ASTM E1384-02
(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
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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.
An American National Standard
Designation: E 1384 – 02
Standard Guide for
Content and Structure of the Electronic Health Record
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(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.
1. Scope E 1381 Specification for Low-Level Protocol to Transfer
Messages Between Clinical Instruments and Computer
1.1 This guide covers all types of healthcare services,
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Systems
including those given in ambulatory care, hospitals, nursing
E 1394 Specification for Transferring Information Between
homes, skilled nursing facilities, home healthcare, and spe-
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Clinical Instruments and Computer Systems
cialty care environments. They apply both to short term
E 1460 Specification for Defining and Sharing Modular
contacts (for example, emergency rooms and emergency medi-
Health Knowledge Bases (Arden Syntax for Medical Logic
cal service units) and long term contacts (primary care physi-
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Modules)
cians with long term patients). The vocabulary aims to encom-
E 1467 Specification for Transferring Digital Neurophysi-
pass the continuum of care through all delivery models.
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ological Data Between Independent Computer Systems
1.2 This guide has four purposes:
E 1633 Specification for the Coded Values Used in the
1.2.1 Identify the content and logical structure of an Elec-
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Computer-Based Patient Record
tronic Health Record (EHR) consistent with currently acknowl-
E 1712 Specification for Representing Clinical Laboratory
edged patient record content. The record carries all health
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Test and Analyte Names
related information about a person over time. It may include
E 1714 Guide for Properties of a Universal Healthcare
history and physical, laboratory tests, diagnostic reports, orders
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Identifier
and treatments documentation, patient identifying information,
E 1715 Practice for an Object-Oriented Model for Registra-
legal permissions, and so on.
tion, Admitting, Discharge, and Transfer (RADT) Func-
1.2.2 Explain the relationship of data coming from diverse
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tions in Computer Based Patient Record Systems
sources (for example, clinical laboratory information manage-
E 1769 Guide for Properties of Electronic Health Records
ment systems, order entry systems, pharmacy information
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and Record Systems
management systems, dictation systems), and other data in the
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2.2 ISO Standards:
Electronic Health Record as the primary repository for infor-
IS 5218 1977 Information Interchange—Representation of
mation from various sources.
Human Sexes
1.2.3 Provide a common vocabulary for those developing,
IS 1000 1981 SI Units and Recommendations for the Use of
purchasing, and implementing EHR systems.
Their Multiples and of Certain Other Units
1.2.4 Provide sufficient content from which data extracts
IS 2955 1983 Information Processing—Representation of
can be compiled to create unique setting “views.”
SI and Other Units in Systems with Limited Character
2. Referenced Documents
Sets
IS 8072 1984 Information Processing Standard—Open Sys-
2.1 ASTM Standards:
tem Interconnection Transport Service Definition
E 792 Guide for Selection of a Clinical Laboratory Infor-
2
IS 8601 1988 Data Elements and Interchange Formats—
mation Management System
Information Interchange (Representation of Dates and
E 1238 Specification for Transferring Clinical Observations
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Times)
Between Independent Computer Systems
IS 6937:1994 Information Technology—Coded Graphic
E 1239 Guide for Description of Reservation/Registration-
Character Set for Text Communication (Revision of Parts
Admission, Discharge, Transfer (R-ADT) Systems for
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1 and 2)
Automated Patient Care Information Systems
IS 10367:1991 Standardized Coded Graphic Character Sets
for Use in 8 Bit Codes
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This guide is under the jurisdiction of ASTM Committee E31 on Healthcare
2.3 Other Health Informatics Standards:
Informatics and is the direct responsibility of Subcommittee E31.19 on Electronic
Health Record Content and Structure.
Current edition approved May 10, 2002. Published August 2002. Originally
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published as E 1384–91. Last previous edition E 1384–01. Available from ISO, 1 Rue de Varembe, Case Postale 56, CH 1211, Geneve,
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Annual Book of ASTM Standards, Vol 14.01. Switzerland.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
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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.
E 1384
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HL7 Health Level Seve
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