CET+-+Clinical+Information+Model

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1.0 Usage of the S&I Clinical Information Model (CIM)
This summary fact sheet is designed to educate new and current stakeholders within the S&I Framework on the purpose and design of the S&I Framework Clinical Information Model (CIM).

2.0 Understanding the Clinical Information Model
In brief, a Clinical Information Model (CIM) is a conceptual definition of the discrete structured clinical information that is used in a clinical context. The model defines the data elements, attributes, possible values and types of attributes that are needed to convey the clinical perspective in a manner that is understandable to a variety of stakeholders, including functional and technical experts. These models support the electronic exchange of health information. For example, the Transitions of Care (TOC) Initiative has developed a CIM to capture the discrete structured clinical information that is used in all transitions of care. Using the TOC CIM as a foundation, the S&I Framework has developed an S&I Framework-wide CIM, which will be used to capture the work of each of the S&I Framework initiatives. The following sections outline the key differences between the TOC CIM, and the S&I Framework CIM.

2.1 Transitions of Care Clinical Information Model (TOC CIM)
The TOC CIM is a specific instance of the S&I Framework CIM and contains the core clinical data needed to support different types of care transitions defined by the Transitions of Care initiative use cases. The TOC CIM is the current basis for the S&I Framework CIM, but remains a specific instance of the S&I Framework CIM, also called a CIM Instance. The TOC CIM is tied to the ConsolidatedCDA standard as its implementation guidance to create a platform-specific model (PSM) within the S&I Framework process.

2.2 S&I Framework CIM
The S&I Framework CIM is used to capture the work of each of the S&I Framework initiatives, which includes and extends beyond the TOC Initiative. The primary objective of the S&I Framework CIM is to provide a common information foundation to each of the S&I Framework initiatives to promote reuse of data elements and objects. This model exists at a platform-independent level to maintain a high-level and abstract model to be tied to implementation guidance as an initiative deems necessary for specific use cases. The development of an S&I Framework CIM offers the following benefits: >
 * Ensures clinical concepts defined and discussed within S&I Framework initiatives are expressed in a standardized format and definition across all S&I Framework initiatives.
 * Decouples implementation guidance for an S&I Framework initiative from the clinical information modeling work.
 * Aligns the S&I Framework to the notion expressed by the HITPC for a single "summary document" which could be drawn from and aligned to the S&I Framework CIM.

3.0 CIM Instances
One of the common misunderstandings of the S&I Framework CIM is that it requires the use of CDA or is a RIM-based model. The S&I Framework CIM does NOT mandate a specific implementation model be applied as it is intended to apply a clinical perspective to data, and not be a technical implementation of clinical data. This principle is known as a platform-independent model and the TOC CIM is the first attempt to represent this platform-independent clinical perspective.

The following figure describes in detail how the work of the TOC CIM is being further leveraged across initiatives within the S&I Framework.



The use of CDA in the TOC CIM is intended to provide the underlying implementation model needed to support each care transition exchange. One of the concerns raised in the Transitions of Care Initiative was that each clinical model requires some level of underlying knowledge of an implementation model, such as the HL7 RIM or an archetype. Thus, the approach used was to create a platform-independent model and then allow implementers to show how they planned to use CDA to implement each of the CIM objects. The TOC CIM is the first example of this approach.

The preference of the S&I Framework, specifically the Transitions of Care Initiative, is that the S&I Framework CIM remain more abstract and high-level to allow implementers to represent and manipulate needed clinical data in the manner they felt best fit their environment. Making CCD the reference model would imply direct linkage to the HL7 RIM, which is not the goal or intention of the TOC Initiative or S&I Framework CIM.
 * //Is there a reason the CCD isn't the reference model?//**

4.0 CIM Representations
The S&I Framework CIM is NOT represented implicitly as an XML in its initial representation. Implementers specifically generate the XML they would like to use in order to implement the S&I Framework CIM on their own. CCD and CDA XSD and UML models are available to support alignment to the TOC CIM, for example. The S&I Framework support team is working to provide access to these XML files through multiple XML schemas in the Model-Driven Health Tools (MDHT). A current TOC CIM XSD has also been developed in support of the TOC CIM Reference Implementation and Pilots Workgroups that demonstrate how the TOC CIM can be implemented in CDA.

An important caveat about the S&I Framework CIM, and the TOC CIM, is that they are both a work in progress and continue to be "living" documents. There is to be ongoing review and modification occurring with clinical representatives, State HIE and Beacon Community stakeholders, and communities of interest from privacy, long term/post-acute care, and other stakeholders. For example, although the current version of the TOC CIM is labeled version 1.5, additional changes are being made to define an additional level of data elements and objects and a new version of the TOC CIM (version 2.0) is slated to be released in November 2011.

5.0 CIM Extensibility
The Query Health Initiative will be the first S&I Framework Initiative to test the extensibility of the S&I Framework CIM. As outlined above, changes to the S&I Framework CIM identified by the Query Health Initiative will be added to the S&I Framework CIM as a CIM Instance. It is through this approach that a Query Health CIM will be created. The expectation for extensibility is that the Query Health CIM would NOT attempt to create its own CIM objects or data elements if one already exists within the S&I Framework CIM. This would violate the principle of reusability inherent to the S&I Framework. Instead, the Query Health initiative would "extend" CIM objects in its own instance of the Query Health CIM to support its needs, and also "delete" any data elements it may not need. In areas where the CIM is not sufficient, it is flexible enough to be expanded to support the needs of a specific initiative. These changes can then be incorporated into the S&I Framework CIM for potential reuse by other initiatives.

6.0 Usage of CIM in Implementations
It is understood that the TOC CIM, which is the basis for the S&I Framework CIM, was developed in a specific context and under its own scope of requirements. In a similar manner, the set of requirements contained in the S&I Framework CIM, may not be adequate for the Query Health Initiative. The usage of the S&I Framework CIM as a starting point simply implies that the Query Health initiative will consider the S&I Framework CIM and NOT try to create Query Health-specific CIM objects that directly contravene existing objects in the S&I Framework CIM. For example, the Query Health Initiative will not try to create a new "Results" CIM object with entirely different data elements than the "Results" CIM object identified in the S&I Framework CIM. It will simply "extend" the "Results" CIM object to support whatever specific requirements that are inherent to Query Health.

It is also important to understand that the S&I Framework CIM is not a "physical" data model, but rather a conceptual/logical data model used to form the basis for a data model. As such, implementers are free to represent and manipulate CIM objects as they see fit.

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