1. Tung Tran, Ph.D

2. What is the EMR? Computerized legal medical record created by healthcare organizations Enables storage and retrieval of patient information Standardized EMR Fulfill the organization needs of organizations Integrated Adaptable

3. Clinical Document Architecture (CDA) Patient Record Architecture Provide an exchange model Discharge summaries Referrals … The content of CDA is based upon other standards DICOM Terminologies (ICD codes, HL7 codes, LOINC codes, …) …

4. Sharing the Medical Record Common patient medical records: History and physical Patient Referral Patient Consultation Progress notes Physician’s Order Discharge Summary CDA is the way of passing medical documents in terms of data values and data elements formats.

5. ASTM E 1384 Patient Encounter Order/Plan Service/Instance Observation Service/Master Problem Practitioner 0,n 1,n 1,1 1,n 0,n

6. Network Communication Techniques HL7 Interface Engine HL7 network protocol is application messaging protocol for healthcare communications. Patient Administration (Admission, Transfer, Discharge) Order Entry (diet, pharmacy order, lab test order) Observation Reporting …

7. EMR Architecture LISSchedule Patient Administration Common Application framework (data management, process management, Interface/Integration, Transport service) Documents Management Various Devices (Web/Applications/User Interfaces Clinical Data Repository Terminology Order Entry Application layer Presentation layer Data layer Local XML Standard XML