EHR Conceptual Information Architecture Blueprint Report. Version: 01

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1 HR Conceptual Information Architecture lueprint Report Version: 01 June 2013

2 Copyright Notice Copyright 2010, ehealth Ontario All rights reserved No part of this document may be reproduced in any form, including photocopying or transmission electronically to any computer, without prior written consent of ehealth Ontario. The information contained in this document is proprietary to ehealth Ontario and may not be used or disclosed except as expressly authorized in writing by ehealth Ontario. Trademarks Other product names mentioned in this document may be trademarks or registered trademarks of their respective companies and are hereby acknowledged. HR Conceptual Information Architecture lueprint Report / Version No 01 ii

3 1. Introduction The mandate of ehealth Ontario is to play a leading role in harnessing information technology and innovation to improve patient care, safety and access in support of the government s health strategy. Its mission is to deliver a comprehensive, patient-focused, secure and private electronic system that will improve the way patients receive care. To support the alignment and integration of the required ehealth initiatives, ehealth Ontario has established a foundational 2015 Technical Architecture lueprint for ehealth solutions in the province of Ontario. The goal of this project is to extend the 2015 blueprint with the Conceptual Information Architecture lueprint for the provincial lectronic Health Record (HR). A counterpart work stream is providing a corresponding usiness Architecture lueprint. ehealth Ontario currently has documented and defined data architectures for subsets of the Provincial HR corresponding to application system implementations. However, an overarching provincial-level HR Conceptual Information Model (CIM) is required. The development of the HR CIM is one of the key initiatives that ehealth has initiated in fiscal 2011, and is the subject of this report. The engagement to develop the architecture started in October 2011, and was completed in January The result of this work is the HR Conceptual Information Architecture lueprint Report. The report includes the emantic model designed to promote a shared understanding of the HR domain prior to developing the conceptual information model. The Conceptual Information Architecture lueprint will be used to enable and fulfill the government s strategic health care initiatives. It creates a foundation for innovation and action to design and implement a Provincial lectronic Health Record that will enable clinicians and patients to participate equally in managing and improving personal health care. 1.1 Purpose and enefits The HR CIA is a complete, high-level view of what information constitutes a person s electronic health record in the Ontario health system, and provides broad outlines of how that information should be structured. It is intended for use by all authorized stakeholders for electronic health records in Ontario, including but not limited to ehealth Ontario, the Ministry of Health and Long-Term Care, Ontario health care providers and clients (patients), and health care information system vendors. The HR CIM provides: A common language to facilitate communication and co-ordination between parties within ehealth Ontario and across the broader ehealth environment, An overarching information structure to guide planning, design, and data integration of ehealth Ontario s systems, and A map of information relevant to the business that serves as the basis for information management and governance, and A Conceptual Information Model (CIM) diagram and definitions. HR Conceptual Information Architecture lueprint Report / Version No 01 3

4 1.2 Definition of lectronic Health Record At the conceptual model level, there is no differentiation between electronic health record and health record, since conceptual models do not take into account how information would be structured differently to reflect the limitations or capabilities of differing media (e.g. electronic vs. paper). The conceptual information model for the electronic health record is therefore the conceptual information model for the health record, regardless of whether the medium is electronic or not. However, in this document we will hereafter refer to the HR because it is the terminology in common use, and is in essence how the health system health record is branded. Also, the term health record rather than electronic health record will be used to convey the same meaning as HR. 1.3 Development Approach At the conceptual model level, there is no differentiation between electronic health record and health record, since conceptual models do not take into account how information would be structured differently to reflect the limitations or capabilities of differing media (e.g. electronic vs. paper). The conceptual information model for the electronic health record is therefore the conceptual information model for the health record, regardless of whether the medium is electronic or not. However, in this document we will hereafter refer to the HR because it is the terminology in common use, and is in essence how the health system health record is branded. Also, the term health record rather than electronic health record will be used to convey the same meaning as HR. The development of the conceptual information architecture involved three groups (members identified in rror! eference source not found.): A Core Team of ehealth Ontario and KPMG architects for the actual development of the model, A Working Group of health information subject matter experts from across ehealth Ontario to review drafts of the model and this report and provide feedback on suggested changes, and A teering Committee for review and approval of deliverables There were three major sources of reference information for the development of the Conceptual Information Model: The data models for existing ehealth Ontario related application systems such as Chronic Disease Management, Medication Management, and Ontario Laboratories Information tandards, specifications and data models developed by five key organizations with a vested interest health information management, namely the International tandards Organization (IO), the Health Level even (HL7), the Canadian Institute for Health Information (CIHI), Canada Health Infoway (CHI), and OntarioMD. The documents referenced from these organizations are listed in rror! eference source not found.. imilar documents from other external organizations such as the National Health ervice in the UK, and the Office of the National Coordinator for Health Information Technology in the U. The documents from these sources are also listed in rror! Reference source not found.. These reference models were considered to represent different views of the HR, and none was considered to be definitive. The Core Team essentially synthesized the HR Conceptual Information Model from these inputs, based on accepted information modelling methods and the team s knowledge of the health information domain. The Core Team recognized that there are diverse interpretations of what an HR is, not only across the industry, but also internally within ehealth Ontario. Accordingly, rather than directly developing the conceptual information model from the beginning, the Core Team established a foundation of agreed basic concepts by developing a semantic model. The semantic model was reviewed throughout its development by the Working Group, and a final draft created to serve as the foundation for developing the conceptual information model. This was completed on December 7, 2011, and approved in principle by the teering Committee subject to revisions required to align with the conceptual information model, which was expected to further evolve the related concepts. HR Conceptual Information Architecture lueprint Report / Version No 01 4

5 The conceptual information model was developed in a similar fashion, with the Working Group reviewing the model as it was being developed. The main elements (entities and relationships) of the CIM were completed at the final working group meeting on January 11, and the model reviewed by the steering committee on January 12. ome detail was then added to the CIM in the form of representative attributes for the entities that facilitate understanding what the entities are. The semantic model and conceptual information model were then documented in this report. An explanation of semantic modeling and conceptual information modeling methods and diagram notation is provided in rror! Reference source not found HR Conceptual Information Model tatus This document represents the first iteration of the HR Conceptual Information Model. It is a complete representation of the health record as defined in section rror! Reference source not found., and may include nformation that is not currently managed in existing databases. The HR Conceptual Information Model is intended to be considered authoritative where definitions do not currently exist for any aspect of the health record. While the intention is to align all future implementation to the HR-CIM, current ehealth Ontario implementations and projects to the CIM where feasible, it does not supersede the information definitions used in those situations unless so stated explicitly. 1.5 Disclaimer The HR Conceptual Information Model does not address privacy and consent aspects for care, but does address information consent with regard to the health record. All elements of the health record are personal health information and as such are subject to ehealth Ontario privacy policies that are comprehensively defined in policy documents issued by ehealth Ontario s Privacy Office. 1.6 Next teps Development of conceptual models is an iterative process. The model will evolve with the introduction of new business requirements, changes in industry standards, technological and clinical innovations. ngagement of clinical groups, Health tandards Organizations and all ehealth Ontario lines of business will have the opportunity to review and refine the model to ensure completeness and usability. As the HR Conceptual Information Model is expanded to include representative data elements, international and pan-canadian code systems and value sets will be used to express the concepts for the data elements in support of semantic exchange and use of health information where applicable. Although reference terminologies are not identified in the conceptual information model, there is an expectation that terminology standards will be determined through collaboration by business areas and standards program in alignment with international, pan Canadian, and jurisdictional standards. HR Conceptual Information Architecture lueprint Report / Version No 01 5

6 2. HR Conceptual Information Model This section presents the HR Conceptual Information Model diagrams (sub-section rror! Reference source ot found.) and definitions of the model entities in the diagrams (sub-section rror! Reference source not found.). The semantic models that produced were a means to an end with the focus being on the conceptual model as the formal representation of the HR CIM. The semantic models included in rror! Reference source not ound. for reference are aligned with the conceptual model. An explanation of how to read these models is provided in rror! Reference source not found Overview To provide an orientation to the Conceptual Information Model diagrams in this section, a high level view of the CIM is provided in Figure 1. This diagram illustrates the key concepts in the CIM, and does not reflect some details that can be found in the CIM diagrams. Although the concepts in the diagram are named in the singular, they represent multiple occurrences and are referred to in the plural where appropriate in the narrative below. Figure 1 Conceptual Information Model Overview The diagram illustrates that the most significant CIM concepts are the Health Care Client, Health Care Providers, Health Care ncounters, Client Teams, Health Care Plans and Client Health Profiles. Health Client is a person who is eligible to receive health care services in Ontario, has received or is receiving health care services in the province of Ontario. HR Conceptual Information Architecture lueprint Report / Version No 01 6

7 A Health Care Provider is person or an organization that provides health care or other health-related services or products. A Health Care ncounter represents a client care event, which may involve a Health Care Provider or if no Health Care Provider are involved, it is defined as a elf-care ncounter. The Health Care ncounter is the CIM construct through which all recorded client care activities are identified. ncounters occur to address Health Concerns, and may also address known Health Conditions as well. While the encounter denotes the occurrence of a care event, it is the Health Care ncounter Output that represents the results of the event. ome outputs are provided only by Health Care Providers, such as a diagnosis that identifies a Health Condition, a clinical procedure, a service being provided, or a requisition for diagnostic procedure, medication, referral, medical device or health care services. Other types of outputs may be provided by the Client as well, such as an observation, a vital sigh such as blood pressure, or a medication taken. The output may be a fulfillment of an item in the Client s Health Care Plan, such as a medication, a fitness exercise, or a procedure performed by a Provider. Outputs are instances of the provisioning of a Health Product or ervice from a Provider, (or the Client in self-serve encounters). An encounter may occur at a geographic or virtual address and it may also be temporary clinic/service area (e.g. flu shot clinic in a mall or pharmacy), mobile location (e.g., ambulance, mobile lab), or in the field (e.g., car, accident site). Client Team is a group of Client upporters and interdisciplinary Health Care Providers working collaboratively with the Health Care Client to support the client s Health Care Plan. ach Client Team member is assigned specific responsibilities on the team, to facilitate care for a Health Care Client directly related to their role. Health Care Plan is an integrated care plan to manage the optimal health of a client, authored by the client and/or provider(s), to address preventative measures or manage existing health conditions experienced by the client; It contains client-centered activities, goals and targets based on best practice guidelines and is monitored by Client Team Members on a regular basis either directly or through automated and directed notifications. Client Health Profile is a combination of information about the client used to access their current health state and potential impacts on their future health. It includes a diverse range of information, including but not limited to: ensitivities, allergies, intolerances and adverse reactions to substances Health Conditions both chronic and transient Family history Physical, lifestyle, behavioral, mental and cultural characteristics pecial needs Immunizations Health Directives Health Concerns arriers both socio-economic and functional information Consent, and mergency contacts 2.2 Diagrams The diagrams in this section show entities without their representative attributes. xplanatory narrative is provided with each diagram to describe its key features. 2.3 Out of cope Data aggregated or derived from atomic data in the model, e.g., as might be defined in a data warehouse data model Information about the processing of health information, or about business functions that process health information Information about how health services are provided, e.g. the contractual relationships between providers. Information about the financial or administrative aspects of health care, e.g. health insurance, health service billing and payments HR Conceptual Information Architecture lueprint Report / Version No 01 7

8 2.3.1 Conceptual ehealth Model class HR CIM - Full Model HR Conceptual Information Model Health Care Provider Health Client Information Consent Health Care Plan ncounter Location Health Care ncounter elf-care ncounter Provider ncounter Provider Organization Provider Person Client upporter Health Care Client mergency Contact Permission Override arrier Client Team Member Client Care Role Type Client Care Notification Alert Reminder Correspondence Health Product Location Provider pisode of Care ocio-economic arrier Functional arrier Permission Plan Component Health Product Medication Health Care ervice Device Implantable Device Health Care ncounter Output Clinical Observation Diagnostic Image Dispense Observation Clinical Procedure elf-reported Observation Diagnostic Image Diagnosis Intake Life vent Clinical LIfe vent Health Condition Transient Condition Chronic Condition Health Concern Adverse Reaction Adverse Drug Reaction ubstance ensitivity Intolerance Allergy Drug-related Allergy Personal Health Characteristic Physical Characteristic Lifestyle Characteristic ehavioural Characteristic Mental Characteristic Cultural Characteristic Health Directive Family History pecial Need Immunization Health Target Activity Goal Plan Health Activity Clinical Guideline Requisition Fitness Activity ducation ncounter Legend Personal Health Profile Client and Provider Diagram Conventions zero or more 1 or more 1 and only 1 (exactly 1) Client Team Health Care Plan Health Product and ervice zero or Health Care ncounters Figure 2 illustrates entities and relationships concerning Health Care ncounters. Figure 2 Health Care ncounter Diagram HR Conceptual Information Architecture lueprint Report / Version No 01 8

9 class HR CIM - ncounter Health Condition Transient Condition Chronic Condition co-morbidity with suffers from for Health Client Life vent Health Care Provider Provider pisode of Care Health Care Client Client upporter Clinical LIfe vent Provider Organization Provider Person carries out cares for consists of addresses participates in participates in causes Health Care ncounter operates at participates in occurs at Provider ncounter elf-care ncounter has Health Concern Health Product Location at ncounter Location occurs at provides addresses situated within available at Health Care ncounter Output Observation referral to Health Product Health Care ervice provided by Clinical Observation Diagnostic Image elf-reported Observation Diagnostic Image Medication of contributes to supplies Device Diagnosis Implantable Device supplies Dispense Intake of ubstance implanted through Clinical Procedure orders Requisition ducation Fitness Activity identifies A Health Care Client can have Health Conditions that are Transient or Chronic, and a Chronic Condition may have a co-morbidity with other Chronic Conditions. A Client may have Health Care ncounters, each of which would be to address one or more Health Concerns. A Health Concern may be caused by a Life vent, and may not necessarily be a health problem, e.g. the need for a medical exam for a pilot s license. Health Care Providers can be Organizations or Persons, and operate at a Health Product Location. Provider Persons rather than Organizations can be the subject of referrals and participate in Provider ncounters with a Health Care Client. There are two types of Health Care ncounters those involving a Provider Person, the others being elf-care ncounters. ncounters of both types provide Health Care ncounter Outputs, although the range of output types from elf-care ncounters that a health care client can use are more limited than those from Provider ncounters. ncounters occur at an ncounter Location, which can also be a Health Product Location. oth can have Client upporters as participants. HR Conceptual Information Architecture lueprint Report / Version No 01 9

10 Provider ncounters that are related to the same Health Condition and the same Provider Person are represented as Provider pisodes of Care, and relationships between Provider pisodes of Care are also represented. Related pisodes can have different or the same Provider Person, can be for different or the same Health Condition, e.g. pisodes of Care for diabetes and heart disease with different specialist Providers, for the same client. Health Product Locations are places where Health Care Products are available, and where Provider Organizations or Provider Persons operate. A location can be situated within a larger location, e.g. an mergency department within a hospital. Health Care ncounter Outputs are provided by Health Care ervices, when there is a Provider Person participating in the ncounter. There are several different types of Outputs, including Observations, Clinical Procedures that may implant Devices in Health Care Clients, Dispense of Devices and Medication, Requisitions that can either be for a Health Product or a referral to a Health Care Provider, and Diagnoses that may identify Health Conditions of Clients. The diagnosis would not identify a Health Condition if the Provider deems the client to be in good health at the time of the encounter Health Care Plans Figure 3 Health Care Plan Diagram class HR CIM - Health Care Plan is sent to is sent to Client Team Member participates as cares for Health Care Client follows suffers from has Transient Condition Health Condition Chronic Condition co-morbidity with Client Care Notification Health Care Plan Health Concern set for Alert Reminder Correspondence includes Clinical Guideline addresses addresses Health Care ncounter Output Observation Clinical Observation monitors develops Plan Component based on elf-reported Observation concerns Plan Health Activity Activ ity Goal Health Target Dispense contributes to fulfills Intake Diagnosis identifies Clinical Procedure Requisition ducation Fitness Activity Figure 3 illustrates entities and relationships concerning Health Care Plans. A Health Care Client may have one Plan or none. A Plan includes one or more Plan Components, each of which can address multiple Health Concerns and/or multiple Health Conditions. A Plan Component can be based on a Clinical Guideline, and can be a Plan Health Activity, Activity Goal, or a Health Target. A Client Team Member may or may not be involved in the development or monitoring of a Plan Component. A Client Care Notification is an Alert, Reminder, or Correspondence sent to a HR Conceptual Information Architecture lueprint Report / Version No 01 10

11 Client Team Member, and optionally to the related Health Care Client. A Notification may concern a Plan Component. A Plan Health Activity may be fulfilled by a Health Care ncounter Output Client Care Teams Figure 4 Client Care Team Diagram class HR CIM - Client Team Client upporter Health Client Health Care Client gives or withdraws follows Information Consent Health Care Plan cares for participates as cares for issues Health Care Provider Provider Person participates as Client Team Member takes on applies to Permission includes Client Care Role Type subject to Prov ider Organization applies to Permission Override monitors Plan Component develops Figure 4 illustrates entities and relationships concerning Client Care Teams. A Client Team Member is a Provider Person or a Client upporter providing care to a Health Care Client in one or more specific Care Roles. A Client Team Member may be involved in the development and/or monitoring of a Plan Component. A Client Care Role Type has one or more standard Permissions for specific types of access (e.g. view, update) to specific health information (e.g., nutrition, treatment plan). A Permission Override may be issued by a Health Care Client to supersede a Permission obtained by a Client Team Member by virtue of their Client Care Role Type. Client upporter and Health Care Client are types of Health Client from a health system perspective. A Care Client may provide Information Consent for access to their health record Personal Health Profiles Figure 5 Personal Health Profile Diagram HR Conceptual Information Architecture lueprint Report / Version No 01 11

12 class HR CIM -Personal Health Profile Health Care Client suffers from has subject to has challenged by names Health Condition ensitivity Personal Health Characteristic arrier Transient Condition Intolerance Allergy Physical Characteristic Mental Characteristic ocio-economic arrier Functional arrier co-morbidity with Chronic Condition Drug-related Allergy Lifestyle Characteristic ehavioural Characteristic Immunization mergency Contact Adverse Reaction to Cultural Characteristic pecial Need Adv erse Drug Reaction Family History to ubstance Health Directiv e Figure 5 illustrates entities and relationships concerning a Health Care Client s health profile, which consists of six areas that relate to the Client s health state and their health care: Health Condition, which is a health state that is Transient or Chronic, and a Chronic Condition may have a co-morbidity with other Chronic Conditions Adverse Reaction to a ubstance which may be a drug ensitivity to a ubstance that is an Intolerance or Allergy Personal Health Characteristic that is: Physical, Mental, Lifestyle, Cultural, or ehavioural in nature, or may be an Immunization, pecial Need, Family History item, or Health Directive arrier to care that is ocio-economic or Functional in nature mergency Contacts HR Conceptual Information Architecture lueprint Report / Version No 01 12

13 3. ntity Definitions The following table defines the entities represented in the diagrams above, in alphabetical order. ntity Activity Goal Adverse Drug Reaction Adverse Reaction Alert Allergy arrier ehavioural Characteristic Chronic Condition Client Care Notification Client Care Role Type Description & Notes A goal set jointly by the provider and/or patient to be achieved, which contributes to improving or maintaining the patient's condition, (e.g. stress reduction, increased fitness, decreased, smoking). A sub-type of Plan Component. An Adverse Drug Reaction is a negative reaction that a Patient has after taking a particular Medications, which may or may not have been caused by the Medications. A subtype of Adverse Reaction. Any unfavorable and unintended symptoms related to the use of a health product, health procedure, therapy, or other substance exposure, or any combination of these. A sub-type of ensitivity. A notification to advise of any deviation from a health care Plan Component, to assist in: the management of issues that arise from the Patient Care Plan such as outstanding planned activities, or the achievement of Activity Goals or Health Targets. A sub-type of Client Care Notification. An immediate or delayed immune reaction caused by exposure to an antigen (allergen). This includes allergies to drug components, i.e., active ingredients and fillers. xamples of nondrug allergies are bee stings, foods, and pollen. A sub-type of ensitivity. A social, economic, or functional limitation that may hinder the patient s capability to self-manage his/her care. An aspect of the way the Health Care Client behaves that is relevant to provision of care, e.g. patient prone to violent behaviour. A sub-type of Personal Health Characteristic. A patient's long-lasting or recurrent medical condition that may require a long period of supervision, observation or care, e.g., diabetes, hypertension, asthma. A subtype of Health Condition. A communication to appropriate Client Team members and/or the Health Care Client, to inform them about something that has happened, should happen, or will happen. Notifications are created to help manage outstanding planned activities, issues or communications that arise from monitoring the Health Care Plan. A type of role that provides a type of care to a Health Care Client, e.g. dietary advisor, primary care provider. HR Conceptual Information Architecture lueprint Report / Version No 01 13

14 Client upporter Client Team Member Clinical Guideline Clinical LIfe vent Clinical Observation Clinical Procedure Correspondence Cultural Characteristic Device Diagnosis Diagnostic Image Dispensing A friend or family member of the Health Care Client, or a trusted person, who is authorized by the client to participate either directly or indirectly in the client s health care. A sub-type of Health Client. The role that a specific Health Care Provider or Client upporter is assigned, to facilitate care for a Health Care Client. A standardized clinical target, the achievement of which would be an indication that the respective Health Care Client has reached a satisfactory state with respect to a specific Health Condition, such as diabetes or asthma. A life event that has clinical significance, e.g. birth, death. An Observation made by a Provider Person. A sub-type of Observation. A clinical activity whose immediate and primary outcome is the alteration of the physical or psychological condition of the subject. urgery is a primary example of physical alteration, but less invasive procedures such as physiotherapy, massage, or blood donation would also apply. A psychotherapy session would be an example of altering a psychological condition. A sub-type of Health Care ncounter Output. A communication relating to the health of, or the provision of health care to, the patient, e.g., patient is advised to reduce alcohol consumption. A sub-type of Client Care Notification. A self-reported characteristic such as ethnicity, race, religion, educational level, and language. A sub-type of Personal Health Characteristic. Materials and equipment intended to be supplied, implanted or used by a patient for the treatment, mitigation, cure or prevention of a medical condition or disease, e.g. insulin syringe, contact lens, pacemaker, artificial hip, casts, splints, crutches, wheelchairs, walkers. A sub-type of Health Product. The identification by a Provider Person of a disease or condition by scientific evaluation of physical signs, symptoms, history, lab test results, and procedures. A sub-type of Health Care ncounter Output. An observation in the form of a spatial representational of a physical subject suitable for visual presentation. (from HL7 v3) A sub-type of Clinical Observation and elf-reported Observation. xamples of Diagnostic Image can include: X-Ray, MRI, Ultrasound, Photograph, CAT can, etc The provision of a Device or Medication by a Provider to a Health Care Client. HR Conceptual Information Architecture lueprint Report / Version No 01 14

15 Drug-related Allergy ducation mergency Contact ncounter Location Family History Fitness Activity Functional arrier Health Care Client Health Care ncounter Health Care ncounter Output Health Care Plan Health Care Provider A sub-type of Health Care ncounter Output. An allergy to a particular Medication, which can be caused by the active ingredient, the filler or the production method, (e.g. an allergy to eggs precludes use of vaccines which were incubated using eggs). A subtype of Allergy. Informing the client about health related activities such as managing a chronic disease, improving state of health, behavior modification, and use of Health Products. A sub-type of Health Care ncounter Output. A person to be contacted in the event of a medical emergency involving the Health Care Client. A place at which health services have been provided in a Health Care ncounter. It is a geographic or virtual address of the place at which the encounter occurred. It may also be temporary (e.g. flu shot clinic in a mall), mobile (e.g., ambulance, mobile lab), or in the field (e.g., car, accident site). Knowledge of pertinent relatives having chronic conditions such as diabetes, heart disease, and cancer. A sub-type of Personal Health Characteristic. An activity that will prevent a health problem, or improve or maintain the patient's physical or mental condition and may help to meet a patient's lifestyle or clinical care target (e.g. exercise, meditation). A sub-type of Health Care ncounter Output. A patient's physical or mental condition that might affect their ability to self-manage the care plan (e.g. blindness). A sub-type of arrier. A person who: is eligible to receive health care services in Ontario, or has received or is receiving health care services in the province of Ontario (i.e. a patient). A sub-type of Health Client. An event occurring at a given time and place, where one or more services or products are provided to assess, maintain or improve the patient s health. The service or product could be from a Health Care Provider, or self-provided. omething produced as a result of a Health Care ncounter. Any number of outputs can be provided as a result of the same encounter, and the output can be provided after the encounter is over. An integrated care plan to manage the optimal health of a patient, authored by the patient and/or provider(s), to address preventative measures or existing health conditions experienced by the patient. It contains patient-centered activities and targets that are based on best practice guidelines and are monitored by Client Team Members on a regular basis. A person or an organization that provides health care or other health-related services or products. HR Conceptual Information Architecture lueprint Report / Version No 01 15

16 Health Care ervice Health Client Health Concern The offering and fulfillment of a specific type of health outcome by a provider to its clients, where each provisioning may require a range of interactions and touch points over time. xamples: rhinoplasty, surgery, pediatrics, obstetrics, acupuncture, chiropractic, massage. An individual who is a recipient of, is eligible to receive, or is acting on behalf of / supporting those receiving health care in Ontario. An issue that prompts an encounter with a Health Care Provider, such as: A health symptom or complaint experienced by the patient, e.g. headaches, back pain, or a health need expressed by the patient, e.g., continuing good health., or a requirement by a third party to establish the patient's health state, e.g. for life insurance, pilot licensing, job application or retention. Health Condition Health Directive Health Product Health Product Location Health Target Immunization Implantable Device Information Consent A health state that persists over time and tends to require intervention or management and is, therefore, distinguished from an observation made at a point in time. A health condition can "morph" over time, changing in nature or acuity, splitting or merging. Health condition is a broad term that includes all diseases and disorders, specifically to denote any illness, injury, disease, or complications from existing health conditions or treatment. An instruction to be followed regarding health care provided by the Health Care Client, e.g. Do not resuscitate. A sub-type of Personal Health Characteristic. Material (i.e. medication or devices), or a service, provided for the treatment, mitigation, cure or prevention of disease or injury. A place at which health products are available. It is a geographic or virtual address of the place at which encounters have occurred, or may occur. It may also be temporary (e.g. flu shot clinic in a mall), mobile (e.g, ambulance, mobile lab), or in the field (e.g, car, accident site). A desired state of a Health Condition or Personal Health Characteristic of a patient that can be measured by clinical tests (e.g, fasting blood glucose level less than 6, provider-assessed weight less than 130 lbs, non-smoker). An application of a technique (e.g. vaccination), that induces immune resistance to a specific disease by exposing the individual to an antigen in order to raise the level of antibodies to that antigen. A sub-type of Personal Health Characteristic. A Device that is implanted in a patient's body. A sub-type of Device. A directive received from a Health Care Client for the purpose of restricting or authorizing access to or sharing of Personal Health Information (PHI) by health information custodians (implied consent directive), or authorizing non-hics to access PHI (explicit consent directive). HR Conceptual Information Architecture lueprint Report / Version No 01 16

17 Intake Intolerance Life vent Lifestyle Characteristic Medication Mental Characteristic Observation The administering of a substance into the body that is key to the management of a Health Care Client's condition(s), e.g. daily consumption of food items, beverages, and oral medication or injected medication. A sub-type of Health Care ncounter Output. An adverse sensitivity to a substance caused by a mechanism other than an immunologic over-response. An incident or occurrence involving the Health Care Client that causes a Health Concern to arise for that client, e.g, accident, exposure to hazardous materials, travel to countries where immunization is advised. A recurring behaviour, or trait related to the way a person lives that is relevant to their health, e.g. recreational drug use, smoking, physical activity, occupational activities, recreational activities. A sub-type of Personal Health Characteristic. A substance intended for use in the treatment, mitigation, cure or prevention of disease. Includes prescription drugs, herbal medicine, vitamins, minerals, Chinese medicine, and other over the counter medicines. A sub-type of Health Product. A mental aspect of a person of which assessments are made, e.g. A sub-type of Personal Health Characteristic. An act of recognizing and noting health-related information about a Health Care Client, evaluating the information, and determining health findings about the client. Observations often involve measurement or other elaborate methods of investigation, but may also be simply assertive statements, findings, symptoms, conclusions, etc. Permission Permission Override Personal Health Characteristic Physical Characteristic Plan Component A sub-type of Health Care ncounter Output. A pre-defined rule that specifies an action that a Client Care Role is authorized to execute, e.g., the Primary Care Provider ( most responsible provider ) role can enroll patients to care programs, and the family member role can view the patient s care plan. The customization of a generic permission privilege that is inherited by the team member in assuming a role. It may be the restriction or relaxation of a permission type pre-defined for the role. For example, normally the Dietician role can only view (not update) the patient s diary. A patient may grant special permission to their dietician to enable him/her to update the nutritional intake portion of their diary. A physical, social, environmental, occupational, or lifestyle factor particular to a patient that may affect his/her health and/or the provision of their health care. A physical aspect of a person of which measurements are taken, e.g. age, gender. A sub-type of Personal Health Characteristic. A part of a Health Care Plan, authored by the patient and/or HR Conceptual Information Architecture lueprint Report / Version No 01 17

18 provider(s), that is: a set of related activities that will be performed by the patient to assist with their Health Care Plan (e.g. disease monitoring, education/training, exercise, food intake, medication, treatment, regular examinations), or a goal for those activities (e.g. monitoring blood glucose on a daily basis, intake of less than 1500 calories per day), or a target with respect to a Health Condition or Personal Health Characteristic, e.g. non-smoker. Plan Health Activity Provider ncounter Provider pisode of Care Provider Organization Provider Person Reminder Requisition elf-care ncounter An activity that the patient will perform for health reasons. An encounter where a Health Care Provider is involved. This could be unplanned (e.g. R visit) or planned (e.g. doctor s appointment). A sub-type of Health Care ncounter. A time interval during which a series of Health Care ncounters are conducted to address one Health Condition by the same Provider Person. An episode of care starts with the very first contact with the provider for the health issue and it ends after the last encounter with the provider for the Health Condition. A hospital stay is represented by a Provider pisode of Care for the admitting doctor. An organization that provides health care or other health-related services or products. A sub-type of Health Care Provider. A person that provides health care or other health-related services or products. May be regulated or non-regulated. A sub-type of Health Care Provider. A prompt to perform a planned activity. A sub-type of Client Care Notification. A request for a Health Product, fulfilled by providers such as: medical laboratories in areas such as chemistry, serology, haematology, microbiology, histology, anatomic pathology, cytology and virology, or diagnostic imaging laboratories in areas such as X-rays, MRIs, ultrasounds, and radiology, or providers of Health Care Products, such as pharmacists, where the request may take the form of a prescription, or health care specialists, for clinical care or evaluation that requires expertise outside the domain of the referring provider, including community services such as home care, genetic profiling, and stress testing. A sub-type of Health Care ncounter Output. An encounter where care is self-provided, e.g. glucometer reading, treatment of a wound, non-prescription medication. HR Conceptual Information Architecture lueprint Report / Version No 01 18

19 elf-reported Observation ensitivity ocio-economic arrier pecial Need ubstance Transient Condition A sub-type of Health Care ncounter. An Observation made by a Health Care Client. A sub-type of Observation. The state, condition, or quality of reacting or being sensitive to an external stimulus, e.g. environment, substance. ocial or economic limitation that may potentially hinder the patient s capability to self-manage the care plan, e.g., customs or beliefs forbidding certain treatments. A sub-type of arrier. A need for measures to be taken that are outside the norm when providing health care, e.g., language translation, mobility assistance. A sub-type of Personal Health Characteristic. Material(s) that the body may be exposed to through ingestion, injection, topical application or in the environment. A Health Condition from which the Health Care Client is expected to recover. A subtype of Health Condition. HR Conceptual Information Architecture lueprint Report / Version No 01 19

20 4. Comparison with other models 4.1. Mapping against internal sources The CIM entities were mapped against the entities in the data models from the existing ehealth Ontario application systems, the details of which are provided in rror! Reference source not found.. The analysis f the results is documented in this section. This section provides a mapping between entities in conceptual and logical data models for current ehealth Ontario application system implementations and the HR Conceptual Information Model (CIM) entities. The entity definitions used by those system models were reviewed as data definition sources for the Conceptual Information Model. These source data models were from the following systems implementations: Chronic Disease Management ystem (CDM) Client Registry and Provider Registry (CR/PR) Diagnostic Imaging/Picture Archiving and Communication ystem (DI-PAC) Medication Management ystem (MM) o conceptual data model (MM-C) o logical data model (MM-L) Ontario Laboratories Information ystem (OLI) The source models define data structures at a level of detail equivalent to or greater than the CIM entities, and may define data structures that are out of scope for the HR. A source entity will be: the equivalent of an CIM entity (e.g. Adverse Reaction is a CIM entity as well as a MM entity), or a sub-type of an CIM entity (e.g., the CDM lood Pressure entity is a sub-type of the CIM Observation entity), in which case the CIM entity is identified as a super-type, or a lower-level entity relative to the CIM entity (e.g., MM Active Ingredient is a lower level data structure related to the CIM Medication entity), in which case the CIM entity is identified as a broader entity, or similar to a CIM entity, but with a different definition (e.g., CDM Patient Health Profile Item maps to four CIM entities: Personal Health Characteristic, Health Condition, ensitivity, and arrier) in which case the CIM entity is identified as a different definition, or represents data that is not part of the HR and is out of scope, (e.g., MM Coverage xtension, defined as an authorization issued by a payer to cover a drug not previously covered by a patient's drug plan ) Chronic Disease Management ystem (CDM) The following table presents the statistics for CDM. CIM Mapping Result # of ntities % of Total quivalent entity 40 41% uper type 44 46% roader ntity 5 5% ubtotal of ntities that fit 89 92% Different Definition 2 2% Not in HR scope 6 6% Total ntities % HR Conceptual Information Architecture lueprint Report / Version No 01 20

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