Campos Fernando, Plazzotta Fernando, Luna Daniel, Baum Analia, de Quirós Fernán González Bernaldo
Health InformationDepartment, Hospital Italiano de Buenos Aires, Argentina.
Stud Health Technol Inform. 2013;192:1169.
Health information exchange ensuring its authenticity and integrity is not a simple task. Many institutions have implemented different solutions to perform this exchange using partial or summary information, and rarely include metadata that establish the context in which they performed the primary data capture. In this setting, we proposed the creation of an alternative architecture, parallel, yet integrated with a traditional electronic health record, based on the relational data model. We used a clinical documents standard, the CDA, whose architecture allows having a scalable document-based electronic clinical data repository, plausible to be shared with the patient, other institutions, other healthcare professionals or funders, with secure and controlled access and that remains unchanged over time. Furthermore, in addition to achieving this redundant clinical data repository, it was possible to reduce printing charts thanks to the portability that this standard allows.
确保健康信息交换的真实性和完整性并非易事。许多机构已实施不同的解决方案，使用部分或汇总信息来进行这种交换，并且很少包含建立其进行原始数据捕获时的上下文的元数据。在此背景下，我们基于关系数据模型提出创建一种替代架构，该架构与传统电子健康记录并行但又相互集成。我们使用了一种临床文档标准——临床文档架构（CDA），其架构允许拥有一个可扩展的基于文档的电子临床数据存储库，该存储库有可能与患者、其他机构、其他医疗保健专业人员或资助者共享，具有安全且可控的访问权限，并且随时间保持不变。此外，除了实现这个冗余的临床数据存储库之外，由于该标准所允许的可移植性，还可以减少打印图表。
