ASTM E1384-99e1
(Guide)Standard Guide for Content and Structure of the Electronic Health Record (EHR)
Standard Guide for Content and Structure of the Electronic Health Record (EHR)
SCOPE
1.1 This guide covers all types of healthcare services, including those given in acute care hospitals, nursing homes, skilled nursing facilities, home healthcare, and specialty care environments as well as ambulatory care. They apply both to short term contacts (for example, emergency rooms and emergency medical service units) and long term contacts (primary care physicians with long term patients). At this time, the standard vocabulary reflects more traditional care. As the standard evolves in the next revisions, the vocabulary will more adequately encompass the entire continuum of care through all delivery models, health status measurement, preventive case, and health education content.
1.2 This guide has five purposes. The first is to identify the content and logical structure of a Electronic Health Record (EHR). The record carries all health related information about a patient over time. It includes such things as observations or descriptions of the patient (for example, the physician's or nurse practitioner's history and physical, laboratory tests, diagnostic imaging reports), provider's orders for observations and treatments, documentation about the actions carried out (for example, therapies or drugs administered), patient identifying information, legal permissions, and so on.
1.2.1 The second goal is to define the relationship of data coming from diverse source systems (for example, clinical laboratory information management systems, order entry systems, pharmacy information management systems, dictation systems), and the data stored in the Electronic Health Record. Recalling that the EHR is the primary repository for information from various sources, the structure of the EHR is receptive to the data that flow from other systems.
1.2.2 Third, in order to accelerate the adoption of EHRs, this guide provides a common vocabulary, perspective, and references for those developing, purchasing, and implementing EHR systems, but it does not deal either with implementation or procurement.
1.2.3 Fourth, this guide describes examples of a variety of views by which the logical data structure might be accessed/displayed in order to accomplish various functions.
1.2.4 Fifth, this guide relates the logical structure of the EHR to the essential documentation currently used in the healthcare delivery system within the United States in order to promote consistency and efficient data transfer. It maps to the clinical data currently in existing data systems and patient care records.
General Information
Standards Content (Sample)
NOTICE: This standard has either been superseded and replaced by a new version or discontinued.
Contact ASTM International (www.astm.org) for the latest information.
e1
Designation: E 1384 – 99 An American National Standard
Standard Guide for
Content and Structure of the Electronic Health Record
(EHR)
This standard is issued under the fixed designation E 1384; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (e) indicates an editorial change since the last revision or reapproval.
e NOTE—Editorial corrections were made throughout the Annex and in Table 6 in February 2000.
1. Scope views by which the logical data structure might be accessed/
displayed in order to accomplish various functions.
1.1 This guide covers all types of healthcare services,
1.2.4 Fifth, this guide relates the logical structure of the
including those given in acute care hospitals, nursing homes,
EHR to the essential documentation currently used in the
skilled nursing facilities, home healthcare, and specialty care
healthcare delivery system within the United States in order to
environments as well as ambulatory care. They apply both to
promote consistency and efficient data transfer. It maps to the
short term contacts (for example, emergency rooms and
clinical data currently in existing data systems and patient care
emergency medical service units) and long term contacts
records.
(primary care physicians with long term patients). At this time,
the standard vocabulary reflects more traditional care. As the
2. Referenced Documents
standard evolves in the next revisions, the vocabulary will
2.1 ASTM Standards:
more adequately encompass the entire continuum of care
E 792 Guide for Selection of a Clinical Laboratory Infor-
through all delivery models, health status measurement, pre-
mation Management System
ventive case, and health education content.
E 1238 Specification for Transferring Clinical Observations
1.2 This guide has five purposes. The first is to identify the
Between Independent Computer Systems
content and logical structure of a Electronic Health Record
E 1239 Guide for Description of Reservation/Registration-
(EHR). The record carries all health related information about
Admission, Discharge, Transfer (R-ADT) Systems for
a patient over time. It includes such things as observations or
Automated Patient Care Information Systems
descriptions of the patient (for example, the physician’s or
E 1381 Specification for Low-Level Protocol to Transfer
nurse practitioner’s history and physical, laboratory tests,
Messages Between Clinical Instruments and Computer
diagnostic imaging reports), provider’s orders for observations
Systems
and treatments, documentation about the actions carried out
E 1394 Specification for Transferring Information Between
(for example, therapies or drugs administered), patient identi-
Clinical Instruments and Computer Systems
fying information, legal permissions, and so on.
E 1460 Specification for Defining and Sharing Modular
1.2.1 The second goal is to define the relationship of data
Health Knowledge Bases (Arden Syntax for Medical Logic
coming from diverse source systems (for example, clinical
Modules)
laboratory information management systems, order entry sys-
E 1467 Specification for Transferring Digital Neurophysi-
tems, pharmacy information management systems, dictation
ological Data Between Independent Computer Systems
systems), and the data stored in the Electronic Health Record.
E 1633 Specification for the Coded Values Used in the
Recalling that the EHR is the primary repository for informa-
Computer-Based Patient Record
tion from various sources, the structure of the EHR is receptive
E 1712 Specification for Representing Clinical Laboratory
to the data that flow from other systems.
Test and Analyte Names
1.2.2 Third, in order to accelerate the adoption of EHRs, this
E 1715 Practice for an Object-Oriented Model for Registra-
guide provides a common vocabulary, perspective, and refer-
tion, Admitting, Discharge, and Transfer (RADT) Func-
ences for those developing, purchasing, and implementing
tions in Computer Based Patient Record Systems
EHR systems, but it does not deal either with implementation
E 1769 Guide for Properties of Electronic Health Records
or procurement.
and Record Systems
1.2.3 Fourth, this guide describes examples of a variety of
2.2 ISO Standards:
This guide is under the jurisdiction of ASTM Committee E-31 on Healthcare
Informatics and is the direct responsibility of Subcommittee E31.19 on Electronic
Health Record Content and Structure. Annual Book of ASTM Standards, Vol 14.01.
Current edition approved May 10, 1999. Published September 1999. Originally Available from ISO, 1 Rue de Varembe, Case Postale 56, CH 1211, Geneve,
published as E 1384 – 91. Last previous edition E 1384 – 96. Switzerland.
Copyright © ASTM, 100 Barr Harbor Drive, West Conshohocken, PA 19428-2959, United States.
E 1384
IS 5218 1977 Information Interchange—Representation of nonresident basis (that is, not requiring overnight stay and not
Human Sexes included in the census). While many inpatients may be
IS 1000 1981 SI Units and Recommendations for the Use of ambulatory, the term ambulatory usually implies that the
Their Multiples and of Certain Other Units patient has come to a location other than his or her home and
IS 2955 1983 Information Processing—Representation of has departed that same day. (Ambulatory care includes non-
SI and Other Units in Systems with Limited Character medical healthcare sites, for example, acupuncture.)
Sets
3.1.3 ambulatory surgery center—a free-standing or
IS 8072 1984 Information Processing Standard—Open Sys-
hospital-based facility offering surgical procedures on patients
tem Interconnection Transport Service Definition
who are admitted and discharged from the facility on the day of
IS 8601 1988 Data Elements and Interchange Formats—
the surgery.
Information Interchange (Representation of Dates and
3.1.4 ancillary service visit—appearance of an outpatient in
Times)
a unit of a hospital or outpatient facility to receive service(s),
IS 6937:1994 Information Technology—Coded Graphic
test(s), or procedures; it is ordinarily not counted as an
Character Set for Text Communication (Revision of Parts
encounter.
1 and 2)
3.1.5 clinic—an outpatient facility providing a limited range
IS 10367:1991 Standardized Coded Graphic Character Sets
of healthcare services, and assuming overall healthcare respon-
for Use in 8 Bit Codes
sibility for the patients.
2.3 Other Health Informatics Standards:
3.1.6 clinic patient—admitted for diagnosis or treatment or
HL7 Health Level Seven (HL7) Version 2.2 1994
follow-up on an ambulatory basis; the clinic assumes overall
ACR/NEMA DICOM Version 3.0
medical responsibility for the patient.
NCPDP National Council for Prescription Drug Programs
3.1.7 continuing care retirement community—an organiza-
(NCPDP) Telecommunication Standard Format Version
tion established to provide housing and services, including
3 Release 2, 1992
healthcare, to people of retirement age.
ANSI ASC X12: Version 3, Release 3 (1992)
3.1.8 electronic health record (EHR)—an electronic patient
X12.84 Healthcare Enrollment and Maintenance Transac-
record that resides in a system specifically designed to support
tion Set (834)
users by providing accessibility to complete and accurate data,
X12.85 Healthcare Claim Payment Transaction Set (835)
alerts, reminders, clinical decision support systems, links to
X12.87 Healthcare Claim Transaction Set (837)
scientific knowledge, and other aids.
2.4 ANSI Standards:
X3.30:1985 [R 1991] Representation for Calendar Date and
3.1.9 emergency patient—a patient admitted to emergency
Ordinal Date room service of a hospital for diagnosis and therapy requiring
X3.4:1986 [R 1992] Coded Character Sets—American Na-
immediate healthcare services.
tional Standard Code for Information Interchange (7-bit
3.1.10 emergency services—immediate evaluation and
ASCII)
therapy rendered in emergency clinical conditions, sustained
X3.43:1986 [R 1992] Information Systems Representation
until the patient can be referred to his or her personal
of Local Time of Day for Information Interchange
practitioner for further care.
X3.50:1986 [R 1992] Representations for U.S. Customary,
3.1.11 encounter—(1) An instance of direct (usually face-
SI, and Other Units to Be Used in Systems with Limited
to-face) interaction, regardless of the setting, between a patient
Character Sets
and a practitioner vested with primary responsibility for
X3.51:1994 Representations of Universal Time, Local Time
diagnosing, evaluating or treating the patient’s condition, or
Differentials, and United States Time Zone References for
both, or providing social worker services. (Encounters do not
Information Interchange
include ancillary services visits or telephone contacts.) (2)A
contact between a patient and a practitioner who has primary
3. Terminology
responsibility for assessing and treating the patient at a given
3.1 Definitions of Terms Specific to This Standard:
contact, exercising independent judgment.
3.1.1 admitting diagnosis—a statement of the provisional
3.1.12 episode—one or more healthcare services received
condition given as the basis for admission to the hospital for
by an individual during a period of relatively continuous care
study.
by healthcare practitioners in relation to a particular clinical
3.1.2 ambulatory care—also called “outpatient care,” that
problem or situation.
preventive or corrective healthcare, or both, provided in
3.1.13 health maintenance organization—an organization
practitioner’s office or clinic setting, or in the hospital on a
which provides health coverage to voluntary enrollees in return
for prepayment of a set fee, regardless of the services used.
4 3.1.14 home healthcare—clinical care provided or super-
Available from HL7, Mark McDougall, Executive Director, 900 Victors Way,
vised by a practitioner, administered at the patient’s home or
Suite 122, Ann Arbor, MI 48108.
Available from ACR/NEMA.
place of residence, thus allowing the patient to remain at home
Available from NCPDP, 4201 North 24th Street, Suite 365, Phoenix, AZ 85016.
during an illness. Home healthcare also addresses care for
Available from DISA (Data Interchange Standards Association).
people with permanent alterations in their health or functional
Available from American National Standards Institute, 11 W. 42nd St., 13th
Floor, New York, NY 10036. status.
E 1384
3.1.15 hospice—a program emphasizing psychosocial sup- or with individuals who have personal knowledge of the patient
port and home physical care, with inpatient care when needed, (or with both). The record contains information about the
for terminally ill patients and their families. patient and other individuals as they relate to the health of the
patient, for example, family history, caregiver support.
3.1.16 hospital—an establishment with an organized medi-
cal staff with permanent facilities that include inpatient beds 3.1.28 patient record system—the set of components that
and continuous medical/nursing services and that provide form the mechanism by which patient records are created,
diagnosis and treatment for patients. used, stored, and retrieved. A patient record system is usually
3.1.17 hospital-based outpatient care—a subset of ambula- located within a healthcare provider/practitioner setting. It
includes people, data, rules and procedures, processing and
tory care utilizing the hospital staff, equipment, and resources
to render preventive or corrective healthcare, or both. storage devices (for example, paper and pen, hardware and
software), and communications and support functions.
3.1.18 inpatient admission—the formal acceptance by a
3.1.29 primary diagnosis—the diagnosis of the condition
hospital of a patient who is to be provided with room, board,
and continuous nursing service in an area of the hospital where that is primarily responsible for the patient’s symptoms and
signs and has the greatest impact on the patient’s health, or is
patients generally stay at least overnight.
the most resource-intensive to treat.
3.1.19 intermediate care facility (ICF)—an institution
which primarily provides health-related care and services to 3.1.30 primary patient record (primary record of care)—the
record that is used by healthcare professionals while providing
individuals who do not require the degree of care or treatment
which a hospital or skilled nursing facility is designated to patient care services to review patient data or document their
own observations, actions, or instructions. (Same as patient
provide, but who, because of their physical or mental condi-
tion, require care and services. health record.)
3.1.20 length of stay (LOS)—the total number of patient 3.1.31 principal diagnosis—a statement of the condition
days for an inpatient episode, calculated by subtracting the date established after study to be chiefly responsible for occasioning
of admission from the date of discharge. If a patient is admitted the admission of the patient to the hospital for care.
and discharged on the same date, the LOS is one day. 3.1.32 provider—a business entity which furnishes health-
3.1.21 licensed practitioners—an individual at any level of care to a consumer; it includes a professionally licensed
practitioner who is authorized to operate a healthcare delivery
professional specialization who requires a public license/
certification to practice the delivery of care to patients. A facility.
practitioner can also be a provider.
3.1.33 referred—admitted exclusively to special diagnostic/
3.1.22 long-term care—healthcare rendered in a non-acute- therapeutic service of the hospital for diagnosis/treatment on an
care facility and to a patient in resident or non-resident status; ambulatory basis. Responsibility remains with the referring
practitioner.
such illness is not severe enough to require an acute care
facility, but is in need of continual supervision and assistance
3.1.34 resident care facility—a residential facility that pro-
by healthcare practitioners. vides regular and emergency health services, when needed, and
3.1.23 longitudinal patient record—a permanent, coordi- appropriate supporting services on a regular basis.
nated patient record of significant information, in chronologi-
3.1.35 school special education—specifically designed in-
cal sequence. It may include all historical data collected or be struction provided by qualified teachers within the context of
retrieved as a user designated synopsis of significant demo-
school, aimed at the acquisition of academic, vocational,
graphic, genetic, clinical and environment
...
Questions, Comments and Discussion
Ask us and Technical Secretary will try to provide an answer. You can facilitate discussion about the standard in here.