Health informatics – Clinical information models – Characteristics, structures and requirements

This document specifies clinical information models (CIMs) as concepts that can be used to define and to structure information for various purposes in health care. It describes requirements for CIM content, structure, context, specification of data elements, data element relationships, metadata and versioning. It also specifies key characteristics of CIMs for use cases, defines a Quality Management system for systematic and effective governance, and provides principles for the transformation and application of CIMs in health information technology.

This document does not include requirements for the content or application of specific CIMs. It also does not specify how to involve specific clinicians, carry out governance or ensure patient safety.

Main sections:

· Scope

· Normative references

· Terms and definitions

· Health care information models – Concept, purpose, contexts and position

· Quality management system for clinical information models

· Clinical information model content, structure and requirements

· Metadata for clinical information models

· Version management of clinical information models

· Annex A: Release and maintenance process example in the Netherlands

· Annex B: Version management backwards compatibility

· Annex C: Guidelines and principles for clinical information modelling