ASTM E1384-07(2013)
(Practice)Standard Practice for Content and Structure of the Electronic Health Record (EHR) (Withdrawn 2017)
Standard Practice for Content and Structure of the Electronic Health Record (EHR) (Withdrawn 2017)
SIGNIFICANCE AND USE
4.1 This Guide has Four Parts:
4.1.1 The first part (Section 5) identifies items of information carried in the traditional paper record organized by the source oriented structures common to paper records. The purpose of this section is to remind users of the spectrum of information that shall be accommodated by the logical structure of a EHR and to present a point of reference for the more abstract description of the patient record that follows.
4.1.2 The second part (Section 6) presents a number of operational principles, including such matters as privacy and security that should guide the implementation and operation of EHRs.
4.1.3 The third part (Section 7) describes a logical data organization and content (common data model) of an EHR. It is not a blueprint for constructing or implementing a EHR system. The model presents an organization according to the major informational structures and content of the EHR. The focus is on the structure required to store all clinically relevant patient information: those that describe the patient's state; the actions directed at the patient variables; and the actions initiated to diagnose, educate, or treat the patient. These are regarded as repository functions of the EHR. This standard does not describe all of the data structures required by applications that might use information contained in the EHR. In particular, the data structures used to control and guide the process of care such as utilization review or quality assurance, and the goals or thresholds (for example, mean length of stay) that might be used to judge the patient's care are not included.
4.1.3.1 There are many different ways to implement physical structures that could map into the model presented. It is emphasized that this standard should neither impede technical progress nor define the precise manner in which the EHR system is implemented.
4.1.3.2 The focus of this guide is on the kinds of information that should be included and upon a global ...
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.
WITHDRAWN RATIONALE
Formerly under the jurisdiction of Committee E3...
General Information
Relations
Standards Content (Sample)
NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
Contact ASTM International (www.astm.org) for the latest information
Designation: E1384 − 07 (Reapproved 2013) An American National Standard
Standard Practice for
Content and Structure of the Electronic Health Record
(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
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
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:
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
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.
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.
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
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.
Data Management, Security, Confidentiality, and Privacy. The last approved version of this historical standard is referenced on
Current edition approved April 15, 2013. Published April 2013. Originally www.astm.org.
approved in 1991. Last previous edition approved in 2007 as E1384 – 07. DOI: Available from HL7, Mark McDougall, Executive Director, 900 Victors Way,
10.1520/E1384-07R13. 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
E1384 − 07 (2013)
(NCPDP) Telecommunication Standard Format Version 3.1.9 emergency services—immediate evaluation and
3 Release 2, 1992 therapy rendered in urgent clinical conditions, sustained until
ANSI ASC X12: Version 3, Release 3 (1992) thepatientcanbereferredtohisorherpersonalpractitionerfor
X12.84 HealthcareEnrollmentandMaintenanceTransaction further care.
Set (834)
3.1.10 encounter—(1) the direct personal contact between a
X12.85 Healthcare Claim Payment Transaction Set (835)
patient and a physician or other person who is authorized by
X12.87 Healthcare Claim Transaction Set (837)
state licensure law and, if applicable, by medical staff bylaws
to order or furnish healthcare services for the diagnosis or
2.3 ANSI Standards:
HL7 EHR TC Electronic Health Record-System Functional treatment of the patient. (2) A contact between a patient and a
practitioner who has primary responsibility for assessing and
Model, Release 1 February, 2007
Health Information Management and Technology: Glossary, treating the patient at a given contact, exercising independent
judgment. Contact may be via an electronic visit.
American Health Information Management Association,
3.1.11 episode—one or more healthcare services received
by an individual during a period of relatively continuous care
3. Terminology
by healthcare practitioners in relation to a particular clinical
problem or situation.
3.1 Definitions of Terms Specific to This Standard:
3.1.1 admitting diagnosis—a provisional description of the
3.1.11.1 episode of care (EOC reimbursement)—a category
reason why a patient requires care in an inpatient hospital
of payments made as lump sums to providers for all healthcare
setting.
services delivered to a patient for a specific illness or over a
specified time period or both; also called bundled payments
3.1.2 ambulatory care—preventive or corrective healthcare
because they include multiple services and may include mul-
services provided on a nonresident basis in a provider’s office,
tiple providers of care.
clinic setting, or hospital outpatient setting. The term ambula-
tory usually implies that the patient has come to a location and
3.1.12 free standing ambulatory surgery center—a) A free
has departed that same day. (Ambulatory care includes medi-
standing outpatient surgical facility is a separate facility that
cine such as acupuncture, specialty clinics for consultation
exists primarily to provide services in connection with surgical
services and retail care centers used for short term immediate
procedures that do not require inpatient hospitalization. b) An
services.)
outpatient surgical facility that has its own national identifier;
is a separate entity with respect to its licensure, accreditation,
3.1.3 ancillary service visit—appearance of an outpatient in
governance,professionalsupervision,administrativefunctions,
a unit of a hospital or outpatient facility to receive service(s),
clinical services, record keeping, and financial and accounting
test(s), or procedures; it is ordinarily not counted as an
systems; has as its sole purpose the provision of services in
encounter for healthcare services.
connection with surgical procedures that do not require inpa-
3.1.4 clinic—an outpatient facility providing a limited range
tient hospitalization; and meets the conditions and require-
ofhealthcareservices,andassumingoverallhealthcarerespon-
ments set forth in the Medicare Conditions of Participation.
sibility for the patients. See also ambulatory care.
3.1.13 health maintenance organization—an organization
3.1.5 clinic patient—a patient who is registered for the
that provides health coverage to voluntary enrollees in return
purpose of diagnosis or treatment or follow-up on an ambula-
for prepayment of a set fee, regardless of the services used.
tory basis.
3.1.14 home health—a) An umbrella term that refers to the
3.1.6 continuing care retirement community—an organiza-
medical and non-medical services provided to patients and
tion established to provide housing and services, including
their families in their places of residence. b) The provision of
healthcare, to people of retirement age.
medical and non-medical care in the home or place of
3.1.7 electronic health record (EHR)—an electronic health
residence to promote, maintain, or restore health or to mini-
record is any information related to the past, present or future
mize the effect of disease or disability.
physical/mental health, or condition of an individual. The
3.1.15 hospice—an interdisciplinary program of palliative
information resides in electronic system(s) used to capture,
care and supportive services that addresses the physical,
transmit, receive, store, retrieve, link and manipulate multime-
spiritual, social and economic needs of terminally ill patients
dia data for the primary purpose of providing health care and
and their families.
health related services.
3.1.16 hospital—an establishment with an organized medi-
3.1.8 emergency patient—a patient admitted to emergency
cal staff with permanent facilities that include inpatient beds
room service of a hospital for diagnosis and therapy requiring
and continuous medical/nursing services and that provides
immediate healthcare services.
diagnostic and therapeutic services for patients as well as
overnight accommodations and nutritional services.
3.1.17 hospital-based outpatient care—a subset of ambula-
AvailablefromNCPDP,4201North24thStreet,Suite365,Phoenix,AZ85016.
tory care utilizing the hospital staff, equipment, and resources
Available from DISA (Data Interchange Standards Association).
to render diagnostic, preventive or corrective healthcare, or
Available fromAmerican National Standards Institute (ANSI), 25 W. 43rd St.,
4th Floor, New York, NY 10036. both.
E1384 − 07 (2013)
3.1.18 inpatient admission—the formal acceptance by a 3.1.28.1 Personal health record—An electronic or paper
hospital of a patient who is to be provided with room, board, record of health information compiled and maintained by the
and continuous nursing service in an area of the hospital where patient or others for patient use (1) .
patients generally stay overnight.
3.1.29 patient record system—the set of components that
3.1.19 intermediate care facility (ICF)—an institution form the mechanism by which patient records are created,
which primarily provides health-related care and services to used, stored, and retrieved. A patient record system is usually
individuals who do not require the degree of care or treatment located within a healthcare provider/practitioner setting. It
which a hospital or skilled nursing facility is designated to includes people, data, rules and procedures, processing and
provide, but who, because of their physical or mental storage devices (for example, paper and pen, hardware and
condition, require care and services. software), and communications and support functions.
3.1.20 length of stay (LOS)—the total number of patient 3.1.30 primary diagnosis—the diagnosis of the condition
daysforaninpatientepisode,calculatedbysubtractingthedate that is primarily responsible for the patient’s symptoms and
ofadmissionfromthedateofdischarge.Ifapatientisadmitted signs and has the greatest impact on the patient’s health, or is
the most resource-intensive to treat.
and discharged on the same date, the LOS is one day.
3.1.31 principal diagnosis—a statement of the condition
3.1.21 licensed practitioners—an individual at any level of
establishedafterstudytobechieflyresponsibleforoccasioning
professional specialization who requires a public license/
the admission of the patient to the hospital for care.
certification to practice the delivery of care to patients. A
practitioner can also be a provider.
3.1.32 provider—a business entity which furnishes health-
care to a consumer; it includes a professionally licensed
3.1.22 longitudinal patient record—a permanent, coordi-
practitioner who is authorized to operate a healthcare delivery
nated patient record of significant information, in chronologi-
facility.
cal sequence. It may include all historical data collected or be
retrieved as a user designated synopsis of significant
3.1.33 referred (patient)—registered exclusively for special
demographic, genetic, clinical and environmental facts and
diagnostic/therapeutic service of the hospital for diagnosis/
events maintained within an automated system.
treatment on an ambulatory basis. Responsibility remains with
the referring practitioner.
3.1.23 long-term care—healthcare rendered in a non-acute-
care facility and to a patient in resident or nonresident status to
3.1.34 resident care facility—a residential facility that pro-
chronically ill, aged, disabled or mentally handicapped indi-
videsregularandemergencyhealthservices,whenneeded,and
vidualswhoareinneedofcontinualsupervisionandassistance
appropriate supporting services on a regular basis.
by healthcare practitioners.
3.1.35 school special education—specifically designed in-
3.1.24 non-licensed practitioner—an individual without a
struction provided by qualified teachers within the context of
public license/certification who is supervised by a licensed/
school, aimed at the acquisition of academic, vocational,
certified individual in delivering care to patients.
language,social,andself-careskills.Includesadaptedphysical
education and use of specialized techniques to overcome
3.1.25 outpatient care—see ambulatory care.
intrinsic learning deficits.
3.1.26 observation—any aspect or attribute of a patient that
3.1.36 secondary diagnosis—a statement of those condi-
can be described at a particular time. Examples include serum
tions coexisting during an encounter that affect the treatment
glucose finding, a chest x-ray impression, a bone density scan
received or the length of stay.
result, vital signs and a progress note.
3.1.37 secondary patient record—a record th
...
Questions, Comments and Discussion
Ask us and Technical Secretary will try to provide an answer. You can facilitate discussion about the standard in here.