropagating "ON"

consumable

0..1 assignedEntity

dataEnterertypeCode*: <= ENTcontextControlCode*: [1..1] <= ContextControlPropagating "OP"noteText: STtime: TS (time entered into)modeCode*: [1..1] <= "ELECTRONIC"

0..1 assignedEntity

notificationContacttypeCode*: <= NOTcontextControlCode*: [1..1] <= ContextControlPropagating "OP"

0..1 patient *

recordTargettypeCode*: <= RCTcontextControlCode*: [1..1] <= ContextControlPropagating "OP"

0..* accession

typeCode*: <= COMPcontextControlCode*: [1..1] <= ContextControlPropagating "OP"contextConductionInd*: [1..1] "false"

componentOf2

Note:For Advanced Beneficiary Noticesor whenconsents are required fortesting (e.g., HIV related tests.)

Note:This is the general almost completely unconstrainedActRelationship. Its use includes composition (COMP),occurrences (OCCR), master file references (INST),fulfillment (FLFS) and replacement (RPLC) as well asnormal ranges (REFV), decision ranges (COND) andgoals. In the DMIM this is left unconstrained, in theRMIMs these might be more constrained.

0..* consent

typeCode*: <= SUBJcontextControlCode*: [1..1] <= ContextControlPropagating "OP"contextConductionInd*: [1..1] "false"

subjectOf

0..* specimen *

subjecttypeCode*: <= SBJcontextControlCode*: [1..1] <= ContextControlPropagating "OP"

Note:For clinical observations that are made directly on the patientinstead of on some specimen.

Note:The author of an ORDer is commonlyknow as the "placer", the author of anordered promise or event is commonlyknown as the "filler". The author ownshis Act, meaning that direct statuscanges on this act can only be issuedby the Author.

1..1 manufacturedProduct *

typeCode*: <= CSM

consumable

0..1 encounter *

componentOf1typeCode*: <= COMPcontextControlCode*: [1..1] <= ContextControlPropagating "OP"contextConductionInd*: [1..1] "false"

1..1 agent *

typeCode*: <= AUTauthor

Note:Includes both, theindividual and theprovider organization.

0..* assignedEntity

typeCode*: <= VRFcontextControlCode*: [1..1] <= ContextControl "OP"noteText: STtime*: TS [1..1] (time of signature)modeCode*: [1..1] <= ParticipationModesignatureCode*: [1..1] <= ParticipationSignaturesignatureText:

verifier

1..1 assignedEntity *

authortypeCode*: <= AUTcontextControlCode*: [1..1] <= ContextControlPropagating "OP"noteText: STtime*: TS [1..1] (time of signature)modeCode*: CE CNE [1..1] <= ParticipationModesignatureCode*: CS CNE [1..1]signatureText:

Note:Includes bothpatient and theinstitution.

CMET: (SPEC) R_Specimen

[universal](COCT_MT080000)

CMET: (OBS) A_ObservationSupporting

[universal](COCT_MT120200)

0..1 observationDefinition *

typeCode*: <= INSTcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "true"

definition

replacementOf

0..* priorObservation

typeCode*: <= RPLCcontextControlCode*: [1..1] <= ContextControlNonPropagating "ON"contextConductionInd*: [1..1] "true"

Note:For orders: the designated performer, if knownand desired at time of ordering. For intents, thepromises and events, the "filler." For individual sub-tasks, used for the technician, etc.

0..* orderOptions

controlVariabletypeCode*: <= CTRLVcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "false"

CMET: (ACT) A_OrderOptions

[universal](COCT_MT210000)

0..* assignedEntity *

performertypeCode*: <= PRFcontextControlCode*: [1..1] <= ContextControlPropagating "OP"

ObservationDefinitionclassCode*: <= OBSmoodCode*: <= DEFid: II [1..1]

Note:Identifies the "master"or "service catalog"entry of theobservation servicebeing performed. Usethis alone or in additionto an observationcode to specify whatis being observed orwhat is to be observed.

1..1 manufacturedDrug *

0..1 manufacturerOrganization

ManufacturedProduct1classCode*: <= MANU

CMET: (ROL) R_Reagent[universal]

(COCT_MT250000)

0..*

OrganizationclassCode*: <= ORGdeterminerCode*: <= INSTANCEname*: ON [1..1]

DrugclassCode*: <= MMATdeterminerCode*: <= INSTANCEcode*: [1..1] <= DrugEntity (Drug code)quantity:desc:

Laboratory Observation Order(POLB_RM002100)

Common entry point for laboratory ordercommunication. This includes single one-timeorders as well as recurring orders. This isused for recurring orders only if the fillersplits recurring orders into their occurrences.

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Design Information Model Diagram

SubstanceAdministrationStepclassCode*: <= SBADMmoodCode*: <= x_ActMoodOrdPrmsEvnid*: II [1..1]code*: CE CWE <= SubstanceAdministrationActCodetext*:statusCode*: CS CNE [0..1]effectiveTime*: IVL<TS>routeCode: <= RouteOfAdministrationdoseQuantity: PQrateQuantity: PQ

1..1 manufacturedProduct *

typeCode*: <= CSM

consumable

1..1 manufacturedDrug *

0..1 manufacturerOrganization

ManufacturedProduct1classCode*: <= MANU

OrganizationclassCode*: <= ORGdeterminerCode*: <= INSTANCEname*: ON [1..1]

DrugclassCode*: <= MMATdeterminerCode*: <= INSTANCEcode*: [1..1] <= DrugEntity (Drug code)quantity:desc:

• 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.

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HL7 V3 Modeling Tools

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HL7 V3 Modeling Tools

RationalRose

RationalRose

ReferenceModel

Repository

RoseTreeRoseTree

R-MIMDesigner

R-MIMDesigner

SchemaGenerator

SchemaGenerator

RIM RIM

R-MIMRIMR-MIM

HMD HMD

XSD

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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.

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Hierarchical Message Definition

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HMD Components

Info

rmat

ion

Mo

del

Map

pin

g

Mes

sag

e E

lem

ent

Sp

ecif

icat

ion

s

Co

mm

on

Co

nst

rain

ts

Mes

sag

e Ty

pe

Sp

ecif

icat

ion

(S)

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HMD Components

Map

pin

g t

o t

he

Info

rmat

ion

Mo

del

Mes

sag

e E

lem

ent

Sp

ecif

icat

ion

s

Co

mm

on

Co

nst

rain

ts

Mes

sag

e Ty

pe

Sp

ecif

icat

ion

(S)

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HL7 XML Schema Generator

HL7 Vocabulary Specification

HL7 Data Type Specification

HL7 XML Schema

Generator

Hierarchical MessageDefinition

XML SchemaSpecification

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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:ActStatusAbortedCancelledCompletedactivityTime*: TS.DATETIME [1..1]value: CD CWE [0..1] <= V:AbnormalityAssessmentValuemethodCode: SET<CE> CWE [0..*] <= V:AbnormalityAssessmentMethod

1..* assessmentOutcome *

typeCode*: = "OUTC"contextConductionInd*: BL [1..1] ="true"

outcome

AssessmentException

classCode*: = "OBS"moodCode*: = "EVN"code*: CD CWE [1..1] <= V:ObservationType ("ASSERTION")value*: SC CWE [1..1] <= V:AssessmentExceptionValue

AbnormalityGrade

classCode*: = "OBS"moodCode*: = "EVN"code*: CD CWE [1..1] <= V:ObservationType ("SEV")uncertaintyCode: CE CNE [0..1] <= V:ActUncertaintyvalue*: CD CWE [1..1] <= V:AbnormalityGradeValue

AssessmentOutcome

0..* assessmentOutcomeAnnotation

typeCode*: = "APND"contextConductionInd*: BL [1..1] ="true"

appendageOf

AssessmentOutcomeAnnotation

classCode*: = "OBS"moodCode*: = "EVN"code*: CD CWE [1..1] <= V:ObservationType ("ASSERTION")value*: SC CWE [1..1] <= V:AssessmentOutcomeAnnotationValue

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Example Schema Specification

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Core Schema

OurSchema

InfrastructureRoot.XSD

Datatype.XSD

Datatype-base.XSD

Voc.XSD

Include Include

Include Include Include

Include

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.

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HL7 V3 Message Implementation Technology

HL7-ConformantApplication

Data

HL7MessageCreation

HL7-ConformantApplication

HL7MessageParsing Data

MessageInstance

XML SchemaSpecification

Hierarchical MessageDefinition

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Questions / Discussion

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The Family of HL7 Standards

• 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

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RIM Derived and Influenced HL7 Standards

• 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

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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

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Clinical Trial Registration and Results Message Specification

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CTRR Development Artifacts

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Document Identifiers and Keywords

Planned Activities, Study Arms, and

References

Study Outcome Measures and Objectives

Study Participants

Regulatory Authorities, Application Submissions

and Authorizations

Target Research Products

(devices and substances)

Study Protocol Document, Study

Description, Features, and Overall Status

Study Sites and Study Site Recruitment

Activities

Study Enrollment

Stratification and Targets

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RMIM to XSD

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Traversing the CTRR RMIM

Entry Point

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HMD – the RMIM serialized

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Study Protocol Document XSD

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Subject XSD

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Clinical Trial Intent XSD

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National Trauma Registry Submission CDA Document Specification

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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.

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Clinical Document Architecture RMIM

Clinical Document

Participating Entities

Structured Document Sections Section Entries

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NTDB CDA RMIM Subset

ClinicalDocumentPatient

Organization

DocumentSection SectionEntry

Act Observ ation Encounter Procedure Organizer

EntryRelationship

1..*

0..1

0..*

+target 1

0..*

+source 1

+clinicalStatement

0..*

+nested0..*

+nesting0..1

1..*

1

+informer

0..*

communicates

1

+recordTarget

1..*

isSubjectOf

1

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From Data Dict. to CDA Impl. Guide

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Scope

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Implementation Guide Development

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DAM: a UML representation of dictionary elements

PreHospitalEcounter

- arrivalDateTime :TS [0..1]- departureDateTime :TS [0..1]- dispatchDateTime :TS [0..1]+ preHospitalTransportationMethodCode :TransportationMethod [0..*]

PreHospitalNerv ousSystemObserv ation

+ glasgowComaEyeResponseValue :INT+ glasgowComaMotorResponseValue :INT+ glasgowComaScoreValue :INT+ glasgowComaVerbalResponseCode :INT

PreHospitalCirculatorySystemObserv ation

+ heartRateAmount :PQ+ systolicBloodPressureAmount :PQ

PreHospitalRespiratorySystemObserv ation

+ arterialOxygenSaturationAmount :PQ+ respiratoryRateAmount :PQ

2.0 Submission::RegistrySubmissionTransaction

0..1 0..1

0..1

0..1

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Organization of DAM Classes

2.0 Submission

+ RegistrySubmissionTransaction

1.0 Patients

+ Patient

3.0 Injury Ev ents

+ InjuryEvent

+ InjurySeverityObservation

4.0 PreHospital Encounters

+ PreHospitalCirculatorySystemObservation

+ PreHospitalEcounter

+ PreHospitalNervousSystemObservation

+ PreHospitalRespiratorySystemObservation

5.0 Hospital Care Episodes

+ HospitalCareEpisode

+ HospitalCirculatorySystemObservation

+ HospitalNervousSystemObservation

+ HospitalPhysiologicalObservation

+ HospitalRespiratorySystemObservation

+ 5.1 Emergency Hospital Encounters

+ 5.2 InpatientHospitalEncounters

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Dictionary to DAMElement ID NTDB Dictionary Element DAM Package DAM Class DAM Attribute

D_01 D_01: PATIENT’S HOME ZIP CODE 2.0 Patients Patient postalAddressD_02 D_02: PATIENT’S HOME COUNTRY 2.0 Patients Patient postalAddressD_03 D_03: PATIENT’S HOME STATE 2.0 Patients Patient postalAddressD_04 D_04: PATIENT’S HOME COUNTY 2.0 Patients Patient postalAddressD_05 D_05: PATIENT’S HOME CITY 2.0 Patients Patient postalAddressD_06 D_06: ALTERNATE HOME RESIDENCE 2.0 Patients Patient residenceStatusCodeD_07 D_07: DATE OF BIRTH 2.0 Patients Patient birthDateD_08 D_08: AGE 2.0 Patients Patient eventRelatedAgeQuantityD_09 D_09: AGE UNITS 2.0 Patients Patient eventRelatedAgeQuantityD_10 D_10: RACE 2.0 Patients Patient raceCodeD_11 D_11: ETHNICITY 2.0 Patients Patient ethnicCodeD_12 D_12: SEX 2.0 Patients Patient genderCodeDG_01 DG_01: CO-MORBID CONDITIONS 5.0 Hospital Care Episodes HospitalCareEpisode coMorbidConditionCodeDG_02 DG_02: ICD-9 INJURY DIAGNOSES 5.0 Hospital Care Episodes HospitalCareEpisode injuryDiagnosisCodeDG_03 DG_03: ICD-10 INJURY DIAGNOSES 5.0 Hospital Care Episodes HospitalCareEpisode injuryDiagnosisCodeED_01 ED_01: ED/HOSPITAL ARRIVAL DATE 5.0 Hospital Care Episodes HospitalCareEpisode arrivalDateTimeED_02 ED_02: ED/HOSPITAL ARRIVAL TIME 5.0 Hospital Care Episodes HospitalCareEpisode arrivalDateTimeED_03 ED_03: INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE 5.0 Hospital Care Episodes HospitalCirculatorySystemObservation systolicBloodPressureAmountED_043 ED_043: INITIAL ED/HOSPITAL PULSE RATE 5.0 Hospital Care Episodes HospitalCirculatorySystemObservation heartRateAmountED_05 ED_05: INITIAL ED/HOSPITAL TEMPERATURE 5.0 Hospital Care Episodes HospitalPhysiologicalObservation temperatureAmountED_06 ED_06: INITIAL ED/HOSPITAL RESPIRATORY RATE 5.0 Hospital Care Episodes HospitalRespiratorySystemObservation respiratoryRateAmountED_07 ED_07: INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE 5.0 Hospital Care Episodes HospitalRespiratorySystemObservation respiratoryAssistanceIndicatorED_08 ED_08: INITIAL ED/HOSPITAL OXYGEN SATURATION 5.0 Hospital Care Episodes HospitalRespiratorySystemObservation arterialOxygenSaturationAmountED_09 ED_09: INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN 5.0 Hospital Care Episodes HospitalRespiratorySystemObservation supplementalOxygenIndicator

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CIM: a CDA influenced UML representation of dictionary elements

Domain AnalysisModel

2

CDA RMIM

ConstrainedInformation Model

ArterialOxygenSaturationObserv ation

+ code :CD = ObservationType- value :PQ

::RespiratorySystemObservation+ classCode :CS = "OBS"+ moodCode :CS = "EVN"

RespiratoryRateObserv ation

+ code :CD = ObservationType- value :PQ

::RespiratorySystemObservation+ classCode :CS = "OBS"+ moodCode :CS = "EVN"

RespiratorySystemObserv ation

+ classCode :CS = "OBS"+ moodCode :CS = "EVN"

PreHospitalEncounterDetail::PreHospitalEncounter

RespiratorySystemEntryRelationship

+ typeCode :CS = x_ActRelationsh...+ contextConductionInd :BL = "true"

0..*

1

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InjuryEv entSection

+ InjuryEventSection

+ StructuredBodyInjuryEventComponent

+ InjuryEventDetai lEntry

(from TraumaRegistrySubmissionDocument)

TraumaRegistrySubmissionDocument

+ HealthcareFacil i ty

+ RegistryParticipant

+ StructuredBodyComponent

+ StucturedBody

+ Submitter

+ TraumaRegistrySubmissionDocument

+ Patient

+ InjuryEventSection

+ PreHospital Encounter Section

+ Hospital Care Episode Section

+ EntryPoint

Patient

+ RecordTarget

+ Patient

+ PatientRole

+ PatientDetai lSection

(from TraumaRegistrySubmissionDocument)

PreHospital Encounter Section

+ PreHospitalEncounterSection

+ StructoredBodyPreHospitalEncounterComponent

+ PreHospitalEncounterDetail

(from TraumaRegistrySubmissionDocument)

Hospital Care Episode Section

+ HospitalCareEpisodeSection

+ StructuredBodyHospitalCareEpisodeComponent

+ HospitalCareEpisodeActivityDetai l

(from TraumaRegistrySubmissionDocument)

Organization of CIM Classes

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DAM to CIM

DAM Class DAM Attribute CIM Class CIM Attribute

Patient birthDate Patient birthTimePatient ethnicCode Patient ethnicGroupCodePatient eventRelatedAgeQuantity PatientAgeObservation valuePatient genderCode Patient administrativeGenderCodePatient industryCode PatientIndustryObservation valuePatient occupationCode PatientOccupationObservation valuePatient postalAddress PatientRole addrPatient raceCode Patient raceCodePatient residenceStatusCode PatientResidenceStatusObservation valueInjuryEvent abbreviatedInjuryCode AbreviatedInjuryObservation valueInjuryEvent airbagDeploymentCode AirbagDeploymentObservation valueInjuryEvent bodyInjuryRegionCode BodyInjuryObservation valueInjuryEvent injurySeverityScoreValue SeverityScoreObservation valueInjuryEvent locationTypeCode LocationTypeObservation valueInjuryEvent occurenceDateTime InjuryEventAct effectiveTimeInjuryEvent postalAddress PostalAddressObservation valueInjuryEvent primaryInjuryCauseCode PrimaryInjuryCauseObservation valueInjuryEvent safetyEquipmentUsedCode SafetyEquipmentUsedObservation valueInjuryEvent supplementalInjuryCauseCode SupplementalInjuryCauseObservation valueInjuryEvent workRelatedEventInd WorkRelatedObservation valuePreHospitalCirculatorySystemObservation heartRateAmount HeartRateObservation valuePreHospitalCirculatorySystemObservation systolicBloodPressureAmount SystolicBloodPressureObservation valuePreHospitalEncounter arrivalDateTime PreHospitalEncounter effectiveTimePreHospitalEncounter departureDateTime PreHospitalEncounter effectiveTime

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IG: Dictionary elements represented as templated CDA constraints

3

CDA RMIM

ConstrainedInformation Model

NTDBImplementation Guide

EMSImplementation Guide

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Organization of IG Templates

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Organization of IG Templates

StucturedBody

+ classCode :CS = "DOCBODY"+ moodCode :CS = "EVN"

StructuredBodyComponent

+ typeCode :CS = "COMP"+ contextConductionInd :BL = "true"

TraumaRegistrySubmissionDocument

+ classCode :CS = "DOCCLIN"+ moodCode :CS = "EVN"+ id :II+ code :CE = DocumentType- effectiveTime :TS

PatientDetailSection::PatientDetailSection

Patient::PatientRole RegistryParticipant

+ classCode :CS = "ASSIGNED"

Submitter

+ typeCode :CS = "INF"+ contextControlCode :CS = "OP"

HealthcareFacility

+ classCode :CS = "ORG"+ determinerCode :CS = "INSTANCE"- id :II

EntryPoint

Patient

+ RecordTarget

+ Patient

+ PatientRole

+ PatientDetailSection

PatientDetailSection

+ PatientDetailSection

+ StucturedBodyPatientDetailComponent

+ PatientDemographicObservation

+ PatientEmploymentObservation

(from Patient)

InjuryEv entSection::InjuryEv entSection PreHospital Encounter Section::PreHospitalEncounterSection

Hospital Care Episode Section::HospitalCareEpisodeSection

InjuryEv entSection

+ InjuryEventSection

+ StructuredBodyInjuryEventComponent

+ InjuryEventDetailEntry

PreHospital Encounter Section

+ PreHospitalEncounterSection

+ StructoredBodyPreHospitalEncounterComponent

+ PreHospitalEncounterDetail

Hospital Care Episode Section

+ HospitalCareEpisodeSection

+ StructuredBodyHospitalCareEpisodeComponent

+ HospitalCareEpisodeActivityDetail

Name: TraumaRegistrySubmissionDocumentAuthor: Salimah ShakirVersion: 1.0Created: 2/7/2013 9:30:31 PMUpdated: 6/14/2013 12:01:15 AM

Act

Entity

Role

Participation

ActRelationship

Foriegn Class

Legend

1..11

1..1

1

1..1

1

1..1

1

1..1

1

1..1

1

0..1

1

1..1

1

HEADER

BODY

ENTRIES

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Dict to DAM to CIM to IGNTDB Dictionary Element CDA Template CDA ITEM CDA Clone CDA Attribute CDA CONF

D_01: PATIENT’S HOME ZIP CODE 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_02: PATIENT’S HOME COUNTRY 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_03: PATIENT’S HOME STATE 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_04: PATIENT’S HOME COUNTY 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_05: PATIENT’S HOME CITY 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_06: ALTERNATE HOME RESIDENCE 5.3 Patient Demographic Observations Organizer 42.c.iv observation value 30000D_07: DATE OF BIRTH 3.1 Trauma Registry Submission Document 8.c.iv.4 patient birthTime 27776D_08: AGE 5.3 Patient Demographic Observations Organizer 43.c.iv observation value 30008D_09: AGE UNITS 5.3 Patient Demographic Observations Organizer 43.c.iv.1 observation value@unit 30455D_10: RACE 5.3 Patient Demographic Observations Organizer 44.c.iv observation value 30508D_11: ETHNICITY 3.1 Trauma Registry Submission Document 8.c.iv.5 patient ethnicGroupCode 27778D_12: SEX 3.1 Trauma Registry Submission Document 8.c.iv.3 patient administrativeGenderCode 27775DG_01: CO-MORBID CONDITIONS 6.5 Hospital Care Episode Observation Organizer 84.c.iv observation value 30385DG_02: ICD-9 INJURY DIAGNOSES 6.5 Hospital Care Episode Observation Organizer 85.c.iv observation value 30397DG_03: ICD-10 INJURY DIAGNOSES 6.5 Hospital Care Episode Observation Organizer 85.c.iv observation value 30397ED_01: ED/HOSPITAL ARRIVAL DATE 5.1 Hospital Care Episode Encounter 31 encounter effectiveTime 30341ED_02: ED/HOSPITAL ARRIVAL TIME 5.1 Hospital Care Episode Encounter 31 encounter effectiveTime 30341ED_03: INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE 6.1 Circulatory System Observation Entry 63.c.iv observation value 29639ED_043: INITIAL ED/HOSPITAL PULSE RATE 6.1 Circulatory System Observation Entry 62.c.iv observation value 29633ED_05: INITIAL ED/HOSPITAL TEMPERATURE 6.7 Hospital Care Physiological Observation 100.c.iv observation value 30431ED_06: INITIAL ED/HOSPITAL RESPIRATORY RATE 6.16 Respiratory System Observation Entry 145.c.iv observation value 30092ED_07: INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE 6.15 Respiratory System Observation 140.c.iv observation value 30437ED_08: INITIAL ED/HOSPITAL OXYGEN SATURATION 6.16 Respiratory System Observation Entry 144.c.iv observation value 30085ED_09: INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN 6.15 Respiratory System Observation 141.c.iv observation value 30441

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Trauma Registry Data Submission IG

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Front Matter: Introduction and Specification Overview

78

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Conformance Verbs

• 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.

79

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Cardinality

• 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.

80

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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.

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Templates

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Document Template

83

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Section Templates

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Entry Templates

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Subentry Templates

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Vocabulary Tables

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Implementation Guide Development

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From Data Dict. to CDA Impl. Guide

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UMTS Project Consolidated Dictionary and

IHE Content Profile Development

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Registry Elements

MedicationAdministration

00307 Medication

MedicationTypeCode

MedicationClassCode

T iming

At Discharge

Pre-Encounter

First 24 Hours

Intra-Encounter

Intra-Procedure

Pre-Procedure

00776 Route

Initial Bolus

Initial Infusion

00238 Frequency

q12hr

q24hr

00423 Status

Administered

Not Administered

Blinded

Contraindicated

00069 Dose Amount00147 Duration00070 Start Date Time00306 Stop Date Time

00303 Dose Code

Full Reduced Other

Within 2 weeks

During Follow-up

Semantic Analysis

DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context Timing Location Cause

00112 Cardiac Arrest Indicator Action.4135 Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode of cardiac arrest.

First Medical Contact

00112 Cardiac Arrest Indicator Action.4140 Cardiac Arrest Pre-Hospital C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility.

First Medical Contact PreHospital

00112 Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest occurred at the outside facility.

First Medical Contact Outside Facility

00112 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.

In Hospital

00112 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.

within 24 hours of procedure

00112 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 Pre-Hospital

00800 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 ventricular tachycardia or ventricular fibrillation

00102 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 bradycardia

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 Cardiac Arrest Indicator TVT.5035 Cardiac Arrest w/in 24 Hours 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

Consolidated Dictionary

0 1 .0 S ubm is s ions ::P a rtic ipa ntIde ntifie r

- i d e n ti f i e rV a l u e :S T

+ i d e n ti f i e rT yp e Co d e :P a rti c i p a n tId e n ti f i e r

0 1 .0 S ubm is s ions ::P a rtic ipa nt

- n a m e :S T

0 1 .0 S ubm is s ions ::S ubm is s ion

- i d e n ti f i e r :S T

+ su b m i ssi o n T i m e P e ri o d :T S .DA T E (IV L )

+ su b m i ssi o n Da te T i m e :T S

0 1 .0 S ubm is s ions ::S ourc e S ys te m P rov ide r

- i d e n ti f i e r :S T {i d }

0 1 .0 S ubm is s ions ::S ourc e S ys te m

- ve rsi o n Id e n ti f i e r :S T

0 1 .0 S ubm is s ions ::Re gis try

- i d e n ti f i e r :S T {i d }

- ve rsi o n Id e n ti f i e r :S T {i d }

0 3 .0 Ca re E pis ode s ::Ca re E pis ode

- a rri va l Da te T i m e :T S

- d i sch a rg e Da te :T S .DA T E

- p a yo rT yp e Co d e :CD [1 ..* ] (S E T )

- a d m i ssi o n S o u rce Co d e :CD

- d i sch a rg e D i sp o si t i o n Co d e :CD

0 2 .0 P a tie nts ::P a tie ntRa c e

- ra ce Co d e :CD

- ra ce De ta i l Co d e :CD [0 ..* ] (S E T )

0 2 .0 P a tie nts ::P a tie nt

- n a m e :E N.P N

- b i rth Da te :T S .DA T E

- se xCo d e :CD

- h i sp a n i c In d i ca to r :B L = No

- e th n i c i tyDe ta i l Co d e :CD [0 ..* ] (S E T )

- p o sta l Zo n e Id e n ti f i e r : I I

+ re si d e n ce Co u n tryCo d e :CD

0 2 .0 P a tie nts ::P a tie ntIde ntifie r

- i d e n ti f i e rV a l u e : I I

+ i d e n ti f i e rT yp e Co d e :P a ti e n tId e n ti f i e r

0 2 .0 P a tie nts ::Re s e a rc hS tudyE nrollm e nt

- e n ro l l e d In d i ca to r :B L = No

0 2 .0 P a tie nts ::C lin ic a lTria l

- tri a l T yp e Co d e :CD

- re se a rch S tu d yNa m e :S T

0 3 .0 Ca re E pis ode s ::E v e ntE pis ode Re la tion

+ re l a t i o n sh i p T yp e Co d e :Re l a t i o n sh i p T yp e

0 4 .0 O bs e rv a tions ::Inv olv e dAna tom ic S ite

+ i n vo l ve m e n tT yp e Co d e : In vo l ve m e n tT yp e

0 4 .0 O bs e rv a tions ::

O bs e rv a tionE v e nt

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 4 .0 O bs e rv a tions ::O bs e rv a tionRe s ult

- o b se rva ti o n Re su l tT yp e Co d e :CD

- co n d i t i o n O n se tDa te T i m e :T S [0 ..1 ]

- e st i m a te d O n si te Da te In d i ca to r :B L = No

- m i ssi n g O n se tT i m e In d i ca to r :B L = No

- o b se rva ti o n V a l u e :A NY

+ o b se rva ti o n V a l u e Ne g a ti o n In d i ca to r :B L = No

0 5 .0 E v e nts ::E v e nt

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 5 .0 E v e nts ::E v e ntE v e ntRe la tion

+ re l a t i o n sh i p T yp e Co d e :Re l a t i o n sh i p T yp e

0 5 .0 E v e nts ::E v e ntP e rform e r

- n a m e :E N.P N

- i d e n ti f i e r : I I

- i sCe rt i f i e d In d i ca to r :B L = No

0 5 .0 E v e nts ::In te rv e ntion

- i n d i ca ti o n Co d e :CD [0 ..1 ]

- a b o rte d Re a so n Co d e :CD [0 ..* ]

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 6 .0 Le s ions ::Le s ion

- l e si o n Co u n te r : INT {i d }

0 6 .0 Le s ions ::Le s ionAffe c te dV e s s e lS e gm e nt

- l e si o n L o ca ti o n Co d e :CD

- se g m e n tCo u n te r : INT

0 6 .0 Le s ions ::Le s ionDe s c riptor

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 6 .0 Le s ions ::Le s ionTre a tm e ntDe v ic e

- d e v i ce Co u n te r : INT

0 7 .0 De v ic e s ::De v ic e

- i d e n ti f i e r : I I

- typ e Co d e :CD

- m a n u fa ctu re rNa m e :E N .O N

- d e v i ce Na m e :S T

- u n i ve rsa l De vi ce Id e n ti f i e r : I I [0 ..1 ]

0 7 .0 De v ic e s ::De v ic e De s c riptor

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 8 .0 Ana tom ic S ite s ::Ana tom ic Re gion

- a n o to m i cRe g i o n Co d e :CD

: :A n a to mi cS i te

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 8 .0 Ana tom ic S ite s ::Ana tom ic S ite

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 8 .0 Ana tom ic S ite s ::Ca rd iov a s c ula rG ra ft

- g ra ftT yp e Co d e :CD

: :Ca rd i o va scu l a rV e sse l

- ca rd i o va scu l a rV e sse l Co d e :CD {i d }

- ve sse l T yp e Co d e :CD

: :A n a to mi cS i te

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 8 .0 Ana tom ic S ite s ::Ca rd iov a s c ula rV e s s e l

- ca rd i o va scu l a rV e sse l Co d e :CD {i d }

- ve sse l T yp e Co d e :CD

: :A n a to mi cS i te

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 8 .0 Ana tom ic S ite s ::V e s s e lS e gm e nt

- ve sse l S e g m e n tCo d e :CD {i d }

: :A n a to mi cS i te

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 9 .0 P roc e dure s ::Arte ria lAc c e s s

- si te Co u n te r :INT

- d i re ct i o n a l i tyT yp e Co d e :CD [0 ..1 ]

- ve sse l Co d e :CD

0 9 .0 P roc e dure s ::Arte ria lC los ure

- a rte ri a l C l o su re Co u n te r :INT {i d }

- m e th o d Co d e :CD [0 ..1 ]

- u n d o cu m e n te d In d i ca to r :B L = No

0 9 .0 P roc e dure s ::Arte ria lC los ure De v ic e

- d e v i ce Co u n te r : INT

0 9 .0 P roc e dure s ::P roc e dure

+ p ro ce d u re T yp e Co d e :CD

: : In te rve n ti o n

- i n d i ca ti o n Co d e :CD [0 ..1 ]

- a b o rte d Re a so n Co d e :CD [0 ..* ]

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 9 .0 P roc e dure s ::P roc e dure De v ic e Us e

- d e v i ce Co u n te r : INT {i d }

- sta tu sCo d e :CD

- a b o rte d Re a so n Co d e :CD [0 ..1 ]

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 9 .0 P roc e dure s ::P roc e dure De s c riptor

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 9 .0 P roc e dure s ::P roc e dure Le s ion

- p re v i o u sl yT re a te d In d i ca to r :B L = No

- cu l p ri tL e si o n In d i ca to r :B L = No

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 9 .0 P roc e dure s ::P roc e dure V a s c ula rAs s e s s m e nt

- ve sse l No tA va i l a b l e In d i ca to r :B L = No

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

1 0 .0 M e dic a tion Adm in is tra tion E v e nts ::

M e dic a tion

+ m e d i ca ti o n Co d e :CD

- n a m e :S T

1 0 .0 M e dic a tion Adm in is tra tion E v e nts ::

M e dic a tionAdm inis tra tionE v e nt

: : In te rve n ti o n

- i n d i ca ti o n Co d e :CD [0 ..1 ]

- a b o rte d Re a so n Co d e :CD [0 ..* ]

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

P ri m a ry C l a ss

De p e n d a n t C l a sse s

V a l u e S e ts

Fo re i g n C l a sse s

Legend

Na m e : NCDR DA M C l a sse s

A u th o r: S a l i m a h S h a ki r

V e rsi o n : 1 .0

Cre a te d : 1 1 /1 2 /2 0 1 2 7 :0 2 :0 0 P M

Up d a te d : 8 /2 6 /2 0 1 3 1 :0 5 :4 4 P M

0 6 .0 Le s ions ::Le s ionTre a tm e ntDe ta il

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

Refers to (1..1)07.0 Devices :: Device

is referred to by (0..*)06.0 Lesions :: LesionTreatmentDevice

0 ..*

as

sig

ns

0 . .1

0 ..*

ha

s ta

rge

t

1

0 ..*

is p

art o

f

0 . .*

is u

se

of

1

i s a typ e

o f

i s a typ e

o f

i s a typ e o f

1 ..*

ad

min

iste

rs

1

i s a typ e

o f

is a

typ

e

of

is p

art o

f

i s a typ e

o f

1 ..* {o rd e re d }

i s p a rt o f

0 ..*

i s p a rt o f

0 ..*

inv

olv

ing

1

0 ..*

h a s ta rg e t

1

0 ..*

i n vo l ve d

1

0 ..*

p e rfo rm e d b y

0 ..*

0 ..1

trea

ted

1

0 ..*

i s l o ca te d i n

1

i s a typ e

o f

0 ..*

ha

s s

ub

jec

t

1

0 ..*

ha

s s

ou

rce

1

0 ..*

is p

art o

f

0 . .*

i s p a rt o f

0 ..*

is p

art o

f

+ su b se cti o n

0 ..*i s g ro u p e d b y

0 ..1

0 ..*

a ffe ct i n g

1

0 ..*

i s p a rt o f

0 ..*

i s u se o f

1

0 ..*

i s p a rt o f

0 ..*

is g

rou

pe

d b

y

1 . .*

h a s su b j e ct

1

0 ..1

w i th i n co n te xt o f

1

1 ..*

p ro v i d e d b y

1

1 ..*

su b m i te d to

1

0 ..*

is p

art o

f

1

+ ch i l d

0 ..*

i s g ro u p e d b y

+ p a re n t

0 ..1

0 ..*

h a s so u rce

1

0 ..*

is u

se

d b

y

1

0 ..*

i s tre a tm e n t o f

1

0 ..*

i d e n ti f i e s

1

0 ..*

h a s ta rg e t

10 ..*

ha

s s

ub

jec

t

1

1 ..*

is a

trait o

f

1

0 ..*

i s u se b y

1

is a

typ

e

of

0 . .*

i s tre a te d b y

1

0 ..*

i s p a rt o f

0 ..*

ide

ntifie

s 1

1 ..*

su b m i te d b y

1

1 ..*

orig

ina

tes

from

1

0 ..*

i s p a rt o f

Conceptual Data Model

(CustodianOrganization)Participant

- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (ParticipantIdentifier.identifierValue) id :II+ (Participant.name) name :EN.ON

(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

(Observation)PatientRaceObservation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# code :CD = "PatientRace"+ (PatientRace.raceCode) value :CD [1..*] (SET)

(Act)SubmissionAct

- classCode :CS = "ACT"- moodCode :CS = "EVN"+ (Submission.identifier) id :II+ (Submission.submissionTimePeriod) effectiveTime :TS (IVL)

(PatientRole)PatientRole

- classCode :CS = "PAT"+ (PatientIdentifier.identifierValue) id :II

(ClinicalDocument)CathPCIRegistryDocument

- classCode :CS = "DOCCLIN"- moodCode :CS = "EVN"+ id :II# code :CE = "CATHPCI"+ effectiveTime :TS

(RecordTarget)RecordTarget

- typeCode :CS = "RCT"- contextControlCode :CS = "OP"

(AssignedCustodian)ParticipantRole

- classCode :CS = "ASSIGNED"

(Custodian)Custodian

- typeCode :CS = "CST"

(StructuredBody)DocumentBody

- classCode :CS = "DOCBODY"- moodCode :CS = "EVN"

(ClinicalDocumentComponent)DocumentComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Section)SubmissionDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "SubmissionDetail"

(StructuredBodyComponent)SubmissionDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Entry)SubmissionActEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(ParticipantRole)SourceSystem

- classCode :CS = "MMAT"

(ClinicalStatementParticipant)Author

- typeCode :CS = "AUT"- contextControlCode :CS = "OP"

(Device)DataCollectionSystem

- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (SourceSystem.versionIdentifier) id :II

(Entity)SourceSystemProvider

- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (SourceSystemProvider.identifier) id :II

(ParticipantRole)TargetRegistry

- classCode :CS = "MMAT"

(ClinicalStatementParticipant)Receiver

- typeCode :CS = "RCV"- contextControlCode :CS = "OP"

(Device)RegistrySystem

- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (Registry.identifier) id.root :II.root+ (RegistryVersionIdentifier) id.extension :II.extension

(Section)PatientDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "PatientDetail"

(StructuredBodyComponent)PatientDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Entry)PatientRaceObservationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Observation)PatientIdentifierObservation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# (PatientIdentifier.typeCode) code :CD+ (PatientIdentifier.identifierValue) value :CD

(Entry)PatientIdentifierObservationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Section)RegistryParticipantDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "RegistryPartic...

(StructuredBodyComponent)RegistryParticipantDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Observation)ParticipantIdentifierObservation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# (ParticipantIdentifier.typeCode) code :CD+ (ParticipantIdentifier.identifierValue) value :CD

(Entry)ParticipantIdentifierObservationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

Entry Point

1..1

1

1..1

1

1..1 1

1..1

isPlayedBy

1

1..1

1

1..1

isScopedBy

1

1..1

1

1..1

1

1..*1

1..1

isPlayedBy

1

isScopedBy

1..11

1..1

isPlayedBy

1

1..11 0..*1

1..1

1

1..11

Constrained Information Model

Account

name : STbalanceAmt : MOcurrencyCode : CEinterestRateQuantity : RTO<MO,PQ>allowedBalanceQuantity : IVL<MO>

DeviceTask

parameterValue : LIST<ANY>

DiagnosticImage

subjectOrientationCode : CE

Diet

energyQuantity : PQcarbohydrateQuantity : PQ

FinancialContract

paymentTermsCode : CE

FinancialTransaction

amt : MOcreditExchangeRateQuantity : REALdebitExchangeRateQuantity : REAL

InvoiceElement

modifierCode : SET<CE>unitQuantity : RTO<PQ,PQ>unitPriceAmt : RTO<MO,PQ>netAmt : MOfactorNumber : REALpointsNumber : REAL

ManagedParticipation

id : SET<II>statusCode : SET<CS>

Observation

value : ANYinterpretationCode : SET<CE>methodCode : SET<CE>targetSiteCode : SET<CD>

PatientEncounter

preAdmitTestInd : BLadmissionReferralSourceCode : CElengthOfStayQuantity : PQdischargeDispositionCode : CEspecialCourtesiesCode : SET<CE>specialAccommodationCode : SET<CE>acuityLevelCode : CE

Procedure

methodCode : SET<CE>approachSiteCode : SET<CD>targetSiteCode : SET<CD>

PublicHealthCase

detectionMethodCode : CEtransmissionModeCode : CEdiseaseImportedCode : CE

SubstanceAdministration

routeCode : CEapproachSiteCode : SET<CD>doseQuantity : IVL<PQ>rateQuantity : IVL<PQ>doseCheckQuantity : SET<RTO>maxDoseQuantity : SET<RTO>substitutionCode : CE

Supply

quantity : PQexpectedUseTime : IVL<TS>

WorkingList

ownershipLevelCode : CE

Container

capacityQuantity : PQheightQuantity : PQdiameterQuantity : PQcapTypeCode : CEseparatorTypeCode : CEbarrierDeltaQuantity : PQbottomDeltaQuantity : PQ

Device

manufacturerModelName : SCsoftwareName : SClocalRemoteControlStateCode : CE...alertLevelCode : CElastCalibrationTime : TS

LivingSubject

administrativeGenderCode : CEbirthTime : TSdeceasedInd : BLdeceasedTime : TSmultipleBirthInd : BLmultipleBirthOrderNumber : INTorganDonorInd : BL

ManufacturedMaterial

lotNumberText : STexpirationTime : IVL<TS>stabilityTime : IVL<TS>

Material

formCode : CE

NonPersonLivingSubject

strainText : EDgenderStatusCode : CE

Organization

addr : BAG<AD>standardIndustryClassCode : CE

Person

addr : BAG<AD>maritalStatusCode : CEeducationLevelCode : CEraceCode : SET<CE>disabilityCode : SET<CE>livingArrangementCode : CEreligiousAffiliationCode : CEethnicGroupCode : SET<CE>

Place

mobileInd : BLaddr : ADdirectionsText : EDpositionText : EDgpsText : ST

Access

approachSiteCode : CDtargetSiteCode : CDgaugeQuantity : PQ

Employee

jobCode : CEjobTitleName : SCjobClassCode : CEsalaryTypeCode : CEsalaryQuantity : MOhazardExposureText : EDprotectiveEquipmentText : ED

LicensedEntity

recertificationTime : TS

Patient

confidentialityCode : CEveryImportantPersonCode : CE

ActRelationship

typeCode : CSinversionInd : BLcontextControlCode : CScontextConductionInd : BLsequenceNumber : INTpriorityNumber : INTpauseQuantity : PQcheckpointCode : CSsplitCode : CSjoinCode : CSnegationInd : BLconjunctionCode : CSlocalVariableName : STseperatableInd : BL

Act

classCode : CSmoodCode : CSid : SET<II>code : CDnegationInd : BLderivationExpr : STtext : EDstatusCode : SET<CS>effectiveTime : GTSactivityTime : GTSavailabilityTime : TSpriorityCode : SET<CE>confidentialityCode : SET<CE>repeatNumber : IVL<INT>interruptibleInd : BLlevelCode : CEindependentInd : BLuncertaintyCode : CEreasonCode : SET<CE>languageCode : CE

0..n

1

outboundRelationship

0..n

source1

0..n

1

inboundRelationship

0..n

target

1

LanguageCommunication

languageCode : CEmodeCode : CEproficiencyLevelCode : CEpreferenceInd : BL

Participation

typeCode : CSfunctionCode : CDcontextControlCode : CSsequenceNumber : INTnegationInd : BLnoteText : EDtime : IVL<TS>modeCode : CEawarenessCode : CEsignatureCode : CEsignatureText : EDperformInd : BLsubstitutionConditionCode : CE...

0..n

1

0..n

1

Entity

classCode : CSdeterminerCode : CSid : SET<II>code : CEquantity : SET<PQ>name : BAG<EN>desc : EDstatusCode : SET<CS>existenceTime : IVL<TS>telecom : BAG<TEL>riskCode : CEhandlingCode : CE

1

0..n

1

0..n

RoleLink

typeCode : CSeffectiveTime : IVL<TS>

Role

classCode : CSid : SET<II>code : CEnegationInd : BLaddr : BAG<AD>telecom : BAG<TEL>statusCode : SET<CS>effectiveTime : IVL<TS>certificateText : EDquantity : RTOpositionNumber : LIST<INT>

0..n

1

0..n

10..n0..1

playedRole0..n

player

0..1

0..n0..1

scopedRole

0..n

scoper

0..1

0..n

1

outboundLink 0..n

source1

0..n

1

inboundLink0..n

target1

HL7 Reference Models

HL7 Clinical Document Architecture RMIM UMTS CDA Template Library

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

HL7 & IHE 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: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

Registry Specific Content Profiles

Standard Clinical Code Systems

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

Registry Specific Business Rules

UMTS Project Activities

1 2

3

45 6

Page 92: Rim derived and influenced hl7 standards

© 2014 All Rights ReservedSlide Number: 92

1. Semantic Analysis

Registry Elements

MedicationAdministration

00307 Medication

MedicationTypeCode

MedicationClassCode

Timing

At Discharge

Pre-Encounter

First 24 Hours

Intra-Encounter

Intra-Procedure

Pre-Procedure

00776 Route

Initial Bolus

Initial Infusion

00238 Frequency

q12hr

q24hr

00423 Status

Administered

Not Administered

Blinded

Contraindicated

00069 Dose Amount00147 Duration00070 Start Date Time00306 Stop Date Time

00303 Dose Code

Full Reduced Other

Within 2 weeks

During Follow-up

Topic Area Mind Map

Decompose composite registry elementsInto interrelated atomic concepts

Page 93: Rim derived and influenced hl7 standards

© 2014 All Rights ReservedSlide Number: 93

2. Terminology Definition

MedicationAdministration

00307 Medication

MedicationTypeCode

MedicationClassCode

Timing

At Discharge

Pre-Encounter

First 24 Hours

Intra-Encounter

Intra-Procedure

Pre-Procedure

00776 Route

Initial Bolus

Initial Infusion

00238 Frequency

q12hr

q24hr

00423 Status

Administered

Not Administered

Blinded

Contraindicated

00069 Dose Amount00147 Duration00070 Start Date Time00306 Stop Date Time

00303 Dose Code

Full Reduced Other

Within 2 weeks

During Follow-up

Topic Area Mind Map

DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context Timing Location Cause

00112 Cardiac Arrest Indicator Action.4135 Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode of cardiac arrest.

First Medical Contact

00112 Cardiac Arrest Indicator Action.4140 Cardiac Arrest Pre-Hospital C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility.

First Medical Contact PreHospital

00112 Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest occurred at the outside facility.

First Medical Contact Outside Facility

00112 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.

In Hospital

00112 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.

within 24 hours of procedure

00112 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 Pre-Hospital

00800 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 ventricular tachycardia or ventricular fibrillation

00102 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 bradycardia

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 Cardiac Arrest Indicator TVT.5035 Cardiac Arrest w/in 24 Hours 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

Consolidated Dictionary Standard Clinical Code Systems

Map atomic concepts to controlledclinical terminologies

Page 94: Rim derived and influenced hl7 standards

© 2014 All Rights ReservedSlide Number: 94

3. Conceptual Data Modeling

DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context Timing Location Cause

00112 Cardiac Arrest Indicator Action.4135 Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode of cardiac arrest.

First Medical Contact

00112 Cardiac Arrest Indicator Action.4140 Cardiac Arrest Pre-Hospital C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility.

First Medical Contact PreHospital

00112 Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest occurred at the outside facility.

First Medical Contact Outside Facility

00112 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.

In Hospital

00112 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.

within 24 hours of procedure

00112 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 Pre-Hospital

00800 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 ventricular tachycardia or ventricular fibrillation

00102 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 bradycardia

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 Cardiac Arrest Indicator TVT.5035 Cardiac Arrest w/in 24 Hours 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

Consolidated Dictionary

01.0 Submissions::ParticipantIdentifier

- identifierValue :ST+ identifierTypeCode :ParticipantIdentifier

01.0 Submissions::Participant

- name :ST

01.0 Submissions::Submission

- identifier :ST+ submissionTimePeriod :TS.DATE (IVL)+ submissionDateTime :TS

01.0 Submissions::SourceSystemProv ider

- identifier :ST {id}

01.0 Submissions::SourceSystem

- versionIdentifier :ST

01.0 Submissions::Registry

- identifier :ST {id}- versionIdentifier :ST {id}

03.0 CareEpisodes::CareEpisode

- arrivalDateTime :TS- dischargeDate :TS.DATE- payorTypeCode :CD [1..*] (SET)- admissionSourceCode :CD- dischargeDispositionCode :CD

02.0 Patients::PatientRace

- raceCode :CD- raceDetailCode :CD [0..*] (SET)

02.0 Patients::Patient

- name :EN.PN- birthDate :TS.DATE- sexCode :CD- hispanicIndicator :BL = No- ethnicityDetailCode :CD [0..*] (SET)- postalZoneIdentifier :II+ residenceCountryCode :CD

02.0 Patients::PatientIdentifier

- identifierValue :II+ identifierTypeCode :PatientIdentifier

02.0 Patients::ResearchStudyEnrollment

- enrolledIndicator :BL = No

02.0 Patients::ClinicalTrial

- trialTypeCode :CD- researchStudyName :ST

03.0 CareEpisodes::Ev entEpisodeRelation

+ relationshipTypeCode :RelationshipType

04.0 Observ ations::Inv olv edAnatomicSite

+ involvementTypeCode :InvolvementType

04.0 Observ ations::Observ ationEv ent

+ observationTypeCode :CD

::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]

04.0 Observ ations::Observ ationResult

- observationResultTypeCode :CD- conditionOnsetDateTime :TS [0..1]- estimatedOnsiteDateIndicator :BL = No- missingOnsetTimeIndicator :BL = No- observationValue :ANY+ observationValueNegationIndicator :BL = No

05.0 Ev ents::Ev ent

- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]

05.0 Ev ents::Ev entEv entRelation

+ relationshipTypeCode :RelationshipType

05.0 Ev ents::Ev entPerformer

- name :EN.PN- identifier :II- isCertifiedIndicator :BL = No

05.0 Events::Intervention

- 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]

06.0 Lesions::Lesion

- lesionCounter :INT {id}

06.0 Lesions::LesionAffectedVesselSegment

- lesionLocationCode :CD- segmentCounter :INT

06.0 Lesions::LesionDescriptor

::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]

06.0 Lesions::LesionTreatmentDev ice

- deviceCounter :INT

07.0 Dev ices::Dev ice

- identifier :II- typeCode :CD- manufacturerName :EN.ON- deviceName :ST- universalDeviceIdentifier :II [0..1]

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]

08.0 AnatomicSites::AnatomicRegion

- anotomicRegionCode :CD

::AnatomicSite- typeCode :CD- lateralityCode :CD

08.0 AnatomicSites::AnatomicSite

- typeCode :CD- lateralityCode :CD

08.0 AnatomicSites::Cardiov ascularGraft

- graftTypeCode :CD

::CardiovascularVessel- cardiovascularVesselCode :CD {id}- vesselTypeCode :CD

::AnatomicSite- typeCode :CD- lateralityCode :CD

08.0 AnatomicSites::Cardiov ascularVessel

- cardiovascularVesselCode :CD {id}- vesselTypeCode :CD

::AnatomicSite- typeCode :CD- lateralityCode :CD

08.0 AnatomicSites::VesselSegment

- vesselSegmentCode :CD {id}

::AnatomicSite- typeCode :CD- lateralityCode :CD

09.0 Procedures::ArterialAccess

- siteCounter :INT- directionalityTypeCode :CD [0..1]- vesselCode :CD

09.0 Procedures::ArterialClosure

- arterialClosureCounter :INT {id}- methodCode :CD [0..1]- undocumentedIndicator :BL = No

09.0 Procedures::ArterialClosureDev ice

- deviceCounter :INT

09.0 Procedures::Procedure

+ procedureTypeCode :CD

::Intervention- 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]

09.0 Procedures::ProcedureDev iceUse

- deviceCounter :INT {id}- statusCode :CD- abortedReasonCode :CD [0..1]

::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::ProcedureDescriptor

::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

- previouslyTreatedIndicator :BL = No- culpritLesionIndicator :BL = No

::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::ProcedureVascularAssessment

- vesselNotAvailableIndicator :BL = No

::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]

10.0 Medication Administration Ev ents::Medication

+ medicationCode :CD- name :ST

10.0 Medication Administration Ev ents::MedicationAdministrationEv ent

::Intervention- 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]

Primary Class

Dependant Classes

Value Sets

Foreign Classes

Legend

Name: NCDR DAM ClassesAuthor: Salimah ShakirVersion: 1.0Created: 11/12/2012 7:02:00 PMUpdated: 8/26/2013 1:05:44 PM

06.0 Lesions::LesionTreatmentDetail

::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]

Refers to (1..1)07.0 Devices :: Device

is referred to by (0..*)06.0 Lesions :: LesionTreatmentDevice

0..*

assig

ns

0..1

0..*

ha

s targ

et

1

0..*

is pa

rt of

0..*

is use

of

1

is a typeof

is a typeof

is a type of

1..*

ad

min

isters

1

is a typeof

is a typ

eo

fis p

art o

f

is a typeof

1..* {ordered}

is part of

0..*

is part of

0..*

invo

lving

1

0..*

has target

1

0..*

involved

1

0..*

performed by

0..*

0..1

trea

ted

1

0..*

is located in

1

is a typeof

0..*

ha

s sub

ject

1

0..*

ha

s sou

rce

1

0..*

is pa

rt of

0..*

is part of

0..*

is pa

rt of

+subsection0..*

is grouped by

0..1

0..*

affecting

1

0..*

is part of

0..*

is use of

1

0..*

is part of

0..*

is gro

up

ed

by

1..*

has subject

1

0..1

within context of

1

1..*

provided by

1

1..*

submited to

1

0..*

is pa

rt of

1

+child0..*

is grouped by

+parent0..1

0..*

has source

1

0..*

is use

d b

y

1

0..*

is treatment of

1

0..*

identifies

1

0..*

has target

10..*

ha

s sub

ject

1

1..*

is a tra

it of

1

0..*

is use by

1

is a typ

eo

f

0..*

is treated by

1

0..*

is part of

0..*

ide

ntifie

s 1

1..*

submited by

1

1..*

orig

ina

tes fro

m

1

0..*

is part of

Conceptual Data Model

Account

name : STbalanceAmt : MOcurrencyCode : CEinterestRateQuantity : RTO<MO,PQ>allowedBalanceQuantity : IVL<MO>

DeviceTask

parameterValue : LIST<ANY>

DiagnosticImage

subjectOrientationCode : CE

Diet

energyQuantity : PQcarbohydrateQuantity : PQ

FinancialContract

paymentTermsCode : CE

FinancialTransaction

amt : MOcreditExchangeRateQuantity : REALdebitExchangeRateQuantity : REAL

InvoiceElement

modifierCode : SET<CE>unitQuantity : RTO<PQ,PQ>unitPriceAmt : RTO<MO,PQ>netAmt : MOfactorNumber : REALpointsNumber : REAL

ManagedParticipation

id : SET<II>statusCode : SET<CS>

Observation

value : ANYinterpretationCode : SET<CE>methodCode : SET<CE>targetSiteCode : SET<CD>

PatientEncounter

preAdmitTestInd : BLadmissionReferralSourceCode : CElengthOfStayQuantity : PQdischargeDispositionCode : CEspecialCourtesiesCode : SET<CE>specialAccommodationCode : SET<CE>acuityLevelCode : CE

Procedure

methodCode : SET<CE>approachSiteCode : SET<CD>targetSiteCode : SET<CD>

PublicHealthCase

detectionMethodCode : CEtransmissionModeCode : CEdiseaseImportedCode : CE

SubstanceAdministration

routeCode : CEapproachSiteCode : SET<CD>doseQuantity : IVL<PQ>rateQuantity : IVL<PQ>doseCheckQuantity : SET<RTO>maxDoseQuantity : SET<RTO>substitutionCode : CE

Supply

quantity : PQexpectedUseTime : IVL<TS>

WorkingList

ownershipLevelCode : CE

Container

capacityQuantity : PQheightQuantity : PQdiameterQuantity : PQcapTypeCode : CEseparatorTypeCode : CEbarrierDeltaQuantity : PQbottomDeltaQuantity : PQ

Device

manufacturerModelName : SCsoftwareName : SClocalRemoteControlStateCode : CE...alertLevelCode : CElastCalibrationTime : TS

LivingSubject

administrativeGenderCode : CEbirthTime : TSdeceasedInd : BLdeceasedTime : TSmultipleBirthInd : BLmultipleBirthOrderNumber : INTorganDonorInd : BL

ManufacturedMaterial

lotNumberText : STexpirationTime : IVL<TS>stabilityTime : IVL<TS>

Material

formCode : CENonPersonLivingSubject

strainText : EDgenderStatusCode : CE

Organization

addr : BAG<AD>standardIndustryClassCode : CE

Person

addr : BAG<AD>maritalStatusCode : CEeducationLevelCode : CEraceCode : SET<CE>disabilityCode : SET<CE>livingArrangementCode : CEreligiousAffiliationCode : CEethnicGroupCode : SET<CE>

Place

mobileInd : BLaddr : ADdirectionsText : EDpositionText : EDgpsText : ST

Access

approachSiteCode : CDtargetSiteCode : CDgaugeQuantity : PQ

Employee

jobCode : CEjobTitleName : SCjobClassCode : CEsalaryTypeCode : CEsalaryQuantity : MOhazardExposureText : EDprotectiveEquipmentText : ED

LicensedEntity

recertificationTime : TS

Patient

confidentialityCode : CEveryImportantPersonCode : CE

ActRelationship

typeCode : CSinversionInd : BLcontextControlCode : CScontextConductionInd : BLsequenceNumber : INTpriorityNumber : INTpauseQuantity : PQcheckpointCode : CSsplitCode : CSjoinCode : CSnegationInd : BLconjunctionCode : CSlocalVariableName : STseperatableInd : BL

Act

classCode : CSmoodCode : CSid : SET<II>code : CDnegationInd : BLderivationExpr : STtext : EDstatusCode : SET<CS>effectiveTime : GTSactivityTime : GTSavailabilityTime : TSpriorityCode : SET<CE>confidentialityCode : SET<CE>repeatNumber : IVL<INT>interruptibleInd : BLlevelCode : CEindependentInd : BLuncertaintyCode : CEreasonCode : SET<CE>languageCode : CE

0..n

1

outboundRelationship

0..n

source1

0..n

1

inboundRelationship

0..n

target

1

LanguageCommunication

languageCode : CEmodeCode : CEproficiencyLevelCode : CEpreferenceInd : BL

Participation

typeCode : CSfunctionCode : CDcontextControlCode : CSsequenceNumber : INTnegationInd : BLnoteText : EDtime : IVL<TS>modeCode : CEawarenessCode : CEsignatureCode : CEsignatureText : EDperformInd : BLsubstitutionConditionCode : CE...

0..n

1

0..n

1

Entity

classCode : CSdeterminerCode : CSid : SET<II>code : CEquantity : SET<PQ>name : BAG<EN>desc : EDstatusCode : SET<CS>existenceTime : IVL<TS>telecom : BAG<TEL>riskCode : CEhandlingCode : CE

1

0..n

1

0..n

RoleLink

typeCode : CSeffectiveTime : IVL<TS>

Role

classCode : CSid : SET<II>code : CEnegationInd : BLaddr : BAG<AD>telecom : BAG<TEL>statusCode : SET<CS>effectiveTime : IVL<TS>certificateText : EDquantity : RTOpositionNumber : LIST<INT>

0..n

1

0..n

10..n0..1

playedRole0..n

player

0..1

0..n0..1

scopedRole

0..n

scoper

0..1

0..n

1

outboundLink 0..n

source1

0..n

1

inboundLink0..n

target1

HL7 Reference Models

Construct a UML model representation ofnormalized terminology concepts

Page 95: Rim derived and influenced hl7 standards

© 2014 All Rights ReservedSlide Number: 95

4. CDA Constraint Modeling01.0 Submissions::ParticipantIdentifier

- identifierValue :ST+ identifierTypeCode :ParticipantIdentifier

01.0 Submissions::Participant

- name :ST

01.0 Submissions::Submission

- identifier :ST+ submissionTimePeriod :TS.DATE (IVL)+ submissionDateTime :TS

01.0 Submissions::SourceSystemProv ider

- identifier :ST {id}

01.0 Submissions::SourceSystem

- versionIdentifier :ST

01.0 Submissions::Registry

- identifier :ST {id}- versionIdentifier :ST {id}

03.0 CareEpisodes::CareEpisode

- arrivalDateTime :TS- dischargeDate :TS.DATE- payorTypeCode :CD [1..*] (SET)- admissionSourceCode :CD- dischargeDispositionCode :CD

02.0 Patients::PatientRace

- raceCode :CD- raceDetailCode :CD [0..*] (SET)

02.0 Patients::Patient

- name :EN.PN- birthDate :TS.DATE- sexCode :CD- hispanicIndicator :BL = No- ethnicityDetailCode :CD [0..*] (SET)- postalZoneIdentifier :II+ residenceCountryCode :CD

02.0 Patients::PatientIdentifier

- identifierValue :II+ identifierTypeCode :PatientIdentifier

02.0 Patients::ResearchStudyEnrollment

- enrolledIndicator :BL = No

02.0 Patients::ClinicalTrial

- trialTypeCode :CD- researchStudyName :ST

03.0 CareEpisodes::Ev entEpisodeRelation

+ relationshipTypeCode :RelationshipType

04.0 Observ ations::Inv olv edAnatomicSite

+ involvementTypeCode :InvolvementType

04.0 Observ ations::Observ ationEv ent

+ observationTypeCode :CD

::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]

04.0 Observ ations::Observ ationResult

- observationResultTypeCode :CD- conditionOnsetDateTime :TS [0..1]- estimatedOnsiteDateIndicator :BL = No- missingOnsetTimeIndicator :BL = No- observationValue :ANY+ observationValueNegationIndicator :BL = No

05.0 Ev ents::Ev ent

- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]

05.0 Ev ents::Ev entEv entRelation

+ relationshipTypeCode :RelationshipType

05.0 Ev ents::Ev entPerformer

- name :EN.PN- identifier :II- isCertifiedIndicator :BL = No

05.0 Events::Intervention

- 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]

06.0 Lesions::Lesion

- lesionCounter :INT {id}

06.0 Lesions::LesionAffectedVesselSegment

- lesionLocationCode :CD- segmentCounter :INT

06.0 Lesions::LesionDescriptor

::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]

06.0 Lesions::LesionTreatmentDev ice

- deviceCounter :INT

07.0 Dev ices::Dev ice

- identifier :II- typeCode :CD- manufacturerName :EN.ON- deviceName :ST- universalDeviceIdentifier :II [0..1]

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]

08.0 AnatomicSites::AnatomicRegion

- anotomicRegionCode :CD

::AnatomicSite- typeCode :CD- lateralityCode :CD

08.0 AnatomicSites::AnatomicSite

- typeCode :CD- lateralityCode :CD

08.0 AnatomicSites::Cardiov ascularGraft

- graftTypeCode :CD

::CardiovascularVessel- cardiovascularVesselCode :CD {id}- vesselTypeCode :CD

::AnatomicSite- typeCode :CD- lateralityCode :CD

08.0 AnatomicSites::Cardiov ascularVessel

- cardiovascularVesselCode :CD {id}- vesselTypeCode :CD

::AnatomicSite- typeCode :CD- lateralityCode :CD

08.0 AnatomicSites::VesselSegment

- vesselSegmentCode :CD {id}

::AnatomicSite- typeCode :CD- lateralityCode :CD

09.0 Procedures::ArterialAccess

- siteCounter :INT- directionalityTypeCode :CD [0..1]- vesselCode :CD

09.0 Procedures::ArterialClosure

- arterialClosureCounter :INT {id}- methodCode :CD [0..1]- undocumentedIndicator :BL = No

09.0 Procedures::ArterialClosureDev ice

- deviceCounter :INT

09.0 Procedures::Procedure

+ procedureTypeCode :CD

::Intervention- 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]

09.0 Procedures::ProcedureDev iceUse

- deviceCounter :INT {id}- statusCode :CD- abortedReasonCode :CD [0..1]

::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::ProcedureDescriptor

::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

- previouslyTreatedIndicator :BL = No- culpritLesionIndicator :BL = No

::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::ProcedureVascularAssessment

- vesselNotAvailableIndicator :BL = No

::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]

10.0 Medication Administration Ev ents::Medication

+ medicationCode :CD- name :ST

10.0 Medication Administration Ev ents::MedicationAdministrationEv ent

::Intervention- 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]

Primary Class

Dependant Classes

Value Sets

Foreign Classes

Legend

Name: NCDR DAM ClassesAuthor: Salimah ShakirVersion: 1.0Created: 11/12/2012 7:02:00 PMUpdated: 8/26/2013 1:05:44 PM

06.0 Lesions::LesionTreatmentDetail

::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]

Refers to (1..1)07.0 Devices :: Device

is referred to by (0..*)06.0 Lesions :: LesionTreatmentDevice

0..*

assig

ns

0..1

0..*

ha

s targ

et

1

0..*

is pa

rt of

0..*

is use

of

1

is a typeof

is a typeof

is a type of

1..*

ad

min

isters

1

is a typeof

is a typ

eo

fis p

art o

f

is a typeof

1..* {ordered}

is part of

0..*

is part of

0..*

invo

lving

1

0..*

has target

1

0..*

involved

1

0..*

performed by

0..*

0..1

trea

ted

1

0..*

is located in

1

is a typeof

0..*

ha

s sub

ject

1

0..*

ha

s sou

rce

1

0..*

is pa

rt of

0..*

is part of

0..*

is pa

rt of

+subsection0..*

is grouped by

0..1

0..*

affecting

1

0..*

is part of

0..*

is use of

1

0..*

is part of

0..*

is gro

up

ed

by

1..*

has subject

1

0..1

within context of

1

1..*

provided by

1

1..*

submited to

1

0..*

is pa

rt of

1

+child0..*

is grouped by

+parent0..1

0..*

has source

1

0..*

is use

d b

y

1

0..*

is treatment of

1

0..*

identifies

1

0..*

has target

10..*

ha

s sub

ject

1

1..*

is a tra

it of

1

0..*

is use by

1

is a typ

eo

f

0..*

is treated by

1

0..*

is part of

0..*

ide

ntifie

s 1

1..*

submited by

1

1..*

orig

ina

tes fro

m

1

0..*

is part of

Conceptual Data Model

(CustodianOrganization)Participant

- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (ParticipantIdentifier.identifierValue) id :II+ (Participant.name) name :EN.ON

(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

(Observation)PatientRaceObservation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# code :CD = "PatientRace"+ (PatientRace.raceCode) value :CD [1..*] (SET)

(Act)SubmissionAct

- classCode :CS = "ACT"- moodCode :CS = "EVN"+ (Submission.identifier) id :II+ (Submission.submissionTimePeriod) effectiveTime :TS (IVL)

(PatientRole)PatientRole

- classCode :CS = "PAT"+ (PatientIdentifier.identifierValue) id :II

(ClinicalDocument)CathPCIRegistryDocument

- classCode :CS = "DOCCLIN"- moodCode :CS = "EVN"+ id :II# code :CE = "CATHPCI"+ effectiveTime :TS

(RecordTarget)RecordTarget

- typeCode :CS = "RCT"- contextControlCode :CS = "OP"

(AssignedCustodian)ParticipantRole

- classCode :CS = "ASSIGNED"

(Custodian)Custodian

- typeCode :CS = "CST"

(StructuredBody)DocumentBody

- classCode :CS = "DOCBODY"- moodCode :CS = "EVN"

(ClinicalDocumentComponent)DocumentComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Section)SubmissionDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "SubmissionDetail"

(StructuredBodyComponent)SubmissionDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Entry)SubmissionActEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(ParticipantRole)SourceSystem

- classCode :CS = "MMAT"

(ClinicalStatementParticipant)Author

- typeCode :CS = "AUT"- contextControlCode :CS = "OP"

(Dev ice)DataCollectionSystem

- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (SourceSystem.versionIdentifier) id :II

(Entity)SourceSystemProv ider

- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (SourceSystemProvider.identifier) id :II

(ParticipantRole)TargetRegistry

- classCode :CS = "MMAT"

(ClinicalStatementParticipant)Receiver

- typeCode :CS = "RCV"- contextControlCode :CS = "OP"

(Dev ice)RegistrySystem

- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (Registry.identifier) id.root :II.root+ (RegistryVersionIdentifier) id.extension :II.extension

(Section)PatientDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "PatientDetail"

(StructuredBodyComponent)PatientDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Entry)PatientRaceObservationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Observation)PatientIdentifierObservation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# (PatientIdentifier.typeCode) code :CD+ (PatientIdentifier.identifierValue) value :CD

(Entry)PatientIdentifierObservationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Section)RegistryParticipantDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "RegistryPartic...

(StructuredBodyComponent)RegistryParticipantDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Observation)ParticipantIdentifierObservation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# (ParticipantIdentifier.typeCode) code :CD+ (ParticipantIdentifier.identifierValue) value :CD

(Entry)ParticipantIdentifierObservationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

Entry Point

1..1

1

1..1

1

1..1 1

1..1

isPlayedBy

1

1..1

1

1..1

isScopedBy

1

1..1

1

1..1

1

1..*1

1..1

isPlayedBy

1

isScopedBy

1..11

1..1

isPlayedBy

1

1..11 0..*1

1..1

1

1..11

Constrained Information ModelHL7 Clinical Document Architecture RMIM

Map UMTS Conceptual Data Model to theHL7 Clinical Document Architecture

Page 96: Rim derived and influenced hl7 standards

© 2014 All Rights ReservedSlide Number: 96

5. UMTS CDA Template Construction

(CustodianOrganization)Participant

- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (ParticipantIdenti fier.identi fierValue) id :II+ (Participant.name) name :EN.ON

(Patient)Patient

- classCode :CS = "PSN"- determinerCode :CS = "INSTANCE"+ (Patient.name) name :EN.PN+ (Patient.sexCode) administrativeGenderCode :CD+ (Patient.birthDate) birthT ime :TS.DATE+ (Patient.hispanicIndicator) ethnicGroupCode :CD

(Observ ation)PatientRaceObserv ation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# code :CD = "PatientRace"+ (PatientRace.raceCode) value :CD [1..*] (SET)

(Act)SubmissionAct

- classCode :CS = "ACT"- moodCode :CS = "EVN"+ (Submission.identi fier) id :II+ (Submission.submissionT imePeriod) effectiveT ime :TS (IVL)

(PatientRole)PatientRole

- classCode :CS = "PAT"+ (PatientIdenti fier.identi fierValue) id :II

(ClinicalDocument)CathPCIRegistryDocument

- classCode :CS = "DOCCLIN"- moodCode :CS = "EVN"+ id :II# code :CE = "CATHPCI"+ effectiveT ime :TS

(RecordTarget)RecordTarget

- typeCode :CS = "RCT"- contextControlCode :CS = "OP"

(AssignedCustodian)ParticipantRole

- classCode :CS = "ASSIGNED"

(Custodian)Custodian

- typeCode :CS = "CST"

(StructuredBody)DocumentBody

- classCode :CS = "DOCBODY"- moodCode :CS = "EVN"

(ClinicalDocumentComponent)DocumentComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Section)SubmissionDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "SubmissionDetai l"

(StructuredBodyComponent)SubmissionDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Entry)SubmissionActEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(ParticipantRole)SourceSystem

- classCode :CS = "MMAT"

(ClinicalStatementParticipant)Author

- typeCode :CS = "AUT"- contextControlCode :CS = "OP"

(Dev ice)DataCollectionSystem

- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (SourceSystem.versionIdenti fier) id :II

(Entity)SourceSystemProv ider

- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (SourceSystemProvider.identi fier) id :II

(ParticipantRole)TargetRegistry

- classCode :CS = "MMAT"

(ClinicalStatementParticipant)Receiv er

- typeCode :CS = "RCV"- contextControlCode :CS = "OP"

(Dev ice)RegistrySystem

- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (Registry.identi fier) id.root :II.root+ (RegistryVersionIdenti fier) id.extension :II.extension

(Section)PatientDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "PatientDetai l"

(StructuredBodyComponent)PatientDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Entry)PatientRaceObserv ationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Observ ation)PatientIdentifierObserv ation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# (PatientIdenti fier.typeCode) code :CD+ (PatientIdenti fier.identi fierValue) value :CD

(Entry)PatientIdentifierObserv ationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Section)RegistryParticipantDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "RegistryPartic...

(StructuredBodyComponent)RegistryParticipantDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Observ ation)ParticipantIdentifierObserv ation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# (ParticipantIdenti fier.typeCode) code :CD+ (ParticipantIdenti fier.identi fierValue) value :CD

(Entry)ParticipantIdentifierObserv ationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

Entry Point

1..1

1

1..1

1

1..1 1

1..1

isPlayedBy

1

1..1

1

1..1

isScopedBy

1

1..1

1

1..1

1

1..*1

1..1

isPlayedBy

1

isScopedBy

1..11

1..1

isPlayedBy

1

1..11 0..*1

1..1

1

1..11

Constrained Information Model UMTS CDA Template Library

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

HL7 & IHE Content Profiles

Specify registry agnostic CDA element usage,cardinality, and value constraints

Page 97: Rim derived and influenced hl7 standards

© 2014 All Rights ReservedSlide Number: 97

6. Registry Content Profile Specification

UMTS CDA Template Library

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

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: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

Registry Specific Business Rules

Specify registry specific CDA element usage,cardinality, and value constraints

Page 98: Rim derived and influenced hl7 standards

© 2014 All Rights ReservedSlide Number: 98

Registry Elements

MedicationAdministration

00307 Medication

MedicationTypeCode

MedicationClassCode

T iming

At Discharge

Pre-Encounter

First 24 Hours

Intra-Encounter

Intra-Procedure

Pre-Procedure

00776 Route

Initial Bolus

Initial Infusion

00238 Frequency

q12hr

q24hr

00423 Status

Administered

Not Administered

Blinded

Contraindicated

00069 Dose Amount00147 Duration00070 Start Date Time00306 Stop Date Time

00303 Dose Code

Full Reduced Other

Within 2 weeks

During Follow-up

Semantic Analysis

DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context Timing Location Cause

00112 Cardiac Arrest Indicator Action.4135 Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode of cardiac arrest.

First Medical Contact

00112 Cardiac Arrest Indicator Action.4140 Cardiac Arrest Pre-Hospital C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility.

First Medical Contact PreHospital

00112 Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest occurred at the outside facility.

First Medical Contact Outside Facility

00112 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.

In Hospital

00112 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.

within 24 hours of procedure

00112 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 Pre-Hospital

00800 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 ventricular tachycardia or ventricular fibrillation

00102 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 bradycardia

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 Cardiac Arrest Indicator TVT.5035 Cardiac Arrest w/in 24 Hours 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

Consolidated Dictionary

0 1 .0 S ubm is s ions ::P a rtic ipa ntIde ntifie r

- i d e n ti f i e rV a l u e :S T

+ i d e n ti f i e rT yp e Co d e :P a rti c i p a n tId e n ti f i e r

0 1 .0 S ubm is s ions ::P a rtic ipa nt

- n a m e :S T

0 1 .0 S ubm is s ions ::S ubm is s ion

- i d e n ti f i e r :S T

+ su b m i ssi o n T i m e P e ri o d :T S .DA T E (IV L )

+ su b m i ssi o n Da te T i m e :T S

0 1 .0 S ubm is s ions ::S ourc e S ys te m P rov ide r

- i d e n ti f i e r :S T {i d }

0 1 .0 S ubm is s ions ::S ourc e S ys te m

- ve rsi o n Id e n ti f i e r :S T

0 1 .0 S ubm is s ions ::Re gis try

- i d e n ti f i e r :S T {i d }

- ve rsi o n Id e n ti f i e r :S T {i d }

0 3 .0 Ca re E pis ode s ::Ca re E pis ode

- a rri va l Da te T i m e :T S

- d i sch a rg e Da te :T S .DA T E

- p a yo rT yp e Co d e :CD [1 ..* ] (S E T )

- a d m i ssi o n S o u rce Co d e :CD

- d i sch a rg e D i sp o si t i o n Co d e :CD

0 2 .0 P a tie nts ::P a tie ntRa c e

- ra ce Co d e :CD

- ra ce De ta i l Co d e :CD [0 ..* ] (S E T )

0 2 .0 P a tie nts ::P a tie nt

- n a m e :E N.P N

- b i rth Da te :T S .DA T E

- se xCo d e :CD

- h i sp a n i c In d i ca to r :B L = No

- e th n i c i tyDe ta i l Co d e :CD [0 ..* ] (S E T )

- p o sta l Zo n e Id e n ti f i e r : I I

+ re si d e n ce Co u n tryCo d e :CD

0 2 .0 P a tie nts ::P a tie ntIde ntifie r

- i d e n ti f i e rV a l u e : I I

+ i d e n ti f i e rT yp e Co d e :P a ti e n tId e n ti f i e r

0 2 .0 P a tie nts ::Re s e a rc hS tudyE nrollm e nt

- e n ro l l e d In d i ca to r :B L = No

0 2 .0 P a tie nts ::C lin ic a lTria l

- tri a l T yp e Co d e :CD

- re se a rch S tu d yNa m e :S T

0 3 .0 Ca re E pis ode s ::E v e ntE pis ode Re la tion

+ re l a t i o n sh i p T yp e Co d e :Re l a t i o n sh i p T yp e

0 4 .0 O bs e rv a tions ::Inv olv e dAna tom ic S ite

+ i n vo l ve m e n tT yp e Co d e : In vo l ve m e n tT yp e

0 4 .0 O bs e rv a tions ::

O bs e rv a tionE v e nt

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 4 .0 O bs e rv a tions ::O bs e rv a tionRe s ult

- o b se rva ti o n Re su l tT yp e Co d e :CD

- co n d i t i o n O n se tDa te T i m e :T S [0 ..1 ]

- e st i m a te d O n si te Da te In d i ca to r :B L = No

- m i ssi n g O n se tT i m e In d i ca to r :B L = No

- o b se rva ti o n V a l u e :A NY

+ o b se rva ti o n V a l u e Ne g a ti o n In d i ca to r :B L = No

0 5 .0 E v e nts ::E v e nt

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 5 .0 E v e nts ::E v e ntE v e ntRe la tion

+ re l a t i o n sh i p T yp e Co d e :Re l a t i o n sh i p T yp e

0 5 .0 E v e nts ::E v e ntP e rform e r

- n a m e :E N.P N

- i d e n ti f i e r : I I

- i sCe rt i f i e d In d i ca to r :B L = No

0 5 .0 E v e nts ::In te rv e ntion

- i n d i ca ti o n Co d e :CD [0 ..1 ]

- a b o rte d Re a so n Co d e :CD [0 ..* ]

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 6 .0 Le s ions ::Le s ion

- l e si o n Co u n te r : INT {i d }

0 6 .0 Le s ions ::Le s ionAffe c te dV e s s e lS e gm e nt

- l e si o n L o ca ti o n Co d e :CD

- se g m e n tCo u n te r : INT

0 6 .0 Le s ions ::Le s ionDe s c riptor

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 6 .0 Le s ions ::Le s ionTre a tm e ntDe v ic e

- d e v i ce Co u n te r : INT

0 7 .0 De v ic e s ::De v ic e

- i d e n ti f i e r : I I

- typ e Co d e :CD

- m a n u fa ctu re rNa m e :E N .O N

- d e v i ce Na m e :S T

- u n i ve rsa l De vi ce Id e n ti f i e r : I I [0 ..1 ]

0 7 .0 De v ic e s ::De v ic e De s c riptor

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 8 .0 Ana tom ic S ite s ::Ana tom ic Re gion

- a n o to m i cRe g i o n Co d e :CD

: :A n a to mi cS i te

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 8 .0 Ana tom ic S ite s ::Ana tom ic S ite

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 8 .0 Ana tom ic S ite s ::Ca rd iov a s c ula rG ra ft

- g ra ftT yp e Co d e :CD

: :Ca rd i o va scu l a rV e sse l

- ca rd i o va scu l a rV e sse l Co d e :CD {i d }

- ve sse l T yp e Co d e :CD

: :A n a to mi cS i te

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 8 .0 Ana tom ic S ite s ::Ca rd iov a s c ula rV e s s e l

- ca rd i o va scu l a rV e sse l Co d e :CD {i d }

- ve sse l T yp e Co d e :CD

: :A n a to mi cS i te

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 8 .0 Ana tom ic S ite s ::V e s s e lS e gm e nt

- ve sse l S e g m e n tCo d e :CD {i d }

: :A n a to mi cS i te

- typ e Co d e :CD

- l a te ra l i tyCo d e :CD

0 9 .0 P roc e dure s ::Arte ria lAc c e s s

- si te Co u n te r :INT

- d i re ct i o n a l i tyT yp e Co d e :CD [0 ..1 ]

- ve sse l Co d e :CD

0 9 .0 P roc e dure s ::Arte ria lC los ure

- a rte ri a l C l o su re Co u n te r :INT {i d }

- m e th o d Co d e :CD [0 ..1 ]

- u n d o cu m e n te d In d i ca to r :B L = No

0 9 .0 P roc e dure s ::Arte ria lC los ure De v ic e

- d e v i ce Co u n te r : INT

0 9 .0 P roc e dure s ::P roc e dure

+ p ro ce d u re T yp e Co d e :CD

: : In te rve n ti o n

- i n d i ca ti o n Co d e :CD [0 ..1 ]

- a b o rte d Re a so n Co d e :CD [0 ..* ]

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 9 .0 P roc e dure s ::P roc e dure De v ic e Us e

- d e v i ce Co u n te r : INT {i d }

- sta tu sCo d e :CD

- a b o rte d Re a so n Co d e :CD [0 ..1 ]

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 9 .0 P roc e dure s ::P roc e dure De s c riptor

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 9 .0 P roc e dure s ::P roc e dure Le s ion

- p re v i o u sl yT re a te d In d i ca to r :B L = No

- cu l p ri tL e si o n In d i ca to r :B L = No

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

0 9 .0 P roc e dure s ::P roc e dure V a s c ula rAs s e s s m e nt

- ve sse l No tA va i l a b l e In d i ca to r :B L = No

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

1 0 .0 M e dic a tion Adm in is tra tion E v e nts ::

M e dic a tion

+ m e d i ca ti o n Co d e :CD

- n a m e :S T

1 0 .0 M e dic a tion Adm in is tra tion E v e nts ::

M e dic a tionAdm inis tra tionE v e nt

: : In te rve n ti o n

- i n d i ca ti o n Co d e :CD [0 ..1 ]

- a b o rte d Re a so n Co d e :CD [0 ..* ]

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

P ri m a ry C l a ss

De p e n d a n t C l a sse s

V a l u e S e ts

Fo re i g n C l a sse s

Legend

Na m e : NCDR DA M C l a sse s

A u th o r: S a l i m a h S h a ki r

V e rsi o n : 1 .0

Cre a te d : 1 1 /1 2 /2 0 1 2 7 :0 2 :0 0 P M

Up d a te d : 8 /2 6 /2 0 1 3 1 :0 5 :4 4 P M

0 6 .0 Le s ions ::Le s ionTre a tm e ntDe ta il

: :O b se rva ti o n E ve n t

+ o b se rva ti o n T yp e Co d e :CD

: :E ve n t

- m e th o d Co d e :CD [0 ..* ] (S E T )

+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n

+ co n te xtCo d e :Co n te xt

- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )

- sta tu sCo d e :CD = Co m p l e te d

- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]

Refers to (1..1)07.0 Devices :: Device

is referred to by (0..*)06.0 Lesions :: LesionTreatmentDevice

0 ..*

as

sig

ns

0 . .1

0 ..*

ha

s ta

rge

t

1

0 ..*

is p

art o

f

0 . .*

is u

se

of

1

i s a typ e

o f

i s a typ e

o f

i s a typ e o f

1 ..*

ad

min

iste

rs

1

i s a typ e

o f

is a

typ

e

of

is p

art o

f

i s a typ e

o f

1 ..* {o rd e re d }

i s p a rt o f

0 ..*

i s p a rt o f

0 ..*

inv

olv

ing

1

0 ..*

h a s ta rg e t

1

0 ..*

i n vo l ve d

1

0 ..*

p e rfo rm e d b y

0 ..*

0 ..1

trea

ted

1

0 ..*

i s l o ca te d i n

1

i s a typ e

o f

0 ..*

ha

s s

ub

jec

t

1

0 ..*

ha

s s

ou

rce

1

0 ..*

is p

art o

f

0 . .*

i s p a rt o f

0 ..*

is p

art o

f

+ su b se cti o n

0 ..*i s g ro u p e d b y

0 ..1

0 ..*

a ffe ct i n g

1

0 ..*

i s p a rt o f

0 ..*

i s u se o f

1

0 ..*

i s p a rt o f

0 ..*

is g

rou

pe

d b

y

1 . .*

h a s su b j e ct

1

0 ..1

w i th i n co n te xt o f

1

1 ..*

p ro v i d e d b y

1

1 ..*

su b m i te d to

1

0 ..*

is p

art o

f

1

+ ch i l d

0 ..*

i s g ro u p e d b y

+ p a re n t

0 ..1

0 ..*

h a s so u rce

1

0 ..*

is u

se

d b

y

1

0 ..*

i s tre a tm e n t o f

1

0 ..*

i d e n ti f i e s

1

0 ..*

h a s ta rg e t

10 ..*

ha

s s

ub

jec

t

1

1 ..*

is a

trait o

f

1

0 ..*

i s u se b y

1

is a

typ

e

of

0 . .*

i s tre a te d b y

1

0 ..*

i s p a rt o f

0 ..*

ide

ntifie

s 1

1 ..*

su b m i te d b y

1

1 ..*

orig

ina

tes

from

1

0 ..*

i s p a rt o f

Conceptual Data Model

(CustodianOrganization)Participant

- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (ParticipantIdentifier.identifierValue) id :II+ (Participant.name) name :EN.ON

(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

(Observation)PatientRaceObservation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# code :CD = "PatientRace"+ (PatientRace.raceCode) value :CD [1..*] (SET)

(Act)SubmissionAct

- classCode :CS = "ACT"- moodCode :CS = "EVN"+ (Submission.identifier) id :II+ (Submission.submissionTimePeriod) effectiveTime :TS (IVL)

(PatientRole)PatientRole

- classCode :CS = "PAT"+ (PatientIdentifier.identifierValue) id :II

(ClinicalDocument)CathPCIRegistryDocument

- classCode :CS = "DOCCLIN"- moodCode :CS = "EVN"+ id :II# code :CE = "CATHPCI"+ effectiveTime :TS

(RecordTarget)RecordTarget

- typeCode :CS = "RCT"- contextControlCode :CS = "OP"

(AssignedCustodian)ParticipantRole

- classCode :CS = "ASSIGNED"

(Custodian)Custodian

- typeCode :CS = "CST"

(StructuredBody)DocumentBody

- classCode :CS = "DOCBODY"- moodCode :CS = "EVN"

(ClinicalDocumentComponent)DocumentComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Section)SubmissionDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "SubmissionDetail"

(StructuredBodyComponent)SubmissionDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Entry)SubmissionActEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(ParticipantRole)SourceSystem

- classCode :CS = "MMAT"

(ClinicalStatementParticipant)Author

- typeCode :CS = "AUT"- contextControlCode :CS = "OP"

(Device)DataCollectionSystem

- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (SourceSystem.versionIdentifier) id :II

(Entity)SourceSystemProvider

- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (SourceSystemProvider.identifier) id :II

(ParticipantRole)TargetRegistry

- classCode :CS = "MMAT"

(ClinicalStatementParticipant)Receiver

- typeCode :CS = "RCV"- contextControlCode :CS = "OP"

(Device)RegistrySystem

- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (Registry.identifier) id.root :II.root+ (RegistryVersionIdentifier) id.extension :II.extension

(Section)PatientDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "PatientDetail"

(StructuredBodyComponent)PatientDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Entry)PatientRaceObservationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Observation)PatientIdentifierObservation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# (PatientIdentifier.typeCode) code :CD+ (PatientIdentifier.identifierValue) value :CD

(Entry)PatientIdentifierObservationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Section)RegistryParticipantDetailSection

- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "RegistryPartic...

(StructuredBodyComponent)RegistryParticipantDetailComponent

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

(Observation)ParticipantIdentifierObservation

- classCode :CS = "OBS"- moodCode :CS = "EVN"# (ParticipantIdentifier.typeCode) code :CD+ (ParticipantIdentifier.identifierValue) value :CD

(Entry)ParticipantIdentifierObservationEntry

- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"

Entry Point

1..1

1

1..1

1

1..1 1

1..1

isPlayedBy

1

1..1

1

1..1

isScopedBy

1

1..1

1

1..1

1

1..*1

1..1

isPlayedBy

1

isScopedBy

1..11

1..1

isPlayedBy

1

1..11 0..*1

1..1

1

1..11

Constrained Information Model

Account

name : STbalanceAmt : MOcurrencyCode : CEinterestRateQuantity : RTO<MO,PQ>allowedBalanceQuantity : IVL<MO>

DeviceTask

parameterValue : LIST<ANY>

DiagnosticImage

subjectOrientationCode : CE

Diet

energyQuantity : PQcarbohydrateQuantity : PQ

FinancialContract

paymentTermsCode : CE

FinancialTransaction

amt : MOcreditExchangeRateQuantity : REALdebitExchangeRateQuantity : REAL

InvoiceElement

modifierCode : SET<CE>unitQuantity : RTO<PQ,PQ>unitPriceAmt : RTO<MO,PQ>netAmt : MOfactorNumber : REALpointsNumber : REAL

ManagedParticipation

id : SET<II>statusCode : SET<CS>

Observation

value : ANYinterpretationCode : SET<CE>methodCode : SET<CE>targetSiteCode : SET<CD>

PatientEncounter

preAdmitTestInd : BLadmissionReferralSourceCode : CElengthOfStayQuantity : PQdischargeDispositionCode : CEspecialCourtesiesCode : SET<CE>specialAccommodationCode : SET<CE>acuityLevelCode : CE

Procedure

methodCode : SET<CE>approachSiteCode : SET<CD>targetSiteCode : SET<CD>

PublicHealthCase

detectionMethodCode : CEtransmissionModeCode : CEdiseaseImportedCode : CE

SubstanceAdministration

routeCode : CEapproachSiteCode : SET<CD>doseQuantity : IVL<PQ>rateQuantity : IVL<PQ>doseCheckQuantity : SET<RTO>maxDoseQuantity : SET<RTO>substitutionCode : CE

Supply

quantity : PQexpectedUseTime : IVL<TS>

WorkingList

ownershipLevelCode : CE

Container

capacityQuantity : PQheightQuantity : PQdiameterQuantity : PQcapTypeCode : CEseparatorTypeCode : CEbarrierDeltaQuantity : PQbottomDeltaQuantity : PQ

Device

manufacturerModelName : SCsoftwareName : SClocalRemoteControlStateCode : CE...alertLevelCode : CElastCalibrationTime : TS

LivingSubject

administrativeGenderCode : CEbirthTime : TSdeceasedInd : BLdeceasedTime : TSmultipleBirthInd : BLmultipleBirthOrderNumber : INTorganDonorInd : BL

ManufacturedMaterial

lotNumberText : STexpirationTime : IVL<TS>stabilityTime : IVL<TS>

Material

formCode : CE

NonPersonLivingSubject

strainText : EDgenderStatusCode : CE

Organization

addr : BAG<AD>standardIndustryClassCode : CE

Person

addr : BAG<AD>maritalStatusCode : CEeducationLevelCode : CEraceCode : SET<CE>disabilityCode : SET<CE>livingArrangementCode : CEreligiousAffiliationCode : CEethnicGroupCode : SET<CE>

Place

mobileInd : BLaddr : ADdirectionsText : EDpositionText : EDgpsText : ST

Access

approachSiteCode : CDtargetSiteCode : CDgaugeQuantity : PQ

Employee

jobCode : CEjobTitleName : SCjobClassCode : CEsalaryTypeCode : CEsalaryQuantity : MOhazardExposureText : EDprotectiveEquipmentText : ED

LicensedEntity

recertificationTime : TS

Patient

confidentialityCode : CEveryImportantPersonCode : CE

ActRelationship

typeCode : CSinversionInd : BLcontextControlCode : CScontextConductionInd : BLsequenceNumber : INTpriorityNumber : INTpauseQuantity : PQcheckpointCode : CSsplitCode : CSjoinCode : CSnegationInd : BLconjunctionCode : CSlocalVariableName : STseperatableInd : BL

Act

classCode : CSmoodCode : CSid : SET<II>code : CDnegationInd : BLderivationExpr : STtext : EDstatusCode : SET<CS>effectiveTime : GTSactivityTime : GTSavailabilityTime : TSpriorityCode : SET<CE>confidentialityCode : SET<CE>repeatNumber : IVL<INT>interruptibleInd : BLlevelCode : CEindependentInd : BLuncertaintyCode : CEreasonCode : SET<CE>languageCode : CE

0..n

1

outboundRelationship

0..n

source1

0..n

1

inboundRelationship

0..n

target

1

LanguageCommunication

languageCode : CEmodeCode : CEproficiencyLevelCode : CEpreferenceInd : BL

Participation

typeCode : CSfunctionCode : CDcontextControlCode : CSsequenceNumber : INTnegationInd : BLnoteText : EDtime : IVL<TS>modeCode : CEawarenessCode : CEsignatureCode : CEsignatureText : EDperformInd : BLsubstitutionConditionCode : CE...

0..n

1

0..n

1

Entity

classCode : CSdeterminerCode : CSid : SET<II>code : CEquantity : SET<PQ>name : BAG<EN>desc : EDstatusCode : SET<CS>existenceTime : IVL<TS>telecom : BAG<TEL>riskCode : CEhandlingCode : CE

1

0..n

1

0..n

RoleLink

typeCode : CSeffectiveTime : IVL<TS>

Role

classCode : CSid : SET<II>code : CEnegationInd : BLaddr : BAG<AD>telecom : BAG<TEL>statusCode : SET<CS>effectiveTime : IVL<TS>certificateText : EDquantity : RTOpositionNumber : LIST<INT>

0..n

1

0..n

10..n0..1

playedRole0..n

player

0..1

0..n0..1

scopedRole

0..n

scoper

0..1

0..n

1

outboundLink 0..n

source1

0..n

1

inboundLink0..n

target1

HL7 Reference Models

HL7 Clinical Document Architecture RMIM UMTS CDA Template Library

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

HL7 & IHE 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: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

Registry Specific Content Profiles

Standard Clinical Code Systems

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

1 SUBENTRY

1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]

Table 1: ClincalEventObservationSubEntry Contexts

Contained By: Contains:

This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.

1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).

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" (CONF:31961).

5. SHALL contain exactly one [1..1] code (CONF:31962).

6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).

7. SHALL contain exactly one [1..1] value (CONF:31964).

8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).

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).

Registry Specific Business Rules

UMTS Project Activities

1 2

3

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© 2014 All Rights ReservedSlide Number: 99

Questions

Page 100: Rim derived and influenced hl7 standards

© 2014 All Rights ReservedSlide Number: 100

Thank You

AbdulMalik ShakirPresident and Chief Informatics Scientist

Hi3 Solutions | your healthcare standards conformance partner3500 West Olive Ave, Suite # 300, Burbank, CA 91505.

Direct: +1 626 644 4491 | Toll Free: +1 800 918 6520

www.hi3solutions.com   | [email protected]