Developing and Implementing an Interoperable Document-based Electronic Health Record

摘要

Health information exchange ensuring its authenticity and integrity is not a simple task. Many institutions have implemented different solutions to perform this exchange using partial or summary information, and rarely include metadata that establish the context in which they performed the primary data capture. In this setting, we proposed the creation of an alternative architecture, parallel, yet integrated with a traditional electronic health record, based on the relational data model. We used a clinical documents standard, the CDA, whose architecture allows having a scalable document-based electronic clinical data repository, plausible to be shared with the patient, other institutions, other healthcare professionals or funders, with secure and controlled access and that remains unchanged over time. Furthermore, in addition to achieving this redundant clinical data repository, it was possible to reduce printing charts thanks to the portability that this standard allows.