Healthcare Information System Standards

In order to achieve interoperability, portability, and data exchange, healthcare information systems must employ standards. Systems that conform to different standards cannot communicate with one another. A plethora of information technology (IT) standards, including standards for messaging, content and coding, networks, electronic data interchange, and electronic health records, are important to healthcare information systems.

It is important to recognize that many IT standards that do not specifically address healthcare also have a tremendous impact on healthcare information systems.

Standards Development Process

There are four methods have been used to establish healthcare IT standards:

 Ad hoc. A standard is established by the ad hoc method when a group of interested people or organizations agrees on a certain specification, without any formal adoption process.

 De facto. A de facto standard arises when a vendor or other commercial enterprise controls such a large segment of the market that its product becomes the recognized norm.

 Government mandate. Standards are also established when the government mandates that the healthcare industry adopt them.

 Consensus. Consensus-based standards come about when representatives from various interested groups come together to reach a formal agreement on specifications.

Classification, Vocabulary, and Terminology Standards

The most widely recognized coding and classification systems, ICD 10-CM, Current Procedural Terminology (CPT), and diagnoses related groups (DRGs). Although these systems do not meet the criteria for full clinical vocabularies, they are used to classify diagnoses and procedures and are the basis for information retrieval in healthcare information systems.

Data Interchange Standards

Much of the healthcare information standards development activity has been in the area of standards for data interchange or integration. There are a few standards that have been developed for this purpose. The following groups of standards are recognized as broad standards addressing all types of applications:

 Health Level Seven Standards.

 Digital Imaging and Communications in Medicine (DICOM)

 National Council for Prescription Drug Programs (NCPDP)

 ANSI X12N standards.

Health Record Content Standards

There are two set of standards currently being developed. The first is the HL7 Functional Model, which provides a reference list of over 160 functions that may be present in HER system. And the second is the ASTM Healthcare Informatics subcommittee’s Continuity of Care Record (CCR) standard, which designed as a standard healthcare data summary.

Although these standards are being developed for different purposes, both address the content of the patient’s electronic health record.