Interesting...
From: John Halamka <jhala...@caregroup.harvard.edu> I've recently been asked to provide a list of the data elements of an EHR which might be used as part of the ARRA mandate to exchange data as part of meaningful use. There are a nearly infinite number of actors, actions and events for data exchange, but in the interest of getting "data liquidity" in healthcare, here are the elements that are most commonly used and represent a great starting point for healthcare information exchange. I always strive for parsimony of standards - the fewest that we need for the purpose. Below you'll see that I've included the standards that support the systems we have in place today as well as the XML/Web-based standards that support newer web-centric systems and healthcare information exchanges. Demographics Content: HL7 2.x for messaging, CCD for document summaries Vocabulary: HITSP Harmonized codesets for gender, marital status Problem List Content: HL7 2.x for messaging, CCD for document summaries Vocabulary: SNOMED-CT Medications Content: NCPDP script for messaging, CCD for document summaries Vocabulary: RxNorm and Structured SIG Allergies Content: HL7 2.x for messaging, CCD for document summaries Vocabulary: UNII for foods and substances, NDC-RT for medication class, RxNorm for Medications Progress Notes and Other Narrative Documents (History and Physical, Operative Notes, Discharge Summary) Content: HL7 2.x for messaging, CCD for document summaries Vocabulary: CDA Templates Departmental Reports (Pathology/Cytology, GI, Pulmonary, Cardiology etc.) Content: HL7 2.x for messaging, CCD for document summaries Vocabulary: SNOMED-CT Laboratory Results Content: HL7 2.x for messaging, CCD for document summaries Vocabulary: LOINC for lab name, UCUM for units of measure, SNOMED-CT for test ordering reason Microbiology Content: HL7 2.x for messaging, CCD for document summaries Vocabulary: LOINC for lab name/observation Images Content: DICOM Administrative Transactions (Benefits/Eligibility, Referral/Authorization, Claims/Remittance) Content: X12 Vocabulary: CAQH CORE Quality Measures Content: Derived from all the data elements above Vocabulary: Derived from all the data elements above Privacy and Security Transport: HTTPS, SOAP/REST Transport Orchestration: WS* Authorization/Access Control: XACML Given that meaningful use needs to be achieved by 2011-2012, it's clear that we cannot rip and replace existing hospital information systems and EHRs. We need to leverage them, upgrade them over time, and install new systems in an incremental fashion. This is really true of any change in healthcare. If we had a greenfield, we would design healthcare delivery, payment, and infrastructure entirely differently. Unfortunately, we do not have a greenfield, we have limited resources, and limited time to achieve healthcare reform, so we need to leverage what we have and evolve it in phases. HITSP will be reformatting and streamlining its previous work over the next 90 days to support ARRA, the HIT Standards and Policies Committees, and ONC. I hope you agree that the list of EHR data elements above is practical, achievable now, and reasonable. ------------------------------------------------------------------------------ This SF.net email is sponsored by: High Quality Requirements in a Collaborative Environment. Download a free trial of Rational Requirements Composer Now! http://p.sf.net/sfu/www-ibm-com _______________________________________________ Care2002-developers mailing list Care2002-developers@lists.sourceforge.net https://lists.sourceforge.net/lists/listinfo/care2002-developers
