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Developing a conformance methodology for clinically-defined medical record headings: A preliminary report
Philip Scott, Steve Bentley, Iain Carpenter, David Harvey, Jan Hoogewerf, Munish Jokhani, Dipak Kalra, Stephen Kay, Ian McNicoll, Mala Bridgelal Ram, Rahil Qamar Siddiqui, Roger Wallhouse, Robert Worden
Jazyk angličtina Země Česko Médium elektronický zdroj
Typ dokumentu práce podpořená grantem, přednášky
- MeSH
- chorobopisy - počítačové systémy MeSH
- chorobopisy - spojování normy MeSH
- elektronické zdravotní záznamy MeSH
- hesláře MeSH
- lékařská informatika MeSH
- terminologie jako téma MeSH
- Publikační typ
- práce podpořená grantem MeSH
- přednášky MeSH
Background: The Professional Records Standards Body for health and social care (PRSB) was formed in 2013 to develop and assure professional standards for the content and structure of patient records across all care disciplines in the UK. Although the PRSB work is aimed at Electronic Health Record (EHR) adoption and interoperability to support continuity of care, the current technical guidance is limited and ambiguous. Objectives: This project was initiated as a proof-ofconcept to demonstrate whether, and if so, how, conformance methods can be developed based on the professional standards. Methods: An expert group was convened, comprising clinical and technical representatives. A constrained data set was defined for an outpatient letter, using the subset of outpatient headings that are also present in the ep- SOS patient summary. A mind map was produced for the main sections and sub-sections. An openEHR archetype model was produced as the basis for creating HL7 and IHE implementation artefacts. Results: Several issues about data definition and representation were identified when attempting to map the outpatient headings to the epSOS patient summary, partly due to the difference between process and static viewpoints. Mind maps have been a simple and helpful way to visualize the logical information model and expose and resolve disagreements about which headings are purely for human navigation and which, if any, have intrinsic meaning. Conclusions: Conformance testing is feasible but nontrivial. In contrast to traditional standards-development timescales, PRSB needs an agile standards development process with EHR vendor and integrator collaboration to ensure implementability and widespread adoption. This will require significant clinical and technical resources.
Centre for Healthcare Modelling and Informatics University of Portsmouth UK
Health and Social Care Information Centre Leeds UK
Health Informatics Unit Royal College of Physicians London UK
Professional Records Standards Body for health and social care London UK
Developing a conformance methodology for clinically-defined medical record headings: A preliminary report [elektronický zdroj] /
Citace poskytuje Crossref.org
Literatura
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- $a Background: The Professional Records Standards Body for health and social care (PRSB) was formed in 2013 to develop and assure professional standards for the content and structure of patient records across all care disciplines in the UK. Although the PRSB work is aimed at Electronic Health Record (EHR) adoption and interoperability to support continuity of care, the current technical guidance is limited and ambiguous. Objectives: This project was initiated as a proof-ofconcept to demonstrate whether, and if so, how, conformance methods can be developed based on the professional standards. Methods: An expert group was convened, comprising clinical and technical representatives. A constrained data set was defined for an outpatient letter, using the subset of outpatient headings that are also present in the ep- SOS patient summary. A mind map was produced for the main sections and sub-sections. An openEHR archetype model was produced as the basis for creating HL7 and IHE implementation artefacts. Results: Several issues about data definition and representation were identified when attempting to map the outpatient headings to the epSOS patient summary, partly due to the difference between process and static viewpoints. Mind maps have been a simple and helpful way to visualize the logical information model and expose and resolve disagreements about which headings are purely for human navigation and which, if any, have intrinsic meaning. Conclusions: Conformance testing is feasible but nontrivial. In contrast to traditional standards-development timescales, PRSB needs an agile standards development process with EHR vendor and integrator collaboration to ensure implementability and widespread adoption. This will require significant clinical and technical resources.
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