Networking and Health Information Exchange

1. Networking and Health Information Exchange EHR Functional Model Standards Lecture a This material (Comp 9 Unit 6) was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material was updated by Normandale Community College, funded under Award Number 90WT0003. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/

2. EHR Functional Model StandardsLearning Objectives • Understand the definition(s) of an Electronic Health Record • Understand various architectures for an EHR • Identify and understand key standards for the EHR • Understand the HL7 EHR Functional Model Standards • Understand the HL7 PHR Functional Model Standard

3. What is an EHR? • Many definitions – why? • What is its form and format? • What is its purpose? • Who is it for?

4. What is an EHR? • Also Known As: • Automated Medical Record • Computerized Medical Record • Computer-Based Medical Record • Electronic Medical Record • Electronic Health Record • It’s not a: • Data Warehouse • Clinical Data Repository • Disease Registry

5. Institute of Medicine (IOM) Definition (1991, 1997) The patient record: • Is a principal repository for data concerning a patient’s health care • Affects virtually everyone associated with providing, receiving, auditing, regulating or reimbursing health care services "A computer-based patient record is an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids.“ (Dick, 1997)

6. Expanding the Definition • Different groups have expanded on these earlier definitions of the EHR • Groups include ISO, CEN, IOM, ASTM, and others • Common understanding is important for sharing and aggregating of clinical data

7. ISO EHR Standards • ISO TR 20514 • EHR Definition, Scope and Context • ISO TS 18308 • Requirements for an Electronic Health Record Reference Architecture • ISO IS 13606-1 • EHR Communication- Part 1: Reference Model

8. ASTM EHR Standards • E 1239 Standard Guide for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Automated Patient Care Information Systems • E 1384 Standard Guide for Content and Structure of the Electronic Health Record • E 1633 Standard Specification for the Coded Values Used in the Electronic Health Record

9. Additional ASTM EHR Standards • E 1715 Standard Practice for an Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (R-ADT) Functions in Computer Based Patient Record Systems • E 1744 Standard Guide for a View of Emergency Medical Care in the Computerized Patient Record • E 1869 Standard Guide for Confidentiality, Privacy, Access, and Data Security Principles for Health Information Including Electronic Health records

10. EHR System (EHR-S) • Includes the data storage and supporting applications that provide value • Includes the functionalities that enable HIT for patient care • Promotes and defines criteria for implementation of the EHR • Makes the EHR the beginning, not the end of the journey

11. EHR-FM • Provides a reference list of functions that shall, should or may be present in an EHR-S. • Enables common understanding of functions sought or available in any given setting. • Includes functions considered essential in at least one care setting.

12. EHR-S FM (HL7 International, 2014)

13. EHR-S FM Sections • Overarching: contains Conformance Criteria that apply to all EHR Systems and consequently must be included in all EHR-S FM compliant profiles. • Care Provision: contains those functions and supporting Conformance Criteria that are required to provide direct care to a specific patient and enable hands-on delivery of healthcare. The functions are general and are not limited to a specific care setting and may be applied as part of an Electronic Health Record supporting healthcare offices, clinics, hospitals and specialty care centers.– • Care Provision Support: focuses on functions needed to enable the provision of care This section is organized generally in alignment with Care Provision Section. For example, CP.4 (Manage Orders) is supported directly by CPS.4 (Support Orders). • Population Health Support: focuses on those functions required of the EHR to support the prevention and control of disease among a group of people (as opposed to the direct care of a single patient. This section includes functions to support input to systems that perform medical research, promote public health, & improve the quality of care at a multi-patient level.

14. EHR-S FM Sections • Administrative Support: focuses on functions required in the EHR-S to enable the management of the clinical practice and to assist with the administrative and financial operations. This includes management of resources, workflow and communication with patients and providers as well as the management of non-clinical administrative information on patients and providers. • Record Infrastructure: consists of functions common to EHR System record management, particularly those functions foundational to managing record lifecycle (origination, attestation, amendment, access/use, translation, transmittal/disclosure, receipt, de-identification, archive…) and record lifespan (persistence, indelibility, continuity, audit, encryption). RI functions are core and foundational to all other functions of the Model (CP, CPS, POP, AS). • Trust Infrastructure: consists of functions common to an EHR System infrastructure, particularly those functions foundational to system operations, security, efficiency and data integrity assurance, safeguards for privacy and confidentiality, and interoperability with other systems. TI functions are core and foundational to all other functions of the Model (CP, CPS, POP, AS and RI).

15. PHR-FM

16. PHR-S FM Sections • Personal Health section: are the subset of PHR-S functions that manage information and features related to self-care and provider based care over time. PH section functions can yield a summary record of an individual’s care, including ad hoc views of the overall PHR. • Supportive section: are the subset of PHR-S functions that assist the PHR Account Holder with administrative and financial requirements. Also included are PHR-S functions that provide input to systems that perform clinical research, promote public health and seek to improve the quality and outcome of health care delivered. • Information Infrastructure section: consists of PHR-S functions that support Personal Health and Supportive section functions. These functions ensure that the PHR-S provides information privacy and security, interoperates with other information systems (including PHR and EHR systems), and helps make PHR-S features accessible and easy to use.

17. Intent of Standard • Is technology neutral • Is implementation neutral • Does not endorse any specific technologies, although examples may mention a specific technology • Is not an EHR specification nor a conformance specification • Is not a definition of an EHR

18. EHR Functional Model StandardsSummary – Lecture a • Several standards from various SDOs that deal with EHR definition, architecture and content • None of these standards are complete and definitive • Unfortunately, the current state of the art for EHRs is similar to the story of five blind men and the elephant • Until a stronger agreement is reached, content interoperability, efficiency, and query will be compromised • We are unlikely to ever have a single standard for an EHR architecture • The reasons include: • Lack of agreement among developers • The proprietary nature of the architectural design • Legacy systems

19. EHR Functional Model StandardsReferences – Lecture a References Dick, R. S., Steen, E. B., & Detmer, D. E. (Eds.). Committee on Improving the Patient Record, Institute of Medicine. (1997). Computer-Based Patient Record : An Essential Technology for Health Care (Rev ed.). Washington, D.C.: The National Academy Press. ASTM. (1996, Feb). Standard Guide for Properties of Electronic Health Records and Record Systems. E1769-95. Health IT Dashboard. (2016) The Office of the National Coordinator for Health IT. HL7 International, (2014, April). HL7 EHR-System Functional Model, Release 2. HL7 International, (2014, May). HL7 Personal Health Record System Functional Model, Release 1. Acknowledgement: The material presented in this lecture was taken from the web sites of the various standards. Details of the standards listed here can be obtained from the various SDOs. There may be a membership cost or other cost associated with the standards. Images Slide 6: Photo of book by W. Ed Hammond, PhD.

20. EHR Functional Model StandardsLecture a This material was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material was updated by Normandale Community College, funded under Award Number 90WT0003.