Pediatric Informatics: Computer Applications in Child Health (Health ...

416 S.T. Rosenbloom and J. Kuhl
the physician will be able to make decisions and prescribe the necessary therapies
more efficiently.
Standards are principles and rules designed to ensure that methods used and
products created reliably and consistently conform to expectations. Software
standards in particular exist to align the structure and data contained in disparate
computer systems and application programs. 7 Typically, such standards detail
the minimum set of functions that the software provides, the methods used to
achieve those functions, and the formatting of the data structure. The goal of
standards is to ensure that both data and users’ experiences are similar from
one computer system to another, and that information can flow easily between
computer systems. 7–9 Standards for EHR systems and clinical data may include
specifications for the terms used to represent medical entities and the relationships
between entities and individual patients. For example, medication standards may
include details about what words and spellings to be used to represent each medication,
ingredient, dosing frequency and dose form, as well as the data structure
that links a given medication to the dates that it was started or refilled and to the
patient who is taking it.
Standards for clinical data exist with the primary objective of enabling it to
be aggregated, shared, and exchanged within and among various EHR systems. 8,9
The ability for data to be shared among computer systems without loss of detail
or meaning is termed “interoperability.” For data to be maximally interoperable, it
must be normalized to a single form and content. This single form and content is
a standard.
32.2 Types of Clinical Data Standards
Data standards designed to support aggregation and exchange generally consist of
three components, each of which may be defined using a terminology or a guideline:
(1) the scope and content of the standard; (2) the syntax and formatting of the
content; and (3) the actual semantics and words used to represent the content. We
will consider each of these types of standards.
32.2.1 Content, Function, and Quality Standards
One major purpose of software standards for EHR systems is to define the core
set of functions, features, and activities that such systems should support. Defining
necessary functions, with descriptions of each, ensures that system developers,
evaluators, and users all have similar expectations of what EHR systems do (and do
not do). A listing of desired functions, features, and activities serves as a standard
for content or quality, because it defines the minimum set of content that a piece of
software should provide, and against which its quality can be judged.