Assessment Scales

return to:Patient Care

Current Action Item: Finish the work from the ballot resolution on the Assessment Scales topic and have it published as DSTU.

DSTU criteria are met, edits are ongoing.

There is work underway for the new R-MIM on scores and assessment scales. This page provides the material which has been in the last ballot. All criteria are met and currently ballot material edits are taking place following the reconciliation decisions.

This paper is organized according to the following three components:

1. Rationale for paying attention to assessment scales / scores / indexes as a separate topic
2. The HL7 v3 ballot material persé: use cases, storyboards, dynamic model, static R-MIM model.
3. Instructions for use to define assessment scale as Detailed Clinical Model, including the coding of it, and use it against the care statement / assessment scale R-MIM.

HL7 Version 3 Standard: Care Provision; Assessment Scales, Release 2 (1st DSTU Ballot)

Unique Ballot Id: V3_PC_AS_R2_D1_2009JAN

This is a release 2 revision of the existing assessment scale R-MIM in the care structures topic which has DSTU status since 2007.

Contributors

Patient Care Co-Chair: William Goossen, RN, PhD, Results4Care & HL7 Netherlands

Patient Care Co-Chair: Lawrence McKnight, MD, Siemens Healthcare, USA

Patient Care Co-Chair: Kevin Coonan, MD, USA

Principal Contributor: Frank Oemig, Agfa HealthCare & HL7 Germany

Principal Contributor: William Goossen, RN, PhD, Results4Care & HL7 Netherlands

Principal Contributor: Kevin Coonan, MD, USA

Principal Contributor: Sylvia Thun, MD, DIMDI, Germany

Principal Contributor: Rainer Röhrig, MD, University Hospital Giessen, Germany

Principal Contributor: Heath Frankel, Ocean Informatics, Australia.

Preface

Notes to Readers

Thank you for reviewing HL7 Version 3 Standard: Care Provision; Assessment Scales, Release 2 (1st DSTU Ballot).

Since the DSTU for assessment scales under care provision care structures new insights in assessment scale representations require an update. In particular, the nesting for subscales, reference ranges, and referring to additional information supporting the scoring require additions. Further, the model should accommodate future development and deployment in HL7 v3 of detailed clinical models. The R-MIM has changed in particular extended with additional classes. The walkthrough is completed, reusing the existing materials from R1 DSTU, but adding application guidelines.

The aim of this release is to provide a generic template based on the clinical statement pattern for use with almost all scores systems and assessment scales. Therefore, it provides a framework for use in messages and documents. This chapter is balloted as a first DSTU to collect comments from the membership.

This document should be available for generic use. Some of the examined scores systems are coming from the German realm. So, with our apologies, sometimes there is no English description provided. Translations will follow within the next cycle.

Changes from Previous Release

Summary of Changes from Release 1

• migration to generic structure (no restriction to specific score systems and assessment scales)
• nesting for subscales (to any depth)
• addition of reference ranges
• referring to additional information supporting the scoring
• to be used in messages and CDA documents
• integration of existing observations
• support of different mood codes

Introduction

Overview

The most fundamental question is always how certain information in HL7 should be transmitted. In most cases, it is information that belongs to the category of "findings" or "observations". Therefore, in HL7 v2.x the OBX-Segment can be used. The code in OBX-2 explains what the observation is about. In HL7 V3 we will find some classes within the RIM and the appropriate domain models.

The so-called Score or assessment systems are findings. Score systems are so-called severity classification systems or point totals systems that pretend to make a quantitative statement on the severity and prognosis of a disease, health condition or functional status. Typically, scores combine individual values into a total which can be interpreted more easily. In the simplest case, it is just a single value or based on two individual values, in a complex case it can consist of several dozen values which are combined using a complex mathematical calculation. Several example assessment scales consist of sub scales with a subtotal score, where nesting of several sub scales to a total score exists.

This document tries to address two kinds of requirements. First, it should define which codes for the most important score and assessment systems must be used. On the other hand, it should explain how the information should be mapped to V3. (The basics may also be used - esp. regarding the definition of codes - to specify how this information can be transmitted with HL7 v2.x messages.) The R-MIM for assessment scales is developed against the Clinical Statement patterns, thus allowing the inclusion of the R-MIM in any message or clinical document example that adheres to the clinical statement pattern specification.

Scope

There are many score systems in use in health care at large ([Wikipedia]). Many systems are in use on an international, national or just hospital wide or individual practice level. Others are just for scientific purposes. Most interesting scores have both validity and reliability characteristics on individual patient level and on population level.

Information about Scores and Assessments

The representation of Assessment scales, scores or indexes in information technology can be based on the Detailed Clinical Models (DCM) approach. Assessment scales require a very strict interpretation of the variable and the value set in order to keep the psychometric / clinimetric characteristics in tact. In particular these scientific characteristics are based on the population investigated and reveal data on validity (fitness for purpose) and reliability (consistency in measurement).

In the DCM the purpose, scientific evidence, instructions for appropriate application, and guidelines for interpretation of such scoring instruments are expressed. In additional the data specification and vocabulary and coding binding are included. The latter is of great importance for the full expression of scales in messages and for our communication the following information are of interest:

• Name + description (short textual description) of the scale or instrument
• List of variables or data elements of which the scale consists
• Code (how to identify the variable / data?)
• Codesystem (what is the originating catalog?)
  • LOINC,
  • alternatively Snomed CT, (if a licence is available),
  • ICD,
  • ICF,
  • ICNP
  • NANDA
  • Realm specific codes or domain specific codes
  • or perhaps proprietary codes (if necessary)
• value (what are the possible/allowed values/information)
• data type (ISO data type format), in particular the Coded Ordinal is frequently applied allowing text specification of the value and the number allowing calculations
• unit (in UCUM)
• interpretation (or interpretation range)
  • value domains/sets
  • codes for each value
• derivation method (how is the total score calculated or derived, e.g. sum score based on scoring each individual variable first).

In addition to this information for an individual score the underlying values used for calculation are of importance as well. But these are also based on the same 6 main points mentioned above.

Application Domains

The score systems can be assigned to specific domains. The following table lists example assessment / score systems (in alphabetic order) per domain with the assigned code (if available).

This can be further completed in future cycles.

Score System	Description	Code	Codesystem
1. Intensive Care and Anasthesia
ABSI	Abbreviated burn severity index	tbd
AIS	Abbreviated Injury System	273254002	Snomed CT
APACHE	Acute Physiology And Chronic Health Evaluation Score APACHE 2: APACHE 3:	9264-3 9265-0	LOINC
ASA	American Society of Anesthesiologists physical status classification	273270000 413347006	Snomed CT
CASUS	Cardiac Surgery Score	tbd
GCS	Glasgow Coma Scale (Beurteilung von Bewusstseinsstörungen bei Erwachsenen)	9269-2 35088-4 386560004	LOINC LOINC Snomed CT
HIS	Hannover Intensiv Score	tbd
HTI	Hospital Trauma Index	273525007	Snomed CT
ISS	Injury Severity Score	273533008	Snomed CT
KISS	Kombiniertes Intensiv Scoring System	tbd
LOD	Logistic Organ Dysfunction Score	58577001	Snomed CT
MOD	Multiple Organ Dysfunction Score
MOF	Multi-Organ-Failure-Score	tbd
MPI	Mannheimer Peritonitis Index	tbd
Ramsay	Ramsay sedation scale	281400004	Snomed CT
RASS	Richmond Agitation Sedation Scale	tbd
SAPS	Simplified Acute Physiology Score SAPS: 273811002 Snomed CT SAPS 2: 273812009 Snomed CT SAPS 3: n.v. ICD-10-GM
SOFA	Sepsis-related Organ Failure Assessment	tbd
TI	Trauma Index	273883005	Snomed CT
TISS	Therapeutic Intervention Scoring System: TISS-10 TISS-28 TISS-76	273878002 tbd	Snomed CT ICD-10-GM
TS	Trauma Score	273884004	Snomed CT
...
2. Patient Care
Barthel-Index (German)	Barthel Index, German version	273302005	Snomed CT ICD-10-GM
Barthel-Index (Dutch)	Barthel Index, Dutch version The Dutch modification makes use of a different scoring though the concept is the same		Snomed CT ICD-10-GM
Barthel-Index, expanded	cognitive function	ICD-10-GM
Braden Scale	Braden Scale	38227-5	LOINC
Braden Skin Ass. Pnl	Braden Skin Assessment Panel	38228-3	LOINC
BradenQ	Braden Scale for young children (<5 years)	tbd	LOINC
FIM	Functional Independence Measure	273469003 U50.-	Snomed CT ICD-10-GM
FRB	Frührehabilitations-Barthel-Index after Schönle	U52.- 273302005	ICD-10-GM Snomed CT
NEMS	Nine equivalents of nursing manpower use score	tbd
Norton	Norton score	278898009	Snomed CT
PPR	Pflegepersonal-Regelung	tbd
Waterlow	Waterlow pressure sore risk score	278897004	Snomed CT
...
3. Psychiatry and Psychology
AMDP	Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie	tbd
LFP	Lübecker Fähigkeitenprofil	tbd
Melba	Merkmalprofile zur beruflichen Eingliederung von Behinderten	tbd
MMSE	Mini Mental State Examination	273617000	Snomed CT ICD-10-GM
...
4. Pediatrics
Pediatric GCS	Pediatric Glasgow Coma Scale	tbd
APGAR	after 1 minute after 5 minutes after 10 minutes	9272-6 9273-4 9271-8	LOINC
...
5. Mobility
	Tinetti-Test
	Timed “Up & Go
	Tandemstand
	Tandemgang
	Chair-Stand-Up
...
6. Cognition
DemTect
TFDD	Test zur Früherkennung von Demenzen mit Depressionsabgrenzung
	Clock Completion
...
7. Nutrition
MNA	Mini Nutritional Assessment(after Guigoz et.al.)
...
8. Psychology
APS	Acute Physiology Score
...
9. Geriatry
GDS	Geriatric Depression Scale	273481004 48544-1	Snomed CT LOINC
...
10. Cardiology
	Framingham Hard Coronary Heart Disease (10-year risk)
	Framingham Coronary Heart Disease (10-year risk)	315039001	SNOMED CT
	Framingham Coronary Heart Disease (2-year risk)
	Framingham Stroke (10-year risk)
	Framingham Intermittent Claudication (4-year risk)
	Framingham Recurring Coronary Heart Disease (2-year risk)
	Framingham Stroke or Death After Atrial Fibrillation (5-year risk)
	Framingham General Cardiovascular Disease (10-year risk)
ASSIGN	Assessing cardiovascular risk using SIGN guidelines
CLASP	Cardiovascular Limitations and Symptoms Profile	315628000	SNOMED CT
CLASP-Angina	Cardiovascular Limitations and Symptoms Profile – Angina Score	135831005	SNOMED CT
CLASP-SOB	Cardiovascular Limitations and Symptoms Profile – Shortness of Breath Score	135833008	SNOMED CT
CLASP-Ankle	Cardiovascular Limitations and Symptoms Profile – Ankle Swelling Score	135832003	SNOMED CT
DTS	Duke Treadmill Score	304915008	SNOMED CT
BorgRPE	Borg Rating of Perceived Exertion Scale	122734	DICOM
BorgCR10	Borg Category Ratio Scale	122735	DICOM
	Echocardiographic Myocardial Segment Assessment – 4 Point Scale	125223	DICOM
	Echocardiographic Myocardial Segment Assessment – 5 Point Scale	125224	DICOM
	Echocardiographic Myocardial Segment Assessment – 5 Point Scale with Graded Hypokinesis	125225	DICOM
11. Oncology
Breslow Level	Tumordicke nach Breslow bei Hauttumoren	tbd
Clark Level	Skin Tumor	tbd
Figo	gynocological tumor	tbd
Holoye	Bronchialkarzinom	tbd
Indiana	metastasierte Hodentumoren	tbd
INSS	Neuroblastom	tbd
Lugano	Hodentumoren	tbd
Marburger	kleinzelliges Bronchialkarzinom	tbd
Binet	lymphatic leukemia	tbd
Durie and Salmon	Plasmocytom	tbd
FAB	FAB-Klassifikation akuter myeloischer Leukämien	tbd
Jansen and Hermans	Haarzellleukämie	tbd
12. not otherwise classified
Bone density		385342005	Snomed CT
BMI	Body-Mass-Index measurement Body-Mass-Index	39156-5 41909-3	LOINC LOINC
BV	Bacterial vaginosis score	B96. N76.	ICD 10
FLACC	Face Legs Activity Cry Consolability Score	tbd
Gleason	Gleason Score	372278000	Snomed CT
HTI	Hospital Trauma Index	273525007	Snomed CT
IADL	IADL (after Lawton and Brody)
LBK	Lübecker Fähigkeitenprofil
MPM	MPM 2 (0) MPM 2 (24, 48, 72) Mortality Prediction Model	273630004 273631000	Snomed CT Snomed CT
PHQ	Personal Health Questionnaire (Depression Score)
PSR	Periodontal Screening and Recording
VAS	visuell analog Scala	tbd
...

Of course, the details for the individual score systems are missing here. They are part of a separate document which is available in form of generated HTML files.

Code-Systems

The code systems are identified by their OIDs which are listed in the following table.

Codesystem	Descrption	Website	OID
LOINC	Logical Observation Identifiers Names and Codes	[www.loinc.org]	2.16.840.1.113883.6.1
ICD 10 GM 2005 icd10gm2005	ICD-Katalog (German modification 2005)	[www.dimdi.de]	1.2.276.0.76.5.304
ICD 10 GM 2006 icd10gm2006	ICD-Katalog (German modification 2006)	[www.dimdi.de]	1.2.276.0.76.5.311
ICD 10 GM 2007 icd10gm2007	ICD-Katalog (German modification 2007)	[www.dimdi.de]	1.2.276.0.76.5.318
ICD 10 GM 2008 icd10gm2008	ICD-Katalog (German modification 2008)	[www.dimdi.de]	1.2.276.0.76.5.330
ICD 10 GM 2009 icd10gm2009	ICD-Katalog (German modification 2009)	[www.dimdi.de]
ICD 10 GM 2010 icd10gm2010	ICD-Katalog (German modification 2010)	[www.dimdi.de]
ICD 10 GM 2011 icd10gm2011	ICD-Katalog (German modification 2011)	[www.dimdi.de]
ICD 10 GM 2012 icd10gm2012	ICD-Katalog (German modification 2012)	[www.dimdi.de]
ICD 10 GM 2013 icd10gm2013	ICD-Katalog (German modification 2013)	[www.dimdi.de]
Snomed CT	SNOMED CT is a concept-based, scientifically validated terminology that provides a unique and permanent concept identifier that can be included in multiple HL7 data types including CD and CE. The concepts are managed to avoid "semantic drift" so the meaning remains constant. If the concept is found to be ambiguous or the meaning changes, the concept is inactivated but still retained and the identifier is never reused. SNOMED CT's concepts are interrelated hierarchically and using description logic.	[www.snomed.org]	2.16.840.1.113883.6.96
OPS 2006 ops2006	Operationsschlüssel	[www.dimdi.de]	1.2.276.0.76.5.310
OPS 2007 ops2007	Operationsschlüssel	[www.dimdi.de]	1.2.276.0.76.5.317
OPS 2008 ops2008	Operationsschlüssel	[www.dimdi.de]	1.2.276.0.76.5.331
OPS 2009 ops2009	Operationsschlüssel	[www.dimdi.de]
Alpha-ID 2008 alphaid208	Alpha-Id 2008	[www.dimdi.de]	1.2.276.0.76.5.329
Alpha-ID 2009 alphaid209	Alpha-Id 2009	[www.dimdi.de]
DICOM	DICOM Controlled Terminology (PS3.16)	[dicom.nema.org]	1.2.840.10008.2.16.4

Foundation

Assessment Scales – Scores Structure Overview

Given the interest in earlier versions of the Care Provision Ballot, further work has been undertaken on representing assessment scales, scores or indexes. The scientific testing of such instruments puts specific requirements and constraints on its use in HL7 v3 message structures in order to not only have a semantically equivalent data exchange, but also to keep the clinimetric characteristics of the instruments as a whole. The assessment scales, scoring systems or indexes are observations with specific characteristics. They can consist of severity classification systems or point totals systems that pretend to make a quantitative statement on the severity and prognosis of a disease or other aspect of human functioning. It is quite often an attempt to convert ‘soft’ observations into ‘hard’ data and evidence. Most of such instruments used in healthcare have been tested extensively on validity, reliability and usability. Many of such scoring instruments are used for decades and worldwide. Typically, assessment scales or scores combine the findings of individual values into a total score which can be interpreted more easily against a reference population. In the simplest case, it is just a single value or based on two individual values, in a complex case it can consist of several dozen values which are combined using a complex mathematical calculation or statistical technique. The scientific validation of a scale from one country, language, domain or patient population to another requires sufficient testing and retesting. Quite often it does require a slight change in meaning in order to achieve a sufficient valid and reliable instrument. Thus the instruments in different languages do differ somewhat. This can be on definition of variable level, or on the actual numbers assigned. The English and Dutch Barthel index for instance use different numbers assigned for the values (e.g. 0, 5, 10 or 15 for English and 0, 1, 2, or 3 for Dutch. Such knowledge is important in order to compare the correct score for individuals appropriately.

This R-MIM tries to give guidelines on the representation in information models, in particular against the HL7 clinical statement pattern and the care statement R-MIM for care provision.

In addition to the information model, the appropriate use of terminology and consistency between the information model and the terminology model are crucial for safe exchange of such observations.

Clinical Statement extract

The R-MIM for the assessment scales / scores can be seen as an extract of - or constraint on - the Clinical and Care Statement Pattern, thus inheriting its characteristics. The R-MIM representation starts on top with the name and identification in the entry-point. For a detailed explanation of all attributes and vocabulary, the reader is referred to generic descriptions of the Reference Information Model, and to the walkthrough of the care statement D-MIM.

Score Observation

The R-MIM then starts with the score observation out of the choice box. As said above, the crucial attributes include:

• ClassCode: used to acknowledge that the score is an observation
• code: used to identify the variable and in which also the code system can be listed.
• text: attribute to allow the name and description of the assessment instrument
• value in which the actual score and where applicable the unit can be entered
• interpretationCode where the interpretation of the value can be explained via codes, often against a reference value.
• In the derivation code the total score for the assessment scale is recorded. In other words: derivation method is for example to add all values of the separate scores towards the total score.
• Effective time is the point in time on which the instrument is scored. In order to be valid and reliable, the scoreItems need to have (almost) the same time stamp. Such constraints posed by assessment instruments are important and expand beyond the mere semantic interoperability. For the receiver it is not only important to understand what the message content means, but also be ascertained that the data are collected based on the guidelines for the instrument. Such guidelines will become available in Detailed Clinical Models.
• In the value of the score, which was created by adding the individual score items, is filled up. This is often a Coded Ordinal data type because it is mandatory to score and fill up all items to get a proper sum score. That is why Mandatory (1..1) component relations often exist for scoring instruments.
• Of course all relevant attributes can be applied as needed.

Component relationship to ScoreItem Observation

In principle, a score is based on specific observations, or other scores. From this point onwards a recursion starts based on the component relationship, allowing either including other score values or observations a score is based upon. Beneath the score Observation is the Observation (OBS) with the name Score Item. Both the class Score and the class ScoreItem have classCode=OBS.

derivedFrom relationship to Care Statement CMET

The derivedFrom relation to care statement allows the user to describe any relevant information related to why a score item is scored this way. It allows to express any human thoughts as observations to go alongside with the score itself, or any circumstances as a procedure being carried out, or a specific encounter when it was measured. The relationship is to the choice box, allowing to make such statements on the level of the assessment instrument as a whole, or for an individual scoreItem.

Linkages to subject and provider roles

Several participations include different human actors, i.e. the patient, the observer, data enterer etc. They are linked to different CMETs providing the required details. The description and explanation of the CMETs is not part of this specification and the reader is referred to the appropriate chapter.

Score System Categories

The Score Systems can be divided into different categories: Those with arbitrary scores, those with discrete values and those with an unspecified number of values. Patient Classification Systems for workload are examples of the first one, the Barthel Index is an example of the second category, the BMI (Body Mass Index) an example for the third.

Arbitrary Scores

A scale is a set of linear values from a certain range. A reference range can be determined. In this case, an interpretation according to the conventional scheme is possible, i.e. a value is interpreted as "normal" if it is within the area - or at least close to one of its borders:

However, it should be noted here that an interpretation as too low is not necessarily combined with the abnormal flag. The flagging is somehow independed from the defined reference range.

For example: BMI

The following is an example from BMI:

Discrete Values (Scores)

Within this category, the "normal range" and the number of all possible values are identical. Therefore, the standard usage of reference ranges does not work. In principle, the whole range is devided into smaller parts each representing a specific interpretation:

The following is the set of interpretations for the German Barthel Index:

Hence, as for the example above, the (German) Barthel Index allows for the values of 0 to 100 in steps of 5. The total reference range, which can be specified, is within the same range, so that the available assessment opportunities (Abnormal flags) are not usable. The interpretation of a score is depending on the part of the reference range to which it belongs. Hence, the referenceRange relationship (one to many) to another OBS with the name ScoreRange.

For example: German Barthel Index

The interpretation shows how the total score should be interpreted. For instance, the Dutch version of the Barthel index has 0-9 for seriously limited, 10-19 for moderately limited and 20 for independent.

As mentioned above, an assessment of the results by the conventional scheme of a reference range, where values outside are too high or too low, does not to apply. All values are falling into the range as defined by the score system. This range is - as explained above - to be divided into sections, which then can be evaluated/interpreted separately. Each score system is going to have its own (new) set of interpretation values. Each score system should get its own set of interpretation values which can be defined according to the following scheme. If the code values are coming from different code systems, then they must be included:

Eventually, some score systems may share the same interpretations. But this is up to individual examinations.

The following table is the interpretation for the German Barthel Index:

Code system	Code	Value (From - To)	(German) Interpretation
ICD 10 GM 2007	U50.00	85 - 95	Leichte motorische Funktionseinschränkung
ICD 10 GM 2007	U50.10	60 - 75	Mittlere motorische Funktionseinschränkung
ICD 10 GM 2007	U50.20	40 - 55	Mittelschwere motorische Funktionseinschränkung
ICD 10 GM 2007	U50.30	20 - 35	Schwere motorische Funktionseinschränkung
ICD 10 GM 2007	U50.40	100 - 100	Keine oder geringe motorische Funktionseinschränkung
ICD 10 GM 2007	U50.50	0 - 15	Sehr schwere motorische Funktionseinschränkung

If this would be done with the Dutch Barthel, the maximum score would be 20, thus altering the reference ranges substantially. Of course it can be divided by 5, but such constraint needs to be made explicit. In particular it is important to identify the scoring instrument per realm. Thus the Dutch and German Barthel indexes would require to have different codes, at least on the value set level to distinhuish the differences.

Storyboard

This D-MIM can be used in different circumstances. Right now, several different use cases are foreseen.

Assessment Scale Define

The D-MIM can be used in definition mood, so that it can convey information about the score system resp. assessment scale itself. This in particular can be derived from Detailed Clinical Model for the specified scale and transformed into the HL7 message content representation.

Assessment Scale Order

The primary codes, i.e. the ones on top level and not for the components, can be used to send a request for an observation using scores and assessments.

Assessment Scale Plan

The adding of such an assessment observation to a care plan to be carried out at a specified data and time.

Assessment Scale Observation

The result of such an observation can be transmitted.

Assessment Scale Query

It should be possible to query for previous results as well. In this instance, the Care Provision R-MIM for lists (A_StatementCollector (REPC_RM000400UV01) can be used to organize multiple assessments, e.g. against a time line to trend the information, or to reveal highest and lowest scores.

Application Roles

According to the use case different combinations of application roles are applicable:

• informer - tracker
• placer - fulfiller
• query placer - query fulfiller

Trigger Events

The associated trigger events depend on the use case. This template an be used in messages and/or documents. Therefore, the events will vary.

Refined Message Information Models

HL7 V3 provides the "Clinical Statement Pattern". Here one can find the activity "Observation" with the necessary details. Facilitating this "basic structure", the pattern/template can be reused in other domains as well.

A_ObservationAssessmentScales-Scores (REPC_RM000125UV)

A score or assessment value is an observation. Therefore, as an entry point the observation act has been chosen. If the total score value is to be transferred only, they may use the Observation-Act directly (and exclusively).

But if the total score including all individual observations, the latter has to be assigned to the score as components. This assignement is done recursively so that a component can be a score itself. Within this recursion one can refer to a score or an observation which is used to calculate the total score. Therefore, the act relationship link is done from Score to ScoreChoice.

Both classes can be linked by participations to CMETs for performer, verifier, author etc. or to refer to a reference range.

Walkthrough

The walkthrough will be done in the following order:

• Score
• Score Item
• Act-Relationship component
• Participation author
• Participation verifier
• Participation performer
• Participation dataEnterer
• Participation subject
• Act-Relationship referenceRange
• Score Range
• Act-Relationship derivedFrom
• CMET A_CareStatement

Class Score

This act conveys information about the score itself and acts as a container (grouping) for the details to this score.

classCode := OBS

A score is an observation. Therefore the classCode is set to “OBS”.

moodCode <= ActMoodCompletionTrack

This value can come from ActMoodCompletionTrack and therefore allows to use in different business cycles. Normally, using "EVN" is foreseen. But "RQO" for requests or "DEF" for conveying information about the assessment scale itself is permitted as well. It depends on the use case.

Here we have to admit, that "DEF" is officially not allowed within clinical statement patterns. This is an action item for the next harmonization meeting.

id (Score-ID) := SET<II> [1..*]

Each Score is identified by a unique id. A value must be provided, esp. if the information is used in different phases of a business cycle.

code (score system) := CD CWE [1..1]

This is the primary value to identify the score system and therefore mandatory. As the R-MIM makes use of a generic structure the code is essential to interpret and understand the contents, i.e. to identify the Assessment Scale. The value may come from different code systems. The possible values can be found in the HTML files generated from the database.

derivationExpr (calculation method) := ST [0..1]

This optional field can be used to specify how the total score is calculated. In most cases the total score will be the sum of its components. But complex mathematical functions and/or logical operations are possible as well. An example of this is the Body Mass index. In some cases the calculation or derivation is a matter of copyright issues.

function	description	Example
direct value	Score only consists of a single value. This value is just interpreted.	RASS Ramsay
sum	The different details are single values which are added into a total.	Barthel Apache II
mathematical calculation	The details are combined according to a mathematical functions.	BMI
combination of the above	The values are combined somehow, e.g. by concatenation.	PPR
...

This specification currently does not provide any help on how the derivation expression should be formulated. This is up for further elaboration. The accompanying Detailed Clinical Model for a score will reveal, if copyright matters permit, the full expression of the formulas or logics.

statusCode (Status) := CS CNE [1..1] <= ActStatus

In most cases the information is transmitted after calculation. Therefore, the statusCode will be "completed".

effectiveTime (observation time) := GTS [0..1]

This element conveys the time of the observation.

languageCode (language) := CE CWE [0..1] <= HumanLanguage

This field contains the language the textual information is expressed in.

value (total Score Value) := ANY [0..1]

This field contains the value of the total score itself. Normally, it will be an integer or coded ordinal. But other datatypes like strings as for PPR ("A1S2") or real values for BMI are allowed as well.

interpretationCode (Interpretation) := SET<CE> CWE [0..*] <= ObservationInterpretation

This field contains the interpretation of the score value. The code comes from a value set which has been defined for this score system.

methodCode := SET<CE> CWE [0..*] <= ObservationMethod

In this attribute it is possible to use codes representing a particular approach to the observation. More guidance will be given in future revisions.

Class ScoreItem

Like the class Score this act conveys information about the component to a score.

classCode := OBS

This act is a placeholder for individual observations. Therefore the classCode is set to “OBS”.

moodCode <= ActMoodCompletionTrack

This value can come from ActMoodCompletionTrack and therefore allows to use in different business cycles. Normally, using "EVN" is foreseen.

id (Score-ID) := SET<II> [0..*]

Each component can be identified by a unique id. A value can be provided. This is esp. useful if the information is used in different phases of a business cycle, e.g. order and observations.

code (score system) := CD CWE [1..1] <= ActCode

This is the primary value to identify the component of the score system and is therefore mandatory. The value may come from different code systems. The possible values can be found in the database.

negationInd := BL [0..1]

This field is used to express the negation of the transmitted statement. Most probably it will be set to "false".

text := ED [0..1]

This field can be used to transmit additional textual information about the score and its details.

statusCode (status) := CS CNE [1..1] <= ActStatus

In most cases the information is transmitted after calculation. Therefore, the statusCode will be "completed".

effectiveTime (observation time) := GTS [0..1]

This is the time when this single observation took place. Normally all observations of a score should be carried out at approximately the same time.

value (score value) := ANY [0..1]

This field contains the value of the score component.

interpretationCode (interpretation of the value) := SET<CE> CWE [0..*] <= ObservationInterpretation

This field contains the interpretation of the score component value. The code comes from a value set which has been defined for this component of the score system.

Act-Relationship component

This act relationship is used to link a score (as parent) to its components (as children). The use is optional.

typeCode := COMP

This value indicates, that the source consists of the target as its parts.

Participation author

Using this participation the information about the author is included. At this place this participation can be used to assign different authors for the different Score Items.

author (information about the author) := [0..*]

The detailed information about the author is optional.

functionCode (function of the author) := CE CWE [1..1] <= ParticipationFunction

This mandatory information introduces the function the author has participated into the creation of the score values.

contextControlCode := CS CNE [0..1] <= ContextControl

This element controls whether the context information from the parent relationship are applicable at this level. Most probably it will be set to "true", but circumstances can be foreseen that specific participations are unknown and cannot be defined thereof.

time (timestamp of documentation) := TS [1..1]

The mandatory attribute time specifies the point in time of the documentation of the score observation.

Participation dataEnterer

This participation is linked to the R_AssignedPerson CMET.

Participation subject

Using this participation information about the patient is conveyed. This participation is linked to the R_Patient CMET.

CMET Choice Box

The following CMETs are assigned to the previously listed participations:

• R_AssignedEntity [universal]
• R_Patient [universal]
• R_RelatedParty [universal]
• R_AssignedPerson [universal]

Act-Relationship referenceRange

In this (optional) Observation the Reference for the score value is documented. This is the range of values that are normal for healthy people

The range determination for measured normal values is not always valid when they are all in the reference range, but need a distinct interpretation.

In this case the „Precondition“ is used.

typeCode := REFV

Setting the typeCode to "REFV" declares this relationsip as a reference range.

contextConductionInd := BL [1..1] = "false"

The context is not used.

seperatableInd := BL [0..1]

This information specifies whether the source class (score value) can be used with the reference range or not.

class ScoreRange

This class is used to convey information about reference ranges. Sometimes this is combined with criteria.

classCode := OBS

Of course, the main class is an observation. Therefore, the classCode is set to "OBS".

moodCode := EVN.CRT

The single values supporting the score values will be exchanged in EventMood.

negationInd := Verneinung BL [1..1] <= false

Reference ranges are not negated.

value (Bereichswert) := ANY CWE [1..1] =

In diesem Feld wird der Normwertbereich angegeben. Typischerweise wird er als Intervall kommuniziert. Es ist aber auch denkbar, dass hier eine Wertemenge angegeben wird, so dass der Datentyp SET<T> zum Einsatz kommt.

Act-Relationship derivedFrom

This act relationhip links the information for the score system and its components to "real" care information. Sometimes objective inormation which has been stated earlier can be reused within a score or at least to calculate the informatione needed within the score components from measured values. This generic relationship allows for inclusion of arbitrary information as needed.

typeCode := DRIV

The score (item) information is derived from care information.

CMET A_CareStatement

Please see CMET specification.

Hierarchical Message Descriptions

As this D-MIM (RMIM) is a generic template for use in messages and/or documents, there is no detailed HMD yet.

These information models are also representable using templates (constraints) based on the Clinical Statement Pattern.

Dynamic Model

This information model represents a generic template which can be used in messages and documents as well. So we skip these details here.

Open Issues

• Description Parent: Care Structures Event Statement (REPC_RM000100UV)
• Is the Snomed CT code for Barthel Index correct? The discussion within the IHTSDO group says, it is wrong.
• On the level of proper coding, further cooperation with IHTSDO and LOINC is being sought.

Discussion

See discussion page.