Abstract
Background: The Professional Records Standards Body
for health and social care (PRSB) was formed in 2013 to
develop and assure professional standards for the content
and structure of patient records across all care disciplines
in the UK. Although the PRSB work is aimed at Electronic
Health Record (EHR) adoption and interoperability to support
continuity of care, the current technical guidance is
limited and ambiguous.
Objectives: This project was initiated as a proof-ofconcept to demonstrate whether, and if so, how, conformance methods can be developed based on the professional standards.
Methods: An expert group was convened, comprising clinical and technical representatives. A constrained data set was defined for an outpatient letter, using the subset of outpatient headings that are also present in the ep- SOS patient summary. A mind map was produced for the main sections and sub-sections. An openEHR archetype model was produced as the basis for creating HL7 and IHE implementation artefacts.
Results: Several issues about data definition and representation were identified when attempting to map the outpatient headings to the epSOS patient summary, partly due to the difference between process and static viewpoints. Mind maps have been a simple and helpful way to visualize the logical information model and expose and resolve disagreements about which headings are purely for human navigation and which, if any, have intrinsic meaning.
Conclusions: Conformance testing is feasible but nontrivial. In contrast to traditional standards-development timescales, PRSB needs an agile standards development process with EHR vendor and integrator collaboration to ensure implementability and widespread adoption. This will require significant clinical and technical resources.
Objectives: This project was initiated as a proof-ofconcept to demonstrate whether, and if so, how, conformance methods can be developed based on the professional standards.
Methods: An expert group was convened, comprising clinical and technical representatives. A constrained data set was defined for an outpatient letter, using the subset of outpatient headings that are also present in the ep- SOS patient summary. A mind map was produced for the main sections and sub-sections. An openEHR archetype model was produced as the basis for creating HL7 and IHE implementation artefacts.
Results: Several issues about data definition and representation were identified when attempting to map the outpatient headings to the epSOS patient summary, partly due to the difference between process and static viewpoints. Mind maps have been a simple and helpful way to visualize the logical information model and expose and resolve disagreements about which headings are purely for human navigation and which, if any, have intrinsic meaning.
Conclusions: Conformance testing is feasible but nontrivial. In contrast to traditional standards-development timescales, PRSB needs an agile standards development process with EHR vendor and integrator collaboration to ensure implementability and widespread adoption. This will require significant clinical and technical resources.
| Original language | English |
|---|---|
| Pages (from-to) | en23-en30 |
| Journal | European Journal of Biomedical Informatics |
| Volume | 11 |
| Issue number | 2 |
| Early online date | 20 Jan 2015 |
| Publication status | Published - 2015 |
Keywords
- Medical records
- Testing
- Electronic health records
- FHIR
- Conformance
- CDA
- Archetype
- OpenEHR
- IHE
- HL7
