4.1 This Guide has Four Parts:

4.1.1 The first part (Section 5) identifies items of information carried in the traditional paper record organized by the source oriented structures common to paper records. The purpose of this section is to remind users of the spectrum of information that shall be accommodated by the logical structure of a EHR and to present a point of reference for the more abstract description of the patient record that follows.

4.1.2 The second part (Section 6) presents a number of operational principles, including such matters as privacy and security that should guide the implementation and operation of EHRs.

4.1.3 The third part (Section 7) describes a logical data organization and content (common data model) of an EHR. It is not a blueprint for constructing or implementing a EHR system. The model presents an organization according to the major informational structures and content of the EHR. The focus is on the structure required to store all clinically relevant patient information: those that describe the patient's state; the actions directed at the patient variables; and the actions initiated to diagnose, educate, or treat the patient. These are regarded as repository functions of the EHR. This standard does not describe all of the data structures required by applications that might use information contained in the EHR. In particular, the data structures used to control and guide the process of care such as utilization review or quality assurance, and the goals or thresholds (for example, mean length of stay) that might be used to judge the patient's care are not included.

4.1.3.1 There are many different ways to implement physical structures that could map into the model presented. It is emphasized that this standard should neither impede technical progress nor define the precise manner in which the EHR system is implemented.

4.1.3.2 The focus of this guide is on the kinds of information that should be included and upon a global description of the organization of that data within the EHR. This guide does not deal in detail with issues related to charges and billing for patient care, only the documentation required to support usual charging and administrative issues.

4.1.3.3 This standard deals with the health information as it would be stored in the EHR, not as it would be sent as a message to or from the EHR. Pains have been taken to be sure that the information content from existing healthcare informatics messages that lie within the scope of the EHR can be mapped into the EHR structure. Where mappings are one-to-one, the EHR data elements have been cross referenced with the message fields. However, the EHR is not just a collection of messages. It makes stronger assumptions about the context in which it exists, so there is not perfect correspondence between the structure and content of messages on the one hand and the EHR on the other.

4.1.3.4 This guide applies across a range of scales. Though the ultimate goal is a EHR that spans the entire nation and the lifetime of an individual, the reality is that EHRs are mostly of much smaller scope (for example, within institutions, communities, or states) and these can be implemented much sooner. This standard is intended to apply equally to all scopes of time and place. Within the scope of a EHR, all master tables and code systems (for example, service catalog, patient registry, patient identifier) will be held in common. It denotes extensions of text content for document format standards and references standard XML designation for document section tags.

4.1.4 The fourth part (Sections 8, 9, 10) describes some alternative views (subsets of information presented in various orderings) of the content and proposes the minimum data elements contained in the EHR. What has been described as the “Longitudinal Health Record” (a very short précis of the patient's entire history) falls into this category. A set of “views” will serve as the user interface to the EHR for various customers. When all of the data is available in a EHR, providing different views of that data to satisfy various user needs and perspectives will be facilitated. Further, the kinds of views that are “required” and their dependencies (differing by institution, by specialty, by health/medical problem, by practitioner) will evolve over time. Section 10 is a repository of data elements to be used as an electronic health record data dictionary (Annex A1) (18).

4.2 General—Healthcare Documentation:

4.2.1 A patient's health record plays five unique roles: (1) It represents that patient's health history, that is, a record of the patient's health states and the health services provided, over time. (2) It provides a method for clinical communication and care planning among the individual healthcare practitioners serving the patient. (3) It serves as the legal document describing the healthcare services provided. (4) It is a source of data for clinical, health services, and outcomes research. (5) It serves as a major resource for healthcare practitioner education.

4.2.2 Keeping complete and accurate records is an essential part of patient care management. Increasing specialization in healthcare and population mobility have increased the fragmentation of the traditional health record. The EHR offers a unified, coordinated, complete repository of patient health information. It includes such things as treatments, prescriptions, test results, diagnostic impressions, and significant genetic, environmental, and clinical healthcare data.

4.2.3 The person's health record consists of the original documentation of their health information and of the associated health and clinical services provided at the various care sites including the results of tests and outcomes of treatments. Each care site will require basic data that may be common to all care sites, data specific to that particular type of care site, and data unique to the individual care site.

4.2.4 The EHR serves all of the functions of the traditional record but has many advantages.

4.2.4.1 It solves the logistic problems of easy access to the paper health/medical record. Information can be concurrently accessed from multiple locations.

4.2.4.2 It will provide efficient communication of information to support coordination of services between care practitioners (See Specification E2369).

4.2.4.3 It calls for data content to be stored so that it links to automatic reminders and alerts to avoid errors of omission and commission.

4.2.4.4 By providing cross-patient retrievals it will provide the statistics needed by clinical, outcomes, health services and policy researchers as well as administrators and managers, to define better policies and practices to improve the healthcare process and make it efficient.

4.2.5 The longitudinal healthcare record, which is the brief synopsis of the significant facts derived from the primary documentation, can be constructed from views of the elements described here.

4.3 The Role of Standards in Healthcare Documentation:

4.3.1 Healthcare informatics standards are essential for an efficient and affordable EHR. Even within a single institution, much of the information that should be stored in the EHR will come from other electronic sources. Message standards are needed to ensure that this data can be transmitted from a source system and received and stored with a EHR without requiring human intervention. The need for information from other healthcare facilities (the hospital would like nursing home records when the patient is admitted and vice versa when the patient is discharged) is even greater. Finally, standard terminology, codes, and formats are the sine qua non for aggregating many EHRs for research and policy purposes.

4.3.2 The model for an EHR described here provides a general guideline that describes the data and data organization for an EHR and recommends minimal content requirements. It promotes common approaches to documentation. The model should be flexible enough to permit the storage of any kind of patient information deemed important by an individual provider, ensure that a minimum set of patient data is maintained, as well as information required by diagnostic and therapeutic services of the future.

1.1 This practice covers all types of healthcare services, including those given in ambulatory care, hospitals, nursing homes, skilled nursing facilities, home healthcare, and specialty care environments. They apply both to short term contacts (for example, emergency rooms and emergency medical service units) and long term contacts (primary care physicians with long term patients). The vocabulary aims to encompass the continuum of care through all delivery models. This practice defines the persistent data needed to support Electronic Health Record system functionality.

1.2 This practice has four purposes:

1.2.1 Identify the content and logical data structure and organization of an Electronic Health Record (EHR) consistent with currently acknowledged patient record content. The record carries all health related information about a person over time. It may include history and physical, laboratory tests, diagnostic reports, orders and treatments documentation, patient identifying information, legal permissions, and so on. The content is presented and described as data elements or as clinical documents. This standard is consistent with eXtensible Markup Language (XML). See Document Type Definition (DTD) 2.1 and W3CXML Schema 1.0

1.2.2 Explain the relationship of data coming from diverse sources (for example, clinical laboratory information management systems, order entry systems, pharmacy information management systems, dictation systems), and other data in the Electronic Health Record as the primary repository for information from various sources.

1.2.3 Provide a common vocabulary for those developing, purchasing, and implementing EHR systems.

1.2.4 Provide sufficient content from which data extracts can be compiled to create unique setting “views.”

1.2.5 Map the content to selected relevant biomedical and health informatics standards.