Formulating EHR Standards

Key Capabilities of an Electronic Health Record System: Letter Report. National Acadamies Press, 2003.

This report provides 8 core functionalities for electronic health records as formulated by the Institute of Medicine (IOM) for use by Health Level 7 (HL7) in creating industry-wide standards.

A press release offers a digest of these recommendations. It reads:

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.

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.

I often use electronic medical record (EMR) interchangeably with electronic health record (EHR). There are a plethora of other terms currently in use to describe nearly the same thing (e.g. PCR, EPR, DMR, …). According to this article EHR casts the widest net.

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