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Data Exchange Standards for Computer-based Patient Records

  • Clement J. McDonald
  • George H. Hripcsak
Part of the Computers in Health Care book series (HI)

Abstract

Three facts, though perhaps self-evident, require emphasis:
  • Medical records, whether paper or electronic, are composed entirely of data, mostly patient data. Without patient data, there is no medical record.

  • Spontaneous generation does not apply to the medical record. All of the data stored in medical records come from elsewhere: from clinical laboratories, pharmacy systems, and radiology systems. Data also come in the form of orders and prescriptions that may be captured from hospital information systems and/or pharmacy systems, respectively.

  • For electronic medical record systems to be practical, a medical record must be able to access many of these existing electronic sources of medical information. Such information is already stored in a variety of different formats, so standards for exchanging such information must be established before they can be easily transferred to a medical resource. Hence, the need for data interchange standards (McDonald and Hammond 1989).

Keywords

National Electrical Manufacturer Association National Electrical Manufacturer Association American National Standard Institute National Electrical Manufacturer Association System Vendor 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Copyright information

© Springer Science+Business Media New York 1992

Authors and Affiliations

  • Clement J. McDonald
  • George H. Hripcsak

There are no affiliations available

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