Toward a National Health Information Infrastructure. Interim Report. Health Care Provider Dimension


Core Content of the Health Care Provider Dimension


A. Patient Record Elements

  • patient identification information
  • sociodemographic identifiers (gender, birthday, age, race/ethnicity, marital status, living arrangements, education level, occupation)
        • health insurance information (including covered benefits)
        • legal consents or permissions
        • referral information
        • correspondence
        • patient history information (may include longitudinal history from PHD, immunizations, allergies, current medications)
        • stated reason for visit
        • external causes of injury/illness
        • symptoms
        • physical exams
        • assessment of patient signs and symptoms
        • diagnoses
        • laboratory, radiology, and pharmacy orders
        • laboratory results
        • radiological images and interpretations
        • record of alerts, warnings, and reminders
        • operative reports
        • vital signs from ICU
        • vital signs from PHD
        • treatment plans and instructions
        • progress notes
        • functional status
        • discharge summaries
        • instructions about access
        • audit log of individuals who accessed the patient record
        • patient amendments to patient record
        • provider notes such as knowledge of patient, patient-provider interactions, patient's access to services

        B. Other Elements That Support Clinical Practice

        • protocols, practice guidelines
        • clinical decision-support programs
        • referral history

        C. Elements from Community Health Dimension

        Depending on the patient, the Health Care Provider Dimension would include additional contextual information necessary for understanding, treating, and planning the care of the patient:

        • aggregate data on the health care of community members
        • community attributes affecting health (e.g. economic status and population age)
        • community health resources (e.g. home health services)
        • community health (e.g. possible environmental hazards at home, work, school, or in the community at large).

        Who Uses the Health Care Provider Dimension?

        The HCPD is primarily for health care providers at or near the point of care. Health care providers include physicians, nurses, allied health professionals, and home health care professionals. They will be able to access health care information from whichever location is necessary to provide the highest quality of patient care and achieve the best possible patient outcome. Secondary users include clinical and public health researchers and payors. Individuals will have access to their own medical information and, if they choose, can authorize their provider to send specific information from a visit to their own personal health records.

        Where Will Information in the Provider Dimension be Stored?

        A monolithic HCPD will not exist. The primary record of care will be stored within the operational control of the provider who captures the original health care information. It may be

        held onsite or on the server of a third-party health information guardian. The primary record of care must be stored in a manner that will protect the completeness of the record and the integrity and confidentiality of the data. It must be part of an information system capable of providing authorized access seven days per week, 24 hours per day. If health care information is sent some place other than the point of care, the recipient of the information is responsible for protecting the confidentiality of the data.

        Privacy, Security, and Confidentiality Concerns

        The NHII will incorporate technologies and practices that enhance the confidentiality and security of personal health information. Access to the patient health record may be restricted by the patient, the data security policies and practices of health care institutions, and/or state or federal laws and regulations. Physicians, nurses, allied health professionals and home health care professionals may have access to essential data in the patient record appropriate to the patient situation.

        The confidentiality of health care information will be protected by limiting access to individual health information with the use of technologies such as authorization, authentication, and restricted access by class, role, or location of the user. Confidentiality will be maintained when personal information is communicated to other health care institutions or providers with technologies such as encryption and electronic signatures.


        The vision of the Health Care Provider Dimension was outlined in the Institute of Medicine's 1997 study, "Computer-Based Patient Record: An Essential Technology for Health Care." However, many events still need to occur before the vision can be fully realized. Though technology advancements have produced much progress, the problem of incomplete and incompatible standards and terminologies, and security, privacy and confidentiality concerns need to be resolved. The full vision of the Health Care Provider Dimension is evolving with the introduction of new technological solutions, standards, and privacy and confidentiality legislation. The measure of success will be a health care system that enables continuous improvement of clinical processes in an efficient and cost-effective manner.

        The Community Health Dimension

        The Community Health Dimension (CHD) of the NHII encompasses a broad range of information, including population-based health data and resources, necessary to improve public health. The CHD will include statutorily authorized data in public health systems and the Health Care Provider Dimension. Anonymous data could be used for research or other public health purposes. The CHD will have strict legal and technological safeguards, including appropriate security and permissions, to protect the confidentiality of data from other dimensions.

        What are the Community Health Benefits of the NHII?

        With improved access to accurate, timely, and comprehensive information, public health professionals will be better able to identify public health threats; assess population health; focus programs and policies on well-defined health problems; inform and educate individuals about health issues; evaluate programs and services; conduct research to address health issues; and perform other essential public health services.

        The CHD will bring specific improvements to public health practice such as enhanced reporting systems to identify emerging and ongoing health problems; improved population health data to help characterize the whole population and specific sub-populations; mechanisms to identify health needs of sub-populations who are especially at risk because of social and/or environmental conditions; and expanded potential to identify factors that affect health throughout the life cycle.

        The CHD will also improve access to and utilization of a wide range of information essential to monitor and protect the public's health through electronic data interchange and decision-support technologies. As the mission of public health in the United States evolves to include greater emphasis on monitoring the quality of health care services, the CHD will facilitate access to and integration of all information needed to improve the population's health. An integral component of the CHD will be mechanisms to protect the confidentiality of individuals' personal data and to improve the security of public health data.

        What are the Community Health Functions of the NHII?

        The functions include the capture, storage, communication, processing and presentation of community health information.

        Information Capture

        The CHD will capture information from conventional sources of public health data, such as vital events, communicable disease surveillance systems, and childhood lead screening and immunization programs. The CHD will also encompass information from less conventional public health sources, for example, the National Spatial Data Infrastructure. Health care providers will send patient encounter information from which all personally identifiable information has been removed for public health monitoring of population health status and health care services. Providers will send personally identifiable information only under strict protocols, for example to track highly contagious diseases or to fulfill other legally-mandated public health responsibilities.

        Information Storage

        There will not be a single database of public health information. Diverse and separate federal, state, and local information systems will be maintained, with greater integration vertically and horizontally.

        Information Communication

        The CHD will provide federal, state and local public health professionals with information about trends in health risks, diseases, and other factors affecting community health. Clinicians and the public will be alerted to communicable disease threats and environmental hazards, and they can receive reminders about immunizations, flu shots, preventive health services and other broad-based health care opportunities. Aggregated community health profiles will be available to the public and to community groups. These community health profiles will not contain any individually identifiable data.

        Information Processing

        CHD data standards will allow the electronic integration of conventional sources of public health data, such as those legally mandated for collection by local and state health departments, along with non-identifiable information from patient encounters. The CHD will include decision-support tools that integrate data analysis and public health practice guidelines.

        Information Presentation

        The CHD will enable public health workers to access data, analyses, directories, and other information resources and tools from the field as well as in public health clinics and offices. The CHD will also provide useful information in usable and accessible formats to individuals, community institutions such as libraries, and community groups for identifying public health problems and planning public health interventions. The information and its presentation will be tailored to users' specific needs.

        What Will the Community Health Dimension Contain?

        In the broadest terms, the community itself will be the focus of information within the CHD. The content will focus on the health and health care of community members, community attributes affecting health, community health resources, and broad measures of community health status. These categories of information support a focus on overall community health needs, rather than individuals and disease events.