PD ISO/TR 12773-2:2009

PD ISO/TR 12773-2:2009 Business requirements for health summary records. Environmental scan

PD ISO/TR 12773 is a technical report that reviews a series of initiatives and implementations worldwide that are collectively called health summary records (HSRs). It provides an environmental scan and descriptive information on HSR initiatives internationally, including “lessons learned”.

The environmental scan was completed by performing web searches and obtaining publicly available documentation on key projects. Project sponsors and/or authorities were contacted as needed to gather additional information and clarify questions and issues arising out of the review

Consumer, clinician, industry and government demands for improved safety, quality, effectiveness and efficiency in healthcare are driving the need for more “connected” care, which in turn requires improved communication of clinical information between multiple providers and subjects of care. Internationally, various “summary” or “snapshot” health records have been developed to meet these communication needs. Many similarities are evident in these initiatives, but their conceptual foundations have not always been articulated with a set of business requirements as their starting point.

The purpose of PD ISO/TR 12773-2 is to identify the common business requirements these initiatives are seeking to address as well as the requirements for standards for health summary records (HSRs) that can guide future HSR development efforts.

Any future ISO initiative to create standards for a generic HSR specification or specifications for one or more types of HSR will leverage existing initiatives and adopt/adapt relevant standards utilized therein. Such HSR specifications are unlikely to require new standards, given that much of their content is deemed “common”, “core”, “essential” or “emergency” in nature and is therefore part of most EHR initiatives world-wide as evidenced in Part 2 of PD ISO/TR 12773.

Contents of PD ISO/TR 12773-2: contain:

• Introduction
• Scope
• Terms and definitions
• Initiatives reviewed
• Key findings
• Summary of initiatives
• Overview
• National E-Health Transition Authority (NEHTA) (Australia) – Clinical data specifications and content specifications
• COMPETE (Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness) – Ontario, Canada
• Core dataset — Ontario Clinical Management System (sponsored by OntarioMD), Ontario, Canada
• Electronic medical summary (e-MS) — British Columbia (BC), Canada
• Medical Summary for Transfer of Patient Data – Physician Office System Program (POSP),
• Alberta, CA Report on the State of Developing Electronic Patient Summaries in European Union

  Member States and Beyond (2007)

• ISO 21549-3:2004 Health informatics — Patient healthcard data — Part 3: Limited clinical data
• NHS England
• NHS Scotland – Emergency care summary (ECS)
• NHS Wales – Individual health record
• Care record summary – Implementation guide for HL7 CDA Release 2 – Levels 1 and 2 (US Realm)
• Continuity of care record E2369 – Specification – ASTM
• Continuity of care document (CCD) – HL7/ASTM
• Medical Summary Integration Profile and Medical Summary Content Specification IHE — Integrating the Healthcare Enterprise
• VistA — United States Veterans’ Health Administration
• Sample health summary records — overview of data groups, specifications for structure, content as applicable
• Australia — National E-Health Transition Authority (NEHTA)
• Canada — Core Dataset — OntarioMD
• Canada — Medical Summary for Transfer of Patient Data (Alberta)
• Canada — Electronic medical summary (British Columbia)
• United States — ASTM Continuity of Care Record
• United States — IHE Content Profiles
• United States — HL7 CDA Care Record Summary Implementation Guide Levels 1 and 2 2006 — Required and optional sections of a CRS (US Realm)
• United States — Personal Health Record — Minimum Common Dataset — AHIMA
• ISO 21549-3, Health informatics — Patient healthcard data — Part 3: Limited clinical data
• NHS UK — Scotland – Emergency Care Summary (ECS)
• Acronym index
• Bibliography

Also available: