An australian proposal for consistent structures, data elements and use of clinical terminologies and classifications.

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Gordon J, Miller G, Britt H. Reality check - reliable national data from general practice electronic health records. Deeble Inst Issues Brief. 2016;(18).

Abstract

General practice electronic health records (EHRs) are currently unregulated. Each system has been developed independently, with no common standards across all systems. 

In Australia, there are at least eight EHRs with inconsistent structures, data elements and use of clinical terminologies and classifications.

The lack of standards across EHRs has made it difficult to: transfer clinical data between EHRs for clinical purposes; link individual health data for integration of care across different sectors of the health care system; and reliably extract patient data for research purposes. 

A national, cohesive approach is needed to develop and implement standards for general practice EHRs.

There are four elements to be addressed:

1. A defined EHR data model that links related data elements

2. Consistent data element labels and definitions

3. Use of standardised clinical terminologies and classifications

4. Accreditation of general practice EHRs.



Created 05/09/2016 - Last modified 11/09/2016