ASTM E1384-07(2013)
Standard Practice for Content and Structure of the Electronic Health Record (EHR)

Standard No.

ASTM E1384-07(2013)

Release Date

2007

Published By

American Society for Testing and Materials (ASTM)

Latest

ASTM E1384-07(2013)

Scope

4.1 This Guide has Four Parts:

4.1.1 The first part (Section 5) identifies items of information carried in the traditional paper record organized by the source oriented structures common to paper records. The purpose of this section is to remind users of the spectrum of information that shall be accommodated by the logical structure of a EHR and to present a point of reference for the more abstract description of the patient record that follows.

4.1.2 The second part (Section 6) presents a number of operational principles, including such matters as privacy and security that should guide the implementation and operation of EHRs.

4.1.3 The third part (Section 7) describes a logical data organization and content (common data model) of an EHR. It is not a blueprint for constructing or implementing a EHR system. The model presents an organization according to the major informational structures and content of the EHR. The focus is on the structure required to store all clinically relevant patient information: those that describe the patient's state; the actions directed at the patient variables; and the actions initiated to diagnose, educate, or treat the patient. These are regarded as repository functions of the EHR. This standard does not describe all of the data structures required by applications that might use information contained in the EHR. In particular, the data structures used to control and guide the process of care such as utilization review or quality assurance, and the goals or thresholds (for example, mean length of stay) that might be used to judge the patient's care are not included.

4.1.3.1 There are many different ways to implement physical structures that could map into the model presented. It is emphasized that this standard should neither impede technical progress nor define the precise manner in which the EHR system is implemented.

4.1.3.2 The focus of this guide is on the kinds of information that should be included and upon a global description of the organization of that data within the EHR. This guide does not deal in detail with issues related to charges and billing for patient care, only the documentation required to support usual charging and administrative issues.

4.1.3.3 This standard deals with the health information as it would be stored in the EHR, not as it would be sent as a message to or from the EHR. Pains have been taken to be sure that the information content from existing healthcare informatics messages that lie within the scope of the EHR can be mapped into the EHR structure. Where mappings are one-to-one, the EHR data elements have been cross referenced with the message fields. However, the EHR is not just a collection of messages. It makes stronger assumptions about the context in which it exists, so there is not perfect correspondence between the structure and content of messages on the one hand and the EHR on the other.

4.1.3.4 This guide applies across a range of scales. Though the ultimate goal is a EHR that spans the entire nation and the lifetime of an individual, the reality is that......

ASTM E1384-07(2013) Referenced Document

• ASTM E1238 Standard Specification for Transferring Clinical Observations Between Independent Computer Systems
• ASTM E1239 Standard Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems
• ASTM E1633 Standard Specification for Coded Values Used in the Electronic Health Record*， 2024-04-20 Update
• ASTM E1639 Standard Guide for Functional Requirements of Clinical Laboratory Information Management Systems
• ASTM E1714 Standard Guide for Properties of a Universal Healthcare Identifier (UHID)
• ASTM E1715 Standard Practice for An Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (RADT) Functions in Computer-Based Patient Record Systems
• ASTM E1769 
• ASTM E2118 Standard Guide for Coordination of Clinical Laboratory Services within the Electronic Health Record Environment and Networked Architectures
• ASTM E2369 Standard Specification for Continuity of Care Record (CCR)*， 2024-04-20 Update
• ASTM E2473 Standard Practice for the Occupational/Environmental Health View of the Electronic Health Record
• ASTM E2538 Standard Practice for Defining and Implementing Pharmacotherapy Information Services within the Electronic Health Record (EHR) Environment and Networked Architectures

ASTM E1384-07(2013) history

• 2007 ASTM E1384-07(2013) Standard Practice for Content and Structure of the Electronic Health Record (EHR)
• 2007 ASTM E1384-07 Standard Practice for Content and Structure of the Electronic Health Record (EHR)
• 2002 ASTM E1384-02a Practice for Content and Structure of the Electronic Health Record (EHR)
• 2002 ASTM E1384-02 Standard Guide for Content and Structure of the Electronic Health Record (EHR)
• 2001 ASTM E1384-01 Standard Guide for Content and Structure of the Electronic Health Record (EHR)
• 1999 ASTM E1384-99e1 Standard Guide for Content and Structure of the Electronic Health Record (EHR)