openEHR to ISO 13606-1, ISO 21090 mapping

Introduction

This page provides information on which a technical solution to bidirectional openEHR / ISO 13606 conversion can be based. Since ISO 13606 uses the ISO 21090 pre-standard for data types, this mapping necessarily involves an openEHR datatype <-> ISO 21090 mapping as well. Key points to note:

there is currently no profile of 21090 (data types) for use in 13606; this means that 13606 currently uses the 'vanilla' 21090 schema and semantics. However many of these don't apply, and guidance now needs to be developed for them in the 13606 context.
the requirements for round-tripping faithfully between 13606 and openEHR have not yet been defined. This will essentially be up to users.

ISO 13606-1

ISO 13606-1 is the model of an EHR Extract, designed to enable data to be shared between EHR systems. Technically it resembles the openEHR reference model, but in a simplified way. In particular , the ENTRY types of openEHR are mapped to a single ENTRY type in 13606, but this is not the only difference. A mapping algorithm is being developed that shold allow a bidirectional transform between openEHR and 13606. The algorithm uses two types of mapping:

pre-defined class and attribute conversions, such as for the 13606 AUDIT_INFO class and the openEHR AUDIT_DETAILS class
a generic algorithm that can be applied between ENTRYs

Predefined conversion rules

Common IM structures

openEHR class	attribute	type	13606 class	attribute	type	description	exceptions / ambiguities
PATHABLE			RECORD_COMPONENT
	parent (not persisted)	PATHABLE		orig_parent_ref	II [0..1]	rule: generate openEHR URI	see mismatches below
LOCATABLE			RECORD_COMPONENT
	uid	UID_BASED_ID [0..1]		rc_id	II [1]	rule: generate openEHR URI	see mismatches below
	archetype_node_id	String [1]		archetype_id	String [0..1] /dt:II	rule: String id->II
	name	DV_TEXT [1]		name	TEXT [1] /dt:CD>CV	rule: DV_TEXT -> TEXT	what are possible name values?
	archetype_details	ARCHETYPED [0..1]
	feeder_audit	FEEDER_AUDIT [0..1]		feeder_audit	AUDIT_INFO [0..1]	rule: follow link & map
	links	Set<LINK> [0..1]		links	Set<LINK> [0..1]	rule: 1:1 iteration
	-			sensitivity	Integer [0..1] /rc:Sensitivity		MISSING IN OPENEHR - could either be on LOCATABLE or on COMPOSITION
				policy_ids	SET<II>		In openEHR, these settings are in the ACCESS_CONTROL object

AUDIT_DETAILS			AUDIT_INFO
	system_id	String [1]		ehr_system	II [1]	rule: String id->II	which system id is being used here?
	committer	PARTY_PROXY [1]		committer	II [1]		which user id is being used here?
	time_committed	DV_DATE_TIME [1]		time_committed	TS [1]	rule: DV_DATE_TIME->TS
	change_type	DV_CODED_TEXT [1]		reason_for_revision	CV [0..1] /dt:CD.CV	rule: DV_CODED_TEXT->CV
	description	DV_TEXT [0..1]		-			LOST INFORMATION [low importance]
+VERSION	lifecycle_state	DV_CODED_TEXT [1]		version_status	CS [0..1] /rc:VersionStatus	rule: DV_CODED_TEXT->CS
+VERSION	preceding_version_id	OBJECT_VERSION_ID[1]		previous_version	II [0..1]	rule: OBJECT_VERSION_ID->II
+VERSION	owner_id	HIER_OBJECT_ID [1]		version_set_id	II [0..1]	rule: HIER_OBJECT_ID->II
PARTY_PROXY			RELATED_PARTY
	external_ref	PARTY_REF [0..1]		party	II [0..1]	rule: OBJECT_REF->II	LOST INFORMATION: namespace, type? [not important]
PARTY_IDENTIFIED
	name	String [0..1]	Demographics_package IDENTIFIED_HEALTHCARE _PROFESSIONAL	name	ENTITY_NAME[*]	rule: String -> ENTITY_NAME synthesis
	identifiers	List<DV_IDENTIFIER> [0..1]	Demographics_package IDENTIFIED_HEALTHCARE _PROFESSIONAL	role	HEALTHCARE_ PROFESSIONAL_ ROLE [*]	rule: for each identifier: DV_IDENTIFIER -> HEALTHCARE_ PROFESSIONAL_ ROLE
PARTY_RELATED			RELATED_PARTY
	relationship	DV_CODED_TEXT [1]		relationship	TEXT /dt:CD.CV	rule: DV_CODED_TEXT->TEXT
PARTY_SELF			RELATED_PARTY			convert to RELATED_PARTY with relationship = self?
PARTICIPATION			FUNCTIONAL_ROLE
	function	DV_TEXT [1]		function	CV [0..1]	rule: DV_CODED_TEXT->CV	LOST INFORMATION openEHR allows not only coded values; non-matches will be lost
	performer	PARTY_PROXY [1]		performer	II [1]	use rule for: PARTY_PROXY.external_ref	LOST INFORMATION some openEHR Party information will be lost; 13606 only permits single II identifier
	time	DV_INTERVAL [0..1]		-		(no mapping available)	LOST INFORMATION
	mode	DV_CODED_TEXT [1]		mode	CS [0..1]	rule: DV_CODED_TEXT->CS
( EVENT_CONTEXT)	health_care_facility	PARTY_IDENTIFIED [0..1]		healthcare_facility	II [0..1]	use rule for: PARTY_PROXY.external_ref	healthcare facility is in openEHR.EVENT_CONTEXT (since there cannot be 2 HCFs in one ENTRY)
( EVENT_CONTEXT)	setting	DV_CODED_TEXT [1]		service_setting	CV [0..1]	rule: DV_CODED_TEXT->CV	service setting is in openEHR.EVENT_CONTEXT (since there cannot be 2 types of service setting in one ENTRY)

Section & Entry structures

openEHR class	attribute	type	13606 class	attribute	type	description	exceptions / ambiguities
SECTION			SECTION

ENTRY			ENTRY
	language	CODE_PHRASE [1]		(items)	ELEMENT	generic mapping rule: map to an ELEMENT object with name attribute set to indicate which source model attribute and value set to a CS; then follow CODE_PHRASE -> CS rule	Can ELEMENT.name be used in this way?
	encoding	CODE_PHRASE [1]		(items)	ELEMENT	generic mapping rule: map to an ELEMENT object with name attribute set to indicate which source model attribute and value set to a CS; then follow CODE_PHRASE -> CS rule	Can ELEMENT.name be used in this way?
	subject	PARTY_PROXY [1]		subject_of_information	RELATED_PARTY	rule: PARTY_PROXY->RELATED_PARTY
				subject_of_information_category	CS [0..1]	proposed rule: where subject in openEHR data is a PARTY_RELATED, the relationship can be mapped to this attribute
	provider	PARTY_PROXY [0..1]		info_provider	FUNCTIONAL_ROLE	map EVENT_CONTEXT. health_care_facility -> healthcare_facility, setting -> setting PARTY_PROXY.external_ref -> performer, set function = fixed value 'provider' mode - not recorded in openEHR	MISSING IN OPENEHR - ENTRY.mode
	-			uncertainty_expressed	Boolean [1]	rule: synthesise to False	Hard to see how this attribute could be a) on all Entries, and b) be a Boolean
CARE_ENTRY			ENTRY
	protocol	ITEM_STRUCTURE		(items)	CLUSTER/ELEMENT	use algorithm 1 below.
	guideline_id	OBJECT_REF		-			INFORMATION LOST (not likely to be present in source in most cases)
ADMIN_ENTRY			ENTRY
	data	ITEM_STRUCTURE		(items)	CLUSTER/ELEMENT	use algorithm 1 below.
OBSERVATION			ENTRY
	data			(items)	CLUSTER/ELEMENT	use algorithm 1 below.
	state			(items)	CLUSTER/ELEMENT	use algorithm 1 below.
EVALUATION			ENTRY
	data	ITEM_STRUCTURE		(items)	CLUSTER/ELEMENT	use algorithm 1 below.
INSTRUCTION			ENTRY
	narrative	DV_TEXT		(items)	ELEMENT	use algorithm 1 below.
	expiry_time	DV_DATE_TIME		(items)	ELEMENT	use algorithm 1 below.
	wf_definition	DV_PARSABLE		(items)	ELEMENT	use algorithm 1 below.
	activities	List<ACTIVITY>		(items)	CLUSTER/ELEMENT	use algorithm 1 below.
ACTIVITY			CLUSTER
	description	ITEM_STRUCTURE		(parts)		use algorithm 1 below.
	timing	DV_PARSABLE		(parts)	ELEMENT	use algorithm 1 below.
ACTION			ENTRY
	time	DV_DATE_TIME		(items)	ELEMENT	use algorithm 1 below.
	description	ITEM_STRUCTURE		(items)	CLUSTER/ELEMENT	use algorithm 1 below.
	ism_transition	ISM_TRANSITION		(items)	CLUSTER	use algorithm 1 below.
	instruction_details	INSTRUCTION_DETAILS		(items)	CLUSTER	use algorithm 1 below.
ISM_TRANSITION			CLUSTER
	current_state	DV_CODED_TEXT		(parts)	ELEMENT	use algorithm 1 below.
	transition	DV_CODED_TEXT		(parts)	ELEMENT	use algorithm 1 below.
	careflow_step	DV_CODED_TEXT		(parts)	ELEMENT	use algorithm 1 below.
INSTRUCTION_DETAILS			CLUSTER
	instruction_id	LOCATABLE_REF		(parts)	ELEMENT	use algorithm 1 below.
	activity_id	String		(parts)	ELEMENT	use algorithm 1 below.
	wf_details	ITEM_STRUCTURE		(parts)	CLUSTER/ELEMENT	use algorithm 1 below.

Sub-ENTRY structures

openEHR class	attribute	type	13606 class	attribute
HISTORY			CLUSTER
	events			(parts)
EVENT			CLUSTER
	data			(parts)
	state			(parts)
POINT_EVENT			CLUSTER

INTERVAL_EVENT			CLUSTER

ITEM_STRUCTURE			CLUSTER

ITEM_TREE			CLUSTER
	items			(parts)
ITEM_TABLE			CLUSTER
	rows			(parts)
ITEM_LIST			CLUSTER
	items			(parts)
ITEM_SINGLE			CLUSTER
	item			(parts)
CLUSTER	items	List<ITEM	CLUSTER

ELEMENT	value	DATA_VALUE [0..1]	ELEMENT
	null_flavour	DV_CODED_TEXT [0..1]

ENTRY Conversion Algorithm (algorithm #1)

To convert between any openEHR concrete ENTRY type, such as OBSERVATION, a generic approach is required. The principle problem is that to convert an instance of any openEHR ENTRY class like OBSERVATION, EVALUATION, etc, we only have ISO13606 ENTRY as a possible target. The same is true for instances of HISTORY, POINT_EVENT, ITEM_TREE etc - they only possible target is CLUSTER. In ISO13606, every RM class has a 'meaning' attribute to be used in this kind of transformations. The meaning codes are

Code	Original Type
OE-01	Observation
OE-02	Protocol
OE-03	Guideline_id
OE-04	Data
OE-05	Period
OE-06	Duration
OE-07	Point_event
OE-08	Event_data
OE-09	Event_state
OE-10	Interval_event
OE-11	Width
OE-12	Sample_count
OE-13	Math_function
OE-14	State
OE-15	Instruction_narrative
OE-16	Instruction_expiry_time
OE-17	Instruction_wf_definition
OE-18	Activity
OE-19	Activity_timing
OE-20	Activity_description
OE-21	Action_description
OE-22	Current_state
OE-23	Transition
OE-24	Careflow_step
OE-25	Instruction_details
OE-26	Instruction_id
OE-27	Activity_id
OE-28	Workflow_details
OE-30	Evaluation
OE-31	Instruction
OE-32	Action
OE-33	Activity_action_archetype_id

Not all openEHR classes are defined as codes, but most of them are. Most notable missing ones: ADMIN_ENTRY, HISTORY, EVENT_CONTEXT.

openEHR

ISO13606

COMPOSITION
  +-content
      +-SECTION
          +-items
              +-OBSERVATION
                  +-data
                      +-HISTORY<ITEM_TREE>
                          +-origin
                          |   +-DATE_TIME
                          +-events
                              +-POINT_EVENT<ITEM_TREE>
                                  +-data
                                      +-ITEM_TREE

COMPOSITION
  +-content
      +-SECTION
          +-members
              +-ENTRY (meaning = 'OE-01') -- OBSERVATION
                  +-items
                      +-CLUSTER -- HISTORY
                          +-obs_time
                          |   +IVL<TS>
                          +-items
                              +-CLUSTER {meaning = 'OE-07') -- POINT_EVENT
                                  +-items
                                      +-CLUSTER

ISO 21090 - Data Types

The 21090 data types are largely derived from HL7v3 data types, and as such contain things not needed by EHR systems. Currently there is no profile for 13606's use of 21090; if it existed it would state which things would not be used in 13606, and for others, how they should be used. Once a profile is developed, it should be used to build a new, simpler XML schema for 13606.

The following table is a list of notes relating to some of the attributes from abstract classes including ANY that need to be dealt with somehow in 13606/openEHR - the QTY data type has been used as the example here. These come either from the standard or from Grahame Grieve, its principal author. These could be used to develop a 13606 profile.

21090 class	attribute	comments
HXIT		21090 spec: Because of the way that the types are defined, a number of attributes of the data types have values with a type derived from HXIT. In these cases the HXIT attributes are constrained to null. The only case where the HXIT attributes are allowed within a data type is on items in a collection (DSET, LIST, BAG, HIST).
	validTimeLow, validTimeHigh	GG: Intended for when a receiver system assembles a structure, but one of the pieces of data comes from somewhere else and is subject to separate life-cycle management - a piece of foreign data. So your own version management/life cycle stuff doesn't apply, but it's state is of sufficient interest to know this. (it's somewhat unusual, therefore, because most data is either handled in system, or its state is not tracked at all) So yes, the normal cycle is not respected (in the local context), but the data is of sufficient interest to track that state from where is is respected (elsewhere) a little. RECOMMENDATION: not directly needed in 13606 profile, but if encountered, may be mapped to some higher level EHR structure attributes?
	controlActRoot, controlActExtension	The idea is that GUIDs would be generated for specific events - like measuring a person's BP. Or the BP being a certain value at a certain time - by some systems, and then used to refer to those events later on. This is a referent-tracking idea See Ceusters et al.
ANY
	nullFlavor	Mostly maps to ELEMENT.nullflavour. Exceptions: on translations of ED, CD, and PQ. But only on CD does it matter. You just swallow that equivalent into the terminology service, so you don't need to map it, only when you convert from DV_CODED_TEXT or whatever, you need to consult the terminology service to decide whether to put a nullFlavor on the translations. Use case: if a single coded value is given in multiple different coding systems, some coding system translations may have different coding outcomes, and therefore in CD they get their own nullFlavor. Name and address parts; should be mappable to openEHR ELEMENT.null_flavour based on archetypes; in 13606??? on the bounds of intervals - straight forward mapping to INTERVAL.upper_bounded etc
	updateMode	RECOMMENDATION: eleminate from 13606 profile
	flavorId	RECOMMENDATION: should not be in model; eleminate from 13606 profile
QTY
	expression	Was designed for representing a prescription dose dependent on external factors (e.g. patient peak flow rate, for an asthma drug). Should not really be on QTY. RECOMMENDATION: remove in all circumstances except prescriptions. HOW TO DETECT THIS???
	uncertainty, uncertaintyType	Appears also to relate only to specific uses of certain kinds of QTY. Could be mappable to openEHR precision and accuracy in some cases. In openEHR, 'uncertainty' is a concept associated with assessments, diagnoses etc.
	originalText	TB: this is a contextual idea that assumes a data entry application situation. The problem is that all kinds of ways of entering data are possible: it could be chosen from a dropdown or tree widget, or be a dial widget, calendar picker, or any one of a myriad of modern GUI entry mechanisms. So I don't see how this field can be meaningfully populated in many source systems anyway; I also don't see what to do with the value of the field if it doesn't match teh stringified version of the data item, e.g. what if this field value is '11/10/2009' and the actual value string is '2009-10-11' - then it is purely duplicate information and of no use; what if the value string is '2009-11-10'? We assume then a US-style interface, but otherwise it is still a duplicate. RECOMMENDATION: probably remove from 13606 profile.

The following table is a map of data types.

openEHR Class	attribute	type	21090 Class	attribute	type	description
DV_BOOLEAN	value	Boolean [1]	BL or BL.NONNULL
DV_STATE	value	DV_CODED_TEXT [1]
	is_terminal	Boolean [1]
DV_IDENTIFIER	issuer	String [1]
	id	String [1]
	type	String [1]
	assigner	String [1]

DV_TEXT	value	String [1]
	hyperlink	DV_URI [0..1]
	mappings	List<TERM_MAPPING>
	encoding	CODE_PHRASE [0..1]
	language	CODE_PHRASE [0..1]
TERM_MAPPING	match	Character [1]
	purpose	DV_CODED_TEXT [0..1]
	target	CODE_PHRASE [1]
CODE_PHRASE	terminology_id	TERMINOLOGY_ID [1]
	code_string	String [1]
DV_CODED_TEXT	defining_code	CODE_PHRASE [1]
DV_PARAGRAPH	items	List<DV_TEXT> [1..*]

DV_ORDERED
	normal_status	CODE_PHRASE [0..1]
	normal_range	DV_INTERVAL<T> [0..1]
	other_reference_ranges	List<REFERENCE_RANGE<T>> [0..1]
DV_INTERVAL<T>
	lower	T->DV_ORDERED [0..1]
	upper	T->DV_ORDERED [0..1]
	lower_included	Boolean
	upper_included	Boolean
	lower_unbounded	Boolean
	upper_unbounded	Boolean
REFERENCE_RANGE<T>	meaning	DV_TEXT [1]
	range	DV_INTERVAL <T> [1]
DV_QUANTIFIED	magnitude_status	String [0..1]
DV_ORDINAL	value	Integer [1]
	symbol	DV_CODED_TEXT [1]
DV_AMOUNT
	accuracy	Real [0..1]
	accuracy_is_percent	Boolean [0..1]
DV_COUNT			INT?
	magnitude	Integer [1]
DV_QUANTITY			REAL?
	magnitude	Double [1]
	precision	Integer [0..1]
	units	String [1]
DV_PROPORTION			RATIO?
	numerator	Real [1]
	denominator	Real [1]
	type	Integer [1]
	precision	Integer [0..1]				openEHR values: 0 = ratio 1 = unitary 2 = percent 3 = fraction
DV_DURATION	value	String [1]				ISO 8601
DV_ABSOLUTE_QUANTITY	accuracy	DV_AMOUNT [0..1]
DV_DATE	value	String [1]	TS.DATE			ISO 8601
DV_TIME	value	String [1]	TS			ISO 8601
DV_DATE_TIME	value	String [1]	TS.DATE_TIME			ISO 8601

DV_TIME_SPECIFICATION
	value	DV_PARSABLE [1]
DV_PERIODIC_ TIME_SPECIFICATION			EIVL or PIVL			HL7 PIVL or EIVL syntax string
DV_GENERAL_ TIME_SPECIFICATION						HL7 GTS syntax string

DV_ENCAPSULATED
	charset	CODE_PHRASE [0..1]	ED or subtype ED.IMAGE, ED.DOC, ED.TEXT, ...	charset	CODE [0..1]	codes: openEHR character sets
	language	CODE_PHRASE [0..1]		language	CODE [0..1]	codes: openEHR languages
DV_MULTIMEDIA
	alternate_text	String
	uri	DV_URI [0..1]		reference	TEL.URL [0..1]
	data	Array <Octet> [0..1]		data	Binary [0..1]
	thumbnail	DV_MULTIMEDIA [0..1]		thumbnail	ED [0..1]
	media_type	CODE_PHRASE [1]		mediaType	CODE [0..1]	codes: openEHR media types
	compression_algorithm	CODE_PHRASE [0..1]		compression	Compression [0..1]	codes: openEHR compression algorithms
	integrity_check	Array <Octet> [0..1]		integrityCheck	Binary [0..1]
	integrity_check_algorithm	CODE_PHRASE [0..1]		integrityCheckAlgorithm	integrityCheckAlgorithm [0..1]	codes: openEHR integrity check algorithms
	size	Integer [1]
DV_PARSABLE
	value	String [1]		xml	XML
	formalism	String [1]
DV_URI	value	String [1]				legal W3C URI
DV_EHR_URI						openEHR constrained version

Mismatches

Model mismatches

Some ISO 13606 data attributes do not currently exist in openEHR, and might be candidates for addition to the reference model. We should make two key points clear here. Firstly openEHR is designed as a high-quality health record architecture, rather than a one-size-fits-all interchange standard. Thus, design decisions in 13606 which are typically taken to accommodate data structures from the largest number of possible source systems do not necessarily make sense in openEHR, which is designed as a coherent EHR, and could be considered one possible 'source' system. Of course, its structures are also extremely useful for intersystem interchange. Accordingly, the relevant question to ask here is: can 13606 accommodate what is in openEHR, rather than the other way around. (ISO 13606 has sometimes been used as a design basis for some EHR systems, rather than for its intended purpose as an interchange format; in such circumstances, due to the above reasons, problems may be encountered in such projects).

Secondly, ISO13606 is an extract, which means its information instances are constructed by processing existing data (which might be relational, objects, XML, etc) and generating the output. Thus the normalisation (i.e. 'factoring') and structure of data items in the 13606 Extract makes sense (hopefully) for sharing data in a context-free manner (i.e. the receiver of the extract can use it as-is, without needing to refer to the source system), but may not be good design for the source system, and in fact may be quite different from the latter. We can thus think of some 13606 attributes as being 'refactored' attributes - they model data that is likely to be located elsewhere in the source system.

The following is a list of information attributes from ISO 13606 not currently supported in openEHR. Recommendations are made as to what to do about these attributes.

ISO 13606 RECORD_COMPONENT.policy_ids

This attribute is defined as follows in the ISO 13606-1 standard:

This attribute identifies one or more access control policies that specifically pertain to this RECORD_COMPONENT and which need to be communicated to the EHR Recipient to govern future access to it. The identifiers may refer to policy information included in this EHR_EXTRACT as defined in Part 4 of this standard, or to policies held in external policy servers to which the EHR Recipient has access.

From part 4:

In the 13606 Part 1 Reference Model every RECORD_COMPONENT within the EHR_EXTRACT includes an optional Policy_ID attribute to permit references to such policies to be made at any level of granularity within the EHR containment hierarchy. Every RECORD_COMPONENT may therefore reference any number of access policies or consent declarations that define the intended necessary privileges and profiles of principals (users, agents, software, devices, delegated actors etc) for future access to it.
It must be remembered that some policies may apply to particular RECORD_COMPONENTs within an EHR, whilst others may apply to the EHR as a whole.

This attribute is a good example of a refactored attribute. The intention in ISO 13606 is to mark each data node with the list of policies that apply to it. However, in an EHR system, the same information model is very unlikely to be used, for at least one very basic reason: if the policies relating to a given data item or document were to change, changes would be required to the document itself. Instead, source systems are much more likely to have a policy server that references data items using whatever internal identification system is available.

Recommendation

This is the case for openEHR systems. The 13606 policy_ids attribute would therefore by populated by extracting the list of policy identifiers (where this makes sense) from the openEHR source system EHR ACCESS_CONTROL object and/or policy service. For conversion in the 13606 -> openEHR direction, the policy_ids found in the 13606 data would have to be matched to policies either in a service in the receiving system, or in a shared policy service. This would rely at least on the presence of a widely standardised policy identification scheme.

ISO 13606 RECORD_COMPONENT.sensitivity

This attribute is defined as follows in ISO 13606-1

The sensitivity of this RECORD_COMPONENT, represented using the code set for this attribute defined in Part 4 of this standard.

Part 4 contains the following:

In addition to the generic representation of EHR access policy information (Annex A), this standard therefore also defines a specification for a minimum basis for communicating the sensitivity of EHR data within an EHR_EXTRACT, by specifying the sensitivity of the RECORD_COMPONENTs within it according to the classification defined in clause 6.1 of this part standard. This classification corresponds to the various sub-domains of EHR data illustrated in Figure 3.
In practice any given EHR system might have other mechanisms for indicating the sensitivity of EHR data or some equivalent concept. This standard does not require EHR systems to store data according to the sensitivity levels defined in clause 6.1, but to be able to map to this classification on generating an EHR_EXTRACT.

This data item, and access policies in general have been discussed by the openEHR ARB in 2006. At the time it was thought that there might not be a single 'sensitivity' for a given data item, such as a document added to the EHR by an obstetrician indicating a woman's pregnancy. The patient in question may be happy for the GP to see this information, but not want it seen at all by her employer (which might be possible for large employers with their own health plans).

Recommendation

xxx

ISO 13606 ENTRY.mode

This attribute does exist in openEHR where the PARTICIPATION class is used. However, in the ENTRY class, the attributes subject and provider are 'hard-modelled', and do not use the generic PARTICIPATION value, since the function and performer are implicit. This does however mean that the mode attribute is also not available for the two principal participants.

Recommendation

This attribute is a candidate for addition to openEHR.

Data mismatches

This category of differences is where the models do map more or less directly, but are used in different ways, resulting in data instances that may not be populated in the same way.

ISO 13606 RECORD_COMPONENT.rc_id, orig_parent_ref

This attribute is probably the biggest challenge of the ISO 13606 model. ISO 13606-1 says the following.

It is important that each RECORD_COMPONENT be uniquely and consistently identified across multiple EHR_EXTRACTS, so that references to or between them remain valid. Examples of such references are semantic links, revision and attestation. The rc_id attribute is of data type Instance Identifier (II), which incorporates an ISO OID; II is currently considered internationally to be the most appropriate data type for persistent identifiers that are required to be globally unique. It is unlikely that contemporary EHR systems will have existing primary keys or internal identifiers that correspond directly to globally-unique II instances. However, an EHR Provider system that has been issued with an organisational OID might use its internal references to construct unique local extensions to that OID and thereby construct globally-unique rc_id values.
Alternatively, it might create completely new rc_ids and retain a record of the mapping of these to each internal identifier, so that any future EHR_EXTRACTS it generates will use consistent rc_id values. It is also unlikely that an EHR Recipient system will be able to use received rc_id values as its internal primary keys for the data, since every database uses a slightly different approach to generating and using such keys. The EHR Recipient might therefore also need to keep a record of the mapping of imported rc_id values to its primary keys, so that future references to those RECORD_COMPONENTS can be appropriately matched, and it can create EHR_EXTRACTs that reapply those rc_id values to the exported data. An alternative approach is for EHR systems to explicitly store the rc_id values along with the clinical data, and treat this as part of the "payload" data and not attempt to use these also as primary keys. It should also be noted that the rc_id does not function as a primary key equivalent within an EHR_EXTRACT i.e. duplicate values of rc_id are permitted if each instance does indeed refer to the same piece of clinical data within the EHR Provider system. [emphasis added]

The key requirement here is:

Extract nodes (i.e. RECORD_COMPONENT instances) must be uniquely and consistently identified across multiple EHR_EXTRACTs (rather than just within a given extract).

Two strategies for populating rc_id are proposed:

use an organisation OID + locally constructed internal identifiers for the nodes in the Extract
create rc_id values (probably GUIDs) on the fly and make both source and target systems keep a record of them.

The second approach implies a serious impost in data management overhead, since it requires an entirely new GUID-based indexing capability to be added to all systems sharing data using 13606, with concomitant costs, even though they have no use for such a capability within the system, or for other sharing methods, such as HL7v2. As a result, the only approach that can realistically be used in EHR systems, including those based on openEHR, is the first. It is assumed for both the rc_id and the orig_parent_ref attributes.

Recommendation

To implement the first approach above in openEHR, ids of the form used in openEHR URIs are used, i.e. COMPOSITION.uid + node path, since COMPOSITION.uid is globally unique (other approaches could be used involving a system identifier as well). COMPOSITION.uid is of type OBJECT_VERSION_ID, described as follows in the specification:

The string form of an OBJECT_VERSION_ID stored in its value attribute consists of three segments separated by double colons ("::"), i.e. (EBNF):
    value: object_id '::' creating_system_id '::' version_tree_id
    object_id: UID
    creating_system_id: UID
    version_tree_id: VERSION_TREE_ID

An example is as follows:

F7C5C7B7-75DB-4b39-9A1E-C0BA9BFDBDEC::87284370-2D4B-4e3d-A3F3-F303D2F4F34B::2

Note that the uid (first and second segments can also be of type ISO Oid, or a reverse internet domain name. This 3-part id globally identifies a versioned openEHR Composition in a distributed network where multiple institutions can create their own local updates from an initial common copy e.g. of medications list. To get to an interior node, a path will be required, of the typical form used in openEHR, from the root node down to the node in question. An example of such a path is:

/content[openEHR-EHR-SECTION.vital_signs.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.heart_rate-pulse.v1 and name/value='Pulse']/data/
events[at0003 and name/value='Any event']/data/items[at1005]

So the identifier to each node in a structure could be something like:

F7C5C7B7-75DB-4b39-9A1E-C0BA9BFDBDEC::87284370-2D4B-4e3d-A3F3-F303D2F4F34B::2/content[openEHR-EHR-SECTION.vital_signs.v1 and name/value='Vital signs']/
items[openEHR-EHR-OBSERVATION.heart_rate-pulse.v1 and name/value='Pulse']/data/events[at0003 and name/value='Any event']/data/items[at1005]

(Note that 'Pulse' and 'Vital signs' could also be represented by Snomed or other codes).