Electronic Health Record
Standards, Coding Systems, Frameworks, and Infrastructures

Discover How Electronic Health Records Are Built to Drive the Next Generation of Healthcare Delivery

The increased role of IT in the healthcare sector has led to the coining of a new phrase "health informatics," which deals with the use of IT for better healthcare services. Health informatics applications often involve maintaining the health records of individuals, in digital form, which is referred to as an Electronic Health Record (EHR). Building and implementing an EHR infrastructure requires an understanding of healthcare standards, coding systems, and frameworks. This book provides an overview of different health informatics resources and artifacts that underlie the design and development of interoperable healthcare systems and applications.

Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures compiles, for the first time, study and analysis results that EHR professionals previously had to gather from multiple sources. It benefits readers by giving them an understanding of what roles a particular healthcare standard, code, or framework plays in EHR design and overall IT-enabled healthcare services along with the issues involved.

This book on Electronic Health Record:

• Offers the most comprehensive coverage of available EHR Standards including ISO, European Union Standards, and national initiatives by Sweden, the Netherlands, Canada, Australia, and many others
• Provides assessment of existing standards
• Includes a glossary of frequently used terms in the area of EHR
• Contains numerous diagrams and illustrations to facilitate comprehension
• Discusses security and reliability of data

Acronyms XXVII

PART ONE Introduction

1 Introduction to EHR 3

1.1 Introduction, 3

1.2 Definition of EHR, 4

1.3 Functions of EHR, 5

1.4 Significance of EHR, 6

1.5 Factors Affecting Implementation of EHR, 7

1.6 Role of Standards, 8

1.7 Role of Clinical Coding Systems, 9

1.8 Role of Standard Frameworks, 9

1.9 Case Studies of National EHR Implementations, 10

PART TWO EHR Standards

2 Standard for EHR Architecture Requirements 15

2.1 Introduction, 15

2.2 ISO/TS 18308 Requirement Specification, 16

2.2.1 Content Structure Model, 16

2.2.2 Inclusion of Clinical and Record Processes, 17

2.2.3 Content Exchange, 17

2.2.4 Privacy and Security, 17

2.2.5 Legal Considerations, 17

2.2.6 Ethical, Consumer/Cultural Aspects, 18

2.2.7 Future-proof Framework, 18

2.3 Discussion, 18

2.4 Conclusion, 20

3 Standard for Healthcare Concepts 23

3.1 Introduction, 23

3.2 CEN/TC EN 13940-1, 24

3.2.1 Actors in Continuity of Care, 24

3.2.2 Health Issues and Their Management, 25

3.2.3 Concepts Related to Responsibility, 25

3.2.4 Time-Related Concepts, 26

3.2.5 Concepts Related to Knowledge, Activities, and Decision Support, 27

3.2.6 Health Data Management, 28

3.3 CEN/TC prEN 13940-2, 28

3.3.1 Healthcare Process, 29

3.4 Discussion, 30

3.5 Conclusion, 32

4 Standard for EHR Functional Specifications 33

4.1 Introduction, 33

4.2 HL7 EHR-S Functional Model, 34

4.2.1 Functional Profiles, 34

4.2.2 Exchange, 36

4.2.3 Security/Privacy, 37

4.3 Comparison of HL7 EHR-S FM and ISO/TS 18308, 38

4.4 Discussion, 39

4.5 Conclusion, 40

5 Standard for EHR Communication 43

5.1 Introduction, 43

5.2 CEN/ISO EN 13606 Requirement Specification, 45

5.2.1 Part 1: Reference Model, 45

5.2.2 Part 2: Archetypes Interchange Specification, 46

5.2.3 Part 3: Reference Archetypes and Term Lists, 49

5.2.4 Part 4: Security, 49

5.2.5 Part 5: Exchange Models, 50

5.3 Discussion, 51

5.4 Conclusion, 53

6 Messaging Standard for Healthcare Data 57

6.1 Introduction, 57

6.2 HL7 v2.x, 58

6.2.1 Message Structure, 60

6.2.2 Auxiliary Messaging Protocols, 61

6.2.3 Usage Scenario, 62

6.2.4 Example of HL7 v2.x Message, 62

6.3 Discussion, 64

6.4 Conclusion, 67

7 Model-Based Messaging Standard for Healthcare Data 69

7.1 Introduction, 69

7.2 HL7 v3, 69

7.2.1 Message Structure, 70

7.2.2 Interaction Model, 74

7.2.3 Role-Based Access Control, 74

7.2.4 HL7 v3 and SNOMED CT, 75

7.2.5 HL7 v3 and Service-Oriented Architecture (SOA), 75

7.3 HL7 v2.x and v3 Comparison, 75

7.4 Discussion, 75

7.5 Conclusion, 77

8 Clinical Document Standards 81

8.1 Introduction, 81

8.2 Clinical Document Architecture (CDA), 82

8.2.1 Document Structures, 82

8.2.2 Example of CDA Component, 83

8.3 Continuity of Care Document (CCD), 85

8.3.1 Example of CCD Component, 86

8.4 Clinical Document Exchange, 87

8.5 Discussion, 87

8.6 Conclusion, 89

9 Standard for Medical Imaging and Communication 93

9.1 Introduction, 93

9.2 DICOM, 94

9.2.1 Information Model, 94

9.2.2 Message Exchange Model, 96

9.3 Improvements in DICOM Standard, 96

9.4 Discussion, 96

9.5 Conclusion, 100

10 Standard for Patient Health Summary 103

10.1 Introduction, 103

10.2 Continuity of Care Record (CCR), 103

10.2.1 Structural Model, 104

10.2.2 Exchange, 106

10.3 Discussion, 107

10.4 Conclusion, 108

PART THREE Coding Systems

11 Coding System for Classification of Diseases and Related Health Problems 113

11.1 Introduction, 113

11.2 ICD, 114

11.2.1 Chapters, 114

11.2.2 Blocks, 114

11.3 Improvements in ICD-10, 114

11.4 Discussion, 116

11.5 Conclusion, 116

12 Coding System for Laboratory Tests and Observations 119

12.1 Introduction, 119

12.2 LOINC, 120

12.2.1 Code Classification, 120

12.2.2 Code Structure, 120

12.2.3 Regenstrief LOINC Mapping Assistant (RELMA), 122

12.3 Discussion, 122

12.4 Conclusion, 123

13 Coding System for Patient Care Procedures 125

13.1 Introduction, 125

13.2 CPT, 126

13.2.1 Data Model, 127

13.2.2 CPT Sections, 128

13.2.3 CPT Index, 128

13.2.4 CPT Symbols, 128

13.2.5 CPT Modifiers, 128

13.2.6 Descriptive Qualifiers, 129

13.3 Discussion, 129

13.4 Conclusion, 130

14 Extended Coding System for Patient Care Procedures 131

14.1 Introduction, 131

14.2 HCPCS, 132

14.2.1 Level I Codes, 132

14.2.2 Level II Codes, 132

14.3 Discussion, 134

14.4 Conclusion, 134

15 Comprehensive Coding System for Clinical Terms 137

15.1 Introduction, 137

15.2 SNOMED CT, 138

15.2.1 Concepts, 138

15.2.2 Structure of SNOMED CT Code, 140

15.3 SNOMED CT Database Browsers, 141

15.4 Discussion, 141

15.5 Conclusion, 142

16 Unified Medical Language System 145

16.1 Introduction, 145

16.2 UMLS-Supported Coding Systems, 146

16.3 UMLS Architecture, 146

16.3.1 Metathesaurus, 146

16.3.2 Semantic Network, 148

16.3.3 Specialist Lexicon and Lexical Tools, 149

16.4 UMLS Licensing, 150

16.5 Discussion, 150

16.6 Conclusion, 151

17 Other Coding Systems 153

17.1 Introduction, 153

17.2 AHFS Drug Information (AHFS DI), 154

17.3 Current Dental Terminology (CDT), 154

17.4 International Classification of Diseases for Oncology (ICD-O), 155

17.5 International Classification of Functioning, Disability and Health (ICF), 155

17.6 Coding Systems for Nursing Practices, 156

17.6.1 North American Nursing Diagnosis Association (NANDA), 156

17.6.2 Nursing Interventions Classification (NIC), 156

17.6.3 Nursing Outcomes Classification (NOC), 156

17.7 Radiology Lexicon (RADLEX), 157

17.8 RxNorm, 157

17.9 Discussion, 157

17.10 Conclusion, 158

PART FOUR Standard Frameworks

18 openEHR 163

18.1 Introduction, 163

18.2 openEHR Process Model, 164

18.3 openEHR Architecture, 166

18.3.1 EHR Information Model, 168

18.3.2 Exchange, 170

18.4 Discussion, 170

18.5 Conclusion, 172

19 Integrating the Healthcare Enterprise (IHE) 175

19.1 Introduction, 175

19.2 IHE Domains, 176

19.2.1 Integration Profiles, 176

19.2.2 Integration Statements, 179

19.2.3 Technical Frameworks, 179

19.3 IHE Initiatives on Electronic Health Record, 180

19.4 Exchange, 180

19.4.1 Cross-Enterprise Document Sharing (XDS), 180

19.5 Security, 181

19.5.1 Audit Trail & Node Authentication (ATNA), 181

19.6 Discussion, 182

19.7 Conclusion, 183

PART FIVE Case Studies: National EHR Efforts

20 Australia's HealthConnect 189

20.1 Introduction, 189

20.2 Overview, 190

20.3 Architecture, 190

20.3.1 EHR Concept, 190

20.3.2 EHR Design, 191

20.3.3 e-Health Services, 193

20.3.4 National Privacy Principles (NPP), 194

20.3.5 Exchange, 194

20.4 Discussion, 195

20.5 Conclusion, 196

21 Austria's ELGA 199

21.1 Introduction, 199

21.2 Overview, 200

21.3 Architecture, 200

21.3.1 Master Patient Index, 201

21.3.2 HSP Index, 201

21.3.3 Authorization System, 202

21.3.4 HSP System, 202

21.3.5 Storage (Document Registry), 202

21.3.6 Network, 202

21.3.7 ELGA Portal, 203

21.4 Functional Implementation, 203

21.4.1 Healthcare Services, 205

21.5 Exchange, 205

21.6 Discussion, 205

21.7 Conclusion, 207

22 Canada's EHRS Blueprint 211

22.1 Introduction, 211

22.2 Overview, 211

22.3 Architecture, 212

22.3.1 Electronic Health Record Solution (EHRS), 212

22.3.2 Electronic Health Record Infostructure (EHRi), 213

22.3.3 Exchange, 216

22.3.4 Legal Framework, 217

22.4 Discussion, 217

22.5 Conclusion, 219

Bibliography, 219

23 Denmark’s MedCom 221

23.1 Introduction, 221

23.2 Overview, 221

23.3 Architecture, 222

23.3.1 EHR Concept, 222

23.3.2 EHR Design, 223

23.3.3 Danish Health Data Network, 223

23.3.4 Security Infrastructure, 224

23.3.5 National Health Portal (Sundheds.dk), 224

23.3.6 Exchange, 225

23.4 Discussion, 225

23.5 Conclusion, 226

24 Hong Kong's eHR Sharing System 229

24.1 Introduction, 229

24.2 Overview, 229

24.3 Architecture, 230

24.3.1 E-Health Engagement Initiative (EEI), 230

24.3.2 eHR Sharing System, 231

24.3.3 Exchange, 233

24.3.4 Security/Privacy Guidelines, 233

24.4 Discussion, 234

24.5 Conclusion, 235

25 India's Health IT Initiatives 239

25.1 Introduction, 239

25.2 Overview, 240

25.3 ITIH Framework, 240

25.4 Recommendations on Guidelines, Standards, and Practices for Telemedicine in India, 242

25.5 iHIND, 244

25.5.1 Architecture, 245

25.5.2 Confidentiality, Access, and Security, 246

25.5.3 Standards, 246

25.6 Other Initiatives, 247

25.6.1 Integrated Disease Surveillance Project, 247

25.6.2 National Rural Telemedicine Network (NRTN), 247

25.6.3 National Medical College Network, 248

25.6.4 Standardization of EHR, 248

25.7 Discussion, 249

25.8 Conclusion, 251

26 Netherlands' AORTA 253

26.1 Introduction, 253

26.2 Overview, 253

26.3 Architecture, 254

26.3.1 Dutch Electronic Patient Dossier (EPD) System, 254

26.3.2 NICTIZ Healthcare IT Infrastructure Workflow, 255

26.3.3 Exchange, 256

26.3.4 Security/Privacy Guidelines, 256

26.4 Discussion, 256

26.5 Conclusion, 257

27 Singapore's NEHR 259

27.1 Introduction, 259

27.2 Overview, 259

27.3 Architecture, 260

27.3.1 Health Clusters, 260

27.3.2 EMR Exchange (EMRX), 260

27.3.3 National Electronic Health Record (NEHR), 261

27.4 Discussion, 263

27.5 Conclusion, 264

28 Sweden's NPO 267

28.1 Introduction, 267

28.2 Overview, 268

28.3 Architecture, 269

28.3.1 Clinical Process Model, 269

28.3.2 Information Model, 270

28.3.3 Sjunet, 271

28.3.4 Electronic Catalog For Health and Social Care, 271

28.3.5 Secure it in Health Services, 271

28.3.6 Basic Services for Information, 271

28.3.7 Regulatory Framework for Information Interoperability in Healthcare, 272

28.3.8 National Patient Summary, 273

28.4 Discussion, 273

28.5 Conclusion, 274

29 Taiwan's Health Information Network 277

29.1 Introduction, 277

29.2 Overview, 278

29.3 Architecture, 278

29.3.1 National Health Information Network (HIN) 2.0, 279

29.4 Exchange, 280

29.4.1 TMT Standard, 280

29.5 Discussion, 282

29.6 Conclusion, 284

30 United Kingdom's Spine 287

30.1 Introduction, 287

30.2 Overview, 287

30.3 Architecture, 288

30.3.1 Spine Infrastructure, 288

30.3.2 Structure of Summary Care Record, 290

30.3.3 Content of Summary Care Record, 290

30.3.4 Security Infrastructure, 291

30.3.5 Exchange, 292

30.4 Discussion, 292

30.5 Conclusion, 294

31 USA's EHR Meaningful Use 295

31.1 Introduction, 295

31.2 Overview, 296

31.3 EHR Meaningful Use, 296

31.3.1 Requirement Specifications, 297

31.4 National Health Information Network (NHIN), 301

31.4.1 NHIN Architecture, 301

31.4.2 Exchange Services, 303

31.4.3 Transaction Profiles, 303

31.4.4 Authorization Framework, 304

31.4.5 NHIN Trial Project, 304

31.4.6 NHIN Direct Project, 304

31.5 Discussion, 304

31.6 Conclusion, 307

PART SIX Findings and Conclusion

32 Findings and Conclusion 313

32.1 EHR Standards, 313

32.2 Coding Systems, 317

32.3 Standard Frameworks, 318

32.4 Case Studies: National EHR Efforts, 319

32.4.1 Quantitative Assessment, 320

32.4.2 Qualitative Assessment, 324

32.5 Recommended Phases for Implementing A National EHR System, 325

Glossary 327

Index 339

PRADEEP K. SINHA, PhD, is the Senior Director (High Performance Computing) at the Centre for Develop- ment of Advanced Computing (C-DAC), India, and coordinator and mentor to several high-technology R&D groups there.

GAUR SUNDER heads research and development at Medical Informatics Group (MIG) at C-DAC, India, and is a member of the eHealth Committee of the Bureau of Indian Standards and the National EHR Standards Committee of the Union Health Ministry of India.

PRASHANT BENDALE is involved in the research and development of the distribution and integration model for building EHR stores at C-DAC.

MANISHA D. MANTRI is involved in the research and development of an evolving EHR model, compliance to eHealth standards, and security policies for EHR systems at C-DAC.

ATREYA C. DANDE is involved in the research and development of EHR standards, national EHR frameworks, distributed technologies, and optimal search algorithms in healthcare at C-DAC.