eHR Content Standards Guidebook - Electronic Health Record Office

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eHR Content Standards GuidebookTable of Content1. Background2. Purposes of the Paper3. Definition of Electronic Health Record4. Framework in Building eHR5. Structured Data & Free Text6. Data Type7. eHR Content8. Level of Compliance9. Implementation10. ReferencesVersion 1.0 Copyright © 2009 – HKSAR Government Page 4 / 18
eHR Content Standards Guidebook1. Background1.1. Healthcare today is confronting an increasing number of tough challenges: highlyspecialized healthcare fields, aging population, escalating healthcare costs, risingexpectations, increasing threats of communicable diseases. Healthcare is nowbeing delivered by teams of practitioner serving patients over long periods. It is notuncommon for a person to be repeatedly asked for one’s medical and social historyby multiple healthcare practitioners during an episode of care. Or, investigationsare repeated because the attending doctor does not know what has been donepreviously and by whom. Sharing timely and accurate patient information amongstvarious highly specialized healthcare practitioners plays a crucial role for thecontinuous delivery of safe, quality and efficient patient care in today’s healthcareenvironment.1.2. Technology enables us to build a longitudinal womb-to-tomb health record.Electronic data can be exchanged amongst different systems and allow users ofdifferent sites and settings to view the record in an integrated fashion. If the sharedclinical data is incorporated into the EMR (electronic medical record) systems of thepractitioners, then the receiving systems can reuse the data for purposes such asclinical decision support. However an interoperable health information systemcannot be realized without extensive standardization. IEEE (1990) definesinteroperability as the ability of two or more systems or components to exchangeinformation (functional interoperability) and to use the information that has beenexchanged (semantic interoperability) (a).1.3. Standardization forms the foundation for accurate and efficient communication ofelectronic data. The current healthcare environment demands a variety ofinformation systems to support its operation, e.g. clinical information systems,laboratory systems, radiology systems, pharmacy systems, financial systems…Standardization allows systems to interface in a uniform way and relieves thedevelopers of clinical software from building separate interfaces for every systemtheir software needs to talk with, thus reducing the cost of technical integration. Byusing standard terminology, information is interpreted by all users with the sameunderstanding. This supports reuse of data, improves the efficiency of healthcareservices by reducing duplicate tests and avoids errors by reducingmiscommunication and reducing data transcription and duplication.1.4. The 2007-08 Policy Address highlighted the requirement of developing aterritory-wide, patient-oriented electronic health record (eHR) (b) with the aims toimprove efficiency and quality of care, improve continuity and integration of care,
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