ASTM E1384-07(2013)

4.1.1 The first part (Section 4.1.2 The second part (Section 4.1.3 The third part (Section 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.

4.2.1 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. (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.

4.2.5 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.

4.3.1 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.

1.2.1 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.