Lloyd David, Kalra Dipak
CHIME--Center for Health Informatics and Multiprofessional Education, University College London, UK.
Stud Health Technol Inform. 2003;96:231-7.
Published requirements for the EHR are principally available via ISO 18308. They are statements defining the generic features necessary in any Electronic Health Record for it to be communicable and complete, retain integrity across systems, countries and time, and be a useful and effective ethico-legal record of care. Examples of requirements are provided in four themes: EHR functional requirements; Ethical, legal, and security requirements; Clinical requirements; Technical requirements. The main logical building blocks of an EHR are described using the terminology of CEN TC251 ENV13606. Examples are given of the placement of attributes to satisfy contextual and other requirements at the level of specific building blocks. A worked example of the use of the building blocks is given for the request-report cycle for an imaging investigation.
电子健康记录（EHR）已发布的要求主要可通过ISO 18308获取。这些要求定义了任何电子健康记录所必需的通用特征，以便其能够进行通信且完整，在不同系统、国家和时间保持完整性，并成为有用且有效的护理伦理法律记录。要求示例分为四个主题：EHR功能要求；伦理、法律和安全要求；临床要求；技术要求。使用CEN TC251 ENV13606的术语描述了EHR的主要逻辑构建块。给出了在特定构建块级别放置属性以满足上下文和其他要求的示例。针对影像检查的请求-报告周期给出了构建块使用的一个实际示例。
