A common set of modeled data elements has been worked on for seven years but the different SDOs have, for the most part, proceeded independently using the particular focus of their immediate constituencies. Nevertheless, there is substantial commonality among the different approaches, even though a rigorous, consistent convention for documenting such commonality is not yet in hand. For example, the ASC X12N of DISA has built its model to reflect those concepts used in administrative transactions and commerce (see http:www.disa.org) while ASTM E-31 (See: www.astm.org) has focused on the Record of Care structure and content, in addition to the content in the ancillary disciplines. HL7 has focused on the data used in interchange both for care and resource management. Thus, through ad hoc communication, a large amount of commonality in the definition of data entities and the representation of their value sets has resulted. While this is a good first step, the ability to achieve a semantically consistent, interoperable set of various functional components of an enterprise information domain for health organizations will depend upon achieving a common basic model for the EHR.

The Core Model depiction below, derived from the ASTM E-1384 Guide for Structure and Content of the EHR and from ASTM E-1715 Standard Practice for an Object Model Representation of Registration, Admitting, Discharge and Transfer (R-ADT) Functions in Electronic Health Record Systems, gives a beginning idea of the grouping of data elements already defined and their implications both in the EHR for care functions and for resource management functions. The Core Model accounts for, in a unified way, both clinical care and resource management aspects of data captured for use in the EHR. Much of the present “administrative” data comes from the demographic and encounter descriptive categories of data. It is used for both healthcare claims/billing activities and for reportable epidemiologic/public health reportable data, including the recent HIPAA (PL 104-191) defined data. The HIPAA data incorporates HCFA Standard Form 1500 and the Unified Billing 92  forms. The major data element segments in the EHR can also be grouped as: Demographic, People, Healthcare Events, Healthcare Assessments, Healthcare Interventions, and Organizations as noted below. The Common Conceptual Objects noted in ASTM Standard Practice E-1715 are included in the following graphical Model of the currently identified Common Core Objects.

 

 

shaded segments are most frequently used

A Tabular Representation is the following:

National Committee on Vital and Health Statistics Core Data Set are in italics

ASTM E-1384 Minimal Data Set are underlined

HIPAA data elements are in bold

 

Demographic        Organization          People        Assessment          Intervention            Events

 

 

DEMOGRAPHIC GROUP

Segment I: Demographics 

PERSON ADA 1000.3

Person name

Previously Registered Name

Universal Patient Identifier

Date-time of Birth

Birthplace
Sex
Race
Ethnic Group
Religion
Marital Status
Education Level
Occupation
Work Phone
Work Address
Citizenship Status
County/Census tract
Temporary Address
Temporary Address Phone
Foreign Residence
 
PERSON RECORD LOCATION
Record Location ID
Date of Earliest Entry
Date of Latest Entry
 
PERSON ADDRESS
Patient Home Address
 Patient Home Phone
 
INDIVIDUAL IDENTIFIER ADA 1000.1
Individual Identifier (Multiple)
Organization
Type
Start Date
End Date
Status
 
ALTERNATE INDIVIDUAL NAME ADA 1000.1
Individual Alternate Name (Multiple)
Usage
Start Date
End Date
 
PATIENT ADA 1000.3
Patient Name --------------->PERSON
Adoption status
Patient Number
Universal Patient Health Number
Archive Data
Location of Chart
Multiple Birth Marker
Birth Order
School name
Military Service/Veteran Status
Current Work Status
Current Vocational Status
Previous Occupations (M)---------->OCCUPATION
Date Completed Occupation
Number in Household
Family Member Name (M) ------------->FAMILY MEMBER
Emergency Contact (relation/friend) Name
Emergency Contact Relationship
Emergency Contact Address
Emergency Contact Home phone
Emergency Contact Business phone
Patient Guardian Name---------------PERSON
Patient Guardian Address
Patient County/Census tract
LNOK Name
LNOK Relationship
LNOK Address
Parental Marital Status
Patient's Language
Interpreter Required
Usual Living Arrangement
 
FAMILY MEMBER ADA 1000.3
Family Member Name
Family Member Relationship
Family Member Name
Family Member SSAN
Family Member Male Parent
Family Member Female Parent
Family Member Spouse
Family Member Sex
Family Member DOB
Family Member Date of Death
Family Member Head of Household Status
Family Member Caregiver Status
Family Member Location
Family Member Occupation-------->OCCUPATION
Family Member Major Diagnosis (M)
 
Segment II: Legal Agreements
Consent Signed/Admit Agreement
Patient Rights Acknowledgement
Directive to Physician
 
RECORD RELEASE INSTANCE
 
Release of Information Datetime
Type of Information Released
Person Releasing

 

ORGANIZATION GROUP

 

Segment III: Financial

 

PAYMENT SOURCE

Payment Source

Payer Group No

Payment Sponsor

Address of Sponsor

 

PEOPLE GROUP

 

Segment IV: Provider/Practitioner

 

HEALTHCARE PRACTITIONER ADA 1000.10

Practitioner Name  ---------->PERSON

Practitioner National Provider ID
Practitioner Profession, Occupation, Specialty
Practitioner Address
Practitioner Electronic Signature
 
PRACTITIONER ROLE
Practitioner Role Name
Practitioner Role Identifier
 
Provider/Practitioner Name
Provider Address
Provider Taxonomy Category
Provider ID
Provider Agency ID
 

HEALTHCARE ASSESSMENT GROUP

 

Segment V: Health Condition/Problem ADA 1000.14

Health Condition/Problem ID

Health Condition/Problem Name

Health Condition/Problem Time of Onset

Health Condition/Status

 

Segment VII: Environmental Stressors

 

Segment VIII: Health History ADA 1000.13

Date of Health History (Multiple)

History Source Contact Name

History Source Relationship

History Present Health

Past History Social

Current Habits

 

Segment IX: Examinations ADA 1000.12

 

Date of Examination (Multiple)

Source of History Present Illness/status Present Health

Review of Systems

Exam Finding (Multiple)

Exam Finding Comment

Exam Health Status Total Measure

Exam Summary

 

Segment XI: Diagnostic Tests/Observations ADA 1000.13

 

Datetime of Test

Name of Requested Test

Test Ordering Facility

Test Ordering Practitioner

Test Performing Facility

Datetime Result Reported

Test Report Text (for Textual Reports)

Test Comments

 

MEASUREMENT/OBSERVATION

Analyte/Measurement/Observation Name (Multiple)

Value

Interpretation

 

MICRO-ORGANISM

Microorganism Requested (Multiple)

Microorganism Attribute (Multiple)

Microorganism Comments

 

HEALTHCARE INTERVENTIONS

 

Segment VI: Immunizations

 

Immunization Name (Multiple)

Immunization Date

 

Segment X: Clinical Orders

 

Clinical Order ID (Multiple)

Clinical Order Datetime

Clinical Order Full Text

 

Segment X: Treatment Plans ADA 1000.15

 

Treatment Plan ID (Multiple) ADA 1000.15

Treatment Plan Description

Health Condition/Problem ID

Treatment Plan Phase (Multiple)

 

Segment XII: Medications ADA 1000.16

 

Prescription/Medication order Datetime (Multiple)

Medication Name

Medication Prescriber

Medication Dose

Medication Vehicle/Form

Medication Route

Medication Frequency

Medication Instructions

Date of Refill (Multiple)

Medication Notes

 

SubSegment XIVD: Therapies

 

Name of Therapy

Therapy Start Time

Therapy Finish Time

Therapy Response Assessment

Therapy Practitioner

Therapy Recommendations

 

SubSegment XIVE: Encounter Operative Procedures

 

Operation Datetime

Operation Anesthesiologist

Operative Procedure

Anesthetic Agent

Post Anesthesia Assessment

Operative Event Datetime

Operative Event Attribute

Complications

Surgeon Signature

Procedure----------->PROCEDURE

 

 

HEALTHCARE EVENT GROUP

 

Segment XIII: Appointments

 

SubSegment XIVA: Encounter Receipt

 

HEALTHCARE ENCOUNTER RECEIPT

Datetime of Encounter

Name of Facility of Encounter

Facility Type

Type of Encounter

Confidentiality Status

Episode ID

Reason for Visit

Mode of Injury

Nature of Injury

Chief Complaint

Health Condition/Problem (Multiple)

Diagnosis

Practitioner ID

 

RECEIPT HEALTH STATUS

Receipt Health Status Measure Name

Receipt Health Status Measure Total Value

 

RECEIPT DIAGNOSIS

Encounter Receipt Diagnosis

Encounter Receipt Health Status

 

SOURCE OF PAYMENT

 

Source of Payment

 

HEALTHCARE ENCOUNTER ACTIVITIES

 

 

SubSegment XIVF/G: Encounter Disposition & Charges

 

HEALTHCARE ENCOUNTER DISPOSITION

Disposition

Disposition Date time

Disposition Destination

Patient Instructions

Disposition Note

Disposition Note Signature

Encounter Charges

Disposition Type

Followup Action

Followup target date

 

DISPOSITION DIAGNOSIS

Disposition Diagnosis Name-->DIAGNOSIS

Diagnosis Type

 

DISPOSITION HEALTH STATUS

Disposition Health Status Measure Name

Disposition Health Status Measure Total Value

 

OPERATIVE PROCEDURE

Admission Surgeon

Admission Surgeon Role

Encounter Procedure  (Multiple)

 

SubSegment XIVC Encounter Care Documentation

 

Clinical Progress Note Datetime (Multiple)

Progress Note Text

Progress Note Signature

Points to Note:

First, note  that  the  key  demographic and administrative data are found in Segment I. These are required to "Register" the patient and to characterize the population of the practice. Consult ASTM E-1239 Guide for Description of Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record Systems and E-1715 Standard Practice  for Object-Oriented Model for Registration Admitting, Discharge and Transfer Functions in Computer based Patient Record Systems for detailed usage.  Second,  note  that  for  each   encounter,   scheduled   or  unscheduled,  the  common   data  characterize the encounter circumstances and  why  the  patient  sought care.  These data  are  needed  not only for claims and reportable data sets  but also to characterize the patient population clinically. Common reportable data also frequently originate in these EHR segments. The most commonly used is the NCVHS “Core Data Set” (See: http://aspe.os.dhhs.gov/datacncl/ncvhsr1.htm), a provisional common reportable data constellation for epidemiology and health policy statistics. The version shown here is the latest (1996) reported list of data elements.