S&I+Framework+CEDD+Overview



=**S&I Framework Clinical Element Data Dictionary**= This summary overview is designed to educate new and current stakeholders within the S&I Framework on the purpose and usage of the S&I Clinical Element Data Dictionary (CEDD).

**Understanding a Data Dictionary**
A data dictionary is a repository of data elements, their corresponding definitions, and attributes of the clinical information that is used in a clinical context. The dictionary lists the data elements and corresponding definitions that are needed to convey the clinical perspective in a manner that is understandable to a variety of stakeholders, including functional and technical experts. Additionally, these data elements support the electronic exchange of health information through a core set of unambiguously-defined data elements that promote semantic compatibility.

**The Need for a Data Dictionary within the S&I Framework**
As S&I Framework initiatives work to harmonize interoperability specifications, a core set of definitions indicating a single data element becomes an integral part of interoperable exchange specifications both within the S&I Framework and across the health care delivery spectrum. While Initiatives are working to solve different interoperability challenges, the maintenance of a data element repository allows for the reuse of terms associated with a defined context. The S&I Clinical Element Data Dictionary (CEDD) repository document provides a single go-to resource for the context and definition of all data elements supporting S&I initiative use cases and S&I Framework technical specifications, content, tools, or services.

The development of an S&I Framework CEDD 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
 * Contains a core-set of unambiguously-defined data elements to be reused throughout the S&I Framework initiatives
 * Ensure semantic compatibility within and across systems in support of interoperability

**Figure 1: S&I Framework CEDD Incorporates Data Elements from S&I Framework Initiatives**

Origin of the S&I CEDD
An analysis of existing standards and barriers to electronic exchange which took place during the development of the Transitions of Care (TOC) Initiative specifications made clear the need for a common information model to represent a core set of data elements and corresponding definitions. While common data elements exist between various health care standards and models, ambiguous definitions prevent accurate harmonization for an interoperable standard.

In order to demonstrate the complex relationships between data elements, the TOC Initiative developed a Clinical Information Model (CIM) which combines the traditional data dictionary model with a logical model. Commonly referred to as an ontology, this type of model does not depend on a rigid parent/child hierarchical structure; rather, data elements or objects may inherit attributes from more than one parent. For example, the Demographics Object serves as the parent object through which multiple child objects, such as Culturally Sensitive Patient Care and Existence of Advance Directives, inherit attributes. This complex relationship is difficult to represent through a two-dimensional model, such as a data dictionary. The ontological approach promotes greater reuse of data elements and allows implementers to manipulate an abstract model while maintaining the same definitions and attributes of data elements. These relationships represented the CIM were initially available through both a UML model and corresponding document.

As an important output of the TOC Initiative, the CIM is best represented in the form of a data dictionary. The transition ensures a clear representation of data elements supporting the TOC use case while maintaining the level of abstraction necessary to support various business needs. In congruence with this change in model and representation, the TOC CIM is now referred to as the TOC CEDD and is only offered in the form of a document. The TOC CEDD provided the basis for the development of the S&I CEDD, which is used to capture data elements from each of the S&I Framework Initiatives.

The Role of the S&I CEDD
The S&I CEDD serves as a repository for the data elements supporting the work of the S&I Framework initiatives. The primary objective of the S&I CEDD is to provide a common information foundation to each of the S&I Framework initiatives and to promote reuse of data elements. The Transitions of Care (TOC) Initiative has developed a CEDD to capture the data elements that are used in all transitions of care. Using the TOC CEDD as a starting point, the S&I Framework has developed this S&I CEDD, which will be used to capture the data elements necessary for each of the S&I Framework initiatives.While the data elements carried over from the TOC Initiative may be added to or revised, the original data elements developed in support of TOC use cases are preserved within the TOC Clinical Element Data Dictionary. Similarly, other initiatives may preserve data elements supporting use cases within specific dictionaries.

S&I CEDD Process
To date, the work on the S&I CEDD has been guided by practicing clinicians and other implementers who are interested in creating a simple, easy to understand data model for functional stakeholders to use. The S&I CEDD also draws heavily from best practices, data dictionaries and information models defined by several organizations, including:

• National E-Health Transition Authority (NEHTA) • Federal Health Information Models (FHIM) • Health Level Seven Version 3 (HL7 V3) • Intermountain Healthcare Clinical Element Model (CEM)

Specific sources of information are drawn from existing work of these organizations to help define the structure of the data element content. It is not the intention in the development of the S&I CEDD to specifically adopt or redefine a particular data dictionary, but simply to draw from previous work already done to create a comprehensive data dictionary specifically targeted to the requirements of clinicians who may not have a deep understanding of care transition data, its structure, and its flow. The role of the S&I CEDD within the S&I Framework is to support initiative processes as a single source for data element semantic representations and corresponding definitions. Additionally, the S&I CEDD data elements may include corresponding data types. The goal is for initiatives to reuse and recommend data elements using the process outlined below.


 * Figure 2: How S&I Framework Initiatives Use the S&I Framework CEDD[[image:Picture_CEDD_Process_Flow.png width="1040" height="384" align="center"]]**

=S&I CEDD Recommendations Process= The S&I Framework Cross-Initiative CEDD WG was created in December 2011 to manage recommended additions and modifications (e.g. new CEDD data elements, edits to existing CEDD data elements) to the S&I CEDD submitted by the S&I Framework initiatives. Work on the S&I CEDD is guided by practicing clinicians and other implementers who are interested in creating a simple, easy to understand data dictionary for functional stakeholders to use. Updates to the S&I CEDD documentation occurs on a monthly basis following consensus approval of all additions and modifications from the WG.

To maintain a common information foundation and to promote reuse of data elements that have been vetted through S&I Framework processes, the S&I Cross-Initiative CEDD WG has adopted a recommendations process to facilitate additions and modifications generated by initiatives. This process requires submission of the S&I CEDD Recommendations Form to the WG containing proposed additions and modifications for inclusion in the S&I CEDD. Analysis of recommendations by the WG acts as a secondary review independent of the initiative harmonization process. This approach ensures thorough standards analysis and protects previously-included data elements from duplication.

**Figure 3:** ** How to Submit Changes to S&I CEDD **

Organization of the S&I CEDD
To best navigate the S&I CEDD, it is important to understand how the data elements are organized. To maintain context, the CEDD Objects are arranged alphabetically and contain data elements with corresponding definitions, examples and guidance, and the sponsoring initiative. The following sections describe the organization of the S&I CEDD depicted in Figure 4.

**Figure 4: S&I CEDD Structure**

S&I CEDD Objects
Data elements composing the S&I Framework CEDD are organized into Objects which map to an underlying concept that is of some familiarity to practicing clinicians and specialists, and other stakeholders who may be involved in healthcare organizations. CEDD Objects are intended to capture a real-world clinical concept and display it in a manner that is understandable to clinicians, patients, and other stakeholders who may be involved in a specific use case. For CEDD Objects, several key pieces of information are defined to assist in understanding clinical meaning. They are summarized in the following table.


 * Table 1: Overview of CEDD Objects**
 * ~ ** Characteristic ** ||~ **Description of the Characteristic** ||
 * **Object Name** || A clinically-relevant name for this CEDD Object – should be understandable to clinicians ||
 * **Object Definition** || A clinically-relevant definition of the CEDD Object ||
 * **Clinical Example** || Provides examples of what this clinical object captures ||


 * Table 2: Example of CEDD Object, Active Medications List**
 * ~ ** CEDD Object ** ||~ ** Object Definition ** ||~ ** Clinical Example ** ||
 * Active Medications List || A list of medications that patient should be taking or an entry of no known medications. The list of medications includes compounds that the patient may be taking (e.g. herbals). The metadata for the Active Medication List is to include: the clinician that last ordered the medication with the date/time stamp of when the medication was last ordered, and whether or not the Active Medication List was reconciled during this encounter and if so by whom, and if not when last reconciled and by whom. || The list of all of the medications that the patient is taking, or has been prescribed, and the patient is thought to be taking. If a clinician reads the patient a list of their medications and the patient reports that they actually stopped taking medication "X," medication X would be removed from the list. D/C reconciliation would include consideration of the pre-hospitalization medications and whether these need to be continued or stopped. ||

**S&I CEDD Data Elements**
A CEDD Data Element is an attribute of a CEDD Object. CEDD Data Elements should be aligned to underlying data elements from the S&I CEDD Objects. When included in an Initiative CEDD, additional data element attributes may include proposed datatypes and corresponding priorities. For CEDD Data Elements, several key pieces of information are defined to assist in understanding clinical meaning. They are summarized in the following table.


 * Table 3: Overview of CEDD Data Elements**
 * ~ **Characteristic** ||~ **Description of the Characteristic** ||
 * **Data Element Name** || A clinically-relevant name for this data element – should be understandable to clinicians, as appropriate ||
 * **Data Element Definition** || A clinically-relevant definition of the data element ||
 * **Clinical Example** || Provides examples of what this clinical term means ||
 * **Sponsoring Initiative** || The initiative that identified the data element ||


 * Table 4: Example of CEDD Data Element, Immunization History Object**
 * ~ **Data Element Name** ||~ Data Element Definition ||~ Clinical Example ||
 * Contraindication || Contraindication is the indicator if this immunization should be continued or should be stopped due to an adverse reaction being observed. || Severe skin rubor, calor, and edema ||

**Applications of S&I CEDD Concepts**
To realize the goal of semantic compatibility, use of S&I CEDD data elements requires the understanding that reuse of data elements is essential. The aforementioned S&I CEDD process outlines S&I CEDD involvement throughout S&I Framework phases. While Initiatives are working to resolve real-world interoperability challenges in varied scenarios involving many different types of stakeholders, reuse of data elements requires analysis of use case functional requirements and standards. During analysis, definitions play a key role in maintaining semantic compatibility and must be reviewed carefully to ensure applicability to a use case. To assist with this process, clinical examples are included to demonstrate intent and context. S&I CEDD Objects offer reusable parent constructs containing specified child data elements. However, it is important to note that the use of a data element does not require the use of the parent Object or other data elements within the Object. Semantic re-usability is focused on the data element level.

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

**//How will the S&I CEDD be maintained?//**
An important caveat about the S&I Framework CEDD is that it is a work in progress and continues to be a "living" document. 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. The S&I CEDD WG is charged with maintenance of the S&I CEDD and additions, edits, and omissions proposed by other initiatives or stakeholders are monitored by WG activities.

**//Should there be any expectation for future initiatives to follow the S&I Framework CEDD to a greater or lesser degree?//**
The plan for future initiatives is to use the S&I Framework CEDD as a repository where initiatives may add, modify, or omit as needed for preservation in a unique and platform-independent data dictionary. The goal is to promote the reuse of data elements and to maintain a single definition of a data element throughout S&I Framework Initiative activities.