Action Verb Hierarches

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Manage (Data)

Capture Maintain Render Exchange Determine

Manage- Data-Visibility

Auto‐

Populate Enter Import Receive

Store Update Remove Extract Present Transmit Export

Import Receive Transmit

Analyze Decide De-Identify Hide Mask Re-Identify Unhide Unmask Archive

Backup Decrypt Encrypt Recover Restore Save

Annotate Attest Edit

Harmonize Integrate Link Tag

Delete Purge

NOTE: EHR‐S FIM is NOT intended to imply a specific architecture or  workflow!

Observation 

• From where I’m sitting, deriving conceptual information models based on the conformance criteria could be useful for consuming a functional profile. I would assume it could be used as reference for developing a domain analysis model for a project, to fill in blanks of conceptual information not expressed by clinical SMEs, and to shorten the learning curve for projects required to adopt the conformance criteria. Regardless of how modeling evolved on the project, the CDM would still be a bridge to validate addressing information needs at a high level. I would not foresee using the CDM or other artifacts verbatim in modeling for a specific project because some the

relationships/associations expressed appear to be more subjective than explicit representation of the conformance criteria. I suggest annotating whether the relationships in the CDM represent explicit conformance criteria or not. For those that are not explicit (SHALL), it should be clear implementers have no obligation to portray those relationships the way they are expressed in the model.

• In reviewing the other artifacts (activity diagrams, and conceptual information model) I was a little concerned that the content suggested a more prescriptive view of EHR functionality, which I’m not sure is a good thing. In the case of the activity diagrams being prototyped, I can see they are not attempting to sequence how tasks within an activity are executed, but using activity diagrams

suggests that is the intended direction. I think that path would be too restrictive for implementers. I think the CIM raises more questions than it answers. This is another one where I think it best left to specific implementation projects. Perhaps other folks will provide a different perspective, but I think the CDM content is the most useful for understanding the conformance criteria for greater adoption.

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Observation 

• We have been having a lot of discussions in patient care, clinical statement, CIMI and MnM regarding representation of clinical content. One of the most important is the recognition and separation of dynamic uses / extracts of information one would see in an EHR-S GUI or CDA v. an information model suited for information exchange, persistence, transformation, analytics, decision

support. A good example of this is the common notions of a “problem list”, “allergy list” or “list of immunizations”. These are artifacts we are used to seeing in paper charts, since there was no other effective means to address longitudinal data which otherwise would be scattered in the linear ordering progress notes. In fact, HL7 defines these working lists as ‘..collects a dynamic list of individual instances of Act via ActRelationship which reflects the need of an individual worker, team of workers, or an organization to manage lists of acts for many different clinical and administrative reasons. Examples of working lists include problem lists, goal lists, allergy lists, and to-do lists.’

• There are also design patterns well suited for static semantics from the (being revised for May ballot) Patient Care domain, all of which are different entry points into a common model. These include a pattern for a Care Record, which corresponds best to the conventional notion of the documentation of an encounter. The Care Record, however, has entries which follow the Health Concern pattern and the Care Plan pattern.

• Health Concerns are anything which affects one’s health which need to be managed/tracked over time. These includes risks, diseases, problems, allergies/intolerances to medications, social circumstances, and complications.

• The Care Plan documents interventions, treatments and orders. Care Plans can have embedded logic, e.g. stating a specific action should (not) be taken if a specific criterion is met. So things like immunization schedules, insulin sliding scales/sick day rules, or complex oncology protocols have a common design basis. While we are used to thinking of Concerns and Plans as future looking, the same pattern is used to document things which have happened (e.g. procedure which has been completed), so the Care Plan includes not just what is currently being done, what is planned, but also what has been done in the past.

• An instance of an encounter’s documentation therefore would have elements from the Care Record (e.g. the signs/symptoms discovered at the time of the encounter), Health Concerns (in a linear narrative like a CDA these typically are organized into the familiar ‘lists’, e.g. allergy list, problem list, PMH), and Care Plan (again in ‘lists’—e.g. medication list). An encounter would also expect to generate new Care Plans and new Health Concerns as part of the clinical decision making. (The A&P in Weed’s POMR).

• By separating the model of use (various lists) from model of meaning (the Patient Care Domain Model plus the derived detailed clinical models which bind terminology, etc.) we can most effectively devise those specifications needed for given use cases.

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Observation 

• I am coordinating with Richard Savage (now working for CDC) on immunizations with Patient Care. I don’t know who the modeling facilitator is for the new immunization project, but if it is a void I might fill in. I am going to start tacking the immunization (JIC) (analysis/conceptual) models and see if I can get them into something which is a better approximation of a real information model of the clinical content static semantics.

• Do you think this is a good point to start to put together the background and socialization needed to come to some decision regarding the representation of static semantics for iEHR? I see two related decisions: #1 what modeling language is going to be used for design, and #2 what is the modeling language used for the wire format. Obviously, with HL7 v3 there is close traceability between the

graphic format in the Visio based RMIM Designer and the resultant MIF2 representation. I believe that the UML based SMD also does this. MIF2 è XSD, so there is a close tie between MIF and something which can be implemented.

• Of course, we could also use HL7 templates (whatever those are) on top of a base model, rather than having all the explicit details in the MIF2. We could even use ADL for this, if we were so inclined. That still leaves us the question about ‘wire format’. I.e. what one server says to another.

• Eventually, I would expect a ‘cleaner’ modeling language to be used for design, with transformation to arbitrary implementable paradigms. Hopefully CIMI will fill this niche. Not in time to do the modeling for JIC, Pharmacy, etc. but hopefully just in time to model the core content of an ambulatory documentation system.

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