EXECUTIVE SUMMARY
policy decisions based on better understanding of the underlying issues, etc., all translating into improved
personal and public health.
Without standards, a lifelong medical record is simply not possible, as different records from different
sources spread across ~80+ years, potentially, needs to be brought meaningfully together. To achieve this, a
set of pre-defined standards for information capture, storage, retrieval, exchange, and analytics that includes
images, clinical codes and data is imperative.
STRATEGIC HIGHLIGHTS
This document provides a structured overview of the key EHR standards with respect to Indian healthcare
system. For every aspect of data/information that is part of any healthcare record system has been addressed
with a short guideline regarding implementation specific to the item-in-context included. Various non-
related recommendations from previous edition have been removed to better streamline the set of standards
selected and achieve harmony among them. A detailed recommendation on the interoperability and
standards, clinical informatics standards, data ownership, privacy and security aspects, and the various
coding systems are also provided. The set of standards given in earlier edition has been updated with their
latest versions as the country moves towards a better implementation. It would not be out of place to note
that certain sections of the document have been removed to provide increased readability and consistency
throughout while avoiding duplication, ambiguity and contradictions.
SCOPE
This document provides a set of recommendations relevant to adoption of electronic health informatics
standards in EHR/EMR and other similar clinical information systems. The scope is limited to identifying the
standards, their intended purposes in such systems, followed by a short guideline-for-implementation
approach. It is understood that with adoption of these standards properly, the data capture, storage, view,
presentation, and transmission will be standardized to levels that will achieve interoperability of both
meaning and data contained in the records. This document does not cater to wider implementation scenarios
such as of administrative, legal or regulatory nature. This document also does not cater to aspects of creation
and operation of local, regional or national infrastructures, indexes, or repositories as they are dealt with by
appropriate regulative/administrative bodies.
LOOKING AHEAD
This document is a continuation of its earlier version, but in many ways reflects the growing confidence in
the path correctly chosen earlier – providing a set of international and proven standards with focus towards
achieving syntactic and semantic interoperability of health records. The idea that any person in India can go
to any health service provider/practitioner, any diagnostic center or any pharmacy and yet be able to access
and have fully integrated and always available health records in an electronic format is not only empowering
but also the vision for efficient 21st century healthcare delivery.
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