Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0

pic Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0 Technical Guide Types of Care

Our Vision Better data. Better decisions. Healthier Canadians. Our Mandate To lead the development and maintenance of comprehensive and integrated health information that enables sound policy and effective health system management that improve health and health care. Our Values Respect, Integrity, Collaboration, Excellence, Innovation

Table of Contents Acknowledgements... 4 CIHI Project Team... 4 About the Canadian Institute for Health Information... 5 About Primary Health Care Data and Information... 5 About This Document... 5 Background... 6 Scope... 6 Out of Scope... 7 Future Considerations... 8 Data Extraction... 8 Additional Data Elements Beyond the Priority Subset... 8 Document Conventions... 8 Entity-Relationship Diagram... 8 Entities and Entity Relationships... 9 Description of Entities... 9 Entity Relationships... 10 Implementation Considerations/Guidance... 11 Client and Provider Identification... 11 Associations Among Data Elements... 11 Adding Data Elements in the Model... 11 Clinical Assessment Indicator Code... 12 Use of Standard Codes for Observation Type Code... 12 Priority Subset Data Elements: Data Model Attributes Maps... 12

Acknowledgements The Canadian Institute for Health Information (CIHI) would like to acknowledge and thank the many individuals and organizations that provided input on this product. In particular, CIHI would like to acknowledge and express its appreciation to the following technical reviewers, who provided invaluable guidance on the content for the Pan-Canadian Primary Health Care Electronic Medical Record : Claudiu Grecu, Standards Lead, ehealth Ontario David Mah, IT Access Analyst, Alberta Health Services Alex Mair, Director, Architecture, Health System Use, Emerging Technology Group, Canada Health Infoway Jeff Niles, Senior Advisor, Health Canada Pavel Platonov, Senior EMR Technical Specialist, PCIS Office, Manitoba ehealth CIHI Project Team The core CIHI project team responsible for developing the Pan-Canadian Primary Health Care Electronic Medical Record included Alison Bidie, Project Lead, Primary Health Care Information Finnie Flores, Program Lead, Architecture and Standards Jing He, Senior Analyst, Primary Health Care Information Caroline Heick, Executive Director, Ontario, Quebec and Primary Health Care Alexander Lim, Senior Coordinator, Primary Health Care Information Martin Ortuzar, Applications Architect, Architecture and Standards Cristina Tomsa, Data Architect, Architecture and Standards Significant project contributions were also made by Husam Alqatami, Andrew Goosen, Deepak Swain and Jennifer Trebell. This product could not have been completed without the generous support and assistance of many other CIHI staff members, including those in information technology and services, layout and design, communications and distribution. 4

About the Canadian Institute for Health Information The Canadian Institute for Health Information (CIHI) collects and analyzes information on health and health care in Canada and makes it publicly available. Canada s federal, provincial and territorial governments created CIHI in 1994 as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI s goal: to provide timely, accurate and comparable information. CIHI s data and reports inform health policies, support the effective delivery of health services and raise awareness among Canadians of the factors that contribute to good health. The year 2014 marks CIHI s 20th anniversary of operation. For more information, visit our website at www.cihi.ca. About Primary Health Care Data and Information CIHI is leading several initiatives to improve primary health care (PHC) data and information across Canada. Working with stakeholders from across the country, our goal is to strengthen and improve the PHC data that is available to providers and health system decision-makers. We help our stakeholders in their efforts to measure, manage and improve PHC by delivering standards, data, reports and knowledge. Our PHC Information program provides national leadership, solutions and support, including PHC Electronic Medical Record Content Standard (PHC EMR CS); Analytical reports; PHC indicators for providers and policy-makers; and PHC survey questions and tools. About This Document This document is intended for technical stakeholders, including EMR vendors and jurisdictional implementers. It is a companion to the PHC EMR CS Priority Subset conceptual and logical data models, clarifying the models, their scope and technical considerations. The conceptual and logical data models were developed to provide an overview of PHC business entities (such as Client and Health Service Event) and the relationships among these entities. The data models are independent of technology (databases, files, etc.). The data models were structured with the Client at the centre to reflect the needs of patient-centred health care. 5

Companion products supporting the PHC EMR CS Priority Subset include PHC EMR CS information sheet; Business view; Frequently asked questions; Implementation guide; and Clinician-friendly pick-lists (CFPLs). Background Informed by consultations and environmental scans, CIHI is working with jurisdictions, clinicians and Canada Health Infoway to support the adoption of the PHC EMR CS by issuing a Priority Subset (45 of the original 106 data elements). The Priority Subset was endorsed by the Jurisdictional Advisory Group (JAG) in December 2013. To support its adoption, CIHI is developing CFPLs for priority data elements, including Health Concern, Clinician Assessment, Reason for Visit, Social Behaviour, Intervention, Diagnostic Imaging Test Ordered, Referral and Vaccine Administered. These pick-lists are constrained lists of clinician-friendly terms mapped to a code system. It is anticipated that jurisdictions will include the Priority Subset, associated CFPLs and relevant PHC reference sets in their EMR vendor requirements. When implemented at the point of care, the adoption of the PHC EMR CS will increase the availability of structured, coded data in EMRs to support quality improvement at the practice and health system levels. The Priority Subset and the focused scope of the CFPLs directly support priority performance measurement for clinicians and decision-makers. For more information on the Priority Subset, CFPLs and PHC indicators, refer to Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0 Business View. Scope The PHC EMR CS data models are conceptual and logical models that support the 45 data elements in the PHC EMR CS Priority Subset. The Priority Subset was developed to support both clinical and health system use PHC clinical program management, health system management, research and monitoring of the health of the population. Data elements in the Priority Subset are identified in Table 1. 6

Table 1: PHC EMR CS Priority Subset and Associated Clinician-Friendly Pick-Lists DE # Data Element Name DE # Data Element Name A1 Client Identifier E29 Observation Height Unit of Measure Code A2 Client Identifier Type Code E30 Observation Weight Number A3 Client Identifier Assigning Authority Code E31 Observation Weight Unit of Measure Code A4 Client Birth Date E34 Observation Encounter Clinical Assessment Code A5 Client Administrative Gender Code F1 Intervention Code A9 Client Status Code F2 Intervention Date A14 Client Residence Postal Code G1 Laboratory Test Name Ordered Code B4 Provider Identifier G2 Laboratory Test Order Date B5 Provider Identifier Type Code H1 Laboratory Test Performed Date B6 Provider Identifier Assigning Authority Code H2 Laboratory Test Result Name Code B7 Provider Role Type Code H3 Laboratory Test Result Value Text (Number, Code) C1 Service Delivery Location Identifier H4 Laboratory Test Result Value Unit of Measure Code C4 Service Delivery Location Postal Code I1 Diagnostic Imaging Test Ordered Code D1 Encounter Request Date I2 Diagnostic Imaging Test Ordered Date D2 Client Encounter Reason Code J1 Diagnostic Imaging Test Performed Date D3 Encounter Date K1 Referral Service Code D4 Encounter Mode Code K2 Referral Requested Date E11 Observation Health Concern Code L1 Referral Occurred Date E12 Observation Health Concern Start Date M1 Medication Prescribed Name Code E14 Observation Social Behaviour Code M2 Medication Prescribed Date E23 Observation Systolic Blood Pressure Number O1 Vaccine Administered Name Code E24 Observation Diastolic Blood Pressure Number O2 Vaccine Administered Date E28 Observation Height Number Note Shaded data elements indicate an associated CPFL. Out of Scope The PHC EMR CS data models do not include a physical model (that is, they are conceptual and logical models only). Additional data elements beyond the Priority Subset are not included in the data models. The focused scope of the PHC EMR CS and CFPLs serves as a starter set for jurisdictions to implement for structured EMR data at the point of care. This technical guide does not include data element definitions, data types, attribute cardinality and permissible values for coded attributes. Such information will be addressed in the PHC EMR CS implementation guide. 7

Future Considerations Data Extraction Presently, CIHI is focused on facilitating the capture of structured EMR data at the point of care through the adoption of the Priority Subset and CFPLs. The pan-canadian Data Extract Specification (DES) was previously developed to support the original 106 data elements and extraction of data from EMR systems. The DES may serve as a point of reference for future activity, but will not be updated and supported by CIHI. Additional Data Elements Beyond the Priority Subset Jurisdictions are able to define and collect data elements beyond the Priority Subset, as driven and supported by their programs and needs. These additional elements may be considered in the longer term for the PHC EMR CS and associated products. Document Conventions Entity-Relationship Diagram The conceptual and logical data models use standard entity-relationship diagram notation. Primary keys are denoted by the symbol l. In the data models, only logical keys are represented. Physical implementations would use surrogate keys instead. Cardinality denotes the number of instances of an entity class that participates in a relationship; it is represented using crow s feet notation. Figure 1: Symbols Used to Denote Cardinality Symbol Meaning One and only one Zero or one Many Zero or many (cont d on next page) 8

Figure 1: Symbols Used to Denote Cardinality (cont d) Symbol Meaning One or many * Zero, one or many Note * Due to limitations with the data modelling tool, the relationship between Encounter and Provider appears to be many-to-many, but it should be one-or-many-to-one-or-many. Subtypes (for example, Health Concern is an exclusive subtype of Observation) use information engineering (IE) subtype notation. In the conceptual and logical data models, exclusive subtypes are denoted with this symbol: Entities and Entity Relationships Description of Entities Client: A person who has received, is receiving or is eligible to receive health care related services or goods. A Client is dependent on a Provider to receive a Health Service Event (HSE). Provider: A person who has delivered, is delivering or has the potential to deliver health care related services or goods. Service Delivery Location: A place where health care related services or goods are provided. A Service Delivery Location is the site of Health Service Events. Health Service Event: A past, current, planned or requested act. This entity is a supertype of the following business entities: Encounter, Observation, Intervention, Lab Request, Diagnostic Imaging Request, Referral Request, Prescribed Medication and Immunization. Encounter: An interaction between a Client and one or more Providers for the purpose of providing one or more health care related services or goods. Intervention: Current and previous services/activities performed within or outside the PHC setting that are relevant to the patient s care. Lab Request: The lab test ordered by the Provider for the Client. 9

Diagnostic Imaging Request: The type of diagnostic imaging test ordered by the Provider for the Client. Referral Request: The type of service or specialty required for the Client requested by the PHC Provider (for example, cardiology). Medication Prescribed: The medications prescribed for the Client. Immunization: The vaccine administered to the Client within and beyond the PHC setting, including current and past vaccination history. Observation: Information derived from performance of a health-related activity. This entity is a supertype of Health Concern, Social Behaviour, Measured Observation, Lab Result, Diagnostic Imaging Result and Referral Result. Health Concern: The Client s relevant conditions, diagnoses and associated past medical history. Social Behaviour: A type of Client behaviour that increases the possibility of disease or injury. This can include risk factors such as tobacco use, alcohol use and abuse of illicit or prescription drugs. Lab Result: A result for analytical services, typically performed by medical laboratories in areas such as chemistry, serology, hematology, microbiology, histology, anatomic pathology, cytology and virology. Measured Observation: Data obtained by performing a health-related activity that is represented by a numeric value. Recordings of a Client s height, weight and blood pressure are examples of Measured Observations. Entity Relationships In most cases, the relationship between entities in the data model has been set to optional (that is, the lower bound of the cardinality is set to 0) to provide flexibility in storing and submitting data and to minimize potential data loss. However, there are some mandatory relationships (that is, the lower bound of the cardinality is set to 1), either to support PHC indicator calculation or because a mandatory relationship makes sense from a PHC workflow perspective. Mandatory relationships between entities include the following: A Health Service Event (HSE) must be associated with a Client. A Social Behaviour must be associated with an Encounter. i A Measured Observation must be associated with an Encounter. i A Provider Client Status must be associated with a Client and Provider. i. Onset of and completion date for Social Behaviour and observation date for Measured Observation (such as blood pressure) are not included in the Priority Subset. However, the data model has a constraint that both Social Behaviour and Measured Observation require an Encounter that has an encounter date. The encounter date, when tied to Social Behaviour and Measured Observation, will support calculation of priority indicators. 10

Implementation Considerations/Guidance Client and Provider Identification CIHI recommends that jurisdictions use a single identifier to identify a Client, such as jurisdictional health card number or RCMP health care number (if applicable). A single identifier for a Provider is also recommended, such as billing number or registration number. The logical data model is designed to support the capture and extraction of data for either single or multiple EMR systems. The association in the data model between a Client (patient) and a Provider allows a uniquely identified Client to be associated with multiple Providers at the same time. This relationship enables aggregation of data from multiple EMR systems into a single jurisdictional view if required. In cases where data from multiple EMR systems is consolidated or aggregated, it is recommended that a single standardized approach be used to identify Clients and Providers. The data elements identifying a Client (A1 Client Identifier, A2 Client Identifier Type Code and A3 Client Identifier Assigning Authority Code) and the data elements identifying a Provider (B4 Provider Identifier, B5 Provider Identifier Type Code, B6 Provider Identifier Assigning Authority Code and B7 Provider Role Type Code) support multiple approaches for identifying a Client and Provider, respectively. However, it is recommended that jurisdictions standardize the identification approach for all EMR systems implementing the PHC EMR CS Priority Subset to simplify the process of extracting and aggregating data into a single view. For example, although the PHC reference set for A2 Client Identifier Type Code includes jurisdictional health number and passport number, these numbers should not be used interchangeably to identify the same Client. It is recommended that a standard approach be developed so that a Client is always identified with the same identifier to enable aggregation of his or her records. Associations Among Data Elements The logical data model specifies the minimum level of associations among data elements to support the calculation of PHC indicators. It is recommended that the data captured within and extracted from an EMR system should maintain this structure. Adding Data Elements in the Model Jurisdictions may add additional data elements to the data model as additional entities or as attributes of new or existing entities. For example, enrollment of a patient with an organization instead of a Provider can be managed through the addition of associative entities. It is recommended that the core relationships in the data model be retained to use the data for PHC indicator calculation. 11

Clinical Assessment Indicator Code E34 Observation Encounter Clinical Assessment Code represents the Provider s professional opinion of the most relevant clinical findings (or most responsible Health Concern) related to the patient s current encounter. The Clinical Assessment Indicator (Ind) Code identifies which instance of Health Concern maps to E34. While the data model allows each instance of a Health Concern to have the Clinical Assessment Indicator Code set, only one instance of Health Concern must have the Clinical Assessment Indicator Code set and assigned as the E34 Observation Encounter Clinical Assessment Code. Example A Client presents to a PHC clinic for control of his hypertension. He also has associated diabetes and asthma. Blood pressure is taken, and results confirm high blood pressure requiring a prescription of atenolol. Hypertension is assigned as the most relevant clinical finding related to the patient s encounter (E34 Observation Encounter Clinical Assessment Code). All three conditions (Hypertension, diabetes and asthma) will be captured as Health Concerns, but only hypertension will have the Clinical Assessment Indicator Code set to indicate that it is the Observation Encounter Clinical Assessment Code (E34). Use of Standard Codes for Observation Type Code The Measured Observation entity has the attribute Observation Type Code, which is used to identify the type of measurement observation (height, weight, systolic and diastolic blood pressure). It is recommended that a standard-based terminology (such as LOINC code) be used to identify the type of observation measured. Priority Subset Data Elements: Data Model Attributes Maps The following tables include the mapping of the Detailed Logical Data Model attributes to the PHC EMR CS Priority Subset data elements. The first map is organized by Detailed Logical Data Model entities and attributes; the second is organized by PHC EMR CS Unique Identifier. 12

Table 2: Map Organized by Data Model Entities and Attributes Data Model Attribute Name Unique Identifier PHC EMR CS Data Element Standard Name Client Client Identifier A1 Client Identifier Client Identifier Type Code A2 Client Identifier Type Code Client Identifier Assigning Authority Code A3 Client Identifier Assigning Authority Code Birth Date A4 Client Birth Date Administrative Gender Code A5 Client Administrative Gender Code Residence Postal Code A14 Client Residence Postal Code Provider Provider Identifier B4 Provider Identifier Provider Identifier Type Code B5 Provider Identifier Type Code Provider Identifier Assigning Authority Code B6 Provider Identifier Assigning Authority Code Provider Role Type Code B7 Provider Role Type Code Provider Client Status Client Status Code A9 Client Status Code Service Delivery Location Service Delivery Location Identifier C1 Service Delivery Location Identifier Postal Code C4 Service Delivery Location Postal Code Encounter Request Date D1 Encounter Request Date Reason Code D2 Client Encounter Reason Code Encounter Date D3 Encounter Date Contact Mode Code D4 Encounter Mode Code Intervention Intervention Code F1 Intervention Code Intervention Date F2 Intervention Date Lab Request Test Ordered Code G1 Laboratory Test Name Ordered Code Test Ordered Date G2 Laboratory Test Order Date Diagnostic Imaging Request Test Ordered Code I1 Diagnostic Imaging Test Ordered Code Test Ordered Date I2 Diagnostic Imaging Test Ordered Date Referral Request Referral Service Code K1 Referral Service Code Referral Requested Date K2 Referral Requested Date Medication Prescribed Medication Code M1 Medication Prescribed Name Code Prescribed Date M2 Medication Prescribed Date (cont d on next page) 13

Table 2: Map Organized by Data Model Entities and Attributes (cont d) Data Model Attribute Name Unique Identifier PHC EMR CS Data Element Standard Name Immunization Vaccine Code O1 Vaccine Administered Name Code Vaccine Administered Date O2 Vaccine Administered Date Health Concern Health Concern Code E11 Observation Health Concern Code E34 Observation Encounter Clinical Assessment Code* Onset Start Date E12 Observation Health Concern Start Date Social Behaviour Social Behaviour Code E14 Observation Social Behaviour Code Measured Observation Observation Type Code N/A N/A Observation Value E23 E24 E28 E30 Observation Systolic Blood Pressure Number Observation Diastolic Blood Pressure Number Observation Height Number Observation Weight Number Observation Unit of Measure E29 E31 Observation Height Unit of Measure Code Observation Weight Unit of Measure Code Lab Result Test Performed Date H1 Laboratory Test Performed Date Test Result Code H2 Laboratory Test Result Name Code Test Result Value Text H3 Laboratory Test Result Value Text (Number, Code) Test Result Unit of Measure H4 Laboratory Test Result Value Unit of Measure Code Diagnostic Imaging Result Test Performed Date J1 Diagnostic Imaging Test Performed Date Test Result Code I1 Diagnostic Imaging Test Ordered Code Referral Result Referral Occurred Date L1 Referral Occurred Date Service Result Code K1 Referral Service Code Notes * Clinical Assessment Indicator Code identifies which instance of Health Concern is E34 Observation Encounter Clinical Assessment Code. Note that only one Health Concern may have the Clinical Assessment Indicator Code set (that is, only one Health Concern can be designated as E34). Observation Type Code identifies the type of observation (systolic blood pressure, height, etc.). Test Result Code may or may not map to I1 Diagnostic Imaging Test Ordered Code to allow for capture of diagnostic imaging results without an order. Service Result Code may or may not map to K1 Referral Service Code to allow for capture of referral results without an order. 14

Table 3: Map Organized by Unique Identifier Unique Identifier PHC EMR CS Data Element Standard Name Data Model Attribute Name* A1 Client Identifier (Client) Client Identifier A2 Client Identifier Type Code (Client) Client Identifier Type Code A3 Client Identifier Assigning Authority Code (Client) Client Identifier Assigning Authority Code A4 Client Birth Date (Client) Birth Date A5 Client Administrative Gender Code (Client) Administrative Gender Code A9 Client Status Code (Client) Client Status Code A14 Client Residence Postal Code (Client) Residence Postal Code B4 Provider Identifier (Provider) Provider Identifier B5 Provider Identifier Type Code (Provider) Provider Identifier Type Code B6 Provider Identifier Assigning Authority Code (Provider) Provider Identifier Assigning Authority Code B7 Provider Role Type Code (Provider) Provider Role Type Code C1 Service Delivery Location Identifier (Service Delivery Location) Service Delivery Location Identifier C4 Service Delivery Location Postal Code (Service Delivery Location) Postal Code D1 Encounter Request Date (Encounter) Request Date D2 Client Encounter Reason Code (Encounter) Reason Code D3 Encounter Date (Encounter) Encounter Date D4 Encounter Mode Code (Encounter) Contact Mode Code E11 Observation Health Concern Code (Health Concern) Health Concern Code E12 Observation Health Concern Start Date (Health Concern) Onset Start Date E14 Observation Social Behaviour Code (Social Behaviour) Social Behaviour Code E23 Observation Systolic Blood Pressure Number (Measured Observation) Observation Value E24 Observation Diastolic Blood Pressure Number (Measured Observation) Observation Value E28 Observation Height Number (Measured Observation) Observation Value E29 Observation Height Unit of Measure Code (Measured Observation) Observation Unit of Measure E30 Observation Weight Number (Measured Observation) Observation Value E31 Observation Weight Unit of Measure Code (Measured Observation) Observation Unit of Measure E34 Observation Encounter Clinical (Health Concern) Health Concern Code Assessment Code F1 Intervention Code (Intervention) Intervention Code F2 Intervention Date (Intervention) Intervention Date G1 Laboratory Test Name Ordered Code (Lab Request) Test Ordered Code G2 Laboratory Test Order Date (Lab Request) Test Ordered Date H1 Laboratory Test Performed Date (Lab Result) Test Performed Date H2 Laboratory Test Result Name Code (Lab Result) Test Result Code H3 Laboratory Test Result Value Text (Number, Code) (Lab Result) Test Result Value Text (cont d on next page) 15

Table 3: Map Organized by Unique Identifier (cont d) Unique Identifier PHC EMR CS Data Element Standard Name Data Model Attribute Name* H4 Laboratory Test Result Value Unit of (Lab Result) Test Result Unit of Measure Measure Code I1 Diagnostic Imaging Test Ordered Code (Diagnostic Imaging Request) Test Ordered Code (Diagnostic Imaging Result) Test Result Code I2 Diagnostic Imaging Test Ordered Date (Diagnostic Imaging Request) Order Test Date J1 Diagnostic Imaging Test Performed Date (Diagnostic Imaging Result) Test Performed Date K1 Referral Service Code (Referral Request) Referral Service Code (Referral Result) Service Result Code** K2 Referral Requested Date (Referral Request) Referral Requested Date L1 Referral Occurred Date (Referral Result) Referral Occurred Date M1 Medication Prescribed Name Code (Medication Prescribed) Medication Code M2 Medication Prescribed Date (Medication Prescribed) Prescribed Date O1 Vaccine Administered Name Code (Immunization) Vaccine Code O2 Vaccine Administered Date (Immunization) Vaccine Administered Date Notes * Text in parentheses is the entity name. Observation Type Code identifies the type of observation (systolic blood pressure, height, etc.). Clinical Assessment Indicator Code identifies which instance of Health Concern is E34 Observation Encounter Clinical Assessment Code. Note that only one Health Concern may have the Clinical Assessment Indicator Code set (that is, only one Health Concern can be designated as E34). Test Result Code may or may not map to I1 Diagnostic Imaging Test Ordered Code to allow for capture of diagnostic imaging results without an order. ** Service Result Code may or may not map to K1 Referral Service Code to allow for capture of referral results without an order. 16

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