ASTM E1384-07
(Guide)Standard Practice for Content and Structure of the Electronic Health Record (EHR)
Standard Practice for Content and Structure of the Electronic Health Record (EHR)
SCOPE
1.1 This practice covers all types of healthcare services, including those given in ambulatory care, hospitals, nursing homes, skilled nursing facilities, home healthcare, and specialty care environments. 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). The vocabulary aims to encompass the continuum of care through all delivery models. This practice defines the persistent data needed to support Electronic Health Record system functionality.
1.2 This practice has four purposes:
1.2.1 Identify the content and logical data structure and organization of an Electronic Health Record (EHR) consistent with currently acknowledged patient record content. The record carries all health related information about a person over time. It may include history and physical, laboratory tests, diagnostic reports, orders and treatments documentation, patient identifying information, legal permissions, and so on. The content is presented and described as data elements or as clinical documents. This standard is consistent with eXtensible Markup Language (XML). See Document Type Definition (DTD) 2.1 and W3CXML Schema 1.0
1.2.2 Explain the relationship of data coming from diverse sources (for example, clinical laboratory information management systems, order entry systems, pharmacy information management systems, dictation systems), and other data in the Electronic Health Record as the primary repository for information from various sources.
1.2.3 Provide a common vocabulary for those developing, purchasing, and implementing EHR systems.
1.2.4 Provide sufficient content from which data extracts can be compiled to create unique setting "views."
1.2.5 Map the content to selected relevant biomedical and health informatics standards.
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Designation: E1384 − 07 AnAmerican National Standard
Standard Practice for
Content and Structure of the Electronic Health Record
1
(EHR)
This standard is issued under the fixed designation E1384; 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 (´) indicates an editorial change since the last revision or reapproval.
1. Scope* 2. Referenced Documents
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1.1 This practice covers all types of healthcare services, 2.1 ASTM Standards:
including those given in ambulatory care, hospitals, nursing E1238 Specification for Transferring Clinical Observations
homes, skilled nursing facilities, home healthcare, and spe- Between Independent Computer Systems (Withdrawn
3
cialty care environments. They apply both to short term 2002)
contacts (for example, emergency rooms and emergency medi- E1239 Practice for Description of Reservation/Registration-
cal service units) and long term contacts (primary care physi- Admission, Discharge, Transfer (R-ADT) Systems for
cians with long term patients). The vocabulary aims to encom- Electronic Health Record (EHR) Systems
pass the continuum of care through all delivery models. This E1633 SpecificationforCodedValuesUsedintheElectronic
practicedefinesthepersistentdataneededtosupportElectronic Health Record
Health Record system functionality. E1639 Guide for Functional Requirements of Clinical Labo-
ratory Information Management Systems (Withdrawn
1.2 This practice has four purposes:
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2002)
1.2.1 Identify the content and logical data structure and
E1714 Guide for Properties of a Universal Healthcare Iden-
organization of an Electronic Health Record (EHR) consistent
tifier (UHID)
with currently acknowledged patient record content. The re-
E1715 Practice for An Object-Oriented Model for
cord carries all health related information about a person over
Registration,Admitting, Discharge, and Transfer (RADT)
time. It may include history and physical, laboratory tests,
Functions in Computer-Based Patient Record Systems
diagnostic reports, orders and treatments documentation, pa-
E1769 Guide for Properties of Electronic Health Records
tient identifying information, legal permissions, and so on.The
and Record Systems
content is presented and described as data elements or as
E2118 Guide for Coordination of Clinical Laboratory Ser-
clinical documents.This standard is consistent with eXtensible
vices within the Electronic Health Record Environment
Markup Language (XML). See Document Type Definition
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and Networked Architectures (Withdrawn 2002)
(DTD) 2.1 and W3CXML Schema 1.0
E2369 Specification for Continuity of Care Record (CCR)
1.2.2 Explain the relationship of data coming from diverse
E2473 Practice for the Occupational/Environmental Health
sources (for example, clinical laboratory information manage-
View of the Electronic Health Record
ment systems, order entry systems, pharmacy information
E2538 Practice for Defining and Implementing Pharmaco-
management systems, dictation systems), and other data in the
therapy Information Services within the Electronic Health
Electronic Health Record as the primary repository for infor-
Record (EHR) Environment and NetworkedArchitectures
mation from various sources.
HL7
1.2.3 Provide a common vocabulary for those developing,
2.2 Other Health Informatics Standards:
purchasing, and implementing EHR systems.
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HL7 Health Level Seven (HL7) Version 2.2 1994 (Version
1.2.4 Provide sufficient content from which data extracts
2.4 and 2.5)
can be compiled to create unique setting “views.”
NCPDP National Council for Prescription Drug Programs
1.2.5 Map the content to selected relevant biomedical and
health informatics standards.
2
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM
1
This practice is under the jurisdiction ofASTM Committee E31 on Healthcare Standards volume information, refer to the standard’s Document Summary page on
Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare the ASTM website.
3
Data Management, Security, Confidentiality, and Privacy. The last approved version of this historical standard is referenced on
Current edition approved Oct. 15, 2007. Published November 2007. Originally www.astm.org.
4
approved in 1991. Last previous edition approved in 2002 as E1384 – 02a. DOI: Available from HL7, Mark McDougall, Executive Director, 900 Victors Way,
10.1520/E1384-07. Suite 122, Ann Arbor, MI 48108.
*A Summary of Changes section appears at the end of this standard
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
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This document is not anASTM standard and is intended only to provide the user of anASTM standard an indication of what changes have been made to the previous version. Because
it may not be technically possible to adequately depict all changes accurately, ASTM recommends that users consult prior editions as appropriate. In all cases only the current version
of the standard as published by ASTM is to be considered the official document.
An American National Standard
Designation:E1384–02a Designation:E1384–07
Standard Practice for
Content and Structure of the Electronic Health Record
1
(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*
1.1 This practice covers all types of healthcare services, including those given in ambulatory care, hospitals, nursing homes,
skilled nursing facilities, home healthcare, and specialty care environments. 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).
The vocabulary aims to encompass the continuum of care through all delivery models. This practice defines the persistent data
needed to support Electronic Health Record system functionality.
1.2 This practice has four purposes:
1.2.1Identify the content and logical structure of an Electronic Health Record (EHR) consistent with currently acknowledged
patient record content. The record carries all health related information about a person over time. It may include history and
physical, laboratory tests, diagnostic reports, orders and treatments documentation, patient identifying information, legal
permissions, and so on.
1.2.1 Identify the content and logical data structure and organization of an Electronic Health Record (EHR) consistent with
currently acknowledged patient record content. The record carries all health related information about a person over time. It may
include history and physical, laboratory tests, diagnostic reports, orders and treatments documentation, patient identifying
information, legal permissions, and so on. The content is presented and described as data elements or as clinical documents. This
standard is consistent with eXtensible Markup Language (XML). See Document Type Definition (DTD) 2.1 and W3CXML
Schema 1.0
1.2.2 Explain the relationship of data coming from diverse sources (for example, clinical laboratory information management
systems, order entry systems, pharmacy information management systems, dictation systems), and other data in the Electronic
Health Record as the primary repository for information from various sources.
1.2.3 Provide a common vocabulary for those developing, purchasing, and implementing EHR systems.
1.2.4 Provide sufficient content from which data extracts can be compiled to create unique setting “views.”
1.2.5 Map the content to selected relevant biomedical and health informatics standards.
2. Referenced Documents
2.1 ASTM Standards:
2
E792Guide for Selection of a Clinical Laboratory Information Management System
E 1238 Specification for Transferring Clinical Observations Between Independent Computer Systems
E 1239Guide for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Automated
2
Patient Care Information Systems
2
E1381Specification for Low-Level Protocol to Transfer Messages Between Clinical Instruments and Computer Systems
2
E1394Specification for Transferring Information Between Clinical Instruments and Computer Systems
2
E1460Specification for Defining and Sharing Modular Health Knowledge Bases (Arden Syntax for Medical Logic Modules)
2
E1467Specification for Transferring Digital Neurophysiological Data Between Independent Computer Systems Practice for
Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record
(EHR) Systems
E 1633 Specification for the Coded Values Used in the Computer-Based PatientElectronic Health Record
2
E1712Specification for Representing Clinical Laboratory Test and Analyte Names
1
This practice is under the jurisdiction ofASTM Committee E31 on Healthcare Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare Data
Management, Security, Confidentiality, and Privacy .
Current edition approved Sept. 10, 2002. Published January 2003. Originally published as E1384–91. Last previous edition E1384–02.
Current edition approved Oct. 15, 2007. Published November 2007. Originally approved in 1991. Last previous edition approved in 2002 as E 1384 – 02a.
2
For referencedASTM standards, visit theASTM website, www.astm.org, or contactASTM Customer Service at service@astm.org. For Annual Book of
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