ASTM E1384-01

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

• Status: Historical
• Publication Date: 09-Nov-2001
• ICS: 01.140.20 - Information sciences
• ICS: 35.240.30 - IT applications in information, documentation and publishing
• Technical Committee: E31 - Healthcare Informatics
• Drafting Committee: E31.25 - Healthcare Data Management, Security, Confidentiality, and Privacy

Relations

• Replaced By: ASTM E1384-02 - Standard Guide for Content and Structure of the Electronic Health Record (EHR)
• Effective Date: 10-May-2002

Standards Content (Sample)

An American National Standard
Designation: E 1384 – 01
Standard Guide 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 displayed in order to accomplish various functions.
1.2.4 Fifth, this guide relates the logical structure of the
1.1 This guide covers all types of healthcare services,
EHR to the essential documentation currently used in the
including those given in acute care hospitals, nursing homes,
healthcare delivery system within the United States in order to
skilled nursing facilities, home healthcare, and specialty care
promote consistency and efficient data transfer. It maps to the
environments as well as ambulatory care. They apply both to
clinical data currently in existing data systems and patient care
short term contacts (for example, emergency rooms and
records.
emergency medical service units) and long term contacts
(primary care physicians with long term patients). At this time,
2. Referenced Documents
the standard vocabulary reflects more traditional care. As the
2.1 ASTM Standards:
standard evolves in the next revisions, the vocabulary will
E 792 Guide for Selection of a Clinical Laboratory Infor-
more adequately encompass the entire continuum of care
2
mation Management System
through all delivery models, health status measurement, pre-
E 1238 Specification for Transferring Clinical Observations
ventive case, and health education content.
2
Between Independent Computer Systems
1.2 This guide has five purposes. The first is to identify the
E 1239 Guide for Description of Reservation/Registration-
content and logical structure of a Electronic Health Record
Admission, Discharge, Transfer (R-ADT) Systems for
(EHR). The record carries all health related information about
2
Electronic Health Record (HER) Systems
a patient over time. It includes such things as observations or
E 1381 Specification for Low-Level Protocol to Transfer
descriptions of the patient (for example, the physician’s or
Messages Between Clinical Instruments and Computer
nurse practitioner’s history and physical, laboratory tests,
2
Systems
diagnostic imaging reports), provider’s orders for observations
E 1394 Specification for Transferring Information Between
and treatments, documentation about the actions carried out
2
Clinical Instruments and Computer Systems
(for example, therapies or drugs administered), patient identi-
E 1460 Specification for Defining and Sharing Modular
fying information, legal permissions, and so on.
Health Knowledge Bases (Arden Syntax for Medical Logic
1.2.1 The second goal is to define the relationship of data
2
Modules)
coming from diverse source systems (for example, clinical
E 1467 Specification for Transferring Digital Neurophysi-
laboratory information management systems, order entry sys-
2
ological Data Between Independent Computer Systems
tems, pharmacy information management systems, dictation
E 1633 Specification for the Coded Values Used in the
systems), and the data stored in the Electronic Health Record.
2
Electronic Health Record
Recalling that the EHR is the primary repository for informa-
E 1712 Specification for Representing Clinical Laboratory
tion from various sources, the structure of the EHR is receptive
2
Procedure and Analyte Names
to the data that flow from other systems.
E 1714 Guide for Properties of a Universal Healthcare
1.2.2 Third, in order to accelerate the adoption of EHRs, this
2
Identifier (UHID)
guide provides a common vocabulary, perspective, and refer-
E 1715 Practice for an Object-Oriented Model for Registra-
ences for those developing, purchasing, and implementing
tion, Admitting, Discharge, and Transfer (RADT) Func-
EHR systems, but it does not deal either with implementation
2
tions in Computer Based Patient Record Systems
or procurement.
E 1769 Guide for Properties of Electronic Health Records
1.2.3 Fourth, this guide describes examples of a variety of
2
and Record Systems
views by which the logical data structure might be accessed/
E 1869 Guide for Confidentiality, Privacy, Access and Data
Security Principles for Health Information Including Com-
1
This guide is under the jurisdiction of ASTM Committee E31 on Healthcare
2
puter Based Patient Records
Informatics and is the direct responsibility of Subcommittee E31.19 on Electronic
Health Record Content and Structure.
Current edition approved Nov. 10, 2001. Published March 2002. Originally
e1 2
published as E 1384 – 91. Last previous edition E 1384 – 99 . Annual Book of ASTM Standards, Vol 14.01.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
1

---------------------- P
...