Representation of Patient Data in Health Information Systems and Electronic Health Records

Abstract

With the development of IT, more and more hospitals and health facilities are currently using electronic health records (EHR) in replacement of the paper-based patient record. The main goal of an EHR is to improve the health care process. Moreover, EHRs make easier the reuse of patient data for other purpose like research studies or management. In this chapter, we first discuss the added value of EHRs. Then we present their main categories and the different ways to represent and coding data in such systems. The place of interoperability standards is critical to integrate EHRs in Health information system. Therefore we present and discuss the two main semantic standards (HL7 and OpenEHR) used to structure and code clinical data in EHRs as well as the initiatives encouraging vendors to implement them