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Health IT Standards for Developers

The document discusses standards for health record IT systems. It covers the need for identity resolution when a person may have multiple health records. It also outlines architectural and functional requirements including conforming with ISO standards for electronic health record systems and information modeling. Structural composition and logical information reference models are important for standardized data capture and understanding.

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8 views1 page

Health IT Standards for Developers

The document discusses standards for health record IT systems. It covers the need for identity resolution when a person may have multiple health records. It also outlines architectural and functional requirements including conforming with ISO standards for electronic health record systems and information modeling. Structural composition and logical information reference models are important for standardized data capture and understanding.

Uploaded by

pmehta.starexhibitions
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HEALTH RECORD IT STANDARDS

Thus, a single person may get to have different identities under which his/her records are captured. A
conflict resolution process may be required to help resolve such cases. At this time, there is no direct
solution available other than to use smart (possibly heuristic) algorithms to attempt to match records
without or with intervention/confirmation of a human supervisor. Such an algorithm may use name
(phonetic or spelling), address (full or parts), date of birth / age, gender, or other such matching details
to mark incoming or searched records as possible or exact match before amalgamation or subsequent
use. ISV may additionally need to provide the ability to merge/demerge patients to support this process
within their solutions.

ARCHITECTURE REQUIREMENTS AND FUNCTIONAL SPECIFICATIONS


A health record system must meet architectural requirements and functional specifications to remain faithful
to the needs of service delivery, be clinically valid and reliable, meet legal and ethical requirements, and
support good medical practices. Therefore, a health record system must conform to the following standards:

1. ISO 18308:2011 Health Informatics – Requirements for an Electronic Health Record Architecture

2. ISO/HL7 10781:2015 Health Informatics - HL7 Electronic Health Records-System Functional Model
Release 2 (EHR FM)

Implementation Guideline: Above two standards, despite being extensive, do not represent the full set of
specifications and requirements that need to be met by a health record system or its many variants (PHR,
etc.) or all possible use cases. The above mentioned standards are to be used as minimum set to be used
within the scope of implementation as per relevance to the system being developed / deployed.

LOGICAL INFORMATION REFERENCE MODEL AND STRUCTURAL COMPOSITION


A health record system must accumulate observable data and information for all clinically relevant events
and encounters. For this purpose, it is important to have common semantic and syntactic logical information
model and structural composition for captured artefacts. Unless the data being captured is standardized, its
communication and understanding may not be same across systems. Therefore, a health record system must
conform to the following standards:

1. ISO 13940 Health Informatics - System of Concepts to Support Continuity of Care

2. ISO 13606 Health Informatics - Electronic Health Record Communication (Part 1 through 3)

3. openEHR Foundation Models Release 1.0.2

3.1 Required Model Specifications: Base Model, Reference Model, Archetype Model

3.2 Optional Model Specifications: Service Model, Querying, Clinical Decision Support

Implementation Guideline: The ISO 13940 (also known as CEN ContSys) is to be generally used for purpose
of modelling and describing concept system and organize information objects. While ISO 13606 set of
standards are basic reference model and related specifications, openEHR provides ISO 18308 conformant

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