Core information standard: CORE INFORMATION STANDARD IMPLEMENTATION GUIDANCE

The standard can be seen as a broad set of “flexible” components (or sections), a sub-set of which will be relevant in different situations for different use cases. It has been designed as a generic standard, not for specific use cases. The expectation is that local health and care localities will prioritise their local use cases and build local interoperability informed by the core information standard.

The sections in the standard differ in terms of how the elements they contain relate to one another. Some, for example ‘legal information’, are sets of independent ‘elements’ or data items, grouped under logical headings. Other sections, for example ‘medications and medical devices’, are sets of related elements with dependencies. A ‘record entry’ within a section is used to indicate that elements are related to one another. Some sections may also include clusters, which are groups of elements within a section that relate to one another. Clusters are similar to a record entry but occur within a single record entry and may repeat for a record entry.

Each element, cluster, record entry and section will have a statement of cardinality, whether there can be zero, one or many entries. They also have a statement of conformance - whether the item is ‘Mandatory’, ‘Required’ or ‘Optional’. An explanation of the meaning of these terms appears in the table below.

Since different components will be populated by different care settings a minimal number of sections and clusters have been defined as ‘Mandatory’. The mandatory sections are Person demographics and GP practice. This is the minimum amount of information required for a record about a person to exist. Many other sections are set to ‘Required’. However, some of the elements within a ‘Required’ section may be ‘Mandatory’. For example, if a record of a medication is shared, ‘Medication name’ is ‘Mandatory’ and must be shared.

The information model includes the following information:

Table 1 – the core information standard data structure

Information Components	Model Description
Section	A section groups together all the information related to a specific topic e.g. ‘Medications and medical devices’ and ‘Person demographics’. It is the highest level to logically group data elements that may be independent or related. For example: ‘Legal information’ includes a set of independent elements or information items, grouped in a logical section. ‘Medications and medical devices’ includes sets of related elements with dependencies between the elements.
Record entry	A record entry within a section is used where a set of information is repeated for a particular item, and there can be multiple items. For example, for each medication there is a set of information associated with that medication. Other examples are allergies or adverse reactions and procedures.
Cluster	This is a set of elements put together as a group and which relate to each other; e.g. medication course details cluster which is the set of elements describing the course of the medication.
Element	The data item. An element can appear in one or more sections e.g. name,
Information model rules and instructions	Explanations
Description	This is the description of the section, record entry, cluster or element. For an element, it describes the information that the element should contain in as plain English as possible.
Cardinality	Each section, record entry, cluster and element will have a statement of cardinality. This clarifies how many entries can be made i.e. zero, one or many entries. The number of records expected and allowed are displayed as: 0……* = zero to many record entries are allowed 0……1 = zero to one record entry is allowed 1……1 = one record is expected 1……* = one to many records are expected For example, the ‘Medications and medical devices’ section may have zero to many medication item records in it and is displayed as 0……*.
Conformance	Conformance defines what information is ‘mandatory’, ‘required’ or ‘optional’ and applies to sections, record entries, clusters and elements. The IT system must be developed to handle all the information elements that are defined in the Standard but not all the information is required for every individual record or information transfer. The following set of rules apply to enable implementers to cater for the end users (senders and receivers) requirements: Mandatory – the information must be included Required – if it exists, the information must be included Optional – a local decision is made as to whether the information is included These rules apply at all levels and give the flexibility to allow local clinical or professional decisions on some information that is included, while being clear on what is important information to include. For example, a person subject to a referral may have many assessments, but not all of these will be relevant to the referral. The conformance can be used to allow just relevant assessments to be included. Assessment Section – Required – i.e. its important information you must include if you have it. Record entry level – Optional – allows a local decision on what assessments are included, so only relevant ones are included based on clinical or professional needs. Assessment elements – Conformance set on the normal basis of which elements for an assessment are mandatory, required or optional. NB: It is permitted to upgrade a conformance rule but not
Valuesets	Valuesets describe precisely how the information is recorded in the system and communicated between systems. This is required for interoperability (for information to flow between one IT system and another). The information can be text, multi-media or in a coded format. If coded it can be constrained to SNOMED CT and specific SNOMED CT reference sets, NHS Data Dictionary values or other code sets.