ASTM E1384-07

ASTM E1384-07 - 15.10.2007

1. Scope

1.1 This practice covers all types of healthcare services, including those given in ambulatory care, hospitals, nursing homes, skilled nursing facilities, home healthcare, and specialty care environments. They apply both to short term contacts (for example, emergency rooms and emergency medical service units) and long term contacts (primary care physicians with long term patients). The vocabulary aims to encompass the continuum of care through all delivery models. This practice defines the persistent data needed to support Electronic Health Record system functionality.

1.2 This practice has four purposes:

1.2.1 Identify the content and logical data structure and organization of an Electronic Health Record (EHR) consistent with currently acknowledged patient record content. The record carries all health related information about a person over time. It may include history and physical, laboratory tests, diagnostic reports, orders and treatments documentation, patient identifying information, legal permissions, and so on. The content is presented and described as data elements or as clinical documents. This standard is consistent with eXtensible Markup Language (XML). See Document Type Definition (DTD) 2.1 and W3CXML Schema 1.0

1.2.2 Explain the relationship of data coming from diverse sources (for example, clinical laboratory information management systems, order entry systems, pharmacy information management systems, dictation systems), and other data in the Electronic Health Record as the primary repository for information from various sources.

1.2.3 Provide a common vocabulary for those developing, purchasing, and implementing EHR systems.

1.2.4 Provide sufficient content from which data extracts can be compiled to create unique setting "views."

1.2.5 Map the content to selected relevant biomedical and health informatics standards.

2. Referenced Documents

X12.85	Healthcare Claim Payment Transaction Set (835)
X12.87	Healthcare Claim Transaction Set (837)
HL7 EHR TC	Electronic Health Record-System Functional Model, Release 1 February, 2007
Health Information Management and Technology:	Glossary, American Health Information Management Association, 2006
X12.84	Healthcare Enrollment and Maintenance Transaction Set (834) Available from American National Standards Institute (ANSI), 25 W. 43rd St., 4th Floor, New York, NY 10036.
HL7	Health Level Seven (HL7) Version 2.2 1994 Available from HL7, Mark McDougall, Executive Director, 900 Victors Way, Suite 122, Ann Arbor, MI 48108. (Version 2.4 and 2.5)
E2118-00	Standard Guide for Coordination of Clinical Laboratory Services within the Electronic Health Record Environment and Networked Architectures (Withdrawn 2002)
ANSI ASC X12:	Version 3, Release 3 (1992) Available from DISA (Data Interchange Standards Association).
E1639-01	Standard Guide for Functional Requirements of Clinical Laboratory Information Management Systems (Withdrawn 2002)
E1633-08	Standard Specification for Coded Values Used in the Electronic Health Record
E1769-95	Standard Guide for Properties of Electronic Health Records and Record Systems (Withdrawn 2004)
E1715-01	Standard Practice for An Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (RADT) Functions in Computer-Based Patient Record Systems
E1714-07	Standard Guide for Properties of a Universal Healthcare Identifier (UHID)
E1238-97	Standard Specification for Transferring Clinical Observations Between Independent Computer Systems (Withdrawn 2002)
E1239-04	Standard Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems
HL007
E2538-06	Standard Practice for Defining and Implementing Pharmacotherapy Information Services within the Electronic Health Record (EHR) Environment and Networked Architectures
E2473-05	Standard Practice for the Occupational/Environmental Health View of the Electronic Health Record
E2369-12	Standard Specification for Continuity of Care Record (CCR) (Withdrawn 2021)
NCPDP National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Format Version 3	Release 2, 1992 Available from NCPDP, 4201 North 24th Street, Suite 365, Phoenix, AZ 85016.