Electronic Health Information Systems Agency Collaborative Workgroup OVERVIEW OF ELECTRONIC HEALTH RECORDS, STANDARDS AND RESOURCES May 8, 2008

KEY BENEFITS OF AN ELECTRONIC HEALTH RECORD The American Health Information Management Association (AHIMA), defines the three essential capabilities of an electronic health record as follows: To capture data at the point of care, To integrate data from multiple internal and external sources, and To support caregiver decision making.

ESSENTIAL CAPABILITIES OF AN ELECTRONIC HEALTH RECORD SYSTEM1 Health information and data. Having immediate access to key information - such as patients' diagnoses, allergies, lab test results, and medications - would improve caregivers' ability to make sound clinical decisions in a timely manner. Result management. The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would increase patient safety and the effectiveness of care. Order management. The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance legibility, reduce duplication, and improve the speed with which orders are executed. Decision support. Using reminders, prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.

ESSENTIAL CAPABILITIES OF AN ELECTRONIC HEALTH RECORD SYSTEM1 Electronic communication and connectivity. Efficient, secure, and readily accessible communication among providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events. Patient support. Tools that give patients access to their health records, provide interactive patient education, and help them carry out home-monitoring and self-testing can improve control of chronic conditions, such as diabetes. Administrative processes. Computerized administrative tools, such as scheduling systems, would greatly improve hospitals' and clinics' efficiency and provide more timely service to patients. Reporting. Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease surveillance." 1. US IOM report, Key Capabilities of an Electronic Health Record System (Tang 2003)

INTEROPERABILITY Data transfer and sharing on much more than a local or enterprise wide scale, Knowledge transfer and integration, Medical terminology transfer, mapping and integration, Image transfer, and Integration with clinical and non-clinical applications. The Value Of Health Care Information Exchange And Interoperability1 defines four levels for interoperability between health information systems: Level 1: Non-electronic data (e.g. mail, telephone), Level 2: Machine-transportable data (e.g. faxed or scanned documents), Level 3: Machine-organizable data (e.g. e-mail, proprietary file formats), and Level 4: Machine-interpretable data (e.g. structured data within standardized messages, XML, etc.). 1. Walker et al 2005

HL7 RIM 2.20 (NORMATIVE)

A VIEW ON STANDARDS ISO 18308 Clinical and technical requirements for an Electronic Health Record Reference Architecture "that supports using, sharing, and exchanging electronic health records across different health sectors, different countries, and different models of healthcare delivery." (2004) ASTM Committee Standards on Electronic Health Record Content and E31.19 Structure CEN 13606 The European electronic healthcare record interoperability standard (2004). Includes: EHR reference model, archetype interchange specification, reference archetypes and term lists, security functions, exchange models to support communication. HL7 v3 Messaging standard for communications “.. between EMR systems and practice management systems." (2003).

A VIEW ON STANDARDS HL7 Clinical An XML-based generic model for the representation and Document transfer of clinical documents. CDA is being used also in Architecture (CDA) electronic health records projects to provide a standard format for entry, retrieval and storage of health information. The CDA release 2.0 was approved as an ANSI standard in May 2005. ASTM Continuity of XML-based document standard for a summary of personal Care Record (CCR) health information (data set) to help achieve interoperability between medical records and to ensure "a minimum standard of health information transportability when a patient is referred or transferred to, or is otherwise seen by, another provider."  

A VIEW ON STANDARDS HL7 Reference The RIM is a single, all-encompassing model of the data Information Model structures that healthcare applications can exchange. It is (RIM) an essential part of the HL7 Version 3 development methodology, as it provides an explicit representation of the semantic and lexical connections that exist between the information carried in the fields of HL7 messages.

HELPFUL REFERENCES Health Level 7 (HL7) Reference Information Model (RIM) / RIM Critique “An Incoherent Standard” HL7 Clinical Document Architecture (CDA) HL7 Message Development Framework ISO 18308: Health Informatics - Requirements for an EMR Architecture ISO 12967: Health Informatics - Service Architecture Part 1 (Enterprise View) ASTM E1384-07: Standard Practice for Content and Structure of the Electronic Health Record The Certification Commission for Healthcare Information Technology (CCIT) Healthcare Information Technology (HIT) Standards Panel Healthcare Information Technology Leadership Panel - Final Report (March 2005) Medicaid Information Technology Architecture American Health Information Community

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