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Preface XVII Acronyms XXVII PART ONE Introduction 1 Introduction to EHR 3 1.1 Introduction, 3 1.2 Definition of EHR, 4 1.3 Functions of EHR, 5 1.4 Significance of EHR, 6 1.5 Factors Affecting Implementation of EHR, 7 1.6 Role of Standards, 8 1.7 Role of Clinical Coding Systems, 9 1.8 Role of Standard Frameworks, 9 1.9 Case Studies of National EHR Implementations, 10 PART TWO EHR Standards 2 Standard for EHR Architecture Requirements 15 2.1 Introduction, 15 2.2 ISO/TS 18308 Requirement Specification, 16 2.2.1 Content Structure Model, 16 2.2.2 Inclusion of Clinical and Record Processes, 17 2.2.3 Content Exchange, 17 2.2.4 Privacy and Security, 17 2.2.5 Legal Considerations, 17 2.2.6 Ethical, Consumer/Cultural Aspects, 18 2.2.7 Future-proof Framework, 18 2.3 Discussion, 18 2.4 Conclusion, 20 3 Standard for Healthcare Concepts 23 3.1 Introduction, 23 3.2 CEN/TC EN 13940-1, 24 3.2.1 Actors in Continuity of Care, 24 3.2.2 Health Issues and Their Management, 25 3.2.3 Concepts Related to Responsibility, 25 3.2.4 Time-Related Concepts, 26 3.2.5 Concepts Related to Knowledge, Activities, and Decision Support, 27 3.2.6 Health Data Management, 28 3.3 CEN/TC prEN 13940-2, 28 3.3.1 Healthcare Process, 29 3.4 Discussion, 30 3.5 Conclusion, 32 4 Standard for EHR Functional Specifications 33 4.1 Introduction, 33 4.2 HL7 EHR-S Functional Model, 34 4.2.1 Functional Profiles, 34 4.2.2 Exchange, 36 4.2.3 Security/Privacy, 37 4.3 Comparison of HL7 EHR-S FM and ISO/TS 18308, 38 4.4 Discussion, 39 4.5 Conclusion, 40 5 Standard for EHR Communication 43 5.1 Introduction, 43 5.2 CEN/ISO EN 13606 Requirement Specification, 45 5.2.1 Part 1: Reference Model, 45 5.2.2 Part 2: Archetypes Interchange Specification, 46 5.2.3 Part 3: Reference Archetypes and Term Lists, 49 5.2.4 Part 4: Security, 49 5.2.5 Part 5: Exchange Models, 50 5.3 Discussion, 51 5.4 Conclusion, 53 6 Messaging Standard for Healthcare Data 57 6.1 Introduction, 57 6.2 HL7 v2.x, 58 6.2.1 Message Structure, 60 6.2.2 Auxiliary Messaging Protocols, 61 6.2.3 Usage Scenario, 62 6.2.4 Example of HL7 v2.x Message, 62 6.3 Discussion, 64 6.4 Conclusion, 67 7 Model-Based Messaging Standard for Healthcare Data 69 7.1 Introduction, 69 7.2 HL7 v3, 69 7.2.1 Message Structure, 70 7.2.2 Interaction Model, 74 7.2.3 Role-Based Access Control, 74 7.2.4 HL7 v3 and SNOMED CT, 75 7.2.5 HL7 v3 and Service-Oriented Architecture (SOA), 75 7.3 HL7 v2.x and v3 Comparison, 75 7.4 Discussion, 75 7.5 Conclusion, 77 8 Clinical Document Standards 81 8.1 Introduction, 81 8.2 Clinical Document Architecture (CDA), 82 8.2.1 Document Structures, 82 8.2.2 Example of CDA Component, 83 8.3 Continuity of Care Document (CCD), 85 8.3.1 Example of CCD Component, 86 8.4 Clinical Document Exchange, 87 8.5 Discussion, 87 8.6 Conclusion, 89 9 Standard for Medical Imaging and Communication 93 9.1 Introduction, 93 9.2 DICOM, 94 9.2.1 Information Model, 94 9.2.2 Message Exchange Model, 96 9.3 Improvements in DICOM Standard, 96 9.4 Discussion, 96 9.5 Conclusion, 100 10 Standard for Patient Health Summary 103 10.1 Introduction, 103 10.2 Continuity of Care Record (CCR), 103 10.2.1 Structural Model, 104 10.2.2 Exchange, 106 10.3 Discussion, 107 10.4 Conclusion, 108 PART THREE Coding Systems 11 Coding System for Classification of Diseases and Related Health Problems 113 11.1 Introduction, 113 11.2 ICD, 114 11.2.1 Chapters, 114 11.2.2 Blocks, 114 11.3 Improvements in ICD-10, 114 11.4 Discussion, 116 11.5 Conclusion, 116 12 Coding System for Laboratory Tests and Observations 119 12.1 Introduction, 119 12.2 LOINC, 120 12.2.1 Code Classification, 120 12.2.2 Code Structure, 120 12.2.3 Regenstrief LOINC Mapping Assistant (RELMA), 122 12.3 Discussion, 122 12.4 Conclusion, 123 13 Coding System for Patient Care Procedures 125 13.1 Introduction, 125 13.2 CPT, 126 13.2.1 Data Model, 127 13.2.2 CPT Sections, 128 13.2.3 CPT Index, 128 13.2.4 CPT Symbols, 128 13.2.5 CPT Modifiers, 128 13.2.6 Descriptive Qualifiers, 129 13.3 Discussion, 129 13.4 Conclusion, 130 14 Extended Coding System for Patient Care Procedures 131 14.1 Introduction, 131 14.2 HCPCS, 132 14.2.1 Level I Codes, 132 14.2.2 Level II Codes, 132 14.3 Discussion, 134 14.4 Conclusion, 134 15 Comprehensive Coding System for Clinical Terms 137 15.1 Introduction, 137 15.2 SNOMED CT, 138 15.2.1 Concepts, 138 15.2.2 Structure of SNOMED CT Code, 140 15.3 SNOMED CT Database Browsers, 141 15.4 Discussion, 141 15.5 Conclusion, 142 16 Unified Medical Language System 145 16.1 Introduction, 145 16.2 UMLS-Supported Coding Systems, 146 16.3 UMLS Architecture, 146 16.3.1 Metathesaurus, 146 16.3.2 Semantic Network, 148 16.3.3 Specialist Lexicon and Lexical Tools, 149 16.4 UMLS Licensing, 150 16.5 Discussion, 150 16.6 Conclusion, 151 17 Other Coding Systems 153 17.1 Introduction, 153 17.2 AHFS Drug Information (AHFS DI), 154 17.3 Current Dental Terminology (CDT), 154 17.4 International Classification of Diseases for Oncology (ICD-O), 155 17.5 International Classification of Functioning, Disability and Health (ICF), 155 17.6 Coding Systems for Nursing Practices, 156 17.6.1 North American Nursing Diagnosis Association (NANDA), 156 17.6.2 Nursing Interventions Classification (NIC), 156 17.6.3 Nursing Outcomes Classification (NOC), 156 17.7 Radiology Lexicon (RADLEX), 157 17.8 RxNorm, 157 17.9 Discussion, 157 17.10 Conclusion, 158 PART FOUR Standard Frameworks 18 openEHR 163 18.1 Introduction, 163 18.2 openEHR Process Model, 164 18.3 openEHR Architecture, 166 18.3.1 EHR Information Model, 168 18.3.2 Exchange, 170 18.4 Discussion, 170 18.5 Conclusion, 172 19 Integrating the Healthcare Enterprise (IHE) 175 19.1 Introduction, 175 19.2 IHE Domains, 176 19.2.1 Integration Profiles, 176 19.2.2 Integration Statements, 179 19.2.3 Technical Frameworks, 179 19.3 IHE Initiatives on Electronic Health Record, 180 19.4 Exchange, 180 19.4.1 Cross-Enterprise Document Sharing (XDS), 180 19.5 Security, 181 19.5.1 Audit Trail & Node Authentication (ATNA), 181 19.6 Discussion, 182 19.7 Conclusion, 183 PART FIVE Case Studies: National EHR Efforts 20 Australia's HealthConnect 189 20.1 Introduction, 189 20.2 Overview, 190 20.3 Architecture, 190 20.3.1 EHR Concept, 190 20.3.2 EHR Design, 191 20.3.3 e-Health Services, 193 20.3.4 National Privacy Principles (NPP), 194 20.3.5 Exchange, 194 20.4 Discussion, 195 20.5 Conclusion, 196 21 Austria's ELGA 199 21.1 Introduction, 199 21.2 Overview, 200 21.3 Architecture, 200 21.3.1 Master Patient Index, 201 21.3.2 HSP Index, 201 21.3.3 Authorization System, 202 21.3.4 HSP System, 202 21.3.5 Storage (Document Registry), 202 21.3.6 Network, 202 21.3.7 ELGA Portal, 203 21.4 Functional Implementation, 203 21.4.1 Healthcare Services, 205 21.5 Exchange, 205 21.6 Discussion, 205 21.7 Conclusion, 207 22 Canada's EHRS Blueprint 211 22.1 Introduction, 211 22.2 Overview, 211 22.3 Architecture, 212 22.3.1 Electronic Health Record Solution (EHRS), 212 22.3.2 Electronic Health Record Infostructure (EHRi), 213 22.3.3 Exchange, 216 22.3.4 Legal Framework, 217 22.4 Discussion, 217 22.5 Conclusion, 219 Bibliography, 219 23 Denmark's MedCom 221 23.1 Introduction, 221 23.2 Overview, 221 23.3 Architecture, 222 23.3.1 EHR Concept, 222 23.3.2 EHR Design, 223 23.3.3 Danish Health Data Network, 223 23.3.4 Security Infrastructure, 224 23.3.5 National Health Portal (Sundheds.dk), 224 23.3.6 Exchange, 225 23.4 Discussion, 225 23.5 Conclusion, 226 24 Hong Kong's eHR Sharing System 229 24.1 Introduction, 229 24.2 Overview, 229 24.3 Architecture, 230 24.3.1 E-Health Engagement Initiative (EEI), 230 24.3.2 eHR Sharing System, 231 24.3.3 Exchange, 233 24.3.4 Security/Privacy Guidelines, 233 24.4 Discussion, 234 24.5 Conclusion, 235 25 India's Health IT Initiatives 239 25.1 Introduction, 239 25.2 Overview, 240 25.3 ITIH Framework, 240 25.4 Recommendations on Guidelines, Standards, and Practices for Telemedicine in India, 242 25.5 iHIND, 244 25.5.1 Architecture, 245 25.5.2 Confidentiality, Access, and Security, 246 25.5.3 Standards, 246 25.6 Other Initiatives, 247 25.6.1 Integrated Disease Surveillance Project, 247 25.6.2 National Rural Telemedicine Network (NRTN), 247 25.6.3 National Medical College Network, 248 25.6.4 Standardization of EHR, 248 25.7 Discussion, 249 25.8 Conclusion, 251 26 Netherlands' AORTA 253 26.1 Introduction, 253 26.2 Overview, 253 26.3 Architecture, 254 26.3.1 Dutch Electronic Patient Dossier (EPD) System, 254 26.3.2 NICTIZ Healthcare IT Infrastructure Workflow, 255 26.3.3 Exchange, 256 26.3.4 Security/Privacy Guidelines, 256 26.4 Discussion, 256 26.5 Conclusion, 257 27 Singapore's NEHR 259 27.1 Introduction, 259 27.2 Overview, 259 27.3 Architecture, 260 27.3.1 Health Clusters, 260 27.3.2 EMR Exchange (EMRX), 260 27.3.3 National Electronic Health Record (NEHR), 261 27.4 Discussion, 263 27.5 Conclusion, 264 28 Sweden's NPO 267 28.1 Introduction, 267 28.2 Overview, 268 28.3 Architecture, 269 28.3.1 Clinical Process Model, 269 28.3.2 Information Model, 270 28.3.3 Sjunet, 271 28.3.4 Electronic Catalog For Health and Social Care, 271 28.3.5 Secure it in Health Services, 271 28.3.6 Basic Services for Information, 271 28.3.7 Regulatory Framework for Information Interoperability in Healthcare, 272 28.3.8 National Patient Summary, 273 28.4 Discussion, 273 28.5 Conclusion, 274 29 Taiwan's Health Information Network 277 29.1 Introduction, 277 29.2 Overview, 278 29.3 Architecture, 278 29.3.1 National Health Information Network (HIN) 2.0, 279 29.4 Exchange, 280 29.4.1 TMT Standard, 280 29.5 Discussion, 282 29.6 Conclusion, 284 30 United Kingdom's Spine 287 30.1 Introduction, 287 30.2 Overview, 287 30.3 Architecture, 288 30.3.1 Spine Infrastructure, 288 30.3.2 Structure of Summary Care Record, 290 30.3.3 Content of Summary Care Record, 290 30.3.4 Security Infrastructure, 291 30.3.5 Exchange, 292 30.4 Discussion, 292 30.5 Conclusion, 294 31 USA's EHR Meaningful Use 295 31.1 Introduction, 295 31.2 Overview, 296 31.3 EHR Meaningful Use, 296 31.3.1 Requirement Specifications, 297 31.4 National Health Information Network (NHIN), 301 31.4.1 NHIN Architecture, 301 31.4.2 Exchange Services, 303 31.4.3 Transaction Profiles, 303 31.4.4 Authorization Framework, 304 31.4.5 NHIN Trial Project, 304 31.4.6 NHIN Direct Project, 304 31.5 Discussion, 304 31.6 Conclusion, 307 PART SIX Findings and Conclusion 32 Findings and Conclusion 313 32.1 EHR Standards, 313 32.2 Coding Systems, 317 32.3 Standard Frameworks, 318 32.4 Case Studies: National EHR Efforts, 319 32.4.1 Quantitative Assessment, 320 32.4.2 Qualitative Assessment, 324 32.5 Recommended Phases for Implementing A National EHR System, 325 Glossary 327 Index 339

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