Health informatics – Electronic health record communication – Part 3: Reference archetypes and term lists

This document is Part 3 of a 5-part series that sets out a system for communicating about electronic health records (EHRs). This system enables the communication of whole or partial EHRs between EHR systems, or between EHR systems and a centralised EHR data repository. Part 3 defines term lists that specify the set of values for each attribute of the Reference Model defined in ISO 13606-1. It also defines normative and informative Reference Archetypes that enable frequently occurring instances of EHR data to be represented within a consistent structure when communicated using this document.

In addition to the direct communication of EHRs, the system can also be used for decision support components, personal health applications and devices that need to access or provide EHR data, or the representation of EHR data within a distributed (federated) record system.

This document is primarily intended to support direct care given to identifiable individuals, self-care by individuals and population monitoring systems such as disease registries and public health surveillance. It may also be useful for other purposes such as teaching, clinical audit, administration and reporting, service management, research and epidemiology, which often require the anonymisation or aggregation of individual records.

Main sections:

· Scope

· Normative references

· Terms and definitions

· Conformance

· Term lists

· Reference archetype for null_flavor

· Reference archetype for the access policy COMPOSITION

· Reference archetypes for demographic entities

· Reference archetypes for medicinal product

· Reference archetypes for clinical information specifications

· Contsys-based clinical reference information structures as the basis for development of clinical archetypes