09 - Networking and Health Information Exchange - Unit 4 - Basic Health Data Standards - Lecture E

Networking and Health
Information Exchange
Basic Health Data Standards
Lecture e
This material Comp9_Unit4e was developed by Duke University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Learning Objectives
2
1. Understand why it is necessary to use a common set of
data elements with common names to be able to
exchange and understand data from other places
(Lecture a)
2. Understand what is meant by semantic interoperability
(Lecture a)
3. Understand many of the sets of controlled vocabularies
in use today how they are used and who requires their
use (Lecture a)

Health IT Workforce Curriculum
Version 3.0/Spring 2012
Networking and Health Information Exchange
Lecture e
Learning Objectives
3
4. Understand the use, purpose and interrelation among
sets of controlled vocabularies in use today (Lectures b
and c)
5. Identify the more common controlled vocabularies in
use today: ICD, CPT, DRG, NDC, RxNorm, and LOINC,
(Lecture b)
6. identify the more common controlled vocabularies in
use today: SNOMED, MEDCIN, MedDRA, Nursing
terminologies, MeSH and UMLS, (Lecture c)
7. Understand data elements; attributes of data elements
(Lecture d)

Lecture e
Learning Objectives
4
8. Understand contribution of master meta-dictionary of
data elements to semantic interoperability (Lecture d)
9. Explain how data structures can be built from basic
data components (Lecture e)
10. Explain how templates and archetypes facilitate
networking and information interchange (Lecture e)
and
11. Discuss Clinical Data Architecture (CDA), Continuity of
Care Document (CCD), and Continuity of Care Record
(CCR) Standards (Lecture f)

Lecture e
Building Data Structures
5
Lecture e
Starting with well-defined, finely-grained data elements, it is
useful to build data structures for consistency in content,
collection, and presentation.
Structures permit binding related data components into a
single structure.
This concept is familiar because we see it on paper forms.
Examples include person names and addresses as well as many
health data components.
The scope ranges from simple compound elements to data
collection protocols.

Compound Data Elements
Attributes similar to data elements
Examples include blood pressure, heart
murmur, titers
Expressed as
Templates (HL7)
Archetypes (openEHR)
Common Message Element Type (CMET)
Clinical Statement
Use XML syntax

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Lecture e
Complex Data Elements
7
Lecture e
Attributes similar to data elements
Examples include drug sensitivity,
microbiology results, body mass index,
pulmonary functional tests
May include description logic and
mathematical calculations
May invoke an action

Common Message Element Type
Administrative complex data elements
defined by groups within HL7.
Examples include person names, addresses,
telephone numbers, etc.
Support international variations
Reusable components
Can be reused without redefining the data
object

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Lecture e
What Is An HL7 Template?
Formally, an HL7 Template is a registered
set of constraints on a balloted HL7 static
model.
HL7 balloted static models are all derived
from the HL7 Reference Information
Model.
Templates are used in the HL7 standards
Clinical Document Architecture.

9
Lecture e
Types of Constraints
HL7 Templates constrain both structure and
content
Structural constraints further restrict model
elements such as cardinality, new class clones
derived from balloted class clones, their
attributes, relationships and HL7 data-types
Non-structural constraints include valid value set
expressions and conditional constraints affecting
more than one model element
Object Constraint Language may be used to
define constraints on the model

10
Lecture e
Document Templates
Applied to the CDA schema to produce a
desired level of information structure and
content for a particular purpose
A particular type of document

Various templates structures may be use
as document templates

11
Lecture e
Atomic Concept Definition Templates
A template applied to part of a static model
that specifies the structure and permitted
coding to completely define a particular
clinical concept
Atomic concept definition templates are
designed to be reusable in many different
contexts
The stereotypical example is Blood
Pressure, composed of two numerical
measures with optional additional
information about patient positioning, cuff
size, etc.

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Lecture e
Computed Measures Templates
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Lecture e
A template applied to an observation that
has multiple components.
The constraints apply to the content and
relationships of the components, but also
describe the computational algorithm that
derives a computed measure from the
component measures

How Are Templates Created?
Different approaches have been used
A static model derived from a balloted
static model using the HL7 Design tools
Derive and then hand refine a static
model schema
New tools that start with a balloted static
model and add constraints
Schematron may be use to validate
business rules
Rule-based validation language

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Lecture e
Archetypes
Archetype denotes a model defining some
domain concept, expressed using
constraints on instance structures of an
underlying reference model
Uses Archetype Description Language
Similar to XML
Easily redefined in XML

15
Lecture e
Detailed Clinical Model
Combines knowledge, data specification,
and terminology
Conceptual specification of the semantics
of discrete structured clinical information
Defines data elements and attributes,
including the possible values
Provides unambiguous detail that cross
clinical; permits consistent use of medical
data; is reusable

16
Lecture e
DCM Template Examples
Apgar Score
Barthel Index
Blood Pressure
Body Height
Body Temperature
Body Weight
Glasgow Coma Score
Pulse Rate
Respiration

17
Lecture e
Clinical Information Modeling
Initiative (CIMI)
Organized in 2011
International with participation from SDOs,
vendors, providers, governments, and
interested parties
Dedicated to providing a common format
for detailed specifications for the
representation of health information
content
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Lecture e
Summary Lecture e
19
Introduction to the concept and kinds of
data structures
Types of data structures including complex
and compound structures
Groups creating data structures include
HL7 (CMETS, templates, clinical
statements, CDAs), CEN, ISO, openEHR
Lecture e
References Lecture e
References
Detailed Clinical Models. (n.d.). Retrieved from HL7 International website:
http://wiki.hl7.org/index.php?title=Detailed_Clinical_Models
Acknowledgement: Material used in this lecture comes from the following sources
Health Level Seven International. (n.d.). Retrieved January 12, 2012, from Health Level Seven International
website: www.hl7.org
openEHR. (n.d.). Retrieved January 12, 2012, from openEHR website: www.openehr.org
International Organization for Standardization. (n.d.). Retrieved January 12, 2012, from ISO website:
www.iso.org/iso/iso_technical_committee?commid=54960
cen - European Committee for Standardization. (n.d.). Retrieved January 12, 2012, from CEN website:
www.cen.eu/cen/Sectors/TechnicalCommitteesWorkshops/CENTechnicalCommittees/Pages/default.aspx?param=
6232&title=CEN/TC%20251

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Lecture e
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