Inventory of Health Care Information Standards. ASTM E1769-95 Standard Guide for Properties of Electronic Health Records and Record Systems

01/01/1997

Contact For More Information

Manager - Committee E31, ASTM

100 Barr Harbor Drive

West Conshohocken, PA 19373

Ph: 610-832-9500

Fax: 610-832-9666

Description Of Standard

This standard defines the requirements, properties, and attributes of a computer-based patient record. It serves as an agreement among all the parties about the goals and constraints of the computer-based patient record, and provides criteria for making tradeoffs and decisions about how the record will be configured. The guide defines a computer-based record as the structured set of demographic, environmental, social, financial, and clinical data elements in electronic form needed to document the healthcare given to a single patient. It discusses how information is entered, dealing with such questions as who can enter, how is information identified, how is it validated, and who is accountable. It describes data attributes, such as permanence, accessibility, reliability, internal consistency, and security. System response time and the ability to process data are considered. Output criteria are addressed, including who can access information, the level of fact detail available, customization of display, multimedia outputs, and export to other systems. The system must protect the rights of the patient to confidentiality and the rights of the care provider to privacy. The concept of connecting together various encounter records of a patient to produce a longitudinal patient record is described. Systems to implement computer-based medical records must support local clinical functions. In addition, they should also be considered nodes of a national clinical network. The data content of the records must meet the needs of all legitimate users, such as payers, regulatory agencies, public health workers, researchers, and quality of care/outcome studies personnel. The records must be mobile and accessible to all authorized users. This ensures easy transport of records when patients move or change care providers. It also permits the extraction of billing, monitoring, and research data into other computer systems. Full logical compatibility among data banks is essential for these purposes.

Readiness Of Standard

The standard is published and is an American National Standard. How can the standard be obtained? ASTM standards are available through the ASTM Customer Service Department by calling 610-832-9585. Standards can also be ordered through the ASTM Web Site at www. astm.org

Indicators Of Market Acceptance

Approximately 2300 copies of the E31 standards have been distributed.

A wide variety of vendors are implementing EHR systems. The standard describes many of the features which are being incorporated into these systems and includes many features which have yet to be implemented by vendors. There has been no feedback to the standards committee from vendors indicating any objection to the features described in the standard other than the technical difficulty of achieving some of the functions described therein.

Level Of Specificity

The standard describes EHR functions at a functional level. It makes no attempt to recommend a specific implementation strategy but rather attempts to outline how the various functions described can interact to provide a functional EHR.

Relationship With Other Standards

Related ASTM standards, notably E 1384, provide information on topics such as the data elements which should be included in an EHR system. Numerous additional standards such as HL7 for data exchange and various coding schemes to determine data content are also relevant.

Identifiable Costs

The cost to implement this standard depends heavily on the technology and methodologies chosen by a specific vendor.

Category/Classification Of The Standard

Health Claim Attachments