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doi:10.3233/978-1-61499-830-3-174

Analysis of HL7 EHRS Functional Model and Suggested Applications in China

Haibin Meng, Huajian Mao, Chenyang Chi, Dongsheng Zhao
Institute of Health Service and Medical Information, Academy of Military Medical Sciences, Beijing, China

Abstract 2009 and was accepted as an international standard ISO/HL7

10781 [4]. In April 2014, the HL7 EHRS FM R2 was released.
HL7 electronic health record system (EHRS) functional model
Compared with the previous edition, this edition made
is an international standard which gives scientific instructions
fundamental change by proposing an entirely new architecture
for EHRS design and implementation. It has the features of
of EHRS FM. It became the ISO standard in 2015 [5].
technological irrelevancy, requirement hierarchy and
functional comprehensiveness. It is composed of overarching, Principles of HL7 EHRS FM
care provision, care provision support, administrative support,
The principles of HL7 EHRS FM can be summarized as
population health support, record infrastructure and trusted
technologically irrelevancy, requirement hierarchy, and
infrastructure. This paper describes the functionalities of each
functional comprehensiveness.
section in detail. To apply this functional model, the history of
Chinese health information system construction is reviewed Technologically Irrelevancy
and the weakness is analyzed as a basis. Then this paper gives With the development of information technology, new
suggestions on the construction of health information system in technologies emerge continously. The functionalities of EHRS
China: to enhance the functionality of healthcare systems, to are constantly implemented by new technology, but the
enhance the information network function of regional health functionality framework of EHRS is relatively stable.
information network (RHIN), and to redesign the trust Therefore, one principle of EHRS FM is to separate the
architecture of RHIN. functional framework from its implementation. The
Keywords: technologically irrelevancy is realized by defining the scope
and content of EHRS functionalities instead of the
Electronic Health Records; Models, Theoretical; Suggestion
technological details of EHRS.
Introduction Requirement Hierarchy
Owing to the diversification of EHRS, the actual EHRS
An Electronic Health Record (EHR) is a repository of conforms to a specific functional profile which is a subset of the
information regarding the health status of a subject of care in EHRS functional model. The conformance criteria have two
computer processable form. Electronic Health Record System levels: the required criteria and optional criteria. The required
(EHRS) is a set of components that form the mechanism by criteria are expressed by mandantory word shall. The optional
which electronic health records are created, used, stored and criteria can be devided into two sub-levels. Suggested criteria
retrieved, including people, data, rules and procedures, are expressed by word should. Permit criteria are expressed by
processing and storage devices, and communication and word may. Requirement hierarchy bring about the flexibility of
support facilities [1]. EHRS functional model (EHRS FM) EHRS FM. It can meet the needs of various application
defines a standard functionality list that presents in an EHRS situations and adapt to various development stages of EHRS.
[2]. As a core model, it determines the main functionality Functional Comprehensiveness
framework that an EHRS should have. At present, China is on Unlike the functional model of common information systems,
the process of constructing interoperable population health HL7 EHRS FM greatly extends the scope of EHRS
information networks [3]. It is essential to get theoretical functionalities. Especially in the arena of information network
instructions from the EHRS FM. In this paper, we introduce the archietecture and trust architectue. It embodies the functional
history and principles of HL7 (Health Level 7) EHRS FM, and comprehensiveness of EHRS.
describes the main content of HL7 EHRS FM Release 2 (R2) in
detail. Then we review the history of Chinese health Description of HL7 EHRS FM R2
information system construction and analyze the weakness of Figure 1 shows the general structure of HL7 EHRS FM R2. It
this construction mode. Further, we give suggestions on consists of 7 sections, which are Overarching (OV), Care
applying EHRS FM to improve the health information system Provision (CP), Care Provision Support (CPS), Administrative
construction in China. Support (AS), Population Health Support (POP), Record
Infrastructure (RI) and Trusted Infrastructure (TI). Each section
HL7 EHRS FM contains functionality list described by ID, type, name,
statement, description and conformance criteria.
History of HL7 EHRS FM
The research of HL7 EHRS FM can be traced back to April,
2003. It was sponsored by HL7 workgroup. In July 2004, it was
approved as a draft standard for trial use. The HL7 EHRS FM
R1 was released in February 2007 and became the ANSI
standard. The HL7 EHRS FM R1.1 was released in November
 H. Meng et al. / Analysis of HL7 EHRS Functional Model and Suggested Applications in China 175

2YHUDUFKLQJ 29 criteria in this section. They belong to 10 categories: support

for health maintenance/preventative care/wellness, support for
&DUH3URYLVLRQ &3 population-based epidemiological investigation, support for
&DUH3URYLVRQ 3RSXODWLRQ+HDOWK $GPLQLVWUDWLYH notification and response, support for monitoring response
6XSSRUW &36 6XSSRUW 323 6XSSRUWδ$6 notifications regarding a specific patient’s health, support for
5HFRUG,QIUDVWUXFWXUH 5, donor management, measurement/analysis/research and
reports, public health related updates, de-identified data request
7UXVW,QIUDVWUXFWXUH 7, management, support for consistent healthcare management of
patient groups or populations, and managing population health
Figure 1–The General Structure of HL7 EHRS FM R2 study related identifiers.
Record Infrastructure (RI)
Overarching (OV)
This section consists of functionalities about record
The Overarching section contains conformance criteria that management. It can be implemented within the architecture of
apply to all EHRS. There are 2 functionalities and 33 a single system or across tightly-coupled systems. There are 37
conformance criteria in this section, including health record functionalities (including subfunctionalities) and 186
report and output, record lifecycle manamgement, secruity conformance criteria organized in 3 categories, including
management , terminology service and system management. record lifecycle and lifespan, record synchronization and record
Care Provision (CP) archive and restore.
This section contains functionalities and conformance criteria Trust Infrastructure (TI)
required to provide direct care to a specific patient and practice This section consists of functionalities related to EHRS trust
of healthcare. Organized in general flow of an encounter, these infrastructure. These functionalities are fundamental to system
functionalities can be used as EHR supporting functionalities to operations, security, efficiency, data integrition, privacy/
various healthcare systems. There are 41 functionalities and confidentiality and interoperability with other systems. There
494 conformance criteria organized in 9 categories, which are are 93 functionalities and 681 conformance criteria organized
managing clinical history, rendering externally-sourced in 9 categories, including security, audit, registry and directory
information, managing clinical documentation, managing services, standard terminology and terminology services,
orders, managing results, managing standards-based interoperability, business rules management,
medication/immunization/treatment administration, managing workflow management, database backup and recovery, and
future care, managing patient education & communication, and system and performance management.
managing care coordination and reporting.
Review of Chinese Health System Development
Care Provision Support (CPS)
The Chinese government regard information technology as an
This section contains functionalities that support the provision important part of modern medicine. Health system construction
of care. It has 76 functionalities and 559 conformance criteria. is an essential part of health reform in China. The development
They are classified into 10 categories as record management, of Chinese health information system can be divided into three
supporting externally-sourced clinical documents, supporting stages, which are shown as below [6].
clinical documentation, supporting orders, supporting for
results, supporting treatment administration, supporting future Stage 1 - Application of Computer Software
care, supporting patient education and communication, This stage is featured as the application of single computer
supporting care coordination and reporting, and managing user software, such as finance management and medicine
help. management. In this period, computer software is used to
Administration Support (AS) replace artifical operation. It is independent and the power of
information technology is not sufficiently revealed.
The Administration Support section includes functionalities
that provide support for the management of the clinical practice Stage 2 - Construction of business systems
and give assistance to the administrative and financial This stage is featured as the construction of various healthcare
operations, such as resource management, workflow, and systems, such as hospital information system (HIS), community
communication with patients and healthcare providers. It also healthcare system, physical examination system, disease
provides support for managing non-clinical administrative prevention and control system, and public health system. These
information on patients and providers. It has 55 functionalities systems realize the automatic process of information and
and 249 conformance criteria. They are categorized as provider increase work efficiency. Designed separately, they have
information management, patient demographics and location simple data integration capability, and can only meet the needs
management and synchronization, personal health record of business activities.
(PHR) interaction management, communication management, Stage 3 - Construction of Regional Health Information
clinical workflow tasking management, resource availability Network
management, encounter/episode of care management, In this stage, the Chinese government began to develop regional
information access for supplemental use, and administrative health information network (RHIN) based on EHR [7]. The
transaction management. goal of RHIN construction is to breake up the barriers of
Population Health Support (POP) isolated systems, integrate existing healthcare systems, realize
This section includes functionalities for supporting public the interoperability and coordination, promote the exchanging
health management and disease prevention and control. It and deep mining/analysis of EHR data. Currently, China will
focuses on special group of people, such as chronical disease build 4 levels of RHINs, which are the national RHIN,
group, women, and children. These functionalities can support provincial RHIN, municipal RHIN and county RHIN [8]. The
data aggregation for medical research, public health promotion, RHINs are based on EHR and take the responsibilities of the
and improving the quality of care. Besides, this section also center of health data exchange and application.
includes functionalities about protecting patient privacy and
supporting patient consents for the secondary uses of medical
records. There are 18 functionalities and 108 conformance
176 H. Meng et al. / Analysis of HL7 EHRS Functional Model and Suggested Applications in China

Weakness Analysis on Chinese Health System Construction Table 2 – Information network functionalities to be enhanced
For a long time, Chinese health system construction has been for RHIN in China
driven by pure information technology and investment. It can
only meet the needs of a specific domain. This construction Functional Type Functionalities to be Enhanced
mode lacks of top-level design and theorical instructions,
Collect clinical documents, externally-
leading to a large number of isolated systems. To solve these Data Collection sourced data, emergency medical system
problems, RHINs are built to create an infrastructure where and Integration originated data, externally-sourced
health information can be shared, exchanged and analyzed. But clinical images, patient-originated data
a thorough integration is needed. That is, to apply HL7 EHRS
FM to Chinese RHIN construction. Structured-document exchange, registry
Record
and directory services, complete logical
Suggestions on Applying HL7 EHRS FM in China Synchoronization
record exchange
Broadly speaking, there are three suggestions on applying
EHRS FM in China. They are shown as follows. Originate, manage, retain, amend,
translate, verify, access , output ,disclose,
Enhancing the Functionalities of Chinese Healthcare transmit , receive, de-identify/ re-identify,
Systems by Means of the EHRS FM Record Lifecycle
pseudomynize,
and Lifespan
In the architecture of RHIN, the healthcare systems can only extract,archive/restore,destroy/identify,
Management
play a role of data provider. Their business functionalities are deprecate/retract, re-activate,
not enhanced by EHR. This leads to the functional stuffless of merge/unmerge, link/unlink record
these systems. For example, a doctor cannot get the clinical entries
history of patient when making a diagnosis. Therefore, it is
Record Archive Archive record entries from online data
needed to extend care provision, care provision support and and Restore structures to near-line or off-line data
administration support functionalities to hospital information structures, restore record entries
systems and community healthcare systems. Meanwhile, it is
needed to extend population health support functionalities to
disease prevention and control/public health system. Table 1
gives the functionality list that can be applied to Chinese Redesigning the Trust Architecture of RHIN
healthcare systems. It is noted that the existing functionalities The traditional concept of information secruity only contains
of healthcare systems are not included. security and audit. But the new trust infrastructure of HL7
EHRS FM R2 greatly extends this concept. It integrates system
Table 1 – Functionalities Applied to Chinese Healthcare management functionalities, such as database backup and
Systems recovery and system and performance management. The
registry and directory services, standard terminology and
Healthcare terminology services, standards-based interoperability,
Applied Functionalities
systems business rules management, and workflow management are
also integrated into the new trust architecture. In China, security
Management of demographics, clinical
design is an important part of RHIN [9]. The security
Hospital history , external- source data, workflow, architecture of RHIN includes identity protection, identity
Information business rules, patient privacy, authentication, identity management, access control,
System correspondence, doctor, finance and
information encryption, digital signature, anonymization and
administration
security audit. Compared with HL7 EHRS FM R2, the security
Disease Health risk notification, epidemiological architectre of RHIN is not sufficient in registry and directory
Prevention and investigation, donor management, health services, standard terminology and terminology services, and
Control/Public assessment , process improvement, standards-based interoperability functionalities. Therefore, it
Health System healthcare management needs to be redesigned according to the new trust infrastructure.
The new trust architecture is shown in Table 3.
Community Future care management, Patient
Healthcare education support
System
Enhancing the Information Network Functionalities of
RHIN
In China, the RHINs play a role of EHR data integration and
exchange. But the systems to be connected are limited to HIS,
disease prevention and control/public health system and
community healthcare sytem. Only limited data types are
supported by RHIN, such as structured data, documents and
images. Compared with the EHRS FM R2, RHIN should extend
the systems to be interfaced, such as physical examination
systems or personal health record (PHR) systems. Secondly, the
data types should also be extended to be compatible with
medical instrument generated data. As an archive management
center, the RHIN has EHR lifecycle manamement
functionalities, such as creating archive, arranging archive,
migrating archive, merge/split archive, final archive and
archive maintenance. These archive functionalities should be
extended as well. Table 2 shows the information network
functionalities to be enhanced for RHIN in China.
 H. Meng et al. / Analysis of HL7 EHRS Functional Model and Suggested Applications in China 177

Table 3 – New Trust Infrastructure of RHIN in China [6] Rao Keqin. Electronic Health Record and Regional Health
Information Network (Business Section).People Health
Press, 2010:40-43
Functional Type FunctionalityName [7] Rao Keqin. Electronic Health Record and Regional Health
Information Network (Technology Section).People Health
Entity authentication, entity Press, 2010:504-536
authorization, entity access control, [8] Chinese National Health and Family Planning Commis-
patient access management, non- sion. The 13th Five-Year Plan of National Population and
repudiation, secure data exchange, secure Health Informationization: 2017.
Security data routing, patient privacy and [9] Ni Ning. Security Analysis for Regional Health Infor-
confidentiality, system operation mation Network. Chinese Journal of Health Informatics
measurements, service availability, and Management, 10(2013):244-247
trusted information exchange
environment
Address for correspondence
Audit triggers, audit log management,
Audit Dongsheng ZHAO
audit notification and review
[email protected]
Registry and Registry services, directory services (86)10-66931123
Directory Service
Standard Standard terminology and terminology
Terminology and models, maintenance and versioning of
Terminology standard terminologies, terminology
Services mapping
Application, structured message, and
structured document interchange
Standards-Based standards, interchange standards
Interoperability versioning and maintenance, standards-
based application integration, interchange
agreements, system integration
Business rules management, workflow
Other management, database backup and
Functionalities recovery, system management operations
and performance

Conclusions
HL7 EHRS FM R2 is the latest advancement in EHRS
functionality design. This version contains several new ideas.
China should learn from this advanced international standard to
improve the functionality design of health systems and promote
the construction and development of RHINs in China.

Acknowledgements
Funding sources for the work and other relevant acknowledge-
ments are noted here. Authors may also present disclosures or
disclaimers to their work in this section.

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