ISO 13606-1:2019
Health informatics — Electronic health record communication — Part 1: Reference model
This document specifies a means for communicating part or all of the electronic health record (EHR) of one or more identified subjects of care between EHR systems, or between EHR systems and a centralised EHR data repository.
It can also be used for EHR communication between an EHR system or repository and clinical applications or middleware components (such as decision support components), or personal health applications and devices, that need to access or provide EHR data, or as the representation of EHR data within a distributed (federated) record system.
This document will predominantly be used to support the direct care given to identifiable individuals or self-care by individuals themselves, or to support population monitoring systems such as disease registries and public health surveillance. Uses of health records for other purposes such as teaching, clinical audit, administration and reporting, service management, research and epidemiology, which often require anonymization or aggregation of individual records, are not the focus of this document but such secondary uses might also find the document useful.
This Part 1 of the multipart series is an Information Viewpoint specification as defined by the Open Distributed Processing ? Reference model: Overview (ISO/IEC 10746-1). This document is not intended to specify the internal architecture or database design of EHR systems.
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Foreword
Introduction
1 Scope
2 Normative references
3 Terms and definitions
3.1 Actors
3.2 Concepts and terms
3.3 Information management
3.4 Privacy and security
3.5 Process management
4 Abbreviations
5 Overview
5.1 Overview of the reference model
5.2 Representing roles and responsibilities within the EHR _EXTRACT
5.2.1 General
5.2.2 Actors playing a role in the actual healthcare process
5.2.3 Actors contributing to the process of documenting care within the EHR
5.2.4 Actors confirming the validity of the EHR documentation
5.2.5 Subject of care
5.2.6 Composer
5.2.7 Committer
5.2.8 Subject of information
5.2.9 Information provider
5.3 About the use of datatypes in this document
6 Common Properties of Record Components
6.1 Base, record and structure components
6.1.1 General
6.1.2 Base component
6.1.3 Electronic health record component
6.1.4 Structure component
6.2 Attestation
6.2.1 General
6.2.2 Attestation information
6.3 Audit information
6.4 Linking record components
6.4.1 General
6.4.2 Link usages
6.4.3 Communicating referenced record components
6.4.4 Link
6.4.5 External link
7 Elements and Data Values
7.1 General
7.2 Data value
7.2.1 Boolean
7.2.2 Attachment
7.2.3 String
7.2.4 Simple text
7.2.5 Coded simple value
7.2.6 Coded value
7.2.7 Instance identifier
7.2.8 URI
7.2.9 Physical quantity
7.2.10 Duration
7.2.11 Real
7.2.12 Integer
7.2.13 Date time
7.2.14 Date
7.2.15 Time
7.2.16 Point in time
8 EHR Components
8.1 General
8.2 Folder
8.2.1 General
8.2.2 Folder
8.3 Compositions
8.3.1 General
8.3.2 Composition
8.4 Content and sections
8.4.1 General
8.4.2 Content
8.4.3 Section
8.5 Entries
8.5.1 General
8.5.2 Entry
8.6 Items and clusters
8.6.1 Item
8.6.2 Cluster
8.7 Element
9 EHR Extract
9.1 General
9.2 EHR extract
9.3 Extracted component set
9.4 Demographic extract
10 Demographics
10.1 General
10.2 Demographic folder
10.3 Demographic entity
10.4 Demographic item
10.5 Demographic cluster
10.6 Demographic element
11 Conformance
Annex A (informative) About the ISO 21090:2011 profile for datatypes
Annex B (informative) Alignment with HL7 FHIR
Annex C (informative) Cross-Domain Interoperability
Bibliography
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Foreword
Introduction
1 Scope
2 Normative references
3 Terms and definitions
3.1 Actors
3.2 Concepts and terms
3.3 Information management
3.4 Privacy and security
3.5 Process management
4 Abbreviations
5 Overview
5.1 Overview of the reference model
5.2 Representing roles and responsibilities within the EHR _EXTRACT
5.2.1 General
5.2.2 Actors playing a role in the actual healthcare process
5.2.3 Actors contributing to the process of documenting care within the EHR
5.2.4 Actors confirming the validity of the EHR documentation
5.2.5 Subject of care
5.2.6 Composer
5.2.7 Committer
5.2.8 Subject of information
5.2.9 Information provider
5.3 About the use of datatypes in this document
6 Common Properties of Record Components
6.1 Base, record and structure components
6.1.1 General
6.1.2 Base component
6.1.3 Electronic health record component
6.1.4 Structure component
6.2 Attestation
6.2.1 General
6.2.2 Attestation information
6.3 Audit information
6.4 Linking record components
6.4.1 General
6.4.2 Link usages
6.4.3 Communicating referenced record components
6.4.4 Link
6.4.5 External link
7 Elements and Data Values
7.1 General
7.2 Data value
7.2.1 Boolean
7.2.2 Attachment
7.2.3 String
7.2.4 Simple text
7.2.5 Coded simple value
7.2.6 Coded value
7.2.7 Instance identifier
7.2.8 URI
7.2.9 Physical quantity
7.2.10 Duration
7.2.11 Real
7.2.12 Integer
7.2.13 Date time
7.2.14 Date
7.2.15 Time
7.2.16 Point in time
8 EHR Components
8.1 General
8.2 Folder
8.2.1 General
8.2.2 Folder
8.3 Compositions
8.3.1 General
8.3.2 Composition
8.4 Content and sections
8.4.1 General
8.4.2 Content
8.4.3 Section
8.5 Entries
8.5.1 General
8.5.2 Entry
8.6 Items and clusters
8.6.1 Item
8.6.2 Cluster
8.7 Element
9 EHR Extract
9.1 General
9.2 EHR extract
9.3 Extracted component set
9.4 Demographic extract
10 Demographics
10.1 General
10.2 Demographic folder
10.3 Demographic entity
10.4 Demographic item
10.5 Demographic cluster
10.6 Demographic element
11 Conformance
Annex A (informative) About the ISO 21090:2011 profile for datatypes
Annex B (informative) Alignment with HL7 FHIR
Annex C (informative) Cross-Domain Interoperability
Bibliography