Health Record Structural Standards

Discussion
Health Record Structural Standards
The electronic health record (EHR) is a cornerstone of health information technology; ideally, it affords the provider access to clinical data about a patient that is accurate, consistent, and complete while supporting the provider’s clinical decision-making process to facilitate the delivery of care to that patient. In addition to the standardization of content, a standardized structure is critical to the successful adoption and use of EHRs. Structural standardization facilitates EHR interoperability and enhances health information exchange, which, in turn, significantly increases the functional usefulness of these records for providers and their organizations.

To prepare for this discussion, you will reflect on the need for EHR structural standardization and the potential impact of this standardization on their utility. You will also take a close look at a variety of EHR data sets and have an opportunity to differentiate between their structural, functional, and developmental specifics. Finally, you will review some commonly used structural standards for patient health records and consider different types of EHR interoperability.
By Day 4, post a comprehensive response to the following:
How can you determine the specific structural components and the potential benefits of the Continuity of Care Record (CCR)?
What is the relationship between the CCR and the Continuity of Care Document (CCD)?
How can you differentiate the structural, functional, and developmental specifics of data sets used to capture patient information?
Read a selection of your colleagues’ postings.
By Day 6, respond to at least one of your colleagues’ postings in one or more of the following ways:
Ask a probing question.
Expand on the colleague’s posting with additional insight and resources.
Offer polite disagreement or critique, supported with evidence.
In addition, you may respond as follows:
Offer and support an opinion.
Validate an idea with your own experience.
Make a suggestion or comment that guides or facilitates the discussion.
Return to this Discussion in a few days to read the responses to your initial posting. Note what you have learned and/or any insights you have gained as a result of your colleagues’ comments. You are not required to post these final insights.

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