Electronic Health Record (EHR) Standards- 2016 for India
The Ministry of Health and Family Welfare, Government of India had introduced a uniform standard- based system for creation and maintenance of Electronic Health Records (EHRs) by the health care providers with the notification of EHR Standards for India in 2013 with an intent to bring standardisation and homogeneity, inter-operability in capture, storage, transmission & use of healthcare information across various Health IT systems.
An Electronic Health Record (EHR) is a collection of various medical records that get generated during any clinical encounter or events. The purpose of collecting medical records is to provide evidence based care, increasingly accurate and faster diagnosis that translates into better treatment at lower costs of care, avoid repeating unnecessary investigations.
With the passage of time, the EHR standards 2013 were revised in line with the contemporary developments, in consultation with the stakeholders at large; and EHR Standards 2016 has been notified for adoption in IT systems by health care institutions/ providers across the country.
With the advent of the envisaged system of EHRs of citizens in an inter-operable manner pan-nation, online availability and accessibility would be ensured. This would facilitate continuity of care, better health outcome and better decision support system and is expected to help in reducing expenditure on avoidable repetitive and similar diagnostic tests.
EHR Standards 2016 document consists of key EHR standards with respect to Indian healthcare system. For every aspect of data/information that is part of any healthcare record system has been addressed with a short guideline regarding implementation specific to the item-in-context included.
Various nonrelated recommendations from previous edition have been removed to better streamline the set of standards selected and achieve harmony among them.
A detailed recommendation on the interoperability and standards, clinical informatics standards, data ownership, privacy and security aspects, and the various coding systems are also provided.
The set of standards given in earlier edition has been updated with their latest versions as the country moves towards a better implementation.
Certain sections of the document have been removed to provide increased readability and consistency throughout while avoiding duplication, ambiguity and contradictions.
The document ‘EHR Standards 2016’ provides a set of recommendations relevant to adoption of electronic health informatics standards in EHR/EMR and other similar clinical information systems.
The scope is limited to identifying the standards, their intended purposes in such systems, followed by a short guideline-for-implementation approach. It is understood that with adoption of these standards properly, the data capture, storage, view, presentation, and transmission will be standardized to levels that will achieve interoperability of both meaning and data contained in the records.
This document does not cater to wider implementation scenarios such as of administrative, legal or regulatory nature. This document also does not cater to aspects of creation and operation of local, regional or national infrastructures, indexes, or repositories as they are dealt with by appropriate regulative/administrative bodies.
To provide a set of international and proven standards with focus towards achieving syntactic and semantic interoperability of health records. The idea is that any person in India can go to any health service provider/practitioner, any diagnostic center or any pharmacy and yet be able to access and have fully integrated and always available health records in an electronic format for efficient 21st century healthcare delivery and these will need to undergo periodic review and update as necessary.
The goals of standards in electronic health record systems are:
- Promote interoperability and where necessary be specific about certain content exchange and vocabulary standards to establish a path forward toward semantic interoperability
- Support the evolution and timely maintenance of adopted standards.
- Promote technical innovation using adopted standards.
- Encourage participation and adoption by all vendors and stakeholders.
- Keep implementation costs as low as reasonably possible
- Consider best practices, experiences, policies and frameworks
- To the extent possible, adopt standards that are modular and not interdependent.
Standards- (for detailed information - click here
- Identification and Demographic Information of Patient
- Architecture Requirements and Functional Specifications
- Logical Information Reference Model and Structural Composition
- Medical Terminology and Coding Standards
- Data Standards for Image, Multimedia, Waveform, Document
- Data Exchange Standards
- Other Standards Relevant to Health Care Systems
- Discharge /Treatment Summary Format
- Personal Healthcare and Medical Devices Interfacing
- Principles of Data Change
- Hardware, Networking and Connectivity, Software Standards
- Health Records in Mobile Devices
- Data Ownership of Health Records
- Data Privacy and Security
The primary aim of interoperability standards is to ensure syntactic (standardisation of the communication between a software client and a server)) and semantic (the ability of services and systems to exchange data in a meaningful/useful way)) interoperability of data amongst systems at all times.
EHR Standards Helpdesk
MoHFW has established a Centre of Excellence named as National Resource Centre for EHR Standards (NRCeS) at C-DAC, Pune to accelerate and promote adoption of EHR standards in India; and made SNOMED CT free-for-use in the country.
(SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms) is a standardized, multilingual vocabulary of clinical terminology that is used by physicians and other health care providers for the electronic exchange of clinical health information.)
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Updated on December 2018