Seminar on eHR Content 20 July 2012 By Karen Szeto Health - - PowerPoint PPT Presentation

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Seminar on eHR Content 20 July 2012 By Karen Szeto Health - - PowerPoint PPT Presentation

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Seminar on eHR Content 20 July 2012 By Karen Szeto Health Informatician, eHRISO Domains Birth record Allergy / Adverse drug reaction Clinical note / summary Radiology examination Investigation report Referral BIRTH

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Seminar on eHR Content

20 July 2012

By Karen Szeto Health Informatician, eHRISO

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Domains

  • Birth record
  • Allergy / Adverse drug reaction
  • Clinical note / summary
  • Radiology examination
  • Investigation report
  • Referral
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BIRTH RECORD

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Birth record

  • Basic information about the eHR Participant’s

birth, e.g. birth date time, birth institution, birth weight, maturity, APGAR scores…

  • Part of the information relating to birth would

be fall under the other sharable scope, e.g. diagnosis, procedure, assessment

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Mind map: Birth record

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Example – Level 1 (Birth record)

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Example – Level 2 (Birth record)

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Example – Level 3 (Birth record)

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eHR viewer: Birth record

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Related files: Birth record

  • Data schema

–Birth record

  • Codex

–Birth institution –Birth location

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Data schema: Birth record

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Codex: Birth institution

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Codex: Birth location

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ALLERGY / ADVERSE DRUG REACTION (ADR)

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Allergy / ADR

– Include information on type of biological, physical

  • r chemical agents that would result in / is proven

to give rise to adverse health effects – Details of the adverse reactions, if occurred, should also be included – Absence of the information does not imply the absence of the condition – Exclude “No known drug allergy” (NKDA) data

– No level 1 data

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Mind map: Allergy

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Example – Level 2 (Allergy)

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Example – Level 3 (Allergy)

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Mind map: ADR

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Example – Level 2 (ADR)

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Example – Level 3 (ADR)

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eHR viewer: Allergy & ADR

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Related files: Allergy / ADR

  • Data schema

– Adverse drug reaction

  • Codex

1. Recognised terminology name – pharmaceutical product 2. ADR severity level

  • Data schema

– Allergy

  • Codex

1. Recognised terminology name – pharmaceutical product 2. Allergy level of certainty 3. Allergic reaction

Next Domain

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Data schema: Allergy

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Data schema: ADR

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Codex: RT name – pharmaceutical product (only 3 allowable RT)

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Codex: Allergy level of certainty

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Codex: Allergic reaction

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Codex: ADR severity level

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CLINICAL NOTE / SUMMARY

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Clinical note / summary

  • Contains information that record/summarize the

followings of a particular clinical encounter/episode:

– Reason originates the episode & eHR participant condition during initial encounter – ADR, allergies and clinical alert found during the encounter/episode

  • these info should also be separately sent to the eHR as the appropriate section

– Major diagnostic findings during the course of the episode – Problems identified – Significant procedures performed & other related therapeutic treatment, e.g. medication – eHR participant’s condition, therapeutic orders or treatment plan for that encounter or while preparing a periodic episode summary or upon termination of an episode – FU arrangement – Education to the eHR participant / family, if applicable

  • Level 1 data only
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Mind map: Clinical note / summary

Clinical meaningful report title, e.g. discharge summary

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Example – Level 1 (Clinical note / summary)

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eHR viewer: Clinical note / summary

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Related Files: Clinical note / summary

  • Data schema

–Clinical note / summary

  • Codex

–Type of clinical note / summary

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Data schema: Clinical note / summary

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Codex: Type of clinical note / summary

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RADIOLOGY EXAMINATION

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Radiology examination

  • Radiology result would include radiology report

and images

– Images: to be implemented in later phases

  • Sub-classified according to radiology modality,

e.g.

– plain x-ray, fluoroscopy, ultrasound, CT, MRI, NM, angiography and vascular IR, non-vascular IR, PET &

  • thers
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Mind map: Radiology examination

Not yet implemented in phase 1

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Example – Level 1 (Radiology examination)

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Example – Level 2 (Radiology examination)

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CT

Example – Level 3 (Radiology examination) (1)

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Example – Level 3 (Radiology examination) (2)

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eHR viewer: Radiology examination

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Related files: Radiology examination

  • Data schema

– Radiology examination

  • Codex

– Radiology modality – Healthcare staff English name prefix – Healthcare staff Chinese name suffix – Procedure healthcare staff type

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Data schema: Radiology examination (1)

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Data schema: Radiology examination (2)

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Codex: Radiology modality

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Codex:

  • HC staff English name prefix
  • HC staff Chinese name suffix
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Codex: HC staff type

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INVESTIGATION REPORT

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Investigation report

  • Other than laboratory and radiology

diagnostics tests, other various types of diagnostic reports would be fall into this domain, for examples:

– Audiogram, Ambulatory BP monitoring, Echocardiogram, Treadmill, Holter, PFT, EEG, EMG, ESWL, ETT …

  • Level 1 data only
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Mind map: Investigation report

Clinical meaningful report title, e.g. Pulmonary function test report

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Example – Level 1 (Investigation report)

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eHR viewer: Investigation report

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Related file: Investigation report

  • Data schema

– Investigation report

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Data schema: Investigation report

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REFERRAL

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Referral

  • Referral documents the information that is

required when a healthcare provider refers all

  • r a portion of an eHR participant’s care to

another healthcare provider, and the reply from the receiving healthcare provider to the referrer

  • Level 1 data only
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Mind map: Referral

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Example – Level 1 (Referral)

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eHR viewer: Referral

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Related files: Referral

  • Data schema

– Referral

  • Codex

– Type of referral

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Data schema: Referral

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Codex: Type of referral

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THANK YOU