Clinical Information Model Initiative (CIMI) Reference Model Specification

Context indicating the known absence of a finding in the subject of information. If the finding is suspected to be absent, use the known or suspected present context instead.

Type supporting the capture of accreditation information.

The ActionContext class aligns with the SNOMED Situations with Explicit Context and provides the context for the ProcedureTopic of a clinical statement. For instance, a statement about a procedure may specify that the procedure has been proposed, ordered, planned, performed or possibly not performed.

Base class for addresses to be specialized based on regional and realm-specific needs.

A record about the admission of a patient to a facility generally for the provision of care.

An entry in the patient record documenting an untoward or unexpected finding observed during the course of an activity or an activity. Adverse events may capture either a workflow breach that may or may not result in harm but that must be documented for quality improvement purposes or an adverse finding whether or not it can be traceable to an actual workflow breach.

An entry in an adverse event report documenting an event that may result in harm to a subject and which must be documented.

An AdverseFinding is any unexpected clinical finding in a patient in the course of care or clinical investigation subject which does not necessarily have a causal relationship with a specific intervention.

An unintended physical injury resulting from exposure to a substance. Note that the manifestation of the adverse reaction is captured in FindingTopic.result attribute.

Estimate of the potential clinical harm, or seriousness, of the reaction to the identified substance.

A part of the body.

Text node with optional attribution

Abstract supertype. Usually maps to a type like “Any” or “Object” in an object system. Defined here to provide the value and reference equality semantics.

Archetypes act as the configuration basis for the particular structures of instances defined by the reference model. To enable archetypes to be used to create valid data, key classes in the reference model act as root points for archetyping; accordingly, these classes have the archetype_details attribute set. An instance of the class ARCHETYPED contains the relevant archetype identification information, allowing generating archetypes to be matched up with data instances.

physical container of items indexed by number

An assertion is used to express findings such as 'patient has diabetes' or 'patient has high blood pressure' that typically indicate whether a patient is part of a specific cohort or set whose members share the characteristic and where the implied value is 'in-set' or 'not-in-set'. It is a finding about a subject that is NOT expressed in the form of a measureable-entity=measurement-value pair (e.g., systolic blood pressure = 120 mmHg). The latter is represented using the EvaluationResult class. Note that EvaluationResults (e.g., measureable entity: eye color, measurement value: blue) can sometimes be expressed as assertions and vice versa (e.g., set of people with blue eye color).

Attribution provides a formal pattern and reusable structure for attributes of a record that describes an activity in a process involved in producing, delivering or otherwise influencing that resource. Attribution provides a critical foundation for assessing authenticity, enabling trust, and allowing reproducibility. Provenance assertions are a form of contextual metadata and can themselves become important records with their own provenance. Provenance statement indicates clinical significance in terms of confidence in authenticity, reliability, and trustworthiness, integrity, and stage in lifecycle (e.g. Document Completion - has the artifact been legally authenticated), all of which may impact security, privacy, and trust policies. Attribution provides a common reference model pattern that may be included directly within a clinical statement (e.g., the metadata associated with the recording of a clinical statement in a system) or within the Provenance pattern when it is preferrable to have such information external to but referencing the clinical statement (see Provenance). Note that, when included directly within a clinical statement, updates made to attribution attribute values will result in a versioning change in the instance. When part of the Provenance class, updates to provenance do not result in an update of the clinical statement referenced by the Provenance class (see Provenance.target).

An abstract class that represents an encounter class.

Type supporting the capture of birth-related information.

logical True/False values; usually physically represented as an integer, but need not be

The BradenScaleAssessmentResult class captures the results of evaluating a patient with the Braden Scale to assess an adult patient's susceptibility to skin breakdown. The summation of the scores ranges from 6-23. Note: this class does not represent the assessment instrument itself which is considered to be a knowledge artifact rather than an entry in a patient record.

a type whose value is an 8-bit value.

The result of an assessment of causality typically done for pharmacovigilance - i.e., whether an adverse reaction was caused by exposure to the suspected entity.

a type whose value is a member of an 8-bit character-set (ISO: 'repertoire').

Type supporting the capture of citizenship information.

This resource identifies an instance or a type of a manufactured item that is used in the provision of healthcare without being substantially changed through that activity. The device may be a medical or non-medical device. Medical devices includes durable (reusable) medical equipment, implantable devices, as well as disposable equipment used for diagnostic, treatment, and research for healthcare and public health. Non-medical devices may include items such as a machine, cellphone, computer, application, etc.

A special type of information entry consisting of a topic and a context. The ClinicalStatement class provides the core pattern for more specific clinical statement archetypes, such as a statement that a finding has been found in a patient or that a procedure has been proposed by a clinical decision support system. The ClinicalStatement pattern defines the core attributes common to most clinical statements and specifies a composition pattern that encourage model component reuse and better alignment with the SNOMED CT Concept Model. A clinical statement is composed of the StatementTopic class (grouping of attributes for capturing information about a procedure or a clinical finding) and the StatementContext class (grouping of attributes providing the context for the statement topic such as whether a procedure was performed, requested, not performed or whether a finding is suspected present or absent in the patient). At the archetype level, the topic and context components are coordinated to form the clinical statement. For instance, the composition of the ProcedureTopic with the NotPerformed context indicates that the given procedure was not performed.

Association class used to represent the relationship between a class and one or more clinical statements where the relationship is qualified by one or more attributes.

An AdverseFinding is any unexpected clinical finding in a patient documented as part of a clinical investigation which does not necessarily have a causal relationship with a specific study intervention. For instance, a study participant developing a fever during the course of the study.

A text item whose value must be the rubric from a controlled terminology, the key (i.e. the code') of which is the code attribute. In other words: a CODED_TEXT is a combination of a CODE_PHRASE (effectively a code) and the rubric of that term, from a terminology service, in the language in which the data was authored. Since CODED_TEXT is a subtype of TEXT, it can be used in place of it, effectively allowing the type TEXT to mean a text item, which may optionally be coded. Misuse: If the intention is to represent a term code attached in some way to a fragment of plain text, CODED_TEXT should not be used.

The component abstract class is used to represent dependent observations, findings, or procedures associated with the parent clinical statement. A dependent component is a component that does not have an independent existence outside of its parent. For instance, the description of a wound bed must exist in the context of a wound assertion. However, a systolic blood pressure measurement can exist independently of a blood pressure panel. This distinction is important. Collections of independent statements should be represented using the composition structure offered by the CompoundClinicalStatement class. Collections of dependent structures should be modeled using the Component pattern.

A composition represents a document such as a patient record, a knowledge artifact, or a catalog definition.

Clinical statement representing multiple units of information that are treated as a whole such as a panel. A compound clinical statement is a collection of independent clinical statement, whether indivisible or compound. By independent, we mean that the content of a compound clinical statement may exist outside of the context of the containing clinical statement without any alterations to its meaning. Note that complex medications are indivisible clinical statements even though their structure may be a composite data structure. They are generally treated as an independent entry in a record and their parts do not constitute independent entries in a record.

Abstract ancestor of all concrete content types. A unit of content that makes up a composition - e.g., a clinical statement in a patient record, a simple or composite action is a knowledge document, a catalog entry in a catalog.

Serves as a common ancestor of all CIMI complex types.

Represents an absolute point in time, as measured on the Gregorian calendar, and specified only to the day. Semantics defined by ISO 8601. Used for recording dates in real world time. The partial form is used for approximate birth dates, dates of death, etc.

Information of about a death event.

Clinical Assertions assert the existence of clinical conditions, diseases, symptoms, etc. in the patient.

Refinement of the Person class with additional attributes.

This resource identifies an instance or a type of a manufactured item that is used in the provision of healthcare without being substantially changed through that activity. The device may be a medical or non-medical device. Medical devices includes durable (reusable) medical equipment, implantable devices, as well as disposable equipment used for diagnostic, treatment, and research for healthcare and public health. Non-medical devices may include items such as a machine, cellphone, computer, application, etc.

The list of diagnosis relevant to this encounter where a diagnosis is defined as 'a.The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and/or review of laboratory data. b.The opinion derived from such an evaluation' American Heritage Dictionary

A feature's physical attributes.

A record pertaining to the discharge of a patient from an institution.

Base class for dispense contexts.

Record of the dispensing event.

Medication dispensing instructions for prospective clinical statements.

Base class for medication dosage instruction and dosage event.

Pattern for the dosing of a medication. Describes the medication dosage information details e.g. dose, rate, site, route, etc.

Pattern for the dosing of a medication. Describes how medication is to be administered or how it should be taken.

Contains properties common to multiple kinds of Encounters which last more than a few hours. Such encounters typically include an admission and discharge process.

Represents a period of time with respect to a notional point in time, which is not specified. A sign may be used to indicate the duration is backwards in time rather than forwards. NOTE a deviation from ISO8601 is supported, allowing the W' designator to be mixed with other designators. See assumed types section in the Support IM. Used for recording the duration of something in the real world, particularly when there is a need a) to represent the duration in customary format, i.e. days, hours, minutes etc, and b) if it will be used in computational operations with date/time quantities, i.e. additions, subtractions etc. Misuse: Durations cannot be used to represent points in time, or intervals of time.

Data structure representing an electronic contact such as an email address or a phone number.

Abstract class defining the common meta-data of all types of encapsulated data.

Emergency is an encounter without a scheduled appointment and urgent clinical services are required.

An interaction between a patient and a practitioner under the auspices of a given organization for the purpose of providing healthcare-related service(s). It is important to understand that if the there is a change in provider or organization, by definition a new encounter will be generated. For example, if a patient is moved from Surgery to Post-Op, a new encounter is generated. Similarly, if a patient receives care from 2 nurses while in Post-Op, there will be 2 encounters.

Root class for entities such as people, organizations, and devices that have a separately identifiable existence.

An ENTRY is the minimal unit of logical information or knowledge documented within a composition such as a clinical statement in a patient record, a knowledge entry in a knowledge artifact, a product in a product catalog, etc... An ENTRY is also the minimal unit of information any query should return, since a whole ENTRY (including subparts) records spatial structure, timing information, and contextual information, as well as the subject and generator of the information.

The outcome of an evaluation of a characteristic. This model holds a 'question' in the key and holds a value in the result. This value is further qualified through the model's properties.

Context associated with non-clinical events such as floods, accidents, and tornadoes.

An non-clinical event such as a natural disaster. Topic allows the capture of information related to such events when they pertain to the clinical context associated with a given patient.

The FindingContext class aligns with the SNOMED Situation with Explicit Context for findings and provides the context for the EvaluationResult and Assertion topics of a clinical statement. For instance, a statement about findings may state that the finding was observed present or absent.

An assertion about a clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept located on a specific body location that has risen to a level of concern.

The characteristics looked for in medical investigations or diagnostics and the outcome.

A generic and not fully structured address expressed using postal conventions (as opposed to GPS or other location definition formats).

Type for representing identifiers of real-world entities. Typical identifiers include drivers licence number, social security number, veterans affairs number, prescription id, order id, and so on.

Clinical statement context for a goal.

Role assumed by an entity acting as a health care consumer.

A healthcare provider role associated with a person.

A non-person health care entity such as a medical group or other organization.

Role associated with the delivery of health care as opposed to a consumer of health care.

A role in a participation.

Patient is being treated 'In-Home' for this encounter.

A hospice encounter.

Experimental class for an imaging procedure. Note that this class is still incomplete at this time.

Represents a clinical statement that cannot be further decomposed into other independent clinical statement. An indivisible clinical statement must be able to stand alone such as a systolic blood pressure measurement which can be interpreted both inside a blood pressure panel or on its own. If the statement cannot stand alone, e.g., the size of a wound which cannot exist outside the context of the wound itself, then the Component pattern should be used instead.

An entry in a patient record or in a report. Generally used for the documentation of clinical information about a subject of information such as a patient or a relative of the patient, asserted by a particular source, recorded, and potentially verified.

A components that go to make up the described item.

Patient has been admitted to the facility and assigned a bed.

An instant in time - known at least to the second and always includes a time zone. Note: This is intended for precisely observed times (typically system logs etc.), and not human-reported times - for them, use date and dateTime. instant is a more constrained dateTime

An integer type

Countable quantities. Used for countable types such as pregnancies and steps (taken by a physiotherapy patient), number of cigarettes smoked in a day. Misuse: Not to be used for amounts of physical entities (which all have units).

Generic class defining an interval (i.e. range) of a comparable type. An interval is a contiguous subrange of a comparable base type. Used to define intervals of dates, times, quantities (whose units match) and so on. The type parameter, T, must be a descendant of the type ORDERED_VALUE, which is necessary (but not sufficient) for instances to be compared (strictly_comparable is also needed). The basic semantics are derived from the class Interval<T>, described in the support RM.

Context indicating that finding is known present or suspected present.

Specialization of Procedure that represents a procedure performed on a collected specimen such as a blood panel or a biopsy.

Measurement resulted from a laboratory.

Type representing proficiency in a language.

container of items, implied order, non-unique membership

Most classes in the CIMI reference model inherit from the LOCATABLE class, which defines the idea of 'locatability in an archetyped structure'. LOCATABLE defines a runtime name and an archetype_node_id. The archetype_node_id is the standardised semantic code for a node and comes from the corresponding node in the archetype used to create the data. The only exception is at archetype root points in data, where archetype_node_id carries the archetype identifier in string form rather than an interior node id from an archetype. LOCATABLE also provides the attribute archetype_details, which is non-Void for archetype root points in data, and carries meta-data relevant to root points. The name attribute carries a name created at runtime. The 'meaning' of any node is derived formally from the archetype by obtaining the text value for the archetype_node_id code from the archetype ontology section, in the language required.

Data structure representing a geographical location such as a location on a map or a location inside a facility.

A long term care encounter.

Class representing a medication. It covers the ingredients and the packaging for a medication.

Base class for the act of prescribing, documenting, administering, or dispensing a medication.

Context for the documentation of a medication dispense event.

Context for a medication order.

Action intended to modify an existing action such as a request to discontinue the administration of a medication or a proposal to cancel an existing order. Experimental

A specialisation of DV_ENCAPSULATED for audiovisual and biosignal types. Includes further metadata relating to multimedia types which are not applicable to other subtypes of DV_ENCAPSULATED.

Abstract supertype for the name of an entity.

Context to express an assertion of absence within an open world context. Typically used for allergy and intolerance statements where the statement of no known drug allergy implies that there might be a medication the patient is allergic to but it is not known and has not been encountered at this time.

A record that a clinical act was initiated by not completed.

A record that a clinical act was not performed and/or never initiated. Do not use this context if the act was initiated or started but aborted or cancelled. Use the NotPerformed context instead.

Abstract class defining the concept of relative quantified amounts. For relative quantities, the +' and -' operators are defined.

An association between a person and a kind of job that the person has held.

An instruction by a healthcare provider to another healthcare provider to perform some act.

Abstract class defining the concept of true quantified values, i.e. values which are not only ordered, but which have a precise magnitude.

Models rankings and scores, e.g. pain, Apgar values, etc, where there is a) implied ordering, b) no implication that the distance between each value is constant, and c) the total number of values is finite. Note that although the term ordinal' in mathematics means natural numbers only, here any integer is allowed, since negative and zero values are often used by medical professionals for values around a neutral point. Examples of sets of ordinal values: -3, -2, -1, 0, 1, 2, 3  — reflex response values 0, 1, 2  — Apgar values This class is used for recording any clinical datum which is customarily recorded using symbolic values. Example: the results on a urinalysis strip, e.g. {neg, trace, , , } are used for leucocytes, protein, nitrites etc; for non-haemolysed blood {neg, trace, moderate}; for haemolysed blood small, moderate, large}.

An organization

One or more encounters at one site within a specified length of time.

Encapsulated data expressed as a parsable String. The internal model of the data item is not described in the openEHR model in common with other encapsulated types, but in this case, the form of the data is assumed to be plaintext, rather than compressed or other types of large binary data.

A party may be either an entity such as a specific person or organization or a role played by an entity such as patient or care provider.

A directed association to a party (i.e., a role or an entity). The PartyAssociation pattern can be used to represent a participation in an activity or a relationship that exists between two parties.

Context associated with the performance of an educational intervention.

This class captures information about counselling or education provided to (or an attempt to provide to) the Patient or to the Patient's representative and provides a means to note how well the Patient understood the information provided. Patient Education may be in the form of written instructions – either pre-defined materials, or personalized instructions – as well as oral counseling. In the case of pre-defined written materials, the educationalMaterialsProvided property may be used to identify the kind of material provided rather than reproducing the text of that material in this class. When personalized written instructions are provided, the text of such instructions can be placed in the textProvided property. The textProvided property may also be used to store a summary of an oral conversation with the Patient.

Context indicating actual performance or execution of a healthcare-related action, e.g., 3rd dose of Hepatitis B vaccine administered on Dec 4th 2012, appendectomy performed today.

Base person class.

Common human name format.

This class represents the prescription context from the perspective of the filling system (i.e., the pharmacy) whereas the Pharmacy Request represents the prescription from the ordering system (i.e., the prescriber). This class is a subtype of the more general Healthcare Promise, which describes properties common to all types or Orders from the filling system perspective– this class adds those properties which are specific to medication orders. This class is called Pharmacy Promise rather than Pharmacy Order following the HL7 V3 convention to use the term Promise to indicate that it is from the filling system’s perspective. There are many properties which are identical to the Order; this is because the pharmacy may change the order, within prescribed limits, for example substituting a generic drug for a brand-named one.

A physical evaluation assessment performed on a patient such as the taking of vital signs at the doctor's office.

Measurement resulting from a physical assessment procedure.

Plain text potentially with simple formatting

A record indicating an action in the planning phase. Typically, this would include a time at which the action is scheduled to be performed.

An integer whose value is greater than zero.

Class representing a patient or provider preference such as a diet preference, best time to contact, preferred communication method, etc ...

Base class for contexts asserting presence or absence of a finding.

Description of a healthcare action, independent of action context.

An order from the perspective of a fulfillment system.

An offer or a suggestion to perform a healthcare act. A recommendation to a provider is an example of proposal made by a CDS system. A proposal must be accepted by an entity in order for it to be performed.

Concept represents a recommendation from a clinical decision support system or advice from a consultation to not perform an act.

The Provenance pattern supports the attachment of attribution information to one or more clinical statements and is not part of the clinical statements themselves. The attachment of provenance information to a clinical statement in this manner does not impact the versioning of the clinical statement target since attribution information is external to the statement.

Education, training or special skills.

A qualitative reference range specified by a code - e.g., abnormal, severely abnormal.

A reference range specifying a quantity interval.

Quantitified type representing scientific quantities, i.e. quantities expressed as a magnitude and units. Units were inspired by the Unified Code for Units of Measure (UCUM), developed by Gunther Schadow and Clement J. McDonald of The Regenstrief Institute. Can also be used for time durations, where it is more convenient to treat these as simply a number of seconds rather than days, months, years.

A parameterizable ratio.

32-bit real numbers in any interoperable representation, including single-width IEEE floating point

A reference range for the specific instance after lookup from, say, a reference range table given specific criteria. Note that this reference range is not definitional in nature but rather refers to the reference range considered for the given observation for a subject.

Used to record and send details about a request for referral service or transfer of a patient to the care of another provider or provider organization.

When an event is to occur.

An request by a healthcare provider or system to another healthcare provider or system to perform some act.

A process where a researcher or organization plans and then executes a series of steps intended to increase the field of healthcare-related knowledge. This includes studies of safety, efficacy, comparative effectiveness and other information about medications, devices, therapies and other interventional and investigative techniques. A ResearchStudy involves the gathering of information about human or animal subjects.

Describes an expected sequence of events for one of the participants of a study. E.g. Exposure to drug A, wash-out, exposure to drug B, wash-out, follow-up.

Type supporting the capture of residency information.

Capacity in which an actor is involved in an activity. For instance, 'attending physician'. Note that attributes of the actor (an entity) that remain constant regardless of the role the actor plays should be part of the entity and not the role. For instance, a person may be a practitioner and a patient. In both cases their date of birth will be the same and thus such information should not be part of the role.

Represents a heading in a heading structure, or section tree . Can also be used to represent a collection of entries without metadata.

An encounter that is similar to outpatient but the patient is admitted to a bed.

A digital signature along with supporting context. The signature may be electronic/cryptographic in nature, or a graphical image representing a hand-written signature, or a signature process. Different Signature approaches have different utilities.

A specimen is a substance, physical object, or collection of objects, that the laboratory considers a single discrete, uniquely identified unit that is the subject of one or more steps in the laboratory workflow. NOTE: It may include multiple physical pieces as long as they are considered a single unit within the laboratory workflow. RELATIONSHIP TO OTHER CLASSES: Specimen results from one to many specimen collection procedure. Specimen is contained in zero to many specimen container. Specimen is used in zero to many specimen processing activity. Specimen results from zero to many processing activity. Specimen is used in zero to many specimen move activity. Specimen results from zero to many move activity.

The specific instance of the procedure in which the specimen was obtained.

Physical object that touches and holds specimen. EXAMPLES: slide, tube, box, jar

Processing step performed on a specimen.

Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.

Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of the statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the provenance of this information (the who, when, where, how, why of the information recorded).

represents unicode-enabled strings

A homogeneous material with a definite composition.

Base class for prospective and retrospective medication substitution information.

Information about a substitution that was performed.

Substitution instructions for prospective dispense clinical statements.

A surgical procedure.

Procedure for the insertion or removal of an implant.

Represents an absolute point in time, specified to the second. Semantics defined by ISO 8601. Used for recording a precise point in real world time, and for approximate time stamps, e.g. the origin of a HISTORY in an OBSERVATION which is only partially known.

Represents a coded term mapped to a TEXT, and the relative match of the target term with respect to the mapped item. Plain or coded text items may appear in the EHR for which one or mappings in alternative terminologies are required. Mappings are only used to enable computer processing, so they can only be instances of CODED_TEXT. Used for adding classification terms (e.g. adding ICD classifiers to SNOMED descriptive terms), or mapping into equivalents in other terminologies (e.g. across nursing vocabularies).

Abstract parent for plain textual and coded text items, which may contain any amount of legal characters arranged as e.g. words, sentences etc (i.e. one Text may be more than one word). Visual formatting and hyperlinks may be included.

Represents an absolute point in time from an origin usually interpreted as meaning the start of the current day, specified to a fraction of a second. Semantics defined by ISO 8601. Used for recording real world times, rather than scientifically measured fine amounts of time. The partial form is used for approximate times of events and substance administrations.

The act of transferring a patient from one location or responsible organization to another. Note that a transfer from organization to another will, by definition, trigger a new encounter. Note that a transfer from one location to another may trigger a new encounter depending on whether the responsible organization has changed. A movement from one bed within the same ward to another probably will not, but a movement from one ward to another probably would.

Assertion of wound tunneling.

Dependent statement indicating the presence or absence of tunneling.

Assertion of wound undermining.

Dependent statement indicating the presence or absence of undermining.

Unique device identifier (UDI) assigned to device label or package.

An integer whose value is greater or equal to zero.

A URI

A reference to an object which conforms to the Universal Resource Identifier (URI) standard. See 'Universal Resource Identifiers in WWW' by Tim Berners-Lee at http://www.ietf.org/rfc/rfc3986.txt. This is a World-Wide Web RFC for global identification of resources. See http://www.w3.org/Addressing for a starting point on URIs.

Structure capturing usage preferences for, say, a name, an address, or contact information.

Services provided includes Telehealth, Web health etc.

An undesired activity or breach of protocol, regardless of whether it resulted in harm to the subject, which must be documented.

An assertion of a wound

Characteristics of the wound's base.

Characteristics of the wound's edge.

Assertion about the exudate associated with a wound.

Dependent statement indicating whether the wound has exudate and the nature of that exudate.