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Health Level Seven, abbreviated to HL7, is a range of global standards for the transfer of clinical and administrative health data between applications with the aim to improve patient outcomes and health system performance. The HL7 standards focus on the application layer, which is "layer 7" in the Open Systems Interconnection model. The standards are produced by Health Level Seven International, an international standards organization, and are adopted by other standards issuing bodies such as American National Standards Institute and International Organization for Standardization. There are a range of primary standards that are commonly used across the industry, as well as secondary standards which are less frequently adopted.
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.
The SOAP note is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.
openEHR is an open standard specification in health informatics that describes the management and storage, retrieval and exchange of health data in electronic health records (EHRs). In openEHR, all health data for a person is stored in a "one lifetime", vendor-independent, person-centred EHR. The openEHR specifications include an EHR Extract specification but are otherwise not primarily concerned with the exchange of data between EHR-systems as this is the focus of other standards such as EN 13606 and HL7.
A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, focused patient data reports and summaries, documentation templates, diagnostic support, and contextually relevant reference information, among other tools. CDSSs constitute a major topic in artificial intelligence in medicine.
Continuity of Care Record (CCR) is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors.
Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. First developed in 1994, it was created and is maintained by the Regenstrief Institute, a US nonprofit medical research organization. LOINC was created in response to the demand for an electronic clinical care and management database and is publicly available at no cost.
Health information exchange (HIE) is the mobilization of health care information electronically across organizations within a region, community or hospital system. Participants in data exchange are called in the aggregate Health Information Networks (HIN). In practice, the term HIE may also refer to the health information organization (HIO) that facilitates the exchange.
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0. The organization published Release 2.0 with its "2005 Normative Edition".
The Continuity of Care Document (CCD) specification is an XML-based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange.
Medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as a diagnosis with the medical context being implicit. The information required for a diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as medical tests, are also done during the process. Sometimes the posthumous diagnosis is considered a kind of medical diagnosis.
The Veterans Health Information Systems and Technology Architecture (VISTA) is the system of record for the clinical, administrative and financial operations of the Veterans Health Administration VISTA consists of over 180 clinical, financial, and administrative applications integrated within a single shared lifelong database (figure 1).
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.
International HL7 implementations is a collection of known implementations of the HL7 Interoperability standard. These do not necessarily refer to cross-border health information systems.
The Fast Healthcare Interoperability Resources standard is a set of rules and specifications for exchanging electronic health care data. It is designed to be flexible and adaptable, so that it can be used in a wide range of settings and with different health care information systems. The goal of FHIR is to enable the seamless and secure exchange of health care information, so that patients can receive the best possible care. The standard describes data formats and elements and an application programming interface (API) for exchanging electronic health records (EHR). The standard was created by the Health Level Seven International (HL7) health-care standards organization.
E-referrals or electronic referrals or electronic consultation is an electronic platform that enables the seamless transfer of patient information from a primary to a secondary treating practitioner's client management system. E-referrals have fast become the best replacement of paper-based referrals, and hold great potential toward the ultimate goal of seamless communication and information sharing between practitioners.
InterSystems HealthShare is a comprehensive healthcare informatics platform designed to serve hospitals, Integrated Delivery Networks (IDNs), and regional and national Health Information Exchanges (HIEs).
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets sanctioned by the Health Insurance Portability and Accountability Act in the United States.
Health Level Seven International (HL7) is a non-profit ANSI-accredited standards development organization that develops standards that provide for global health data interoperability.
Clinical data standards are used to store and communicate information related to healthcare so that its meaning is unambiguous. They are used in clinical practice, in activity analysis and finding, and in research and development.
References
- ↑ "Clinical Interoperability is Happening". Change Healthcare. Retrieved 23 August 2020.
- ↑ "Carequality Hits Over 1 Billion Clinical Document Exchanges". EHR Intelligence.
- ↑ "First Survey of the SHIEC Shows HIES provide Critical National Infrastructure". Strategic Health Information Exchange Collaborative(SHIEC).
- ↑ "Consolidated CDA Overview". Office of the National Coordinator for Health IT.
- ↑ "C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes – US Realm)". HL7.
- ↑ "Care Plan (V2)". HL7.
- ↑ "Consultation Note (V3)". HL7.
- ↑ "CCD (V23)". HL7.
- ↑ "Diagnostic Imaging Report (V3)". HL7.
- ↑ "Discharge Summary (V3)". HL7.
- ↑ "H&P (V3)". HL7.
- ↑ "Operative Note (V3)". HL7.
- ↑ "Procedure Note (V3)". HL7.
- ↑ "Progress Note (V3)". HL7.
- ↑ "Transfer Summary (V3)". HL7.
- ↑ "Unstructured Document (V3)". HL7.