US Standards for Health Record Systems

1. US Standards for Health Record Systems James J. Cimino, M.D. Columbia University, New York For the Health Information Management Systems Society (HIMSS)

2. The Need for Standards • Patient Safety • Quality of Care • Cost Effectiveness • Patient Involvement • Performance Evaluation • Research • Health Surveillance • Disaster Response

3. Current State of Standards • Reporting – mandatory, intrusive • Terminology – incomplete, not mandatory • Messaging – incomplete, not mandatory • Integration – not at all

4. A Look at Some US Efforts • Bottom-Up: Health Level 7 (HL7) • Top-Down: Integrating the Healthcare Enterprise (IHE)

5. Bottom-Up: Health Level 7 (HL7) • Need for information exchange standard • Message is the unit of information • One actor tells another actor about an event • Began in 1986 with 14 members, now with 2000 members and worldwide chapters

6. HL7 Version 2 Message MSH|^~\&|MENDONC|UPLAB|CICSU9|20000209025800||ORU|0000000001|P|2.1||| PID|||3131313||SANDIEGO^CARMEN|||F||||||||||||| OBR|||M09000HABC0000^1|59058^TROPONINI^L^32506|||20000209025800|||||||20000209025800|^|NOR||||||||HE|F||^^^^^R|^^||||||||| OBX|1|NM|59058^TROPONIN I^MED|0|0.1|ng/ml|0-0.4|||||||||||||||

7. Patient ambulatory_status_cd birth_order_amt living_arrangement_cd 1 living_dependency_cd multiple_birth_ind Person newborn_baby_ind birth_dttm birthplace_addr citizenship_country_cd confidentiality_constraint_cd deceased_dttm deceased_ind disability_cd organ_donor_ind education_level_cd ethnic_group_cd 1 gender_cd language_cd marital_status_cd military_branch_of_service_cd military_rank_nm preferred_pharmacy_id military_status_cd nationality_cd primary_name_representation_cd primary_name_type_cd primary_nm race_cd religious_affiliation_cd takes_on_role_of student_cd very_important_person_cd is_a_role_of 0..1 Reference Information Model for HL7 Version 3 (RIM)

8. Person birth_dttm birthplace_addr citizenship_country_cd confidentiality_constraint_cd deceased_dttm deceased_ind disability_cd education_level_cd Patient ambulatory_status_cd ethnic_group_cd birth_order_amt gender_cd living_arrangement_cd language_cd 1 living_dependency_cd marital_status_cd multiple_birth_ind military_branch_of_service_cd newborn_baby_ind military_rank_nm organ_donor_ind military_status_cd preferred_pharmacy_id nationality_cd 1 1 is_a_role_of takes_on_role_of primary_name_representation_cd primary_name_type_cd 0..1 primary_nm race_cd religious_affiliation_cd student_cd very_important_person_cd Reference Information Model for HL7 Version 3 (RIM) 1 1

9. HEALTH LEVEL 7 REFERENCE INFORMATION MODEL RIM_0088 Master_service released January, 1999 allowable_processing_priority_cd has_as_participant 0..* 0..* Producer_of_master_service 0..* 0..* produces is_produced_by 0..1 0..1 service_producing_department_type_cd Financial_transaction allowable_reporting_priority_cd reflects agreements made through harmonization in November, 1998 alternate_desc billing_reference_txt is_categorized_by desc 0..* 0..* challenge_information_txt extended_amt 1 1 confidentiality_cd is_requested_by Healthcare_finances Healthcare_finances Master_tables Healthcare_finances fee_schedule_cd 0..* 0..* is_associated_with effective_dt insurance_amt factors_that_may_affect_observation_desc posting_dt fee_amt Patient_encounters Healthcare_finances Healthcare_stakeholders Healthcare_finances qty fixed_canned_message_cd 0..* 0..* pertains_to 1 1 transaction_batch_id is_target imaging_measurement_modality_cd is_entered_by transaction_cd incompatible_change_dttm has_target 0..* 0..* transaction_dt Authentication 0..* 0..* instrument_identifier_coding_system_nm 0..* 0..* is_related_to authentication_dt transaction_id Master_service_relationship instrument_identifier_nm 1 1 0..* 0..* Clinical_document_header type_cd relationship_type_cd transaction_type_cd 0..* 0..* documents authentication_dt interpretation_considerations_desc is_related_to is_related_to is_associated_with reflex_testing_trigger_rules_desc unit_amt availability_status_cd kind_of_quantity_observed_cd constraint_txt 0..* 0..* unit_cost_amt change_reason_cd last_update_dttm 0..* 0..* quantitytiming_qt 1..* 1..* is_covered_by is_related_to completion_status_cd method_cd Resource_request is_related_to allowable_substitutions_cd confidentiality_status_cd method_desc duration_qty 1 1 content_presentation_cd nature_of_service_cd Healthcare_document_authenticator has_source 0..* 0..* Appointment_request is_the_purchaser_of 1 1 start_dttm document_header_creation_dt observation_id_suffix_txt appointment_rqst_reason_cd is_source 1 1 Health_benefit_plan_purchaser is_requested_by 1 1 0..* 0..* requests start_offset_qty file_nm orderable_service_ind has_as_a_contact Patient_information_disclosure appointment_rqst_type_cd 0..1 0..1 is_a 0..1 0..1 disclosure_dttm status_cd id patient_preparation_desc equip_selection_criteria_pv 0..1 0..1 info_disclosed_desc of has_been_originated_by 0..* 0..* 0..1 0..1 last_edit_dt point_versus_interval_cd Originator id is_delivered_during info_requested_desc is_a_role_of origination_dt 1 1 portable_device_ind location_selection_criteria_pv reason_cd reporting_priority_cd preferred_ordering_method_txt pertains_to occurence_id is_a 0..1 0..1 requested_dttm results_report_dttm Stakeholder_identifier requests preferred_scheduling_method_txt 1 1 1 1 is_instantiated_as priority_cd effective_dt 0..* 0..* urgency_cd storage_status_cd procedure_medication_cd repeating_interval_duration_qty is_issued_by id Document_recipient of transcription_dt 0..1 0..1 has_been_received_by 0..* 0..* report_display_order_txt requested_ri identifier_type_cd requests 0..* 0..* type_cd is_requested_by required_credentials_desc rqst_event_reason_cd issued_dt 1..* 1..* 0..* 0..* 0..* 0..* service_alternate_id is_transcribed_by 0..* 0..* 0..1 0..1 rqsted_duration_qty is_a 0..1 0..1 qualifying_information_txt Durable_medical_equipment_request Patient_appointment_request Patient_service_location_request service_alternate_identifier_coding_system_nm Individual_healthcare_practitioner_request start_dt Service_scheduling_request quantity_amt type_cd is_provided_to termination_dt practitioner_type_cd is_parent_document_for 0..* 0..* allowable_substitutions_cd service_alternate_identifier_nm time_selection_criteria_pv type_cd 0..* 0..* duration_qty service_alternate_name_use_cd 0..* 0..* transcribes may_be_contained_in issues 1 1 requests start_dttm service_alternate_nm 0..1 0..1 Master_specimen_requirement 0..* 0..* 0..* 0..* 0..* 0..* 0..* 0..* additive_cd 0..* 0..* start_offset_qty service_contraindication_cd Identifier_issuing_authority 0..* 0..* requests is_assigned_to Transcriptionist 0..* 0..* requests effective_dt may_request container_desc may_request status_cd service_desc has_as_a_parent_document may_request requests termination_dt 1 1 takes_on_role_of container_preparation_desc service_performance_schedule_cd Stakeholder addr container_volume_amt 0..1 0..1 is_requested_by service_primary_nm takes_on_role_of 1 1 credit_rating_cd derived_specimen_cd is_assigned 1 1 is_identified_as 1 1 is_the_recipient_of 0..1 0..1 service_requirement_desc may_act_as_a 1 1 email_address_txt is_a_role_of 0..1 0..1 minimum_collection_volume_amt service_type_cd is_a_role_of 0..1 0..1 Patient_information_recipient Individual_healthcare_practitioner_group 1 1 takes_on_role_of takes_on_role_of 1 1 Stakeholder_affiliation phon normal_collection_volume_amt id 1 1 standard_time_to_perform_dttm is_requested_by affiliation_type_cd Durable_medical_equipment type_cd id 1 1 takes_on_role_of special_handling_desc target_anatomic_site_cd desc participates_as_primary_in 1 1 0..* 0..* has_as_primary_participant slot_size_increment_qty specimen_priorities_cd target_of_service_cd effective_dt belongs_to 0..1 0..1 1..* 1..* participates_in type_cd specimen_retention_time_amt 1 1 contains takes_on_role_of 0..* 0..* universal_service_id termination_dt 0..* 0..* refers_to_person_by specimen_type_cd is_used_by universal_service_identifier_coding_system_nm 0..* 0..* is_requested_by 0..1 0..1 contains takes_on_role_of 1 1 1 1 collects Resource_slot 0..* 0..* universal_service_identifier_nm offset_qty is_a_role_of 0..1 0..1 Durable_medical_equipment_group takes_on_role_of 1 1 1 1 1 1 takes_on_role_of quantitytiming_qt id quantity_amt Person_alternate_name 0..* 0..* effective_dt is_scheduled_by is_specified_for Service_intent_or_order_relationship Accident_information_source 0..* 0..* join_cd resource_type_cd relationship_type_cd has_as_secondary_participant cd slot_state_cd reflex_testing_trigger_rules_desc nm start_dttm 0..1 0..1 constraint_txt 0..* 0..* is_reserved_by reason_cd Master_numeric_range has_as_target 0..* 0..* Stakeholder_affiliate quantitytiming_qt is_the_source_of range_type_cd Health_chart 0..* 0..* is_managed_by termination_dt family_relationship_cd health_chart_id is_a_role_of is_ordered_on 0..* 0..* belongs_to condition_desc participates_as_secondary_in 1 1 type_cd health_chart_type_cd high_range_amt 0..1 0..1 0..1 0..1 status_cd contains 0..1 0..1 high_gestation_age_amt Master_treatment_service 0..* 0..* 0..* 0..* is_housed_at Master_observation_service has_as_source is_an_instance_of contains 1 1 dea_level_cd high_value_amt instrument_id 0..* 0..* is_for 1 1 drug_category_cd is_target_for low_age_amt permitted_data_type_cd 0..* 0..* Schedule Durable_medical_equipment_slot Individual_healthcare_practitioner_slot has takes_on_ 1 1 Patient_slot Patient_service_location_slot contains id 1 1 formulary_status_cd low_gestation_age_amt processing_time_qty 0..1 0..1 categorizes role_of Service_intent_or_order Health_chart_deficiency has_an_assessment_of Organization 0..* 0..* medication_form_cd low_value_amt specimen_required_ind charge_type_cd 1..* 1..* is_basis_for assessment_dt 0..* 0..* 0..* 0..* 0..* 0..* organization_name_type_cd 1 1 takes_on_role_of Employer 1 1 0..* 0..* pharmaceutical_class_cd 1 1 race_subspecies_txt typical_turnaround_time_qty clarification_phon is_a_scheduleable_unit_for desc effective_dt organization_nm is_a_scheduleable_unit_for is_a_scheduleable_unit_for 0..1 0..1 is_a_role_of 1 1 assigns 0..* 0..* applies_to is_a_scheduleable_unit_for route_cd sex_txt end_condition_cd level_cd termination_dt standard_industry_class_cd 0..* 0..* has_as_a_contact is_source_for 1 1 takes_on_role_of therapeutic_class_cd species_txt entering_device_cd type_cd 1 1 is_employer_of 0..1 0..1 is_assessed_against 0..* 0..* escort_required_ind 0..* 0..* expected_performance_time_qty takes_on_role_of 1 1 has_as_basis 0..1 0..1 filler_order_id is_a_contact_for 0..* 0..* has_as_a_subdivision filler_txt is_a_contact_for 0..* 0..* Contact_person is_a_contact_for 0..* 0..* is_a_subdivision_of conforms_to order_control_cd contact_reason_cd 1 1 involves 1 1 participates_in Appointment_contact_person participates_in order_control_reason_cd role_cd is_a_contact_for 0..* 0..* Master_continuous_observation 0..1 0..1 is_a_role_of 0..* 0..* Master_categorical_observation Master_calculated_observation order_effective_dttm corresponding_SI_unit_of_measure_cd may_act_in_ 0..* 0..* abnormal_result_cd derivation_rule_desc order_group_id customary_unit_of_measure is_a_contact_for 0..* 0..* the_role_of allowed_value_type_cd order_id delta_check_numeric_change_computation_method_txt critical_result_cd 1 1 1 1 has order_placed_dttm delta_check_numeric_change_threshold_amt has_as_ normal_result_cd Person order_quantitytiming_qt delta_check_numeric_high_value_amt employer Person_employment birth_dttm preferred_coding_system_cd Administrative_birth_event pertains_to addr 1 1 has placer_order_id delta_check_numeric_low_value_amt baby_detained_ind birthplace_addr valid_answer_cd has_as_participant 0..* 0..* effective_dt placer_txt delta_check_numeric_retention_days_qty birth_certificate_id citizenship_country_cd 0..* 0..* 0..1 0..1 hazard_exposure_txt Notary_public planned_patient_transport_cd Administrative_patient_death length_and_decimal_precision_amt birth_method_cd confidentiality_constraint_cd effective_dt death_certificate_id Active_participation is_a_role_of 0..1 0..1 job_class_cd report_results_to_phon minimum_meaningful_increment_amt birth_recorded_county_cd begin_dttm deceased_dttm notary_county_cd death_certificate_recorded_dt job_title_nm response_requested_cd si_conversion_factor_txt birth_recorded_dt Guarantor end_dttm deceased_ind notary_state_cd death_classification_cd financial_class_cd phon has service_body_site_cd 1 1 newborn_days_qty duration_tm disability_cd termination_dt has_as_a has_as_a_contact guarantees_ death_dttm 0..* 0..* is_billed_to household_annual_income_amt protective_equipment_txt service_body_site_modifier_cd stillborn_ind participation_type_cd education_level_cd Patient has_as_participant 0..1 0..1 _contact issues payment_under death_location_nm household_size_qty 0..1 0..1 salary_amt ambulatory_status_cd service_body_source_cd 1 1 1 1 takes_on_role_of ethnic_group_cd has 1 1 death_notification_source_nm 0..1 0..1 0..* 0..* salary_type_cd participates_in target_of_service_cd birth_order_amt 1 1 gender_cd 0..* 0..* is_part_of is_a_role_of is_scheduled_by 0..1 0..1 1 1 death_verification_cd status_cd transport_arranged_ind living_arrangement_cd Insurer language_cd 0..* 0..* may_be_referred_to_in participates_in 0..1 0..1 death_verification_dt 1 1 is_requested_by effective_dt termination_dt has_as_ 0..1 0..1 transport_arrangement_responsibility_cd living_dependency_cd marital_status_cd death_verification_nm termination_dt occupation_cd 1 1 a_contact takes_on_role_of transport_mode_cd enters multiple_birth_ind 1 1 0..* 0..* is_entered_at military_branch_of_service_cd is_a_role_of 0..1 0..1 job_status_cd when_to_charge_dttm newborn_baby_ind military_rank_nm 0..1 0..1 has_as_target organ_donor_ind when_to_charge_txt military_status_cd 0..1 0..1 pertains_to has_as_employee issues 0..* 0..* 1 1 1 1 has 1 1 preferred_pharmacy_id results_status_cd is_fulfilled_by 0..1 0..1 nationality_cd 0..1 0..1 is_a_contact_for is_target_of offers 1..* 1..* 0..1 0..1 Insurance_certification_contact intent_or_order_cd 1 1 0..1 0..1 is_a_role_of takes_on_role_of participation_type_cd primary_name_representation_cd is_a_role_of has_as_target join_cd is_employee_in 0..1 0..1 has_as_reason 0..* 0..* 1 1 is_issued_by 1 1 has_as_a_contact primary_name_type_cd has 1 1 1 1 is_a_role_of takes_on_role_of 0..* 0..* primary_nm Billing_information_item pertains_to Employee 0..* 0..* Insurance_certification Episode participates_in 1 1 condition_cd appeal_reason_cd 0..1 0..1 desc race_cd Target_participation 1 1 occurrence_cd has begin_dttm 1 1 certification_day_qty has_payment_ has episode_type_cd religious_affiliation_cd has_as_target 0..* 0..* occurrence_dt end_dttm effective_dt guaranteed_by 1..* 1..* is_target_of id student_cd 1 1 has is_source_for 0..1 0..1 occurrence_span_cd Guarantor_contract duration_tm id is_issued_by list_closed_ind very_important_person_cd 0..* 0..* 1..* 1..* billing_hold_ind has_as_target 0..* 0..* Patient_billing_account is_involved_in occurrence_span_from_dt participation_type_cd 1 1 0..* 0..* insurance_verification_dttm 0..* 0..* affirms_insurance_coverage_for has_as_primary_facility outcome_txt account_id 0..1 0..1 billing_media_cd specfies Preauthorization occurrence_span_thru_dt modification_dttm authorized_encounters_amt recurring_service_ind adjustment_cd charge_adjustment_cd Administrative_patient_accident has_coverage_affirmed_by Observation_intent_or_order 1 1 Referral has_a_primary_provider quantity_amt 0..* 0..* Dietary_intent_or_order accident_death_ind Treatment_intent_or_order non_concur_cd 0..* 0..* patient_hazard_cd provides_validation_for authorized_visits_qty authorized_period_begin_dt 1 1 authorization_information_txt contract_duration_cd diet_type_cd takes_on_role_of dosage_txt quantity_type_cd accident_desc non_concur_effective_dttm is_target_of reason_for_study_cd desc authorized_period_end_dt 0..* 0..* billing_status_cd contract_type_cd dietary_instruction_desc earliest_dispense_dt value_amt has 1 1 accident_dttm penalty_amt relevant_clinical_information_txt reason_txt id certification_required_ind effective_dt dietary_tray_type_cd Indication_cd is_validated_by 1 1 1 1 value_cd accident_location_desc reporting_priority_cd termination_dt issued_dttm is_obtained_from 0..* 0..* current_unpaid_balance_amt interest_rate_amt service_period_cd has_parts non_form_authorized_ind has_parts accident_state_cd Healthcare_benefit_product 0..* 0..* specimen_action_cd report_of_eligibility_dt fulfills requested_dttm delete_dt periodic_payment_amt service_type_cd providers_treatment_instruction_txt assignment_of_benefits_ind authorizes 0..1 0..1 0..1 0..1 Disability accident_type_cd has_as_target 1 1 has report_of_eligibility_ind restriction_desc deleted_account_reason_cd priority_ranking_cd effective_dt Service_event 1 1 rejection_reason_cd benefit_product_desc job_related_accident_ind orders 0..* 0..* attestation_dttm status_cd 0..* 0..* expected_insurance_plan_qty 0..1 0..1 termination_dt pertains_to has_as_active_participant 0..* 0..* return_to_work_auth_dt pertains_to has_payment_guaranteed_by requested_give_rate_amt is_part_of id 0..* 0..* assessment_dttm attestation_due_dt status_change_dttm expected_payment_source_cd 1 1 Treatment_intent_or_order_revision termination_dt requested_give_strength_amt benefit_plan_nm provides_payment_guarantee_for delivers 0..* 0..* 0..* 0..* dispense_package_method_cd Healthcare_benefit_coverage begin_dttm includes 1 1 0..* 0..* notice_of_admission_dt unable_to_work_effective_dt is_target_for substitution_allowed_ind annual_limit_amt benefit_plan_type_cd 0..* 0..* belongs_to 1 1 is_associated_with 1 1 dispense_package_size_amt charge_to_practice_amt has_parts is_part_of 1..* 1..* notice_of_admission_ind 0..* 0..* is_present_in supplier_special_dispensing_instruction_cd benefit_desc benefits_coordination_ind provides_opinion_on give_indication_cd is_documented_by 0..* 0..* charge_to_practice_cd 0..* 0..* patient_financial_class_cd is_a_role_of has_as_target 0..* 0..* verification_required_ind benefit_product_nm cob_priority_amt 0..1 0..1 is_assigned 1 1 give_per_time_unit_cd Bad_debt_collection_agency patient_sensitivity_cd price_schedule_id Certification_second_opinion has_parts dependent_coverage_ind combine_baby_bill_ind 0..1 0..1 0..* 0..* effective_dt is_charged_to Service_event_relationship give_rate_amt consent_cd purge_status_cd relationship_type_cd dependent_coverage_limit_amt effective_dt 0..1 0..1 status_cd is_associated_with last_refilled_dttm declined_ind 1 1 has_charges_for purge_status_dt effective_dttm eligibility_source_cd max_give_amt service_desc 1..* 1..* report_of_eligibility_dt is_part_of is_authorized_by 1..* 1..* lifetime_limit_amt group_benefit_ind 0..1 0..1 0..* 0..* has_as_source min_give_amt end_dttm Diagnostic_related_group is_provided_by retention_ind 0..* 0..* 0..* 0..* termination_dttm mail_claim_party_cd 0..1 0..1 has_assigned_to_it is_assigned_to base_rate_amt Patient_encounter Preferred_provider_participation needs_human_review_ind is_part_of is_billed_from filler_id 1 1 signature_on_file_dt administrative_outcome_txt role_cd 1 1 agreement_type_cd policy_source_cd has_parts is_assigned_as is_performed_at 0..* 0..* capital_reimbursement_amt order_revision_PTcomp is_reason_for filler_order_status_cd 0..* 0..* special_program_cd cancellation_reason_cd effective_dt baby_coverage_ind release_information_cd is_governed_by is_source_for 0..1 0..1 governs cost_weight_amt order_revision_PTrout filler_order_status_dttm 0..* 0..* 1 1 Healthcare_benefit_service stoploss_limit_ind desc termination_dt blood_deductible_amt status_cd id access_protocol_desc order_revision_quantitytiming_qt 0..1 0..1 has 1..* 1..* recurring_service_cd 0..* 0..* Appointment suspend_charges_ind 1 1 has encounter_classification_cd copay_limit_ind termination_dt Service_reason major_diagnostic_category_cd appointment_disposition_cd capitation_ind is_assigned_to ordered_administration_method_cd scheduled_start_dttm reserves is_evidence_for determination_dttm total_adjustment_amt 0..* 0..* 0..* 0..* has_as_a_prior_account end_dttm daily_deductible_amt operating_reimbursement_amt appointment_duration_qty coinsurance_ind prescription_id service_event_desc documentation_dttm 0..* 0..* total_charge_amt 0..1 0..1 has_as_evidence expected_insurance_plan_qty 0..* 0..* non_covered_insurance_cd involves 0..* 0..* 0..* 0..* reimbursement_amt appointment_reason_cd coinsurance_pct providers_administration_instruction_cd pertains_to specimen_received_dttm 0..* 0..* reason_txt total_payment_amt first_similar_illness_dt has_as_care_provider policy_amount_class_cd are_booked_in 0..* 0..* is_an_assignment_of 0..* 0..* Bad_debt_billing_account standard_day_qty appointment_request_reason_cd copayment_amt refills_allowed_qty specimen_action_cd has_as_care_recipient separate_bill_ind Risk_management_incident bad_debt_recovery_amt follow_up_type_cd policy_amt standard_total_charge_amt appointment_timing_tq deductible_amt incident_cd refills_doses_dispensed_qty nm Encounter_drg 1 1 bad_debt_transfer_amt id involves policy_category_cd approval_ind trim_high_day_qty appointment_type_cd lower_coverage_limit_amt incident_dttm Patient_departure refills_remaining_qty family_awareness_txt has_as_reason 0..* 0..* transfer_to_bad_debt_dt patient_classification_cd actual_discharge_disposition_cd policy_deductible_amt assigned_dttm trim_low_day_qty cancellation_dttm pay_cap_limit_amt incident_severity_cd 0..1 0..1 Patient_admission substitution_status_cd individual_awareness_cd transfer_to_bad_debt_reason_cd purpose_cd 0..1 0..1 is_reason_for admission_dttm discharge_dttm policy_limit_day_qty confidential_ind cancellation_reason_cd pcp_referral_ind incident_type_cd suppliers_dispensing_instruction_cd confidential_ind is_the_prior_account_for record_signing_dttm admission_reason_cd discharge_location_id policy_scope_cd cost_outlier_amt estimated_duration_amt primary_care_provider_ind total_daily_dose_amt special_courtesies_cd admission_referral_cd expected_discharge_disp_cd room_coverage_type_amount_cd desc 0..* 0..* is_for event_reason_cd review_ind total_daily_dose_cd start_dttm 1..* 1..* admission_source_cd is_scheduled_by grouper_review_cd expected_end_dttm upper_coverage_limit_amt 0..* 0..* schedules is_assigned_by status_cd admission_type_cd grouper_version_id expected_service_desc 1 1 is_preceded_by transport_requirement_cd 0..* 0..* patient_valuables_desc outlier_days_qty 0..1 0..1 expected_start_dttm 0..* 0..* provides_coverage_for is_offered_by 0..* 0..* urgency_cd 1 1 has_as_participant pre_admit_test_ind outlier_reimbursement_amt id Collected_specimen_sample terminates triage_classification_cd readmission_ind has_as_purchaser 0..* 0..* body_site_cd outlier_type_cd 0..1 0..1 precedes occurence_id 0..* 0..* Consent Care_event medical_service_cd valuables_location_desc Assessment collection_body_site_modifier_cd is_collected_by overbook_ind Patient_arrival confidentiality_constraint_cd precedes collection_end_dttm acuity_level_cd scheduling_begin_dttm 0..* 0..* collection_method_modifier_cd arrival_dttm scheduling_completed_dttm is_terminated_by preceded 1 1 collection_scheduled_dttm arrival_type_cd scheduling_status_cd 0..* 0..* is_sourced_from 1 1 1 1 has follows collection_start_dttm 0..1 0..1 medical_service_id status_cd Champus_coverage Medicaid_coverage Medicare_coverage Healthcare_service_provider is_preceded_by 1 1 collection_volume_amt source_of_arrival_cd handicapped_program_cd aid_category_cd effective_dt urgency_cd board_certification_type_cd Inpatient_encounter actual_days_qty condition_cd mode_cd non_avail_cert_on_file_ind eligibility_cd visit_type_cd board_certified_ind is_assigned_to 0..* 0..* estimated_days_qty handling_cd retirement_dt id wait_list_priority_amt certification_dt is_assigned 1 1 Advance_directive Procedure Treatment_service_event Goal Clinical_observation id station_id Condition_node lifetime_res_delay_day_qty effective_dt Allergy competence_ind anesthesia_cd Health_issue prescription_id is_target_of action_cd 0..1 0..1 abnormal_result_ind actual_resolution_dttm allergen_id diagnosis_cd method_of_collection_desc lifetime_reserve_day_qty license_id directive_cd anesthesia_minutes_qty refills_remaining_qty 1 1 action_dttm participates_as last_observed_normal_values_dttm 0..* 0..* is_collected_during estimated_resolution_dttm 1 1 participates_in allergy_cd onset_dttm number_of_sample_containers_qty medicare_coverage_type_cd recertification_dt disclosure_level_cd delay_reason_txt notes_txt classification_cd nature_of_abnormal_testing_cd life_cycle_status_dttm allergy_reaction_cd billing_priority_amt specimen_additive_txt program_type_cd specialty_cd life_quality_desc incision_closed_dttm PTrout current_review_status_cd clinically_relevant_begin_dttm lifecycle_status_cd 1..* 1..* allergy_reaction_description_txt pertains_to severity_cd specimen_danger_cd renal_cd termination_dt mortuary_preference_nm incision_open_dttm PTcomp current_review_status_dttm clinically_relevant_end_dttm management_discipline_cd allergy_severity_cd classification_cd specimen_source_cd termination_dt Location_encounter_role notarization_dt priority_amt indication_cd episode_of_care_id observation_method_cd onset_time_txt allergy_type_cd accommodation_cd confirmation_status_cd transport_logistics_cd assessment_dttm procedure_cd expiration_dttm established_dttm observation_status_cd onset_dttm Master_patient_service_location assessment_dttm effective_dttm persistence_cd is_primary_facility_for 1 1 is_scheduled_by employment_related_ind procedure_dttm substance_lot_number_txt addr evaluation_cd observation_status_dttm ranking_amt employment_related_ind location_role_cd probability_amt is_associated_with 0..1 0..1 closing_dt procedure_functional_type_cd substance_manufacturer_cd evaluation_comment_txt observation_sub_id employment_related_ind status_cd probability_txt 1..* 1..* procedure_minute_qty desc expected_achievement_dttm 0..* 0..* observation_value_txt pertains_to 1 1 has termination_dttm prognosis_desc houses 1 1 modifier_cd email_address Encounter_practitioner goal_list_priority_amt probability_amt transfer_reason_cd participation_type_cd prognosis_awareness_desc id life_cycle_dttm references_range_txt collects 0..1 0..1 provides_services_on_behalf_of 0..* 0..* specified_in transfer_reason_desc cd licensed_bed_qty life_cycle_status_cd universal_service_identifier_suffix_txt usage_approved_ind 0..* 0..* 0..* 0..* nm management_discipline_cd user_defined_access_check_txt provides_patient_services_at is_participant_for opening_dt next_review_dttm value_type_cd 1..* 1..* belongs_to contains 0..* 0..* 1..* 1..* Patient_service_location_group is_requested_by phon 0..1 0..1 previous_review_dttm value_units_cd is_a_role_of id is_included_in 0..* 0..* service_specialty_cd Healthcare_provider_organization review_interval_cd is_a_role_of 0..1 0..1 Treatment_service_give slot_size_increment_qty target_txt 0..1 0..1 1 1 is_requested_by Treatment_service_dispense administration_desc Treatment_service_administration dispense_package_method_cd status_cd target_type_cd administered_rate_txt give_per_time_unit_cd Individual_healthcare_practitioner dispense_package_size_amt type_cd is_entry_location_for goal_cd 1 1 completion_status_cd desc give_quantitytiming_qt needs_human_review_ind equipment_type_cd substance_refusal_reason_cd fellowship_field_cd 0..1 0..1 is_target_for give_rate_amt rejection_reason_txt 0..1 0..1 substitution_cd graduate_school_nm includes max_give_amt is_location_for 0..1 0..1 substitution_cd system_entry_dttm graduation_dt min_give_amt provides 1 1 suppliers_special_dispensing_instruction_cd is_the_primary_provider_for 0..1 0..1 position_cd needs_human_review_ind total_daily_dose_amt practitioner_type_cd substitution_status_cd is_scheduled_by 1 1 primary_care_ind supplier_special_administration_instruction_cd 1 1 participates_as residency_field_cd belongs_to 1..* 1..* slot_size_increment_qty is_requested_by 1 1 Reference Information Model for HL7 Version 3 (RIM)

10. Reference Information Model for HL7 Version 3 (RIM) • Consensus view of the healthcare world • Flexible structures • Emphasizes meanings of health information • Object-oriented

11. HEALTH LEVEL 7 REFERENCE INFORMATION MODEL RIM_0088 Master_service released January, 1999 allowable_processing_priority_cd has_as_participant 0..* 0..* Producer_of_master_service 0..* 0..* produces is_produced_by 0..1 0..1 service_producing_department_type_cd Financial_transaction allowable_reporting_priority_cd reflects agreements made through harmonization in November, 1998 alternate_desc billing_reference_txt is_categorized_by desc 0..* 0..* challenge_information_txt extended_amt 1 1 confidentiality_cd is_requested_by Healthcare_finances Healthcare_finances Master_tables Healthcare_finances fee_schedule_cd 0..* 0..* is_associated_with effective_dt insurance_amt factors_that_may_affect_observation_desc posting_dt fee_amt Patient_encounters Healthcare_finances Healthcare_stakeholders Healthcare_finances qty fixed_canned_message_cd 0..* 0..* pertains_to 1 1 transaction_batch_id is_target imaging_measurement_modality_cd is_entered_by transaction_cd incompatible_change_dttm has_target 0..* 0..* transaction_dt Authentication 0..* 0..* instrument_identifier_coding_system_nm 0..* 0..* is_related_to authentication_dt transaction_id Master_service_relationship instrument_identifier_nm 1 1 0..* 0..* Clinical_document_header type_cd relationship_type_cd transaction_type_cd 0..* 0..* documents authentication_dt interpretation_considerations_desc is_related_to is_related_to is_associated_with reflex_testing_trigger_rules_desc unit_amt availability_status_cd kind_of_quantity_observed_cd constraint_txt 0..* 0..* unit_cost_amt change_reason_cd last_update_dttm 0..* 0..* quantitytiming_qt 1..* 1..* is_covered_by is_related_to completion_status_cd method_cd Resource_request is_related_to allowable_substitutions_cd confidentiality_status_cd method_desc duration_qty 1 1 content_presentation_cd nature_of_service_cd Healthcare_document_authenticator has_source 0..* 0..* Appointment_request is_the_purchaser_of 1 1 start_dttm document_header_creation_dt observation_id_suffix_txt appointment_rqst_reason_cd is_source 1 1 Health_benefit_plan_purchaser is_requested_by 1 1 0..* 0..* requests start_offset_qty file_nm orderable_service_ind has_as_a_contact Patient_information_disclosure appointment_rqst_type_cd 0..1 0..1 is_a 0..1 0..1 disclosure_dttm status_cd id patient_preparation_desc equip_selection_criteria_pv 0..1 0..1 info_disclosed_desc of has_been_originated_by 0..* 0..* 0..1 0..1 last_edit_dt point_versus_interval_cd Originator id is_delivered_during info_requested_desc is_a_role_of origination_dt 1 1 portable_device_ind location_selection_criteria_pv reason_cd reporting_priority_cd preferred_ordering_method_txt pertains_to occurence_id is_a 0..1 0..1 requested_dttm results_report_dttm Stakeholder_identifier requests preferred_scheduling_method_txt 1 1 1 1 is_instantiated_as priority_cd effective_dt 0..* 0..* urgency_cd storage_status_cd procedure_medication_cd repeating_interval_duration_qty is_issued_by id Document_recipient of transcription_dt 0..1 0..1 has_been_received_by 0..* 0..* report_display_order_txt requested_ri identifier_type_cd requests 0..* 0..* type_cd is_requested_by required_credentials_desc rqst_event_reason_cd issued_dt 1..* 1..* 0..* 0..* 0..* 0..* service_alternate_id is_transcribed_by 0..* 0..* 0..1 0..1 rqsted_duration_qty is_a 0..1 0..1 qualifying_information_txt Durable_medical_equipment_request Patient_appointment_request Patient_service_location_request service_alternate_identifier_coding_system_nm Individual_healthcare_practitioner_request start_dt Service_scheduling_request quantity_amt type_cd is_provided_to termination_dt practitioner_type_cd is_parent_document_for 0..* 0..* allowable_substitutions_cd service_alternate_identifier_nm time_selection_criteria_pv type_cd 0..* 0..* duration_qty service_alternate_name_use_cd 0..* 0..* transcribes may_be_contained_in issues 1 1 requests start_dttm service_alternate_nm 0..1 0..1 Master_specimen_requirement 0..* 0..* 0..* 0..* 0..* 0..* 0..* 0..* additive_cd 0..* 0..* start_offset_qty service_contraindication_cd Identifier_issuing_authority 0..* 0..* requests is_assigned_to Transcriptionist 0..* 0..* requests effective_dt may_request container_desc may_request status_cd service_desc has_as_a_parent_document may_request requests termination_dt 1 1 takes_on_role_of container_preparation_desc service_performance_schedule_cd Stakeholder addr container_volume_amt 0..1 0..1 is_requested_by service_primary_nm takes_on_role_of 1 1 credit_rating_cd derived_specimen_cd is_assigned 1 1 is_identified_as 1 1 is_the_recipient_of 0..1 0..1 service_requirement_desc may_act_as_a 1 1 email_address_txt is_a_role_of 0..1 0..1 minimum_collection_volume_amt service_type_cd is_a_role_of 0..1 0..1 Patient_information_recipient Individual_healthcare_practitioner_group 1 1 takes_on_role_of takes_on_role_of 1 1 Stakeholder_affiliation phon normal_collection_volume_amt id 1 1 standard_time_to_perform_dttm is_requested_by affiliation_type_cd Durable_medical_equipment type_cd id 1 1 takes_on_role_of special_handling_desc target_anatomic_site_cd desc participates_as_primary_in 1 1 0..* 0..* has_as_primary_participant slot_size_increment_qty specimen_priorities_cd target_of_service_cd effective_dt belongs_to 0..1 0..1 1..* 1..* participates_in type_cd specimen_retention_time_amt 1 1 contains takes_on_role_of 0..* 0..* universal_service_id termination_dt 0..* 0..* refers_to_person_by specimen_type_cd is_used_by universal_service_identifier_coding_system_nm 0..* 0..* is_requested_by 0..1 0..1 contains takes_on_role_of 1 1 1 1 collects Resource_slot 0..* 0..* universal_service_identifier_nm offset_qty is_a_role_of 0..1 0..1 Durable_medical_equipment_group takes_on_role_of 1 1 1 1 1 1 takes_on_role_of quantitytiming_qt id quantity_amt Person_alternate_name 0..* 0..* effective_dt is_scheduled_by is_specified_for Service_intent_or_order_relationship Accident_information_source 0..* 0..* join_cd resource_type_cd relationship_type_cd has_as_secondary_participant cd slot_state_cd reflex_testing_trigger_rules_desc nm start_dttm 0..1 0..1 constraint_txt 0..* 0..* is_reserved_by reason_cd Master_numeric_range has_as_target 0..* 0..* Stakeholder_affiliate quantitytiming_qt is_the_source_of range_type_cd Health_chart 0..* 0..* is_managed_by termination_dt family_relationship_cd health_chart_id is_a_role_of is_ordered_on 0..* 0..* belongs_to condition_desc participates_as_secondary_in 1 1 type_cd health_chart_type_cd high_range_amt 0..1 0..1 0..1 0..1 status_cd contains 0..1 0..1 high_gestation_age_amt Master_treatment_service 0..* 0..* 0..* 0..* is_housed_at Master_observation_service has_as_source is_an_instance_of contains 1 1 dea_level_cd high_value_amt instrument_id 0..* 0..* is_for 1 1 drug_category_cd is_target_for low_age_amt permitted_data_type_cd 0..* 0..* Schedule Durable_medical_equipment_slot Individual_healthcare_practitioner_slot has takes_on_ 1 1 Patient_slot Patient_service_location_slot contains id 1 1 formulary_status_cd low_gestation_age_amt processing_time_qty 0..1 0..1 categorizes role_of Service_intent_or_order Health_chart_deficiency has_an_assessment_of Organization 0..* 0..* medication_form_cd low_value_amt specimen_required_ind charge_type_cd 1..* 1..* is_basis_for assessment_dt 0..* 0..* 0..* 0..* 0..* 0..* organization_name_type_cd 1 1 takes_on_role_of Employer 1 1 0..* 0..* pharmaceutical_class_cd 1 1 race_subspecies_txt typical_turnaround_time_qty clarification_phon is_a_scheduleable_unit_for desc effective_dt organization_nm is_a_scheduleable_unit_for is_a_scheduleable_unit_for 0..1 0..1 is_a_role_of 1 1 assigns 0..* 0..* applies_to is_a_scheduleable_unit_for route_cd sex_txt end_condition_cd level_cd termination_dt standard_industry_class_cd 0..* 0..* has_as_a_contact is_source_for 1 1 takes_on_role_of therapeutic_class_cd species_txt entering_device_cd type_cd 1 1 is_employer_of 0..1 0..1 is_assessed_against 0..* 0..* escort_required_ind 0..* 0..* expected_performance_time_qty takes_on_role_of 1 1 has_as_basis 0..1 0..1 filler_order_id is_a_contact_for 0..* 0..* has_as_a_subdivision filler_txt is_a_contact_for 0..* 0..* Contact_person is_a_contact_for 0..* 0..* is_a_subdivision_of conforms_to order_control_cd contact_reason_cd 1 1 involves 1 1 participates_in Appointment_contact_person participates_in order_control_reason_cd role_cd is_a_contact_for 0..* 0..* Master_continuous_observation 0..1 0..1 is_a_role_of 0..* 0..* Master_categorical_observation Master_calculated_observation order_effective_dttm corresponding_SI_unit_of_measure_cd may_act_in_ 0..* 0..* abnormal_result_cd derivation_rule_desc order_group_id customary_unit_of_measure is_a_contact_for 0..* 0..* the_role_of allowed_value_type_cd order_id delta_check_numeric_change_computation_method_txt critical_result_cd 1 1 1 1 has order_placed_dttm delta_check_numeric_change_threshold_amt has_as_ normal_result_cd Person order_quantitytiming_qt delta_check_numeric_high_value_amt employer Person_employment birth_dttm preferred_coding_system_cd Administrative_birth_event pertains_to addr 1 1 has placer_order_id delta_check_numeric_low_value_amt baby_detained_ind birthplace_addr valid_answer_cd has_as_participant 0..* 0..* effective_dt placer_txt delta_check_numeric_retention_days_qty birth_certificate_id citizenship_country_cd 0..* 0..* 0..1 0..1 hazard_exposure_txt Notary_public planned_patient_transport_cd Administrative_patient_death length_and_decimal_precision_amt birth_method_cd confidentiality_constraint_cd effective_dt death_certificate_id Active_participation is_a_role_of 0..1 0..1 job_class_cd report_results_to_phon minimum_meaningful_increment_amt birth_recorded_county_cd begin_dttm deceased_dttm notary_county_cd death_certificate_recorded_dt job_title_nm response_requested_cd si_conversion_factor_txt birth_recorded_dt Guarantor end_dttm deceased_ind notary_state_cd death_classification_cd financial_class_cd phon has service_body_site_cd 1 1 newborn_days_qty duration_tm disability_cd termination_dt has_as_a has_as_a_contact guarantees_ death_dttm 0..* 0..* is_billed_to household_annual_income_amt protective_equipment_txt service_body_site_modifier_cd stillborn_ind participation_type_cd education_level_cd Patient has_as_participant 0..1 0..1 _contact issues payment_under death_location_nm household_size_qty 0..1 0..1 salary_amt ambulatory_status_cd service_body_source_cd 1 1 1 1 takes_on_role_of ethnic_group_cd has 1 1 death_notification_source_nm 0..1 0..1 0..* 0..* salary_type_cd participates_in target_of_service_cd birth_order_amt 1 1 gender_cd 0..* 0..* is_part_of is_a_role_of is_scheduled_by 0..1 0..1 1 1 death_verification_cd status_cd transport_arranged_ind living_arrangement_cd Insurer language_cd 0..* 0..* may_be_referred_to_in participates_in 0..1 0..1 death_verification_dt 1 1 is_requested_by effective_dt termination_dt has_as_ 0..1 0..1 transport_arrangement_responsibility_cd living_dependency_cd marital_status_cd death_verification_nm termination_dt occupation_cd 1 1 a_contact takes_on_role_of transport_mode_cd enters multiple_birth_ind 1 1 0..* 0..* is_entered_at military_branch_of_service_cd is_a_role_of 0..1 0..1 job_status_cd when_to_charge_dttm newborn_baby_ind military_rank_nm 0..1 0..1 has_as_target organ_donor_ind when_to_charge_txt military_status_cd 0..1 0..1 pertains_to has_as_employee issues 0..* 0..* 1 1 1 1 has 1 1 preferred_pharmacy_id results_status_cd is_fulfilled_by 0..1 0..1 nationality_cd 0..1 0..1 is_a_contact_for is_target_of offers 1..* 1..* 0..1 0..1 Insurance_certification_contact intent_or_order_cd 1 1 0..1 0..1 is_a_role_of takes_on_role_of participation_type_cd primary_name_representation_cd is_a_role_of has_as_target join_cd is_employee_in 0..1 0..1 has_as_reason 0..* 0..* 1 1 is_issued_by 1 1 has_as_a_contact primary_name_type_cd has 1 1 1 1 is_a_role_of takes_on_role_of 0..* 0..* primary_nm Billing_information_item pertains_to Employee 0..* 0..* Insurance_certification Episode participates_in 1 1 condition_cd appeal_reason_cd 0..1 0..1 desc race_cd Target_participation 1 1 occurrence_cd has begin_dttm 1 1 certification_day_qty has_payment_ has episode_type_cd religious_affiliation_cd has_as_target 0..* 0..* occurrence_dt end_dttm effective_dt guaranteed_by 1..* 1..* is_target_of id student_cd 1 1 has is_source_for 0..1 0..1 occurrence_span_cd Guarantor_contract duration_tm id is_issued_by list_closed_ind very_important_person_cd 0..* 0..* 1..* 1..* billing_hold_ind has_as_target 0..* 0..* Patient_billing_account is_involved_in occurrence_span_from_dt participation_type_cd 1 1 0..* 0..* insurance_verification_dttm 0..* 0..* affirms_insurance_coverage_for has_as_primary_facility outcome_txt account_id 0..1 0..1 billing_media_cd specfies Preauthorization occurrence_span_thru_dt modification_dttm authorized_encounters_amt recurring_service_ind adjustment_cd charge_adjustment_cd Administrative_patient_accident has_coverage_affirmed_by Observation_intent_or_order 1 1 Referral has_a_primary_provider quantity_amt 0..* 0..* Dietary_intent_or_order accident_death_ind Treatment_intent_or_order non_concur_cd 0..* 0..* patient_hazard_cd provides_validation_for authorized_visits_qty authorized_period_begin_dt 1 1 authorization_information_txt contract_duration_cd diet_type_cd takes_on_role_of dosage_txt quantity_type_cd accident_desc non_concur_effective_dttm is_target_of reason_for_study_cd desc authorized_period_end_dt 0..* 0..* billing_status_cd contract_type_cd dietary_instruction_desc earliest_dispense_dt value_amt has 1 1 accident_dttm penalty_amt relevant_clinical_information_txt reason_txt id certification_required_ind effective_dt dietary_tray_type_cd Indication_cd is_validated_by 1 1 1 1 value_cd accident_location_desc reporting_priority_cd termination_dt issued_dttm is_obtained_from 0..* 0..* current_unpaid_balance_amt interest_rate_amt service_period_cd has_parts non_form_authorized_ind has_parts accident_state_cd Healthcare_benefit_product 0..* 0..* specimen_action_cd report_of_eligibility_dt fulfills requested_dttm delete_dt periodic_payment_amt service_type_cd providers_treatment_instruction_txt assignment_of_benefits_ind authorizes 0..1 0..1 0..1 0..1 Disability accident_type_cd has_as_target 1 1 has report_of_eligibility_ind restriction_desc deleted_account_reason_cd priority_ranking_cd effective_dt Service_event 1 1 rejection_reason_cd benefit_product_desc job_related_accident_ind orders 0..* 0..* attestation_dttm status_cd 0..* 0..* expected_insurance_plan_qty 0..1 0..1 termination_dt pertains_to has_as_active_participant 0..* 0..* return_to_work_auth_dt pertains_to has_payment_guaranteed_by requested_give_rate_amt is_part_of id 0..* 0..* assessment_dttm attestation_due_dt status_change_dttm expected_payment_source_cd 1 1 Treatment_intent_or_order_revision termination_dt requested_give_strength_amt benefit_plan_nm provides_payment_guarantee_for delivers 0..* 0..* 0..* 0..* dispense_package_method_cd Healthcare_benefit_coverage begin_dttm includes 1 1 0..* 0..* notice_of_admission_dt unable_to_work_effective_dt is_target_for substitution_allowed_ind annual_limit_amt benefit_plan_type_cd 0..* 0..* belongs_to 1 1 is_associated_with 1 1 dispense_package_size_amt charge_to_practice_amt has_parts is_part_of 1..* 1..* notice_of_admission_ind 0..* 0..* is_present_in supplier_special_dispensing_instruction_cd benefit_desc benefits_coordination_ind provides_opinion_on give_indication_cd is_documented_by 0..* 0..* charge_to_practice_cd 0..* 0..* patient_financial_class_cd is_a_role_of has_as_target 0..* 0..* verification_required_ind benefit_product_nm cob_priority_amt 0..1 0..1 is_assigned 1 1 give_per_time_unit_cd Bad_debt_collection_agency patient_sensitivity_cd price_schedule_id Certification_second_opinion has_parts dependent_coverage_ind combine_baby_bill_ind 0..1 0..1 0..* 0..* effective_dt is_charged_to Service_event_relationship give_rate_amt consent_cd purge_status_cd relationship_type_cd dependent_coverage_limit_amt effective_dt 0..1 0..1 status_cd is_associated_with last_refilled_dttm declined_ind 1 1 has_charges_for purge_status_dt effective_dttm eligibility_source_cd max_give_amt service_desc 1..* 1..* report_of_eligibility_dt is_part_of is_authorized_by 1..* 1..* lifetime_limit_amt group_benefit_ind 0..1 0..1 0..* 0..* has_as_source min_give_amt end_dttm Diagnostic_related_group is_provided_by retention_ind 0..* 0..* 0..* 0..* termination_dttm mail_claim_party_cd 0..1 0..1 has_assigned_to_it is_assigned_to base_rate_amt Patient_encounter Preferred_provider_participation needs_human_review_ind is_part_of is_billed_from filler_id 1 1 signature_on_file_dt administrative_outcome_txt role_cd 1 1 agreement_type_cd policy_source_cd has_parts is_assigned_as is_performed_at 0..* 0..* capital_reimbursement_amt order_revision_PTcomp is_reason_for filler_order_status_cd 0..* 0..* special_program_cd cancellation_reason_cd effective_dt baby_coverage_ind release_information_cd is_governed_by is_source_for 0..1 0..1 governs cost_weight_amt order_revision_PTrout filler_order_status_dttm 0..* 0..* 1 1 Healthcare_benefit_service stoploss_limit_ind desc termination_dt blood_deductible_amt status_cd id access_protocol_desc order_revision_quantitytiming_qt 0..1 0..1 has 1..* 1..* recurring_service_cd 0..* 0..* Appointment suspend_charges_ind 1 1 has encounter_classification_cd copay_limit_ind termination_dt Service_reason major_diagnostic_category_cd appointment_disposition_cd capitation_ind is_assigned_to ordered_administration_method_cd scheduled_start_dttm reserves is_evidence_for determination_dttm total_adjustment_amt 0..* 0..* 0..* 0..* has_as_a_prior_account end_dttm daily_deductible_amt operating_reimbursement_amt appointment_duration_qty coinsurance_ind prescription_id service_event_desc documentation_dttm 0..* 0..* total_charge_amt 0..1 0..1 has_as_evidence expected_insurance_plan_qty 0..* 0..* non_covered_insurance_cd involves 0..* 0..* 0..* 0..* reimbursement_amt appointment_reason_cd coinsurance_pct providers_administration_instruction_cd pertains_to specimen_received_dttm 0..* 0..* reason_txt total_payment_amt first_similar_illness_dt has_as_care_provider policy_amount_class_cd are_booked_in 0..* 0..* is_an_assignment_of 0..* 0..* Bad_debt_billing_account standard_day_qty appointment_request_reason_cd copayment_amt refills_allowed_qty specimen_action_cd has_as_care_recipient separate_bill_ind Risk_management_incident bad_debt_recovery_amt follow_up_type_cd policy_amt standard_total_charge_amt appointment_timing_tq deductible_amt incident_cd refills_doses_dispensed_qty nm Encounter_drg 1 1 bad_debt_transfer_amt id involves policy_category_cd approval_ind trim_high_day_qty appointment_type_cd lower_coverage_limit_amt incident_dttm Patient_departure refills_remaining_qty family_awareness_txt has_as_reason 0..* 0..* transfer_to_bad_debt_dt patient_classification_cd actual_discharge_disposition_cd policy_deductible_amt assigned_dttm trim_low_day_qty cancellation_dttm pay_cap_limit_amt incident_severity_cd 0..1 0..1 Patient_admission substitution_status_cd individual_awareness_cd transfer_to_bad_debt_reason_cd purpose_cd 0..1 0..1 is_reason_for admission_dttm discharge_dttm policy_limit_day_qty confidential_ind cancellation_reason_cd pcp_referral_ind incident_type_cd suppliers_dispensing_instruction_cd confidential_ind is_the_prior_account_for record_signing_dttm admission_reason_cd discharge_location_id policy_scope_cd cost_outlier_amt estimated_duration_amt primary_care_provider_ind total_daily_dose_amt special_courtesies_cd admission_referral_cd expected_discharge_disp_cd room_coverage_type_amount_cd desc 0..* 0..* is_for event_reason_cd review_ind total_daily_dose_cd start_dttm 1..* 1..* admission_source_cd is_scheduled_by grouper_review_cd expected_end_dttm upper_coverage_limit_amt 0..* 0..* schedules is_assigned_by status_cd admission_type_cd grouper_version_id expected_service_desc 1 1 is_preceded_by transport_requirement_cd 0..* 0..* patient_valuables_desc outlier_days_qty 0..1 0..1 expected_start_dttm 0..* 0..* provides_coverage_for is_offered_by 0..* 0..* urgency_cd 1 1 has_as_participant pre_admit_test_ind outlier_reimbursement_amt id Collected_specimen_sample terminates triage_classification_cd readmission_ind has_as_purchaser 0..* 0..* body_site_cd outlier_type_cd 0..1 0..1 precedes occurence_id 0..* 0..* Consent Care_event medical_service_cd valuables_location_desc Assessment collection_body_site_modifier_cd is_collected_by overbook_ind Patient_arrival confidentiality_constraint_cd precedes collection_end_dttm acuity_level_cd scheduling_begin_dttm 0..* 0..* collection_method_modifier_cd arrival_dttm scheduling_completed_dttm is_terminated_by preceded 1 1 collection_scheduled_dttm arrival_type_cd scheduling_status_cd 0..* 0..* is_sourced_from 1 1 1 1 has follows collection_start_dttm 0..1 0..1 medical_service_id status_cd Champus_coverage Medicaid_coverage Medicare_coverage Healthcare_service_provider is_preceded_by 1 1 collection_volume_amt source_of_arrival_cd handicapped_program_cd aid_category_cd effective_dt urgency_cd board_certification_type_cd Inpatient_encounter actual_days_qty condition_cd mode_cd non_avail_cert_on_file_ind eligibility_cd visit_type_cd board_certified_ind is_assigned_to 0..* 0..* estimated_days_qty handling_cd retirement_dt id wait_list_priority_amt certification_dt is_assigned 1 1 Advance_directive Procedure Treatment_service_event Goal Clinical_observation id station_id Condition_node lifetime_res_delay_day_qty effective_dt Allergy competence_ind anesthesia_cd Health_issue prescription_id is_target_of action_cd 0..1 0..1 abnormal_result_ind actual_resolution_dttm allergen_id diagnosis_cd method_of_collection_desc lifetime_reserve_day_qty license_id directive_cd anesthesia_minutes_qty refills_remaining_qty 1 1 action_dttm participates_as last_observed_normal_values_dttm 0..* 0..* is_collected_during estimated_resolution_dttm 1 1 participates_in allergy_cd onset_dttm number_of_sample_containers_qty medicare_coverage_type_cd recertification_dt disclosure_level_cd delay_reason_txt notes_txt classification_cd nature_of_abnormal_testing_cd life_cycle_status_dttm allergy_reaction_cd billing_priority_amt specimen_additive_txt program_type_cd specialty_cd life_quality_desc incision_closed_dttm PTrout current_review_status_cd clinically_relevant_begin_dttm lifecycle_status_cd 1..* 1..* allergy_reaction_description_txt pertains_to severity_cd specimen_danger_cd renal_cd termination_dt mortuary_preference_nm incision_open_dttm PTcomp current_review_status_dttm clinically_relevant_end_dttm management_discipline_cd allergy_severity_cd classification_cd specimen_source_cd termination_dt Location_encounter_role notarization_dt priority_amt indication_cd episode_of_care_id observation_method_cd onset_time_txt allergy_type_cd accommodation_cd confirmation_status_cd transport_logistics_cd assessment_dttm procedure_cd expiration_dttm established_dttm observation_status_cd onset_dttm Master_patient_service_location assessment_dttm effective_dttm persistence_cd is_primary_facility_for 1 1 is_scheduled_by employment_related_ind procedure_dttm substance_lot_number_txt addr evaluation_cd observation_status_dttm ranking_amt employment_related_ind location_role_cd probability_amt is_associated_with 0..1 0..1 closing_dt procedure_functional_type_cd substance_manufacturer_cd evaluation_comment_txt observation_sub_id employment_related_ind status_cd probability_txt 1..* 1..* procedure_minute_qty desc expected_achievement_dttm 0..* 0..* observation_value_txt pertains_to 1 1 has termination_dttm prognosis_desc houses 1 1 modifier_cd email_address Encounter_practitioner goal_list_priority_amt probability_amt transfer_reason_cd participation_type_cd prognosis_awareness_desc id life_cycle_dttm references_range_txt collects 0..1 0..1 provides_services_on_behalf_of 0..* 0..* specified_in transfer_reason_desc cd licensed_bed_qty life_cycle_status_cd universal_service_identifier_suffix_txt usage_approved_ind 0..* 0..* 0..* 0..* nm management_discipline_cd user_defined_access_check_txt provides_patient_services_at is_participant_for opening_dt next_review_dttm value_type_cd 1..* 1..* belongs_to contains 0..* 0..* 1..* 1..* Patient_service_location_group is_requested_by phon 0..1 0..1 previous_review_dttm value_units_cd is_a_role_of id is_included_in 0..* 0..* service_specialty_cd Healthcare_provider_organization review_interval_cd is_a_role_of 0..1 0..1 Treatment_service_give slot_size_increment_qty target_txt 0..1 0..1 1 1 is_requested_by Treatment_service_dispense administration_desc Treatment_service_administration dispense_package_method_cd status_cd target_type_cd administered_rate_txt give_per_time_unit_cd Individual_healthcare_practitioner dispense_package_size_amt type_cd is_entry_location_for goal_cd 1 1 completion_status_cd desc give_quantitytiming_qt needs_human_review_ind equipment_type_cd substance_refusal_reason_cd fellowship_field_cd 0..1 0..1 is_target_for give_rate_amt rejection_reason_txt 0..1 0..1 substitution_cd graduate_school_nm includes max_give_amt is_location_for 0..1 0..1 substitution_cd system_entry_dttm graduation_dt min_give_amt provides 1 1 suppliers_special_dispensing_instruction_cd is_the_primary_provider_for 0..1 0..1 position_cd needs_human_review_ind total_daily_dose_amt practitioner_type_cd substitution_status_cd is_scheduled_by 1 1 primary_care_ind supplier_special_administration_instruction_cd 1 1 participates_as residency_field_cd belongs_to 1..* 1..* slot_size_increment_qty is_requested_by 1 1

12. Act ActRelationship Participation classCode : CS typeCode : CS moodCode : CS typeCode : CS outboundRelationship inversionInd : BL id : SET<II> RoleLink functionCode : CD source contextControlCode : CS code : CD contextControlCode : ... 0..n 0..n 1 1 sequenceNumber : INT Role negationInd : BL CS priorityNumber : INT cla text : ED sequenceNumber : 0..n 0..n pauseQuantity : PQ ssC statusCode : SET<CS> INT 1 1 checkpointCode : CS inboundRelationship ode effectiveTime : GTS ... target splitCode : CS : derivationExpr : ST 0..n 0..n 1 1 joinCode : CS CS 0..n availabilityTime : TS negationInd : BL ... priorityCode : SET<CE> conjunctionCode : CS activityTime : GTS localVariableName : ST repeatNumber : IVL<INT> seperatableInd : BL confidentialityCode : SET<CE> ManagedParticipation interruptibleInd : BL ... levelCode : CE independentInd : BL uncertaintyCode : CE reasonCode : SET<CE> languageCode : CE substitutionConditionCode : CE LivingSubject EntityHeir Organization RoleHeir Patient Material Employee ad ... Guarantor ... ... job min ... Cod istr e : ... ... Supply Procedure Observation SubstanceAdministration AssignedEntity quantity : PQ methodCode : SET<CE> ManufacturedMaterial value : ANY routeCode : CE Place ActHeir ... expectedUseTime : approachSiteCode : PatientEncounter lotN interpretationCode : SET<CE> approachSiteCode : SET<CD> mo IVL<TS> ... ... preAdmitTestInd : BL methodCode : SET<CE> doseQuantity : IVL<PQ> bileI admissionReferralSourceCode : CE targetSiteCode : SET<CD> rateQuantity : IVL<PQ> ... lengthOfStayQuantity : PQ doseCheckQuantity : SET<RTO> dischargeDispositionCode : CE Access maxDoseQuantity : SET<RTO> ... substitutionCode : CE app LicensedEntity ... WorkingList Account ... InvoiceElement ... name : ST modifierCode : SET<CE> Person balanceAmt : MO NonPersonLivingSubject Device unitQuantity : RTO<PQ,PQ> DeviceTask currencyCode : CE add Container unitPriceAmt : RTO<MO,PQ> ... ... ma parameterValue : LIST<ANY> ... interestRateQuantity : RTO<MO,PQ> r : netAmt : MO nuf cap Diet allowedBalanceQuantity : IVL<MO> BA SchedulableResource PublicHealthCase factorNumber : REAL ... acit energyQuantity : PQ G< ... pointsNumber : REAL yQ detectionMethodCode : CE carbohydrateQuantity : ... DiagnosticImage ... transmissionModeCode : PQ FinancialTransaction subjectOrientationCode : CE ... FinancialContract amt : MO creditExchangeRateQuantity : REAL paymentTermsCode : CE debitExchangeRateQuantity : REAL Message Control ControlAct 0..1 0..1 Infrastructure (Structured documents) ... ContextStructure 1 1 ... 0..1 0..1 QueryEvent ... 0..n 0..n Message HEALTH LEVEL 7 vers payload REFERENCE INFORMATION MODEL ClinicalDocum Table ionI VERSION 1.18 (RIM_0118) QueryAck ent QuerySpec d : summary : ST messageQueryCode : CE setId : II ST width : ST messageQueryCode : CE queryResponseCode : CS versionNumber : INT ... ... rules : CS SortControl modifyCode : CS Provisionsal version reflects changes to RIM naming conventions TableStructure resultTotalQuantity : INT ... cellspacing : responseElementGroupId : approved in October 2002. Changes will be formally adopted in RIM seq ... char : ST 1 1 ... SET<II> Harmonization Meeting 11/14-15/2002. 1 1 ... acknowledgingMessage 0..n 0..n charoff : acknowledgedMessage 1 1 responseModalityCode : CS ... ... Enitites Acts QueryContinuation LinkHtml LocalAttr payload ... acknowledgement 1 1 1..* 1..* href Roles Other ... Acknowledgement : ... typ eCo ... Infrastructure (Structured Parameter 1 1 SelectionExpression Infrastructure (Message 0..n 0..n QueryByParameter QueryBySelection documents) control) ... userAsRight 0..n 0..n 0..1 0..1 0..n 0..n 0..n 0..n TableCell TableColumnStructure 0..n 0..n userAsLeft sco ... LocalMarkup Billboard produced by: Rochester Outdoor Advertising pe : des CS ... ... 0..1 0..1 0..1 0..1 leftSide rightSide 0..1 0..1 ParameterList RelationalExpression ParameterItem LogicalExpression ... ele ... ... RIM Class Diagram V1.19 Living Entity Role Entity Patient 0..n 0..n 1 1 Entity target inboundLink 0..n 0..n 1 1 cla LanguageCommunication source outboundLink ssC player playedRole lan ode 0..1 0..1 gua 0..n 0..n : 0..n 0..n 1 1 ... scoper scopedRole CS 0..n 1 1 det 0..1 0..1 0..n 0..n 1..n 1..n erm ... HasRole CommunicationFunction ... 1..* 1..* 0..* 0..* 1 1 Transmission AttentionLine 0..* 0..* id : ... 0..n 0..n ... 0..n 0..n Person 0..1 0..1 Batch refe ren ... • 6 Primary Subject Areas • 72 Classes • 276 Attributes • 94 Relationships • 59 Data types (approx)

13. Terminology and Information Model Information Model Terminology

14. Bottom-Up: Status of HL7 • Version 2 widely used • No standard for implementation • Not mandatory • RIM is in development • Common Document Architecture (CDA)

15. For more information: www.hl7.org

16. Top-Down: Integrating the Healthcare Enterprise (IHE) • Standards needed for implementing standards • IHE formed in 1997 • Health Information Management and Systems Society (HIMSS) • Radiology Society of North America (RSNA) • International participation: Canada, France, Germany, Italy, Japan, Korea, Netherlands, Norway, Spain, United Kingdom • Includes: societies, users, vendors, consultants, standards development organizations

17. IHE: A Standard Process for Adoption of Standards • Interoperability Problem Identification: identify common interoperability problems (information access, clinical workflow, administration, underlying infrastructure) • Integration Profile Specification: chose standards that address the problems - document them in an IHE integration profile • Connect-a-thon Testing: Vendors implement one or more IHE integration profiles into their products and test them for mutual interoperability at the annual IHE Connect-a-thon • Integration Statements and Requests for Proposals (RFPs): • Vendors publish IHE integration statements to document IHE integration profiles supported by their products • Users can reference the IHE integration profiles in requests for proposals, greatly simplifying the systems acquisition process.

18. Product IHE IntegrationStatement Requirements IHEConnect-a-thon IHEDemonstration Product With IHE Easy to Integrate Products Standards (e.g. ASTM-CCR HL7 CDA) IHEIntegration Profiles B IHEIntegration Profile A RFP A Proven Standards Adoption Process IHE Connect-a-thonResults User Site

19. IHE Integration Profiles - Radiology • Scheduled Workflow • Patient information Reconciliation • Consistent Presentation of Images • Post-processing Workflow • Reporting Workflow • Evidence Documents • Other profiles: • information technology infrastructure • cardiology • laboratory

20. IHE Connect-a-thons • Centerpiece of the IHE testing process • Weeklong interoperability-testing event • Validation of the participants' integration work • Systems exchange information with complementary systems from multiple vendors • Support of functions in the Integration Profiles

21. IHE Connect-a-thons Massive yearly events : 60-70 vendors 120-160 engineers Over 100 systems ….integrated in 5 days Vendors do not pass… until an IHE Project Manager attests it !

22. Participating and Contributing Vendors (America) GE Healthcare Heartlab Hitachi Medical Corporation Hologic, Inc IDX Systems Corporation IMCO Technologies InSiteOne INFINITT Konica Minolta Marotech, Inc. McKesson Information Solutions Medcon Medical Manager Health Systems Mediface Co., Ltd. Merge eFilm Mortara Procom Philips Medical Systems RASNA Imaging Systems Sectra Sentillion Siemens Medical Solutions Softmedical Stentor, Inc StorCOMM, Inc Swissray International, Inc Tiani Medgraph AG Toshiba America Medical Systems UltraVisual Medical Systems Vital Images, Inc. Voxar Limited WebMD XIMIS Agfa HealthCare Algotec Systems, Ltd. Berdy Camtronics Canon Medical Systems Carefx Cedara Software Corporation Cerner Corporation CSIST Dictaphone DR Systems Dynamic Imaging Eastern Informatics Eastman Kodak Company Emageon Eclipsys Fujifilm Medical Systems

23. How to participate in IHE? As a User or Vendor Contributor • Become a member of a Technical Committee • Become a member of Regional/National Committees As a Vendor Participant • Comment on integration profiles • Attend Educational Workshops (September) • Participate to Connect-a-thons As a User/Consultant Participant • Comment on integration profiles • Attend Educational Workshops (September) • Attend Connect-a-thons • Include IHE Integration Profiles in your RFPs and Integration Projects.

24. W W W . I H E . N E T Providers and Vendors Working Together to Deliver Interoperable Health Information Systems in the Enterprise and Across Care Settings