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HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
 HL7’s Version 3
Standards:
The Essence of Model-
driven Standards

George W. Beeler, Jr. Ph.D.

Co-Chair, HL7 Modeling & Methodology Committee
Principal, Beeler Consulting LLC
woody@beelers.com

© 2010 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Mission
„ HL7 provides standards for interoperability that
improve care delivery, optimize workflow,
reduce ambiguity and enhance knowledge
transfer among all of our stakeholders, including
healthcare providers, government agencies, the
vendor community, fellow SDOs and patients. In
all of our processes we exhibit timeliness,
scientific rigor and technical expertise without
compromising transparency, accountability,
practicality, or our willingness to put the needs
of our stakeholders first.

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HL7 Mission (2)

„ Interoperability
“Ability of two or more systems or components to
exchange information and to use the information
that has been exchanged”
¾ [IEEE Standard Computer Dictionary: A
Compilation of IEEE Standard Computer
Glossaries, IEEE, 1990] Semantic
Functional interoperability
interoperability

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Core requirements for standard
exchanges
„ Nouns –items we communicate about
¾ Typically actions and physical things (persons,
places, etc.)
„ Phrases - the essential bindings between
nouns
¾ An action happens to a person
¾ One action causes another
¾ A person performs an action
„ Vocabulary & model – common definitions
¾ Assure common perspective
¾ Prescribe the nouns and phrases we can use
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How is Version 3 “better”?
„ Conceptual foundation – a single, common reference
information model to be used across HL7
„ Semantic foundation – in explicitly defined concept
domains drawn from the best terminologies
„ Abstract design methodology that is technology-
neutral – able to be used with whatever is the preferred
technology: documents, messages, services,
applications
„ Maintain a repository of the semantic content to
assure a single source, and enable development of
support tooling

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 Class Diagram – Normative RIM
Release 1
Participation
ActRelationship
typeCode : CS Act
typeCode : CS
functionCode : CD classCode : CS
1 0..n inversionInd : BL
Entity Role RoleLink contextControlCode : CS moodCode : CS source outboundRel ationship
target inboundLink contextControlCode : CS
classCode : CS classCode : CS sequenceNumber : INT id : SET<II>
1 0..n typeCode : CS 0..n contextConductionInd : BL
determinerCode : CS id : SET<II> negationInd : BL code : CD 1
player source outboundLi nk effectiveTime : IVL<TS> sequenceNumber : INT
LanguageCommunication playedRole noteText : ED negationInd : BL
id : SET<II> code : CE priorityNumber : INT

languageCode : CE
modeCode : CE
proficiencyLevelCode : CE
preferenceInd : BL
Participation
code : CE 0..1 0..n negationInd : BL time : IVL<TS> derivationExpr : ST
target inboundRelationshi p pauseQuantity : PQ
quantity : SET<PQ> addr : BAG<AD> 1 0..n modeCode : CE 0..n
1
text : ED
checkpointCode : CS
0..n 1 name : BAG<EN> scoper scopedRole telecom : BAG<TEL> awarenessCode : CE statusCode : SET<CS> 1 0..n
splitCode : CS
desc : ED 0..1 0..n statusCode : SET<CS> signatureCode : CE effectiveTime : GTS
joinCode : CS
statusCode : SET<CS> effectiveTime : IVL<TS> signatureText : ED activityTime : GTS
negationInd : BL
existenceTime : IVL<TS> certificateText : ED performInd : BL availabilityTime : TS
conjunctionCode : CS
telecom : BAG<TEL> quantity : RTO substitutionConditionCode : CE priorityCode : SET<CE>
localVariableName : ST
riskCode : CE positionNumber : LIST<INT> confidentialityCode : SET<CE>
seperatableInd : BL
handlingCode : CE repeatNumber : IVL<INT>
interruptibleInd : BL
levelCode : CE
ManagedParticipation independentInd : BL
id : SET<II> uncertaintyCode : CE
statusCode : SET<CS> reasonCode : SET<CE>
languageCode : CE

LivingSubject
administrativeGenderCode : CE Organization Employee
Material jobCode : CE Patient
birthTime : TS addr : BAG<AD>

Entity Role
deceasedInd : BL formCode : CE jobTitleName : SC confidentialityCode : CE
standardIndustryClassCode : CE
deceasedTime : TS jobClassCode : CE veryImportantPersonCode : CE
multipleBirthInd : BL salaryTypeCode : CE
multipleBirthOrderNumber : INT salaryQuantity : MO LicensedEntity
organDonorInd : BL hazardExposureText : ED
protectiveEquipmentText : ED recertificationTime : TS Supply Procedure
Place ManufacturedMaterial Observation SubstanceAdministration
PatientEncounter quantity : PQ methodCode : SET<CE> Account
mobileInd : BL lotNumberText : ST value : ANY routeCode : CE InvoiceElement
expectedUseTime : IVL<TS> approachSiteCode : SET<CD> name : ST
addr : AD expirationTime : IVL<TS> preAdmitTestInd : BL interpretationCode : SET<CE> approachSiteCode : SET<CD> modifierCode : SET<CE>
Access targetSiteCode : SET<CD> balanceAmt : MO
directionsText : ED stabilityTime : IVL<TS> admissionReferralSourceCode : CE methodCode : SET<CE> doseQuantity : IVL<PQ> unitQuantity : RTO<PQ,PQ>
approachSiteCode : CD lengthOfStayQuantity : PQ targetSiteCode : SET<CD> currencyCode : CE
positionText : ED rateQuantity : IVL<PQ> unitPriceAmt : RTO<MO,PQ>
targetSiteCode : CD dischargeDispositionCode : CE interestRateQuantity : RTO<MO,PQ>
gpsText : ST doseCheckQuantity : SET<RTO> netAmt : MO
gaugeQuantity : PQ specialCourtesiesCode : SET<CE> allowedBalanceQuantity : IVL<MO>
maxDoseQuantity : SET<RTO> factorNumber : REAL
specialAccommodationCode : SET<CE> pointsNumber : REAL
acuityLevelCode : CE
WorkingList
Person ownershipLevelCode : CE FinancialContract
addr : BAG<AD> Device
NonPersonLivingSubject Container paymentTermsCode : CE
maritalStatusCode : CE manufacturerModelName : SC
educationLevelCode : CE strainText : ED softwareName : SC capacityQuantity : PQ
raceCode : SET<CE> genderStatusCode : CE heightQuantity : PQ

Acts
localRemoteControlStateCode : CE DeviceTask FinancialTransaction
diameterQuantity : PQ ControlAct Diet
disabilityCode : SET<CE> alertLevelCode : CE PublicHealthCase amt : MO
livingArrangementCode : CE capTypeCode : CE energyQuantity : PQ parameterValue : LIST<ANY>
lastCalibrationTime : TS detectionMethodCode : CE creditExchangeRateQuantity : REAL
religiousAffiliationCode : CE separatorTypeCode : CE carbohydrateQuantity : PQ
transmissionModeCode : CE DiagnosticImage debitExchangeRateQuantity : REAL
ethnicGroupCode : SET<CE> barrierDeltaQuantity : PQ
bottomDeltaQuantity : PQ diseaseImportedCode : CE subjectOrientationCode : CE

Physical things of … participate in Acts …

Encounters, Observations,
• 4 …
interest Primary Subject Areas
procedures, medications …
Persons,
• Organizations,
35 Classes
• Places
181 , Attributes … take on Roles in Entities in Roles
• 9 health care …
Associations participate as …
• 28 Patient, Physician, Employer
Generalizations Performer, Author, target

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 Action – the focus of health care
communication & documentation
„ The reason we want to automate health care data is
to be able to document the actions taken to treat a
patient:
¾ A request or order for a test is an action
¾ The report of the test result is an action
¾ Creating a diagnosis based on test results is an action
¾ Prescribing treatment based on the diagnosis is an action
„ In simple terms, a medical record is a record of each
of the individual actions that make up the
diagnosis, treatment and care of a patient.

© 2010 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Five core concepts of the RIM
„ Every happening is an Act
¾ Procedures, observations, medications, supply,
registration, etc.
„ Acts are related through an ActRelationship
¾ composition, preconditions, revisions, support, etc.
„ Participation defines the context for an Act
¾ author, performer, subject, location, etc.
„ The participants are Roles
¾ patient, provider, practitioner, specimen, employee etc.
„ Roles are played by Entities
¾ persons, organizations, material, places, devices, etc.

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 RIM Core Classes
Role Act
Link Relationship
0..* 0..* 0..* 0..*

1 1 1 1
0..*
1 plays 0..* 1
Entity 0..*
Role 1
Participation 0..*
Act
1 scopes

Organization Procedure
Patient
Living Subject Observation
Employee
Person Patient Enc’nt’r
LicensedEntity
Material Substance Adm
Access
Place Supply
Referral
Financial act
Noun Phrase Working list
Account
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“Rules” for HL7 Designs

„ An HL7 model can not include any “class”,

that is not a sub-type of a defined class in
the RIM
„ The “Associations” and “Attributes” used
must be subtypes of the associations and
attributes defined for that class in the RIM
„ Cardinality, data types and other class
properties, can be restricted from their RIM
values, but not extended.
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Binding Terminology to a Model
Concept Domain is a named category of like concepts (semantic
type) that will be bound to one or more coded elements
[documented by specifying a name, a narrative definition]
Code System is defined as a collection of codes with associated
designations and meanings [as simple as a table, as complex as
SNOMED-CT]
Value Set represents a uniquely identifiable set of valid concept
representations, where any concept representation can be tested to
determine whether or not it is a member of the value set [usually the
concept representations are drawn from a single Code System].
Domain-to-ValueSet Binding is an assertion that a particular Value
Set provides a complete representation of the content of the
Concept Domain using values drawn from a particular code
system(s)

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Domain–Value Set Binding Example

Binding

Definition

Concept Domain defines concepts to represent an

attribute in a particular design
Code system provides a set of coded concepts
Value set selects a sub-set of the coded concepts
Binding asserts that a particular value set “satisfies”
the domain
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The “essence” of Version 3
„ Apply the ‘best practices’ of software development
to developing standards – a model-based
methodology
„ Predicate all designs on two semantic foundations
– a reference information model and a complete,
carefully-selected set of terminology domains
„ Require all Version 3 standards to draw from
these two common resources
„ Use software-engineering style tools to support
the process.

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Tools – for developers and
implementers
„ Enabled by the presence of “processable”
representations of V3 standards – data bases and
XML representations
„ Tools for defining, refining and documenting these
designs
¾ Enforce the “rules” for refinement and localization
¾ Draw their starting content from RIM, Vocabulary and
previous models
¾ Produce processable aritfacts that allow this cycle to repeat
„ Designed to allow rapid deployment and application
of the specifications to particular locale

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The problem

Storyboard: A clinician, using a local medical

office support system, orders a lab test for
one of her patients. The test will be
performed on a specimen collected at her
office. She will send the specimen by
courier, and expects to receive a
confirmation that the test will be performed,
and a result of the test.

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 RIM Core Classes
ObservationDefinition

Role Act
classCode*: <= OBS
moodCode*: <= DEF

HealthCareOrganization
Link Relationship
id: SET<II>
SET<II> [0..*]
[0..*]
code: CD CWE [0..1] <= ActCode
classCode*: <= ORG
determinerCode*: <= INSTANCE 0..* 0..* definition
0..* 0..* 0..* obs
id: SET<II> [0..*] typeCode*: <= INST
name: BAG<EN> [0..*] 0..1 representedHealthCareOrganization
1 1 1 1
0..*
0..* healthCareProvider ObservationRequest
1 plays AssignedPractitioner author 0..* 1
Entity Role
classCode*: <= ASSIGNED
0..* id: SET<II> [0..*] 1 typeCode*: <= Participation
AUT 0..*
classCode*:
moodCode*: <= RQO Act
<= OBS

id: SET<II> [0..*]

1 scopes code: CD CWE [0..1] <= ActCode
title: ED [0..1]
Person 0..1 assignedPerson effectiveTime: GTS [0..1]
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: BAG<EN> [0..*]

Organization Procedure
Patient
Living Subject Observation
Employee
Person Patient Enc’nt’r
LicensedEntity
Material Substance Adm
Access
Place Supply
Referral
Financial act
Working list
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Account
Assembling content – relational
phrase

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Demo
Order
Example – POLB_RM992100
Author

Physician

Performer

Laboratory

Subject

Specimen

Record target

Patient

Definition

Ordered test

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The essence of Version 3
„ A family of specifications
„ Built upon a single model of
¾ How we construct our messages
¾ The domain of discourse
¾ The attributes used
„ Constructed in a fashion to rapidly develop
a comprehensive, fully constrained
specification in XML

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Bringing it together
„ One Reference Model, one set of tools, one
process produce
¾ The mundane – a Common element for patient
¾ The complex – a specification to communicate
annotated ECGs for clinical trials
¾ Large, rich sets – electronic claims, clinical trial
data
¾ The esoteric – clinical genomics
¾ The basics – message control (headers)
„ All taken from RIM to schemas, and
published with a single set of effective tools

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Version 3 Normative Editions
„ After HL7 ballots individual Version 3 standards
¾ Under our consensus process
¾ Ballot until you satisfy your own toughest critics – your self
„ These are registered as ANSI specifications
„ Grouped informally as:
¾ Domains – topic of healthcare interest
¾ Common – Content shared by/across domains
¾ Infrastructure – enables communication
¾ Foundation – the basis for the V3 family of standards
„ And bundled into a comprehensive Normative
Edition
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Content of V3 Normative Editions
„ Final publication form of all Normative
Specifications (ANSI registered)
„ Supporting Reference Material –
methodology guide, readers guides, etc.
„ Processable representations of all
content – data bases, XML interchange
format, schemas, etc.
„ Documented dependency hierarchy

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 Table of Contents
Help for readers

Fundamental models – RIM,

vocabulary, data types, rules

Message wrappers and so on

Patient and insurance accounting,

Patient management, Scheduling

CDA
Public Health Messaging

Clinical studies
© 2010 Health Level Seven ® International. All Rights Reserved. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Foundation

ANSI/ISO Standard RIM

Data types as HL7/CEN/ISO Spec
Refinement “rules” standardized
Templates & Terminology in DSTU
Vocabulary concept domains, code
systems & value sets

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Infrastructure, Implementation &
Services

Messaging and Registry infrastructure

Message Transport in variety of modes
Message expression in XML & UML
Services (SOA) specifications

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Array of Specific Domains

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Version 3 - where is it being used?
As CDA documents, as SOA designs, as
interchanged Messages
„ In large-scale projects deriving from
governmental mandates
„ For communications between multiple,
independent, “non-integrated” entities
„ Whereever there are requirements to
communicate parts of an EHR and to
maintain the integrity of the EHR data
relationships
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The power of HL7 and Version 3
„ Consensus standards, developed by volunteers
who come from countries around the world to
undertake “practical” informatics
„ Welcoming new participants, and their ideas
„ Founded on solid principles of system design,
focusing on models & terminology
„ Models that emphasize clinical concepts, and
the supporting context needed for decision
support, clinical decision making and just plain
“solid patient care”
Thank you!
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