CEN 13606-1 Reference model

The CEN 13606 reference model that underpins the exchange of EHR information. This model is an information model that contains a set of classes and attributes. The CEN 13606 approach is to represent the reference model as a set of unified Modeling Language (UML) diagrams. The outcome is a hierarchical model reflecting the hierarchical nature of real heath records. The 13606-1 reference model is composed of a number of classes which build on each other to provide the representation of an EHR extract. These classes include:

EHR Extract class:- identifies who the extract is about and what system the extract has been extracted from. EHR data is (optionally) comprised of directory of folders. The EHR data is made up of compositions (records authored together and committed to the EHR), demographics and access control policies
Recorded component:- this is a super class of other classes. These record component classes build from a simple element to more an more complex structures These classes include:

Element - a single value
Item - a single element, a list of elements, a cluster or a list of clusters. Item therefore allows the representation of a wide range of data structures.
Entry - items recorded for a single recording in the EHR (e.g. a single observation)
Section - entries grouped together
Composition - set of record components authored during a users clinical sessions and stored in the EHR (e.g. a progress note)
Folders - allows grouping of the record. Folders can include other folders, compositions or used to organise (selected subset) of the EHR extract.
Other classes such as audit, record linkages, access policy and message

Using such a hierarchy an EHR extract can be built starting with elements and then successively grouping into items, entries, sections, compositions and folders.