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Home > ICD-10
Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures
Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures
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Description

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. Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures 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 the United States, 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

About the Authors

Pradeep K. Sinha, PhD, is the senior director of high performance computing at the Centre for Development of Advanced Computing (C-DAC), India, and coordinator and mentor to several high-technology research and development groups there.

Gaur Sunder heads research and development at medical informatics group 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.

Table of Contents

Preface

Acronyms

Part One: Introduction

1: Introduction to EHR

1.1 Introduction,

1.2 Definition of EHR,

1.3 Functions of EHR,

1.4 Significance of EHR,

1.5 Factors affecting implementation of EHR,

1.6 Role of standards,

1.7 Role of clinical coding systems,

1.8 Role of standard frameworks,

1.9 Case studies of national EHR implementations,

Part Two: EHR Standards

2: Standard for EHR architecture requirements

2.1 Introduction,

2.2 ISO/TS 18308 requirement specification,

2.2.1 Content structure model,

2.2.2 Inclusion of clinical and record processes,

2.2.3 Content exchange,

2.2.4 Privacy and security,

2.2.5 Legal considerations,

2.2.6 Ethical, consumer/cultural aspects,

2.2.7 Future-proof framework,

2.3 Discussion,

2.4 Conclusion,

3: Standard for healthcare concepts

3.1 Introduction,

3.2 CEN/TC EN 13940-1,

3.2.1 Actors in continuity of care,

3.2.2 Health issues and their management,

3.2.3 Concepts related to responsibility,

3.2.4 Time-related concepts,

3.2.5 Concepts related to knowledge, activities, and decision support,

3.2.6 Health data management,

3.3 CEN/TC prEN 13940-2,

3.3.1 Healthcare process,

3.4 Discussion,

3.5 Conclusion,

4: Standard for EHR functional specifications

4.1 Introduction,

4.2 HL7 EHR-S functional model,

4.2.1 Functional profiles,

4.2.2 Exchange,

4.2.3 Security/privacy,

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

4.4 Discussion,

4.5 Conclusion,

5: Standard for EHR communication

5.1 Introduction,

5.2 CEN/ISO EN 13606 requirement specification,

5.2.1 Part 1: Reference model,

5.2.2 Part 2: Archetypes interchange specification,

5.2.3 Part 3: Reference archetypes and term lists,

5.2.4 Part 4: Security,

5.2.5 Part 5: Exchange models,

5.3 Discussion,

5.4 Conclusion,

6: Messaging standard for healthcare data

6.1 Introduction,

6.2 HL7 v2.x,

6.2.1 Message structure, 60

6.2.2 Auxiliary messaging protocols,

6.2.3 Usage scenario,

6.2.4 Example of HL7 v2.x message,

6.3 Discussion,

6.4 Conclusion,

7: Model-based messaging standard for healthcare data

7.1 Introduction,

7.2 HL7 v3,

7.2.1 Message structure,

7.2.2 Interaction model,

7.2.3 Role-based access control,

7.2.4 HL7 v3 and SNOMED CT,

7.2.5 HL7 v3 and service-oriented architecture (SOA),

7.3 HL7 v2.x and v3 comparison,

7.4 Discussion,

7.5 Conclusion,

8: Clinical document standards

8.1 Introduction,

8.2 Clinical document architecture (CDA),

8.2.1 Document structures,

8.2.2 Example of CDA component,

8.3 Continuity of Care document (CCD),

8.3.1 Example of CCD component,

8.4 Clinical document exchange,

8.5 Discussion,

8.6 Conclusion,

9: Standard for medical imaging and communication

9.1 Introduction,

9.2 DICOM,

9.2.1 Information model,

9.2.2 Message exchange model,

9.3 Improvements in DICOM standard,

9.4 Discussion,

9.5 Conclusion,

10: Standard for patient health summary

10.1 Introduction,

10.2 Continuity of care record (CCR),

10.2.1 Structural model,

10.2.2 Exchange,

10.3 Discussion,

10.4 Conclusion,

Part Three: Coding Systems

11: Coding system for classification of diseases and related health problems

11.1 Introduction,

11.2 ICD,

11.2.1 Chapters,

11.2.2 Blocks,

11.3 Improvements in ICD-10,

11.4 Discussion,

11.5 Conclusion,

12: Coding system for laboratory tests and observations

12.1 Introduction,

12.2 LOINC,

12.2.1 Code classification,

12.2.2 Code structure,

12.2.3 Regenstrief LOINC mapping assistant (RELMA),

12.3 Discussion,

12.4 Conclusion,

13: Coding system for patient care procedures

13.1 Introduction,

13.2 CPT,

13.2.1 Data model,

13.2.2 CPT sections,

13.2.3 CPT index,

13.2.4 CPT symbols,

13.2.5 CPT modifiers,

13.2.6 Descriptive qualifiers,

13.3 Discussion,

13.4 Conclusion,

14: Extended coding system for patient care procedures

14.1 Introduction,

14.2 HCPCS,

14.2.1 Level I codes,

14.2.2 Level II codes,

14.3 Discussion,

14.4 Conclusion,

15: Comprehensive coding system for clinical terms

15.1 Introduction,

15.2 SNOMED CT,

15.2.1 Concepts,

15.2.2 Structure of SNOMED CT code,

15.3 SNOMED CT database browsers,

15.4 Discussion,

15.5 Conclusion,

16: Unified medical language system

16.1 Introduction,

16.2 UMLS-supported coding systems,

16.3 UMLS architecture,

16.3.1 Metathesaurus,

16.3.2 Semantic network,

16.3.3 Specialist lexicon and lexical tools,

16.4 UMLS licensing,

16.5 Discussion,

16.6 Conclusion,

17: Other coding systems

17.1 Introduction,

17.2 AHFS drug information (AHFS DI),

17.3 Current dental terminology (CDT),

17.4 International classification of diseases for oncology (ICD-O),

17.5 International classification of functioning, disability and health (ICF),

17.6 Coding systems for nursing practices,

17.6.1 North American Nursing Diagnosis Association (NANDA),

17.6.2 Nursing interventions classification (NIC),

17.6.3 Nursing outcomes classification (NOC),

17.7 Radiology lexicon (RADLEX),

17.8 RxNorm,

17.9 Discussion,

17.10 Conclusion,

Part Four: Standard Frameworks

18: openEHR

18.1 Introduction,

18.2 openEHR process model,

18.3 openEHR architecture,

18.3.1 EHR information model,

18.3.2 Exchange,

18.4 Discussion,

18.5 Conclusion,

19: Integrating the healthcare enterprise (IHE)

19.1 Introduction,

19.2 IHE domains,

19.2.1 Integration profiles,

19.2.2 Integration statements,

19.2.3 Technical frameworks,

19.3 IHE initiatives on electronic health record,

19.4 Exchange,

19.4.1 Cross-enterprise document sharing (XDS),

19.5 Security,

19.5.1 Audit trail & node authentication (ATNA),

19.6 Discussion,

19.7 Conclusion,

Part Five: Case Studies: National EHR Efforts

20: Australia's HealthConnect

20.1 Introduction,

20.2 Overview,

20.3 Architecture,

20.3.1 EHR concept,

20.3.2 EHR design,

20.3.3 E-Health services,

20.3.4 National privacy principles (NPP),

20.3.5 Exchange,

20.4 Discussion,

20.5 Conclusion,

21: Austria's ELGA

21.1 Introduction,

21.2 Overview,

21.3 Architecture,

21.3.1 Master patient index,

21.3.2 HSP index,

21.3.3 Authorization system,

21.3.4 HSP system,

21.3.5 Storage (document registry),

21.3.6 Network,

21.3.7 ELGA portal,

21.4 Functional implementation,

21.4.1 Healthcare services,

21.5 Exchange,

21.6 Discussion,

21.7 Conclusion,

22: Canada's EHRS blueprint

22.1 Introduction,

22.2 Overview,

22.3 Architecture,

22.3.1 Electronic health record solution (EHRS),

22.3.2 Electronic health record infostructure (EHRi),

22.3.3 Exchange,

22.3.4 Legal framework,

22.4 Discussion,

22.5 Conclusion,

Bibliography,

23: Denmark's MedCom

23.1 Introduction,

23.2 Overview,

23.3 Architecture,

23.3.1 EHR concept,

23.3.2 EHR design,

23.3.3 Danish health data network,

23.3.4 Security infrastructure,

23.3.5 National health portal (Sundheds.dk),

23.3.6 Exchange,

23.4 Discussion,

23.5 Conclusion,

24: Hong Kong's eHR sharing system

24.1 Introduction,

24.2 Overview,

24.3 Architecture,

24.3.1 E-Health engagement initiative (EEI),

24.3.2 eHR sharing system,

24.3.3 Exchange,

24.3.4 Security/privacy guidelines,

24.4 Discussion,

24.5 Conclusion,

25: India's health IT initiatives

25.1 Introduction,

25.2 Overview,

25.3 ITIH framework,

25.4 Recommendations on guidelines, standards, and practices for telemedicine in India,

25.5 iHIND,

25.5.1 Architecture,

25.5.2 Confidentiality, access, and security,

25.5.3 Standards,

25.6 Other initiatives,

25.6.1 Integrated disease surveillance project,

25.6.2 National rural telemedicine network (NRTN),

25.6.3 National medical college network,

25.6.4 Standardization of EHR,

25.7 Discussion,

25.8 Conclusion,

26: Netherlands' AORTA

26.1 Introduction,

26.2 Overview,

26.3 Architecture,

26.3.1 Dutch electronic patient dossier (EPD) system,

26.3.2 NICTIZ healthcare IT infrastructure workflow,

26.3.3 Exchange,

26.3.4 Security/privacy guidelines,

26.4 Discussion,

26.5 Conclusion,

27: Singapore's NEHR

27.1 Introduction,

27.2 Overview,

27.3 Architecture,

27.3.1 Health clusters,

27.3.2 EMR exchange (EMRX),

27.3.3 National electronic health record (NEHR),

27.4 Discussion,

27.5 Conclusion,

28: Sweden's NPO

28.1 Introduction,

28.2 Overview,

28.3 Architecture,

28.3.1 Clinical process model,

28.3.2 Information model,

28.3.3 Sjunet,

28.3.4 Electronic catalog for health and social care,

28.3.5 Secure it in health services,

28.3.6 Basic services for information,

28.3.7 Regulatory framework for information interoperability in healthcare,

28.3.8 National patient summary,

28.4 Discussion,

28.5 Conclusion,

29: Taiwan's health information network

29.1 Introduction,

29.2 Overview,

29.3 Architecture,

29.3.1 National health information network (HIN) 2.0,

29.4 Exchange,

29.4.1 TMT standard,

29.5 Discussion,

29.6 Conclusion,

30: United Kingdom's spine

30.1 Introduction,

30.2 Overview,

30.3 Architecture,

30.3.1 Spine infrastructure,

30.3.2 Structure of summary care record,

30.3.3 Content of summary care record,

30.3.4 Security infrastructure,

30.3.5 Exchange,

30.4 Discussion,

30.5 Conclusion,

31: USA's EHR meaningful use

31.1 Introduction,

31.2 Overview,

31.3 EHR meaningful use,

31.3.1 Requirement specifications,

31.4 National health information network (NHIN),

31.4.1 NHIN architecture,

31.4.2 Exchange services,

31.4.3 Transaction profiles,

31.4.4 Authorization framework,

31.4.5 NHIN trial project,

31.4.6 NHIN direct project,

31.5 Discussion,

31.6 Conclusion,

Part Six: Findings and Conclusion

32: Findings and conclusion

32.1 EHR standards,

32.2 Coding systems,

32.3 Standard frameworks,

32.4 Case studies: National EHR efforts,

32.4.1 Quantitative assessment,

32.4.2 Qualitative assessment,

32.5 Recommended phases for implementing a national EHR system,

Glossary

Index

Publication Date: December 2012
Number of Pages: 376
ISBN 13: 978-1-1182-8134-5
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