HSCIC Data Dictionary for Care Modelling Approach Dr. Rahil Qamar Siddiqui Health and Social Care Information Centre, NHS, England

Logical Models for Care Two level modelling process Level one: High level models (for initial discussion with health informaticians and clinicians) Level two: Logical models (technical models for discussion with health informaticians and technical modellers)

Level one: High level Examination Finding Example: Royal College Outpatients Headings document

Level two: Logical models Bottom-up modelling approach OVERVIEW..(1)

Level two: Logical models Bottom-up modelling approach..(2) CLINICAL STATEMENT SUB-PARTS: CLUSTER & ELEMENT Where clinical statements have a more complex structure, each of the sub-parts of a clinical statement should be modelled as independent, reusable models using the ITEM classes: CLUSTER and ELEMENT. These clinical statement sub-parts may represent both the core data describing parts of a statement and, optionally, other details the – examination method (technique and/or device used), – the patient’s physical state, – assertion status such as presence/absence, normality/abnormality indicators of the core value. When modelling a clinical statement sub-part it is appropriate to start at the CLUSTER class as the ISO Reference Model allows for nesting of CLUSTERs within CLUSTERs as well as inclusion of one or more ELEMENTs which hold the actual data

CLUSTER: Blood Pressure Measurement

CLUSTER: Blood Pressure Measurement State

Level two: Logical models Bottom-up modelling approach..(3) CLINICAL STATEMENT: ENTRY Clinical Statements in this document refer to clinical observations, requests, results, actions, plans, instructions, intentions, interpretations, reasoning etc. which may have a simple or a more complex structure. Each of the CLUSTERs represents a single, indivisible, and reusable clinical statement sub-part which are then collectively modelled in an ENTRY, which is used to record information in an EHR as a single, indivisible clinical statement. The ENTRY class also helps to provide the set of context attributes that help to facilitate the safe interpretation of the clinical statement.

ENTRY: Blood Pressure

Level two: Logical models Bottom-up modelling approach..(4) COLLECTIONS: SECTION The term Collections is used to refer to a group of clinical statements which might be viewed together under a common heading for human consumption. These collections are modelled using the CONTENT class: SECTION. Within DD4C, the SECTION class should be used only when implementation-specific requirements warrant the need for headings such as is the case with the Royal Colleges headings. NOTE: Else the CLUSTER and ENTRY models should be used to logically model the clinical content irrespective of how it is desired to be viewed by specific user communities.

SECTION: Vital Signs

SECTION: Examination Findings

Level two: Logical models Bottom-up modelling approach..(5) ORGANISERS: COMPOSITIONs and FOLDERs Collections of clinical statements could be included in high- level organiser groups to which authoring, attesting, and auditing information can be associated. These organisers help in human readability, storage, and communication rather than machine computability and semantics. COMPOSITIONs are typically used to communicate extracts of records both internally within an organisation such as Admission and Handover records, as well as records that might be communicated externally such as Discharge, Outpatients, and Referral records. Each instance of a COMPOSITION is about a single subject of care.

COMPOSITION: Outpatients