Standard of Electronic Health Record

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Standard of Electronic Health Record
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Definition and Scope

• Electronic medical record
• Departmental EMR
• Inter-departmental EMR
• Hospital EMR
• Inter-hospital EMR
• Electronic patient record
• Computerised patient record
• Electronic health care record
• Electronic client record
• Virtual EHR
• Personal health record
• Digital medical record
• Clinical data repository
• Computerised medical record
• Population health record

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Definition and Scope
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The basicgeneric EHR

• The basicgeneric definition for the EHR is a
  repository of information regarding the health
  status of a subject of care, in computer
  processable form.
• no assumptions about the health system of any
  country or region
• no assumptions about the type of information in
  the record

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The shareable EHR

• The sharing of EHR information can take place at
  three different levels
• Level 1
• Level 2
• Level 3 The Integrated Care EHR

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Purpose of the EHR(primary)

• The primary purpose of the EHR is to provide a
  documented record of care that supports present
  and future care by the same or other clinicians.
• The primary beneficiaries are the patient and the
  clinician(s).

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Purpose of the EHR(Secondary)

• medico-legal evidence of care provided,
  indication of compliance with legislation,
  reflection of the competence of clinicians,
• quality management continuous quality
  improvement studies, utilisation review,
  performance monitoring (peer review, clinical
  audit, outcomes analysis), benchmarking,
  accreditation,
• education training of clinicians and other
  health professionals,
• research development and evaluation of new
  diagnostic modalities, disease prevention
  measures and treatments, epidemiological studies,
  population health analysis,
• public and population health - access to quality
  information to enable the effective determination
  and management of real and potential public
  health risks.
• policy development health statistics analysis,
  trends analysis, casemix analysis,
• health service management resource allocation
  and management, cost management, reports and
  publications, marketing strategies, enterprise
  risk management, and
• billing/finance/reimbursement insurers,
  government agencies, funding bodies.

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The key role of interoperability

• There are two main levels of shareability or
  interoperability of information
• functional interoperability the ability of two
  or more systems to exchange information (so that
  it is human readable by the receiver)
• semantic interoperability the ability for
  information shared by systems to be understood at
  the level of formally defined domain concepts (so
  that information is computer processable by the
  receiving system).

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four pre-requisites of interoperability

1. a standardised EHR reference model
2. standardised service interface models
3. a standardised set of domain-specific concept
   models
4. standardised terminologies

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Standard Organization

• ASTM(The American Society for Testing and
  Materials )
• CEN/TC251 (Comité Européen de Normalisation
  Technical Committee 251 "Health Informatics)
• DICOM(Digital Imaging and Communications in
  Medicine)
• EBI (European BioInformatics Institute)
• ETSI (European Telecommunications Standards
  Institute)
• HL7(Health Level 7)
• HIMSS(Healthcare Information and Management
  Systems Society)
• IEEE (Institute of Electrical and Electronics
  Engineers)
• ISO/TC215 (International Organisation for Standard
  ization Technical Committee 215 "Health Informatic
  s" )
• OASIS (Organisation for the Advancement of
  Structured Information Standards)
• Regenstrief Institute (Logical Observation Identif
  iers Names and Codes )

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• ISO (International Organization for
  Standardization) is the world's largest developer
  and publisher of International Standards.
• ISO is a non-governmental organization that forms
  a bridge between the public and private sectors
• Founded on 23 February 1947
• It is headquartered in Geneva, Switzerland
• ISO has 157 national members

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TC 215 - Health informatics

• Standardization in the field of information for
  health, and Health Information and Communications
  Technology (ICT) to achieve compatibility and
  interoperability between independent systems.
  Also, to ensure compatibility of data for
  comparative statistical purposes (e.g.
  classifications), and to reduce duplication of
  effort and redundancies.

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The Evolution of ICT in Health Care
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Organizations in liaison

• CDISC - Clinical Data Interchange Standards
  Consortium, Inc.
• DICOM - Digital Imaging and Communications in
  Medicine Standards Committee
• ICN - International Council of Nurses
• IHTSDO - International Health Terminology
  Standards Development Organization
• IMIA - International Medical Informatics
  Association
• UNECE - United Nations Economic Commission for
  Europe
• W3C - World Wide Web Consortium
• WHO - World Health Organization

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Subcommittee/Working Group

• TC 215/WG 1 Data structure
• TC 215/WG 2 Data interchange
• TC 215/WG 3 Semantic content
• TC 215/WG 4 Security
• TC 215/WG 5 Health cards
• TC 215/WG 6 Pharmacy and medicines business
• TC 215/WG 7 Devices
• TC 215/WG 8 Business requirements for Electronic
  Health Records
• TC 215/WG 9

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ISO TC215 Scope

• Health informatics generally interpreted as
  ISO/OSI Level 7
• Some groups work in Levels 1-6 by reference to
  other standards.

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