1. A brief HL7 Version 3 Introduction for CIMI
Mark Shafarman
Past Chair HL7
with additional HL7 “roles” of
past co-chair International Council
past co-chair Control/Query TC
past member Architectural
Review Board
co-chair Templates WG
CEO & Chief Information Architect
Shafarman Consulting, Inc.
8/15/2012
C HL7 Int'l and Shafarman Consulting, Inc.

2. Agenda: Brief overview of the HL7 v 3 Reference Information Model
The HL7 RIM – model of clinical information content
Some examples from the 2011 Normative edition
Discussion/Questions
8/15/2012

3. Core concepts of HL7 v3 RIM
The “Act” class and its specializations represent every action of interest in health care.
Specifically – “an action of interest that has happened, can happen, is happening, is intended to happen, or is requested/demanded to happen. An act is an intentional action in the business domain of HL7. Healthcare (and any profession or business) is constituted of intentional actions. An HL7 Act instance is a record of such an intentional action.
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4. Core concepts of RIM Every happening is an Act
Procedures, observations, medications, supply, registration, etc.
Acts are related through an Act_relationship
composition, preconditions, revisions, support, etc.
• Participation defines the context for an Act
author, performer, subject, location, etc.
The participants are Roles
patient, provider, practitioner, specimen, healthcare facility etc.
Roles are played by Entities
persons, organizations, material, places, devices, etc.
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5. C. 2012 HL7 Int'l and Shafarman Consulting, Inc.
RIM Core Classes
Entity
Participation
Role
Adminis-
trative Acts
Financial Acts
Clinical
Acts
Observation
Procedure
Supply
Substance Adm
Performer
Author
Witness
Subject
Destination
...
Living Subject
Person
Organization
Material
Place
...
Patient
Employee
Assigned Entity
Certified Entity
Guarantor
...
Account,
Invoice
Element,
Financial
Contract,
Transaction
Patient
Encounter,
Registry
8/15/2012
C HL7 Int'l and Shafarman Consulting, Inc. 5

6. How does HL7 manage this abstraction?
In the first HL7 RIM models, each concept had a visible (physical) class or association to represent it
In current RIM:
We only include a class when it adds new attributes and associations
for the rest, use coded “structural” attributes –
‘class’ or ‘type’ codes
‘mood’ or ‘determiner’ codes
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7. Structural metadata Why are these named structural attributes?
because they use codes to represent concepts that would previously have been part of the model structure
Each structural attribute has a specific HL7 concept domain with an HL7-defined ‘fixed’ value set.
In an ontological context, the formal code sets for the structural attributes form the RIM metadata ontology.
Note that this now has a parallel in SNOMED CT, which also has a formal metadata ontology.

8. The RIM is an extensional model
But it also has the ability to have formal healthcare ontologies bound to specific attributes (linked to Intentional model world).
For SNOMED CT there is the Terminfo implementation guide.
LOINC is another standard terminology/ontology that is commonly bound to RIM models.
These two aspects support applying description logic to the analysis of RIM model instances.

9. RIM Core Classes & Attributes
Entity
Role
Participation
Act
classCode CS
code : CD
determinerCode : CS
statusCode : CS 1
classCode : CS
code : CE
effectiveTime : IVL<TS>
typeCode : CS
time : IVL<TS>
classCode : CS
code : CD
moodCode : CS
statusCode : CS
activityTime : GTS
plays
0..* 1
0..* 1
0..* 1
scopes
0..*
Six kinds of attributes define semantics of each “backbone class: typeCode(classCode), code, time, mood(determiner), status, id
8/15/2012
C HL7 Int'l and Shafarman Consulting, Inc.

10. RIM Core Structural Attribute Value Sets
Entity.
classCode
Living Subject
Person
Organization
Material
Place
...
Act.
classCode
Observation
Procedure
Supply
Substance Adm
Financial …
Participation
.typeCode
Performer
Author
Witness
Subject
Destination
...
Entity
Role
Participation
Act
classCode CS
code : CD
determinerCode : CS
statusCode : CS 1
classCode : CS
code : CE
effectiveTime : IVL<TS>
typeCode : CS
time : IVL<TS>
classCode : CS
code : CD
moodCode : CS
statusCode : CS
activityTime : GTS
plays
0..* 1
0..* 1
0..*
Role.
classCode
Patient
Employee
Assigned Entity
Certified Entity
Guarantor
...
Act.
moodCode
Definition
Intent
Request
Event
Criterion
...
Entity.
determiner
Code
Kind
Instance
Qualified Group 1
validates
0..*
8/15/2012
C HL7 Int'l and Shafarman Consulting, Inc.

11. E.g. Value Set for moodCode (a Structural Attribute)
3 instances of Act, specialization OBServation, act.code attribute = “wbc”
(actually = the corresponding LOINC code for White Blood Count)
moodCode=RQO
effectiveTime
2pm PST”
(No Value
Attribute in
this model)
moodCode=EVN
effectiveTime
1pm PST”
(Observation)
Value=“xxx”
moodCode=Goal
effectiveTime
=“11/1/07”
(Goal)
Value=“yyy”
Add example of re-use of same class, but with different moodCode values and different attribute constraints
Wbc Order (Request) to occur on
Wbc Observation of ‘xxx’ made on
Wbc goal of specific value of ‘yyy’ to be attained by 11/1/07
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12. C. 2012 HL7 Int'l and Shafarman Consulting, Inc.
Person (in role of Patient) participates as subject of an Observation (lab test, performed)
Entity.
classCode
Person
Act.
classCode
Observation
Participation
.typeCode
Subject
Entity
Role
Participation
Act
classCode CS
code : CD
determinerCode : CS
statusCode : CS 1
classCode : CS
code : CE
effectiveTime : IVL<TS>
typeCode : CS
time : IVL<TS>
classCode : CS
code : CD
moodCode : CS
statusCode : CS
activityTime : GTS
plays
0..* 1
0..* 1
0..*
Role.
classCode
Patient
Act.
moodCode
Event
...
Entity.
determiner
Code
Instance 1
validates
0..*
8/15/2012
C HL7 Int'l and Shafarman Consulting, Inc.

13. C. 2012 HL7 Int'l and Shafarman Consulting, Inc.
Person in role of physician <assigned entity> participates as author of an Observation (lab test order)
Entity.
classCode
Living Subject
Person
Organization
Material
Place
...
Act.
classCode
Observation
Procedure
Supply
Substance Adm
Financial …
Participation
.typeCode
Performer
Author
Witness
Subject
Destination
...
Entity
Role
Participation
Act
classCode CS
code : CD
determinerCode : CS
statusCode : CS 1
classCode : CS
code : CE
effectiveTime : IVL<TS>
typeCode : CS
time : IVL<TS>
classCode : CS
code : CD
moodCode : CS
statusCode : CS
activityTime : GTS
plays
0..* 1
0..* 1
0..*
Role.
classCode
Patient
Employee
Assigned Entity
Certified Entity
Guarantor
...
Act.
moodCode
Definition
Intent
Request
Event
Criterion
...
Entity.
determiner
Code
Kind
Instance
Qualified Group 1
validates
0..*
8/15/2012
C HL7 Int'l and Shafarman Consulting, Inc.

14. A single act may have multiple participations
Entity
Role
Participation
classCode CS
code : CD
determinerCode : CS
statusCode : CS 1
0..*
classCode : CS
code : CE
effectiveTime : IVL<TS>
typeCode : CS
time : IVL<TS>
plays
0..* 1
0..*
0..* 1
scopes
Person in role of physician <assigned entity> participates
as author of an Observation (lab test order) 1
Act
classCode : CS
code : CD
moodCode : CS
statusCode : CS
activityTime : GTS 1
0..*
Entity
Role
Participation
classCode CS
code : CD
determinerCode : CS
statusCode : CS 1
classCode : CS
code : CE
effectiveTime : IVL<TS>
typeCode : CS
time : IVL<TS>
0..*
plays 1
0..*
Note that these two participations can be combined in a single model, i.e. a lab test order has both a patient subject, and an ordering physician 1
scopes
0..*
Person (in role of Patient) participates as subject of an Observation Order (lab test order)
8/15/2012
C HL7 Int'l and Shafarman Consulting, Inc.

15. RIM Core Classes & Attributes
We have shown parts of some of the basic HL7 defined value sets for structural attributes, but entity.code, role.code, and act.code are key attributes that use non-HL7 standard terminologies.
E.g. for act.code, LOINC and SNOMED-CT, are key value sets for observation and procedure concept domains.
Entity
Role
Participation
Act
classCode CS
code : CD
determinerCode : CS
statusCode : CS 1
classCode : CS
code : CE
effectiveTime : IVL<TS>
typeCode : CS
time : IVL<TS>
classCode : CS
code : CD
moodCode : CS
statusCode : CS
activityTime : GTS
plays
0..* 1
0..* 1
0..* 1
scopes
0..*
Six kinds of attributes define semantics of each “backbone class: typeCode(classCode), code, time, mood(determiner), status, id
8/15/2012
C HL7 Int'l and Shafarman Consulting, Inc.

16. Two other critical RIM classes
ActRelationship: creates formal relationships between acts, such as:
E.g. (structural) — Comp, component,
As in a CBC observation (complete blood count) has component acts RBC (red blood cell count); WBC, white blood cell count; etc.
E.g. (causal) — RSON, reason; CIND: contraindication; PRCN, precondition
And several types of qualifiers and modifiers
8/15/2012

17. Two other critical RIM classes
RoleLink: A <rarely used> connection between two roles expressing a dependency between those roles and permitting the authorization or nullification of a dependent role based on status changes in its causal or directing role.
E.g. A role of assignment or agency depends on another role of employment, such that when the employment role is terminated, the assignments are terminated as well.

19. RIMBAA note The previous diagram, the “RIM on (just) one page.”
Is the basic SQL design for RIMBAA systems.
But this requires (see below) using the structural variables to navigate the RIM models. (another presentation)

20. V3 and physical data Act, specialization “observation” Act.class=“OBS”
Act.code=<code for observation type>
E.g. LOINC, SNOMED, etc. (per HL7 “realm”)
Act.mood
Event for actual measurement
Request for “order/request” for measurement
Act.ID=“instance identifier” for the measurement
Act.value= the physical observation
DataType of act.value is, as in v 2.x, allowed to be any appropriate datatype (usually PQ, physical quantity; may be Set(PQ).
Act.effectiveTime= “physiologically relevant time of observation” (e.g. “when in the patient’s life the observation was made)
8/15/2012

21. V3 and physical data Act/observation continued:
interpretationCode (SET<CE>)
One or more codes specifying a rough qualitative interpretation of the observation, such as "normal", "abnormal", "below normal", "change up", "resistant", "susceptible", etc
methodCode (SET<CE>)
Examples: Blood pressure measurement method: arterial puncture vs. sphygmomanometer (Riva-Rocci), sitting vs. supine position, etc.
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22. V3 and physical data Act/observation continued:
targetSiteCode (SET<CD>)
A code specifying detail about the anatomical site or system that is the focus of the observation if this information is not already implied by the observation definition or Act.code.
Constraints: The targetSiteCode value, if specified, must not conflict with what is implied about the target site or system from the observation definition and the Act.code.
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24. Summary
We have briefly reviewed
an introduction to the RIM
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25. …Further Discussion… …Other topics?... …Questions?... 8/15/2012
Suggested Topics for Further discussion: This presentation has covered only #1 below. 
HL7 is currently supporting clinical information models in several ways:  
1)  basic v3 which has excellent support for semantic interoperability and which includes the (now-ISO) RIM and datatypes,
and a more up-to-date interchange format.
2) CDA:      a) the CDA release 3 ballot is now out, and could provide some useful guidance     
b)  there are several national implementation guides for CDA (in the US these are the C32, C80 and C83)     
c) the CCDA (consolidated CDA) is out     
d) there is Green-CDA (and CDA compliant implementation that is much smaller in size, and which has been
adopted by the NHS)     
e) several sets of CDA implementation tools: Lantana, NHS, DECOR projects in the Netherlands, Austria, and one of the Scandinavian Countries
3) Templates -related     
a) the templates ITS (implementable technology specification): a current pilot project: at this point we have succeeded in translating the requirements for a number of CCDA template specifications into a DECOR-format that can be shared across systems; a later phase of the project will research doing the same with MDHT CDA templates     
b) the Templates Registry Business Process Analysis Requirements, now on ballot as an Informative document
4) the HingX project (HL7 is an early adapter).  This is a generic artifacts registry, that can support any type of clinical model specifications. It is an OHT project, and uses 3b as a basis for its registry functionality. A progress report on the pre-alpha implementation will be available by the time of the September meeting, and perhaps a live demo could be arranged (See HingX.org)
5) FHIR: Fast Health Interoperability Resources: a current for-comment HL7 ballot see (    Again, an update should be available at the
September meeting.  
8/15/2012