Interoperable EHR Standard
The Interoperable EHR (iEHR) Standard allows sharing of relevant clinical information (e.g. health conditions, discharge summaries, consultation notes, referrals, health services rendered) through a jurisdictional Shared Health Record Repository.
The iEHR standard facilitates the sharing of clinical information that is not specific to other business domain standards (e.g. drug, laboratory). The iEHR standard, in conjunction with the other standards, allows authorized providers to access updated health information to support timely clinical decision-making and continuity of care.
Interoperable EHR Standard CDFU *
Supports clinical information-sharing generated primarily on the basis of clinical assessments. Includes:
- Clinical Observations – Allows users to record and retrieve a wide variety of coded observations about a patient which are expressed as subjective information or objective findings such as symptoms and diagnosis, physical examination findings etc. or observations about a patient which can be expressed as a direct count or measured amount such as blood pressure, etc.
- Professional Services – Allows users to record and retrieve information about professional health care services the patient has received e.g. cognitive therapies (targeted to changing behaviour or thought perspective) or direct physical manipulation or modification of the patient such as surgery, physical therapy, etc.
- Health Conditions – Allows users to record, update and retrieve information about patient illnesses, injuries or other alterations in physiological state e.g. diabetes pregnancy; provides a “problem list” for providers – a current and up-to-date list of active patient problems that need to be managed
- Care Compositions – Allows users to group relevant information into “folder-like” groupings for ease of viewing and retrieving information
- Allergy/Intolerance/Adverse Reaction – Allows user to record, update and retrieve information about sensitivity (allergy or intolerance) experienced by the patient when exposed to a particular substance (drug or non-drug) or a category of substances, or when the cause of the reaction is not definitively known
- Patient Note – Allows user to record and retrieve comments about the patient or about a particular patient’s profile (such as Medication, Lab, DI, etc.)
- Clinical Documents – Allows the capture of patient health data in an encapsulated, contextualized manner with capability of displaying rendered content and communication between systems: Discharge/Care Summary; Referral; Clinical Observation Document)
- EHR Clinical Summary/Profile – Allows users to quickly find information about all health care services that have been recorded in the EHR for a particular patient, regardless of whether they are domain-or Shared Health Record related. The profile can be customized based on the needs of particular provider groups
- Increases access to integrated patient information including clinical information that is primarily based on clinical assessment across the continuum of care
- Supports timely and informed decision making
- Increases patient safety by reducing medical errors because complete and up to date timely clinical information is available
- Improves ability to achieve desired health outcomes - health providers can access and effectively use comprehensive clinical information
- Improves coordination of care since relevant clinical information can be shared across the continuum of care
|MESSAGING & TERMINOLOGY INFORMATION
- Messaging: HL7 V3.0
- Terminology: HL7 Terminology Code Systems, SNOMED CT, ICD-10-CA, CCI, Free Text, LOINC
* Status Definitions
Canadian Draft for Use (CDFU) - The standard has been developed but it may or may not be implemented or be in use. The standard is considered ready to be used by early adopters: however, change is probable as stakeholders begin using the standard in implementations.
Canadian Approved Standards (CAS) - The standard is in use for the purpose(s) or context(s) for which it was intended. Only those parts of the standard that have been implemented or are in use can progress for consideration as CAS. This decision point signifies that the standard has reached a level of stability and is comprehensive enough such that major changes are not expected.
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