The Standardized EMR

1. The Standardized EMR Tung Tran, Ph.D

2. What is the EMR? • Computerized legal medical record created by healthcare organizations • Enables storage and retrieval of patient information • Standardized EMR • Fulfill the organization needs of organizations • Integrated • Adaptable

3. Clinical Document Architecture (CDA) • Patient Record Architecture • Provide an exchange model • Discharge summaries • Referrals • … • The content of CDA is based upon other standards • DICOM • Terminologies (ICD codes, HL7 codes, LOINC codes, …) • …

4. Sharing the Medical Record • Common patient medical records: • History and physical • Patient Referral • Patient Consultation • Progress notes • Physician’s Order • Discharge Summary • CDA is the way of passing medical documents in terms of data values and data elements formats.

5. 0,n 0,n Patient 0,n 1,n Encounter 0,n 0,n 0,n 1,n 0,n 0,n 1,n Problem Order/Plan Practitioner 1,n 0,n 0,n 0,n 0,n 0,n Service/Instance 0,n 0,n 0,n Observation 0,n 1,1 0,n Service/Master ASTME 1384

6. Network Communication Techniques • HL7 Interface Engine • HL7 network protocol is application messaging protocol for healthcare communications. • Patient Administration (Admission, Transfer, Discharge) • Order Entry (diet, pharmacy order, lab test order) • Observation Reporting • …

7. Various Devices (Web/Applications/User Interfaces Presentation layer Order Entry Patient Administration Documents Management LIS Schedule Application layer Common Application framework (data management, process management, Interface/Integration, Transport service) Standard XML Clinical Data Repository Terminology Local XML Data layer EMR Architecture

8. Thank you