Developing and implementing an interoperable document-based electronic health record. 2013

Fernando Campos, and Fernando Plazzotta, and Daniel Luna, and Analia Baum, and Fernán González Bernaldo de Quirós
Health InformationDepartment, Hospital Italiano de Buenos Aires, Argentina.

Health information exchange ensuring its authenticity and integrity is not a simple task. Many institutions have implemented different solutions to perform this exchange using partial or summary information, and rarely include metadata that establish the context in which they performed the primary data capture. In this setting, we proposed the creation of an alternative architecture, parallel, yet integrated with a traditional electronic health record, based on the relational data model. We used a clinical documents standard, the CDA, whose architecture allows having a scalable document-based electronic clinical data repository, plausible to be shared with the patient, other institutions, other healthcare professionals or funders, with secure and controlled access and that remains unchanged over time. Furthermore, in addition to achieving this redundant clinical data repository, it was possible to reduce printing charts thanks to the portability that this standard allows.

UI MeSH Term Description Entries
D008498 Medical Record Linkage The creation and maintenance of medical and vital records in multiple institutions in a manner that will facilitate the combined use of the records of identified individuals. Record Linkage, Medical,Linkage, Medical Record,Linkages, Medical Record,Medical Record Linkages,Record Linkages, Medical
D004282 Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information. Documentations
D001118 Argentina Country located in southern South America, bordering the South Atlantic Ocean, between Chile and Uruguay.
D016247 Information Storage and Retrieval Organized activities related to the storage, location, search, and retrieval of information. Information Retrieval,Data Files,Data Linkage,Data Retrieval,Data Storage,Data Storage and Retrieval,Information Extraction,Information Storage,Machine-Readable Data Files,Data File,Data File, Machine-Readable,Data Files, Machine-Readable,Extraction, Information,Files, Machine-Readable Data,Information Extractions,Machine Readable Data Files,Machine-Readable Data File,Retrieval, Data,Storage, Data
D017410 Practice Guidelines as Topic Works about directions or principles presenting current or future rules of policy for assisting health care practitioners in patient care decisions regarding diagnosis, therapy, or related clinical circumstances. The guidelines may be developed by government agencies at any level, institutions, professional societies, governing boards, or by the convening of expert panels. The guidelines form a basis for the evaluation of all aspects of health care and delivery. Clinical Guidelines as Topic,Best Practices,Best Practice
D057286 Electronic Health Records Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations. Some versions include direct linkages to online CONSUMER HEALTH INFORMATION that is relevant to the health conditions and treatments related to a specific patient. Electronic Health Record Data,Electronic Medical Record,Electronic Medical Records,Computerized Medical Record,Computerized Medical Records,Electronic Health Record,Medical Record, Computerized,Medical Records, Computerized,Health Record, Electronic,Health Records, Electronic,Medical Record, Electronic,Medical Records, Electronic
D038622 Internationality The quality or state of relating to or affecting two or more nations. (After Merriam-Webster Collegiate Dictionary, 10th ed) Globalization,International Aspects,International Perspectives,International Relations,Multinational Aspects,Multinational Perspectives,Aspect, International,Aspect, Multinational,Aspects, International,Aspects, Multinational,International Aspect,International Perspective,Multinational Aspect,Multinational Perspective,Perspective, International,Perspective, Multinational,Perspectives, International,Perspectives, Multinational,Relations, International
D066275 Health Information Exchange Organizational framework for the dissemination of electronic healthcare information or clinical data, across health-related institutions and systems. Its overall purpose is to enhance PATIENT CARE. Medical Information Exchange,Exchange, Health Information,Exchange, Medical Information,Exchanges, Health Information,Exchanges, Medical Information,Health Information Exchanges,Information Exchange, Health,Information Exchange, Medical,Information Exchanges, Health,Information Exchanges, Medical,Medical Information Exchanges

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