RACSEL: Technical Recommendations for Electronic Health Record Implementation

This book presents a study on international health informatics standards that pave the ground for technical and syntactic interoperability in the implementation of an Electronic Health Record (EHR). This method is useful to exchange patients’ clinical data and information between institutions in the country and to facilitate interoperability between countries in the network to carry out this exchange.

This study has focused on the analysis of use cases agreed upon by RACSEL’s Technical Working Groups, that aim to show in a coherent way what and how to share information between the different countries in the network, using current international standards.

To comply with these use cases, the reference model (section 1.8 of the document) to be adopted in the respective countries has been defined. This definition will help to achieve technical and syntactic interoperability in the regional EHR system for Latin America and the Caribbean. Before this step, the document presents some key references (section 1.7.) As shown in the process of adapting the standards within the same country, which facilitates the implementation of its national EHR and its subsequent communication with neighboring countries when they wish to exchange medical documents.

We divide the document into two large blocks. In the first block (sections 1.2 to 1.5.), key information is provided both to help understand the material as a whole and to provide background information. The second block (sections 1.6 to 1.10.), explains the reference model on which the study is focused, limiting the scope in the agreed use cases. All content is structured in the following sections:

• Introduction
  • Description of the objective and parts of this volume
• Key concepts
  • Definition of concepts that allow for a better understanding of the document as a whole and help avoid ambiguities
• Standards and organizations
  • Information on currently standards and organizations
• Projects related to EHR
  • Summarized information about projects related to EHR sharing of patient medical information between different agencies
• Tools and services
  • Description of some of the most used tools to work with standards of functional and syntactic interoperability that can be used to implement an EHR
• Use cases
  • Description of the use cases on which this reference model focuses
• Prior needs in each country
  • Description of references for a country to improve interoperability in its health institutions and facilitate its path towards the cross-border information exchange model
• Cross-border information exchange model
  • Description of the proposed model for the exchange of information between RACSEL’s network member countries
• RACSEL patient summary
  • Description of the functional requirements of the patient summary and the proposed structure based on HL7 CDA R2
• Proposed EHR profiles
  • Description of the IHE profiles proposed to achieve the cross-border exchange of RACSEL, determined by the architecture model proposed by the architecture component