Common Information Model

The PATHABLE class defines the pathing capabilities used by nearly all classes in the openEHR reference model, mostly via inheritance of LOCATABLE. The defining characteristics of PATHABLE objects are that they can locate child objects using paths, and they know their parent object in a compositional hierarchy. The parent feature is defined as abstract in the model, and may be implemented in any way convenient.

A number of functions provide the path functionality, of which item_at_path() and items_at_path() are the key functions. The former returns an item corresponding to a unique path, i.e. a path that resolves against the data structure to a single node. The latter returns a list of items corresponding to a non-unique path. These functions can be used safely using the following pattern, but can also be used without checking the validity of paths, if this is known a priori in the code anyway.

Most classes in the openEHR reference model inherit from the LOCATABLE class, which defines the idea of 'locatability in an archetyped structure'. LOCATABLE defines a runtime name and an archetype_node_id. The archetype_node_id is the standardised semantic code for a node and comes from the corresponding node in the archetype used to create the data. The only exception is at archetype root points in data, where archetype_node_id carries the archetype identifier in string form rather than an interior node id from an archetype. LOCATABLE also provides the attribute archetype_details, which is non-Void for archetype root points in data, and carries meta-data relevant to root points. The name attribute carries a name created at runtime. The 'meaning' of any node is derived formally from the archetype by obtaining the text value for the archetype_node_id code from the archetype ontology section, in the language required.

The name and archetype_node_id valuesin a LOCATABLE instance are often the same semantically, but may differ. For example, in "problem/SOAP" Sections (i.e. headings), the name of a section at the problem level might be "diabetes", but its meaning might be "problem". The default value for name should be assumed to be the text value in the local language for the archetype_node_id code on the node in question, unless explicitly set otherwise.

The data in any part of the EHR may be obtained from a feeder system, i.e. a source system which does not obey the versioning, auditing and content semantics of openEHR (data in the EHR which have been sourced from another openEHR system are dealt with in the Common IM, Change control section). The FEEDER_AUDIT class defines the semantics of an audit trail which is constructed to describe the origin of data that have been transformed into openEHR form and committed to the system. There are a number of aspects to the problem of transforming data for committal into an openEHR system, dealt with in the following subsections.

There are two ways to refer to a demographic identity in the openEHR EHR: using PARTY_REF directly, which records an identifier of the party in some external system, and using PARTY_PROXY, consisting of a small amount of descriptive data, depending on the subtype, and an optional PARTY_REF. The semantics of PARTY_REF are described in the Base Types identification package, while the semantics of PARTY_PROXY and use of PARTY_REF in such entities are described below. The approach taken in openEHR for representing demographic and user entities in the EHR data isbased on the following assumptions:

The PARTY_PROXY class and subtypes model references to parties based on these assumptions. The semantics of PARTY_PROXY enable a flexible approach: in stricter environments that have identity management and demographic services, and where there is an entry in such a service for the party in question, PARTY_PROXY.external_ref will be non-Void, while in other environments, it will be empty.

The two subtypes correspond to the mutually distinct categories of the 'subject of the record', known as the 'self' party in openEHR, and any other party. Whenever the record subject has to be referred to in the record, an instance of PARTY_SELF is used, while PARTY_IDENTIFIED is used for all other situations. The latter class provides for optional human-readable names and formal identifiers, each keyed by purpose or meaning.

The PARTY_RELATED type is used whenever the relationship of the party to the record subject is required. Relationships are coded and include familial ones ('mother', 'uncle', etc) as well as relationships like 'donor', 'travelling companion' and so on.

The Participation abstraction models the interaction of some Party in an activity. In the openEHR reference models, participations are actually modelled in two ways. In situations where the kinds of participation are known and constant, they are modelled as a named attribute in the relevant reference model. For example, the committer: PARTY_PROXY attribute in AUDIT_DETAILS models a participation in which the function is "committal". Where the kind of participation is not known at design time, a descendant of the generic PARTICIPATION class is used.

Attestation is another concept which occurs commonly in health information. An attestation is an explicit signing by one healthcare agent of particular content for various particular purposes, including:

Here it is modelled as a subtype of AUDIT_DETAILS, meaning that it is logically a kind of audit, with additional information pertinant to the act of signing. The contents of an ATTESTATION are as follows:

The digital signature, if present, is generated using the openPGP standard (IETF RFC 4880) as, according to the process shown below.

In this process, the attestation object is serialised into a canonical text form, and then hashed to create a digest. A digital signature is created from the hash, using the user’s private key. The result is then radix-64 encoded to create an ASCII string so as to remove or reduce potential problems with subsequent communication. The openPGP standard ensures that the transformations and algorithms used to create the signature are indicated within it (i.e. the signature is self-describing).

The serialisation process works by the simple rule of serialising the entire Attestation object (note that the proof attribute will be Void at this point) into an agreed XML, openEHR ODIN or other text format, then applying the subsequent transformations to the serialised data, then writing the digest result back into the proof attribute.

Normally the list of items being attested should be a single Entry or Composition, but there is nothing stopping it including fine-grained items, even though separate attestation of such items does not appear to be commensurate with good clinical information design or process.

The reason attribute is used to indicate why the attestation occurred, and is coded using the openEHR Terminology group "attestation reason", which includes values such as "authorisation" and "witnessed". The is_pending attribute marks the attestation as either having been done or awaiting completion depending on its value. This facilitates querying the record to find items needing to be signed or witnessed. When an attestation is required, the most common scenario will be that a Composition Version will be committed with a commit_audit of type ATTESTATION, rather than just AUDIT_DETAILS; the is_pending flag will be set to True to indicate that the committed information needs to be signed by another person. When signing occurs, it will cause a new ATTESTATION object to be added to the VERSION.attestations list, this time with is_pending set to False, and the appropriate proof supplied. Thus, the common situation in which content is committed to the record and needs later review and signing by a senior person will cause the creation of two ATTESTATION objects.

Directory paths are built using the name attribute values inherited from LOCATABLE into each FOLDER object. In real data, these will usually be derived from the value of the archetype_node_id attribute, plus a uniqueness modifier if required. Example paths (e.g. within the EHR):

Uniqueness modifiers are appended in brackets, and are only needed to differentiate folders at the same node that would otherwise have the same names, e.g.

The classes VERSIONED_OBJECT<T>, VERSION<T>, ORIGINAL_VERSION<T> and IMPORTED_VERSION<T> are generic classes, with the generic parameter type T being the type of the data. This ensures that all versions in a given VERSIONED_OBJECT are of the same type, such as COMPOSITION, FOLDER, or PARTY and that the version container itself is properly typed.

Each VERSIONED_OBJECT has a unique identifier recorded in the uid attribute (a HIER_OBJECT_ID typically containing a GUID), and a reference to the owning object (e.g. the owning EHR) in the owner_id attribute (this is typically also a GUID). The latter helps ensure that in storage systems, Versioned objects are always correctly allocated to their enclosing repository, such as an EHR.

The data in a VERSIONED_OBJECT are in the form of a collection of instances of the two VERSION<T> subtypes, and are available only via the functional interface of VERSIONED_OBJECT. How the representation of this collection is implemented inside the VERSIONED_OBJECT is not defined by this specification, only the form of any given version is. Implementations of VERSIONED_OBJECT might range from the simple (all versions stored as full copies in a list) to a sophisticated compressed versioning approach as used in software file version control and some object databases. (The persistent data format of implementations of VERSIONED_OBJECT developed by different organisations will in general be incompatible. For purposes of sharing, an interoperable expression of VERSIONED_OBJECT is defined by the X_VERSIONED_OBJECT class in the EHR Extract IM.)

Within a Versioned object, each version is an instance of a subtype of the class VERSION<T>. The abstract VERSION class defines the generic notion of a version containing some data, that has been committed to the repository as a member of a Contribution. Accordingly, it records the Contribution in the contribution attribute and the audit in commit_audit. A Version also knows its position in the version tree within the container. It has a version identifier, uid, and knows on which version in the tree it was based (i.e. what version was checked out to create the current version), preceding_version_uid (Void if it is the first version). Both of these identifiers are globally unique (see base_types.identification package in the BASE component). These properties are abstract in the VERSION class, since they are defined as being stored or computed respectively in its subtypes.

All Versions in a given version container have a uid that includes the uid of the container; in other words, the uid of a Version is its container’s uid plus further version identification for that particular version with respect to others in the same container. The VERSION.owner_id function extracts the uid field of the owning VERSIONED_OBJECT from the uid of the VERSION.

The VERSION class has two subtypes. The first, ORIGINAL_VERSION<T>, represents a Version created with original content (stored form of data property) at the time of creation (including from non-openEHR local feeder systems), and potentially attested (signed). It includes as attributes the current version (uid) and the preceding version (preceding_version_uid). It also knows the lifecycle state of its content. If it was the result of a merge (see Section 6.4.2) of versions other than the preceding version, the identifiers of these versions will be recorded in the attribute other_input_version_uids. All instances of VERSION<T> in non-distributed openEHR systems will be instances of ORIGINAL_VERSION<T>. The ORIGINAL_VERSION is also the unit of copying in a distributed environment.

The second subtype is IMPORTED_VERSION<T>, and acts as a wrapper of an ORIGINAL_VERSION<T>. It has its own contribution and commit_audit (inherited from VERSION<T>), and contains the original version being imported in its item attribute. Its uid and preceding_version are defined as functions, returning the corresponding attribute values from the wrapped ORIGINAL_VERSION object (in other words, an IMPORTED_VERSION does not have its own version identifier distinct from the version it is wrapping). The semantics of importing are described below in Section 6.4.1. Figure 8 illustrates typical arrangements of ORIGINAL_VERSION and IMPORTED_VERSION objects within VERSIONED_OBJECTs, in turn within an EHR (if this is an EHR system), ultimately within an identified system. The two VERSIONED_OBJECTs are shown representing "medications" and "problem list", to give some idea of correspondence of versioning structures to logical data. Star icons represent digital signatures.

An underlying design concept of the versioning model defined here is known as the 'virtual version tree'. The idea is simple in the abstract. Information is committed to a repository (such as an EHR) in lumps, each lump being the 'data' of one Version. Each Version has its place within a version tree, which in turn is maintained inside a Versioned object. The virtual version tree concept means that any given Versioned object may have numerous copies in various systems, and that the creation of versions in each is done in such a way that all versions so created are in fact compatible with the 'virtual' version tree resulting from the superimposition of the version trees of all copies. This is achieved using simple rules for version identification, described below, and is done to facilitate data sharing. Two very common scenarios are served by the virtual version tree concept:

The uid attribute of the class VERSIONED_OBJECT<T> is in fact the Uid of the virtual version tree for a given logical item (such as the "problem list" of a certain patient) - that is to say, the uid will be the same in all copies of the same Versioned object in a distributed system.

The versioning scheme used in openEHR guarantees that no matter where data are created or copied, there are no inconsistencies due to sharing, and that logical copies are explicitly represented. This is achieved by the design of Version identifiers.

Since a versioned repository (i.e. a collection of VERSIONED_OBJECTs) is by definition indelible, all logical changes including deletions, additions, modifications (including error corrections and content changes), importing and attestations of existing items, are achieved by physically committing new Versions, or for attestations, new Attestation objects to existing Versions. Each logical type of change is achieved as follows:

In a typical application situation, one or more of the above changes may be committed to a repository as a Contribution. For example during a patient encounter, the following might occur:

These two changes together constitute a logical change-set, and would typically be included in the one Contribution. In general, there might be any combination of the logical change types in a single commit by an application, corresponding to a single real-world business event, such as a GP Encounter, although attestations, deletions and corrections will usually be the only change within a Contribution. In every case, regardless of the combination, a CONTRIBUTION object will be created, listing the affected VERSION objects, and including its own audit object, whose change_type attribute captures the aggregate of the changes in the Compositions making up its versions. This may sometimes be approximate, and is not expected to be used as a computable value. Typical values for CONTRIBUTION.audit.change_type:

The list of all Contribution objects for a version repository (such as an EHR) provides a complete history of the change-sets made to the repository and is the basis for performing 'rollback' to access previous informational states of the EHR. Conversely, each Version object contains a reference to the Contribution that caused it to be created.

Audits are recorded in the form of instances of the class AUDIT_DETAILS (common.generic package), which defines a set of attributes which form an audit trail, namely system_id, committer, time_committed, change_type, and description or its subtype ATTESTATION, which adds a number of other attributes (see below). When an ORIGINAL_VERSION instance is created locally, the commit_audit attribute contains an audit object recording the local act of committal. However, if the Version being committed does not correspond to local data creation, but instead contains a copy of an ORIGINAL_VERSION originally created and commited elsewhere, it is committed locally as an instance of the IMPORTED_VERSION class. Both the contribution and commit_audit of the latter object correspond to the local act of committal, while the knowledge of the original Contribution and committal are retained inside the wrapped `ORIGINAL_VERSION instance. Original versions can be copied any number of times; in each system into which they are imported, an IMPORTED_VERSION is created as a wrapper.

This simple scheme ensures that the audit from initial creation - which is the clinically meaningful audit - is preserved no matter how many times the Version is copied to other systems; it also ensures that from the point of view of the version container, the local commit audit and Contribution always correspond to the local act of committal.

The CONTRIBUTION class also contains an audit attribute. Whenever a CONTRIBUTION is committed, this attribute captures to the time, place and committer of the committal act; these three attributes (system_id, committer, time_committed of AUDIT_DETAILS) should be copied into the corresponding attributes of the commit_audit of each VERSION included in the CONTRIBUTION. This is done to enable sharing of versioned entities independently of which Contributions they were part of.

The time_committed attribute in both the Contribution and Version audits should reflect the time of committal to an EHR server, i.e. the time of availability to other users in the same system. It should therefore be computed on the server in implementations where the data are created in a separate client context.

In terms of database management, Contributions are similar to nested transactions. An attempt to commit a Contribution should only succeed if each Version and/or Attestation in the Contribution is committed successfully.

At the time of committal of a Version, a digital signature of the object can be made. In this process, a Version object (an ORIGINAL_VERSION or IMPORTED_VERSION) is serialised into canonical form which is then hashed to produce a digest. If public key or equivalent infrastructure is in place so that users are able to sign content, a digital signature can be created from the hash, using the user’s private key. Either way, the result is then radix-64 encoded to create an ASCII string so as to remove or reduce potential problems with subsequent communication. The openPGP standard ensures that the trasformations and algorithms used to create the signature are indicated within it.

The signature can serve two purposes. If only the hashing step is done, the digest acts as a data integrity check, indicating if the data have been tampered with after creation. If the signing step is carried out, it authenticates the user as the author of the content to readers of the content. In a versioned EHR system, it also acts as a non-repudiation measure, since the signature is stored permanently with the data. To circumvent hacking of the data, public notarisation of the signature can be used. The signature, if present, is generated according to the openPGP standard (IETF RFC 4880), following the process shown below.

The serialisation process works by the simple rule of serialising the entire Version object (note that the signature attribute will be Void at this point) into an agreed XML, ODIN or other text format, then applying the subsequent transformations to the serialised data, then writing the digest result back into the signature attribute. If the object to be serialised is an IMPORTED_VERSION, the process is the same - all attributes of the object are serialised and then used to generate a signature. The result will be that the IMPORTED_VERSION instance will carry its own signature which signifies the act of importing and making available locally an ORIGINAL_VERSION from another system.

It should be noted that the signing process here creates a signature of a logical form of the content, not a particular graphical or other directly human interpretable view. Usually the relationship between the data and what is seen on the screen is assumed to be 1:1 in a reliable system. If however the equivalent of a signature of a screen image or other literal form of the data are needed, then the Attestation form of the commit_audit is needed. This is described below.

One of the most important uses of signatures in openEHR data is likely to be within EHR Extracts, since they can provide an assurance authenticity and integrity of the data to a receiver who has no knowledge of the quality of the processes used in the originating system.

The ORIGINAL_VERSION.attestations attribute allows attestations to be associated with the data in an original version. Attestations are treated in openEHR as a kind of audit with additional attributes, and are described in detail in the common.generic package section of this specification. Any number of attestations to be associated with each Version in a Versioned object. Attestations can be added at any time after committal of the content being attested. They can be used as required by enter prise processes or legislation, and indicate by whom and when the item in question was attested. A digital "proof" is also required, although no assumption is made about the form of such proof.

Attestations may be used in different ways as follows.

Normally, Attestations refer to the entire version to which they are attached. However, it is possible for an ATTESTATION instance to refer to some finer-grained item within the data of the version, such as a single ENTRY within a COMPOSITION.

When subsequent Versions are added, the existing Attestations can not be assumed to be valid for the new Version, since the nature of an attestation is that it records the witnessing of exactly the content displayed at the time of witnessing.

Content in Original versions has a lifecycle state associated with it, modelled using the ORIGINAL_VERSION.lifecycle_state attribute, which is coded from the openEHR Terminology 'version lifecycle state' group. The possible values are 532|complete|, 553|incomplete|, 523|deleted|, 800|inactive| and 801|abandoned|.

The following diagram shows the formal state machine of the ORIGINAL_VERSION.lifecycle_state attribute.

One basic rule that must be observed with the use of states is that any transition requires the commit of a new version, even if the content is otherwise unchanged. This also means that transitions through a number of successive states entails a number of commits, each recording one transition.

Within the lifecycle described above, deletion of existing top-level content items (i.e. the entire data contents of a Version) is somewhat of a special case in openEHR and in EHRs in general. Medicolegal and traceability requirements mean that information cannot be literally removed, since it must always be possible to revert back to a previous state of the record in which the deleted information is intact. Accordingly, information can only ever be logically deleted. This is achieved by the following procedure in the Version container in question:

Logical deletion can be used for various reasons, including patient direction to remove material, and in the situation where information about a different patient has been incorrectly committed to a record, and has to be removed.

The version identification scheme described here is adapted from (Hnìtynka & Plášil, 2004). VERSION objects are identified by a uid attribute of type OBJECT_VERSION_ID, which is a three-part String identifier consisting of the sub-parts extractable via the accessors object_id(), creating_system_id() and version_tree_id() (see the base_types.identification package in the BASE component), in which the object_id() part is a copy of the uid of the owning VERSIONED_OBJECT version container.

The following figure illustrates the scheme. The VERSIONED_OBJECT.uid value - here, "1234" - is used as the object_id() part of the uid of every contained VERSION. Accordingly, each of those versions will have a uid following the pattern "1234:system_id:version_tree_id". The use of the version_tree_id and system_id parts of the identifier are explained in the sections below. The function VERSION.owner_id() is provided to enable a caller to easily obtain the 'owning version container' identifier.

The following figure provides an example of multiple VERSIONs within a VERSIONED_OBJECT, where one of the versions has been merged from another system. This highlights the identifiers; details of original and merged versions are described below.

One of the most common operations in distributed versioned environments, particularly in healthcare, is that content created in one system is imported into another system, modified in the receiving system and subsequently sent back to the first system. This information pathway corresponds to scenarios such as the patient being referred from primary care into a hospital, and later being discharged into primary (or other care).

The usual need when the first system receives changes made to the data by the second system is to merge them back into the trunk of the version tree. Logically a 'merge' is the operation of using two versions of the same content to create a third version. How the source versions are used will vary based on the semantics of the information; it could be that the either is simply taken in its totality and the other discarded, or some mixture might be created of the two in a process of editing by the user. In many cases in health, such as where the content is a medication or problem list, the user in the original system will review the received content and create a new trunk version locally using that content, since it will be deemed to be the most accurate available in the clinical computing environment. This scenario is illustrated below.

In this figure, versions 1 and 2 of the content (e.g. a medication list) from Versioned object with uid= 1 are copied from system A (e.g. a GP) to system B (e.g. a hospital). In system B, changes are made to version 2, creating a branch (as an instance of IMPORTED_VERSION<T>) as required by the rules described above. These changes (modified medication list) are then imported back into system A. The system A user performs a merge operation to create a new trunk version 3, using the sysB::2.1.2 and sysA::2 content as input, in which he may do any of the following:

In all cases, the result is that system A now has an up-to-date medication list for the patient, as judged by the merging clinician. The new Version is an instance of ORIGINAL_VERSION<T>, and the other_input_version_uids attribute is updated to include the OBJECT_VERSION_ID representing sysB::2.1.2. This should be done even if its content was not used in the merge, since it indicates which source versions were considered in the merge operation. It does not need to include sysA::2, since this is already known in the preceding_version_uid.

If in system A a modification had been done to the sysA::2 version, creating sysA::3, in parallel with the system B changes, then a conflict situation is likely when the merge attempt is made. This may need to be resolved by a human user, for whom an automated merge attempt could be presented on the screen as a starting point, much as current source code control tools do today.

An unintended but not uncommon situation is when distinct Version containers are created for the same real-world entity. For example, separate EHRs can be created for the one patient, due to patient identification errors or other procedural or administrative problems. Each record is likely to contain some logically duplicated basic information, as well as information unique to that record, e.g. contributed by different hospital departments. Within the one EHR, unintentionally distinct Version containers might be created for the same logical item, such as the patient’s problem list. These erroneous situations are eventually detected, and need to be rectified. Logically what is required is to merge the two records (each potentially consisting of numerous Version containers) into one, as shown below.

The merge procedure is as follows:

As for copying and merging, an important consequence of this procedure is that the resulting record (i.e. the target of the merge procedure) continues to correctly represent previous states of the repository, regardless of how many recent merges have occurred.

It will not be uncommon that whole VERSIONED_OBJECTS need to be moved to another system, e.g. due to a move of a complete patient record (due to the patient moving), or re-organisation of EHR data centres. The semantics of a move are different from those of copying: with a move, there is no longer a source instance after the operation; the destination instance becomes the primary instance.

When the move is effected, the identifier of the system in which the VERSIONED_OBJECT now exists will usually be different from what it was before. As a consequence, subsequent versions of the content created in a moved version container will now have the uid.creating_system_id set to the id of the new system. This creates another variation on the version lineage, one in which the uid.creating_system_id value can change in the trunk line, as shown in below.

Authored resources contain natural language elements, and are therefore created in some original language, recorded in the orginal_language attribute of the AUTHORED_RESOURCE class. Information about translations is included in the translations attribute, which allows for one or more sets of translation details to be recorded. A resource is translated by doing the following:

The languages_available function provides a complete list of languages in the resource.

What is normally considered the 'meta-data' of a resource, i.e. its author, date of creation, purpose, and other descriptive items, is described by the RESOURCE_DESCRIPTION and RESOURCE_DESCRIPTION_ITEM classes. The parts of this that are in natural language, and therefore may require translated versions, are represented in instances of the RESOURCE_DESCRIPTION_ITEM class. Thus, if a RESOURCE_DESCRIPTION has more than one RESOURCE_DESCRIPTION_ITEM, each of these should carry exactly the same information in a different natural language.

The AUTHORED_RESOURCE.description attribute is optional, allowing for resources with no meta-data at all, e.g. resources in a partial state of construction. The translations attribute may still be required, since there may be other parts of the resource object (specified by a class into which AUTHORED_RESOURCE is inherited) that are language-dependent.

When the resource is considered to be in a state where changes to it should be controlled, the is_controlled attribute is set to True, and all subsequent changes should have an audit trail recorded. Usually controlled resources would be managed in a versioned repository (e.g. implemented by CVS, Subversion or similar systems), and audit information will be stored somewhere in the repository (e.g. in version control files). The revision_history attribute defined in the AUTHROED_RESOURCE class is intended to act as a documentary copy of the revision history as known inside the repository, for the benefit of users of the resource. Given that resources in different places may well be managed in different kinds of repositories, having a copy of the revision history in a standardised form within the resource enables it to be used interoperably by authoring and other tools.

Every change to a resource committed to the relevant repository causes a new addition to the revision_history.