TEPR

Standards

Many standards as well as regulations are being developed that will impact on our use of electronic medical records.

HL7 Reference Information Model

A proprietary standard, the standard for communication of healthcare data. HL7 is an ANSI accredited standards developer for clinical and operational edi. Subject domains include order entry, result reporting, clinical observations, scheduling, patient care, immunizations, discharge summaries, adverse event reporting, automated waveforms, medical transcriptions, referrals, consultations, clinical trials and nursing care plans. It's European counterpart is called CEN

HIPPA - the Health Insurance Portability and Accountability Act of 1996

"The secretary shall adopt standards for transactions, and data elements for such transactions, to enable health information to be exchanged electronically that are appropriate for financial and administrative transactions consistent with the goals of improving the operation of the health care system and reducing costs. ... shall adopt standards providing fro a standard unique health identifier for each individual... shall adopt standards for code sets for appropriate data elements for financial and administrative transactions...specify procedures for the electronic transmission and authentication of signatures..... transfer of information among health plans."

XML

a mark-up language (like HTML is markup language for www) that includes tags useful for transferring medical information.

SNOMED

The systematized nomenclature of medicine.

ISO

International Standards Organization

ANSI

American National Standards Institute - under ISO

TC 215

An ISO Technical Committee dealing with Health Informatics, with working groups for health records, messaging, health concept representation and security.

ASTM E31 - from the American Society for Testing and Materials

ASTM E31 includes provisions on EMR's, confidentiality, communication and decision support. These can be ordered for about $20 each from http://www.astm.org

HISB

Healthcare Informatics Standards Board, and ANSI board working to harmonize with other countries' standards, including CEN

CCOW

Clinical Context Object Working Group, changed name to Visual Integration Technical Committee- now under HL7, and concerns coordinating applications on a workstation desktop (choose a patient record in one program and a CT viewer automatically logs on and pulls up the same patient.)

PRA

Patient Record Architecture - under HL7

More information and the slideshow can be ordered from peterw@medrecinst.com