Keikha Leila, Farajollah Seyede Sedigheh Seied, Safdari Reza, Ghazisaeedi Marjan, Mohammadzadeh Niloofar
Tehran University of Medical Sciences in Tehran, Iran.
Department of Health Information Management at Tehran University of Medical Sciences in Tehran, Iran.
Perspect Health Inf Manag. 2018 Jan 1;15(Winter):1f. eCollection 2018 Winter.
In developing countries such as Iran, international standards offer good sources to survey and use for appropriate planning in the domain of electronic health records (EHRs). Therefore, in this study, HL7 and ASTM standards were considered as the main sources from which to extract EHR data.
The objective of this study was to propose a hospital data set for a national EHR consisting of data classes and data elements by adjusting data sets extracted from the standards and paper-based records.
This comparative study was carried out in 2017 by studying the contents of the paper-based records approved by the health ministry in Iran and the international ASTM and HL7 standards in order to extract a minimum hospital data set for a national EHR.
As a result of studying the standards and paper-based records, a total of 526 data elements in 174 classes were extracted. An examination of the data indicated that the highest number of extracted data came from the free text elements, both in the paper-based records and in the standards related to the administrative data. The major sources of data extracted from ASTM and HL7 were the E1384 and Hl7V.x standards, respectively. In the paper-based records, data were extracted from 19 forms sporadically.
By declaring the confidentiality of information, the ASTM standards acknowledge the issue of confidentiality of information as one of the main challenges of EHR development, and propose new types of admission, such as teleconference, tele-video, and home visit, which are inevitable with the advent of new technology for providing healthcare and treating diseases. Data related to finance and insurance, which were scattered in different categories by three organizations, emerged as the financial category. Documenting the role and responsibility of the provider by adding the authenticator/signature data element was deemed essential.
Not only using well-defined and standardized data, but also adapting EHR systems to the local facilities and the existing social and cultural conditions, will facilitate the development of structured data sets.
在伊朗等发展中国家，国际标准为电子健康记录（EHR）领域的调查和适当规划提供了良好的资源。因此，在本研究中，HL7和ASTM标准被视为提取EHR数据的主要来源。
本研究的目的是通过调整从标准和纸质记录中提取的数据集，为国家EHR提出一个由数据类和数据元素组成的医院数据集。
这项比较研究于2017年进行，研究了伊朗卫生部批准的纸质记录内容以及国际ASTM和HL7标准，以提取国家EHR的最小医院数据集。
通过研究标准和纸质记录，共提取了174个类别的526个数据元素。对数据的检查表明，无论是纸质记录还是与行政数据相关的标准中，提取数据数量最多的是自由文本元素。从ASTM和HL7提取的数据的主要来源分别是E1384和Hl7V.x标准。在纸质记录中，数据是从19种表格中零星提取的。
ASTM标准通过声明信息的保密性，承认信息保密性问题是EHR发展的主要挑战之一，并提出了新型入院方式，如电话会议、远程视频和家访，随着提供医疗保健和治疗疾病的新技术的出现，这些方式是不可避免的。由三个组织分散在不同类别的与财务和保险相关的数据，合并为财务类别。通过添加认证者/签名数据元素来记录提供者的角色和责任被认为是必不可少的。
不仅使用定义明确且标准化的数据，而且使EHR系统适应当地设施以及现有的社会和文化条件，将有助于结构化数据集的开发。
