eHR Content Standards Guidebook - Electronic Health Record Office

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eHR Content Standards Guidebookcodes, and migrate to international codes (Hong Kong version) for both data fields(Level 2.2). This facilitates the integration of same type of information at the eHRand supports easy retrieval of health information at the eHR. However, at this level,same concept could be differently represented by various institutes, e.g. diabetesmellitus could be recorded as DM, diabetes mellitus, or D.M. Human interpretationis required to understand the meaning of the shared data. Yet, such flexibility couldbe confusing sometimes as the same description could carry different meanings, e.g.PID could be pelvic inflammatory disease, or prolapsed intervertebral disc.8.5. With experience, healthcare practitioners are expected to provide field value usinginternational codes, Hong Kong version (Level 3.2) to support a fully interoperableeHR. The clinical data should be coded to as granular a level as possible. Bythen, all healthcare organizations are providing data with reference to the same setof terminology, and they can reuse the data captured by the other healthcareorganizations. The eHR can also provides information for her secondary uses, e.g.public health purpose, health services planning.Table 2 eHR Information Standards: Level of ComplianceHKeHRHL7Data field1 1 institutional (free text)description2.1 2 institute-defined code withinstitutional description2.2 2 ‧ institute-defined code‧ institutional description‧ international code (HK)3.1 3 ‧ institute-defined code‧ institutional description‧ international code (HK)3.2 3 ‧ institute-defined code‧ institutional description‧ international code (HK)‧ fully specifiedField ContentValueinstitutional (free text)descriptioninstitutional (free text)descriptioninstitutional description‧ institute-defined code‧ institutional description‧ international code (HK)‧ institute-defined code‧ institutional description‧ international code (HK)PDFYYYYYVersion 1.0 Copyright © 2009 – HKSAR Government Page 16 / 18
eHR Content Standards Guidebook9. Implementation9.1. A phased approach is recommended for passing data to the eHR with reference tothe experience of developing electronic medical records at overseas and Hong Kong.Such phased approach facilitates the healthcare providers to develop their clinicalinformation systems and also identifies the prioritization of the development ofrelated health information standards.9.2. At the initial stage, healthcare providers can send the most essential items at ahuman readable level to the eHR for ongoing health care. At later stage with morehealth information standards being well defined and as providers’ systems are moreadvanced, health data can be sent at a semantic based machine readable level tothe eHR. Please refer to table 3 for details.PersonHealthcare practitionerEncountersReferralEpisode summaryAdverse reactions / allergiesProblemsProceduresAssessment / physicalexaminationSocial historyPast medical historyFamily historyMedicationImmunizationClinical requestsDiagnostic test resultsCare & treatment planKey :Table 3 : eHR Implementation PhasesLevel 1 Level 2 Level 3Phase 1 Phase 2 Phase 3 Phase 4 Phase 5Version 1.0 Copyright © 2009 – HKSAR Government Page 17 / 18
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