ISO 18308 pdf download – Health informatics — Requirements foran electronic health record architecture

ISO 18308 pdf download – Health informatics — Requirements foran electronic health record architecture.
3.31
healthcare professional
person authorized to be involved In the direct provision of certain healthcare provider activities In a jurisdiction according to a med’ianisrn recognized in that jurisdiction
NOTE Adapted from EN 13940.1:2007
3.32
healthcare provider
healthcare organization or healthcare professional involved in the direct provision of heallhcare
[EN 13940-1:2007]
3.33
health mandate
statement aulhonzed by the subect of care, an authorized representative of the subject of care, or by the authonty of law, defining the scope and limits of the specific role assigned to one healthcare party, and delineating its responsibilities towards that subØct of care with regard to this role
[EN 13940-1:2007]
3.34
Identifier
unarrtiguous name, in a given naming context
[ISO/IEC 10745-2:2009, 12.2]
3.35
implied consent
consent inferred from signs, actions, or facts, or by Inaction or silence
3.36
information model
structured specification, expressed graphically and/or in narrative, of the information requirements of a domain
3,37
integrity
stale of an artefact that has not been altered, deliberately or accidentally
3.38
knowledge model
structured specification of facts that are true for a given domain
3,39
organization
unique framework of authority within which a person a persons act, or are desIgnated to act towards some purpose
NOTE Adapted from ISQ(IEC 6523-1:1998, 31.
3.40
persisted
stored on a permanent basis
3.41
personal health record
PHR
health record, or part of a health record, for which the subject of care a a legal representative of the subject of care Is the data controller
3.52
wodiflow
depiction of the actual sequence of the operations ci actions taken in a process
NOTE A wo.1flow reflects the successive decisions end activities in the perfonnance of a process
4 AbbrevIations
EHR electronic health record
EHR-S electronic health record system I1SOIHL7 107811
EHRA electronic health record architecture
PHR personal health record
PHR-S personal health record system
5 EHR business objectives
5.1 IntroductIon
This informative clause lists the high-level business objectives for electronic health records, which should be
supported by relevant information and knowledge models and services provided by an EHR architecture.
5.2 Health system objectives
HSOI The EHR should enable the consistent capture, processing, retention, protection and communication of health Information such that interoperabllty is achieved In support of shared care, improved quality of care. effective resource management, providing evidence of actions taken in heattti(care), and in support of the uses of anonymized information for health system management.
HSO2 The EHR should enable authonzed users to access health information that is relevani intact. appropriate to their permissions and within a timeframe that Is appropnate to the context.
HSO3 The EHR should enable authorized users to access health Information seamlessly and as originally organized, independently of the EHR sysfeme and of the physical formats in which it was originally stored.
HSO4 The EHR should enable the communication of all health information between care settings, subject to appropflale consent and access rights, to a sufficient quality to support safe shared clmical care
HSO5 The EHR should help ensure that subjects of care receive the most appropriate care as quickly and safely as possible by:
— enabling the documentation and sharing of information about the care and progress of care within and between clmical teams, and to other care providers;
acting as an source for decision support applicatIons:
— enabling more informed care through more rapid diagnoses and more appropriate treatments;
— avoiding unnecessary duplication of examinations, tests and other procedures, identifying and avoiding risks.
providing a framework for standardized representation of information, and the consistent use of codingsystems within that representation, that improves data quality at source and enhances reuse of data;
providing information for audit of individual clinical cases,and for quality assurance relating to servicesand outcomes;
providing information for research into best clinical practice and the design of clinical guidelines;
acting as a source of information to support knowledge discovery，although without prejudicing theprotection of privacy;
acting as a source of information for decisions about the management of healthcare systems, by jurisdictions and by authorized bodies.
HSo7 The EHR should support strategic planning decisions by:
enabling the monitoring and improvement of the quality of care provided,including the achievement ofstandards of care specified in contracts and guidelines;
enabling the monitoring of costs,e.g. by providing tools for evaluating cost-per-pathology or diagnosisrelated groups, or similar cost and resource calculating methods;
acting as a source of information to support the management of the cost of healthcare provision and oflitigation.