The Research And Practice On Constructing A Document Architecture And Data Element Groups For Resident’s Electronic Health Records

Objective：For the purpse of integrating diverse paper-based health recordforms in Wuwei city into electronic health record (EHR) documents that areconsistent with a health information model and national regulations throughfew and common information components, this study is intended (1) to developa document architecture for resident’s EHR,(2) to define contents of thedocument architecture, including content module, data element groups, dataelement and their properties, and (3) to practice the developed documentarchitecture and data element groups to build a EHR system for the aim offacilitating health information sharing, as well as confirming integrity andapplicability of these developed components.Method:(1) The EHR document architecture was developed by referencingHL7Clinical Document Architecture and Australia health information meta-model.(2) The Continuous Process Improvement Model including fouriterative cycles of plan, do, check and evaluate was used in constructing thecontent modules and data element groups. The development of thesecomponents based on22health record forms in the Basic Public Health ServiceSpecifications (BPHSS) and38health record forms currently used in Wuwei,and complied with HL7Reference Information Model (RIM).(3) After aboveprocesses are complete, document instances were created to explain the ideaand step of creating an EHR document using the document architecture anddata element groups, as well as to test the applicability of these developedresults.(4) By creating the document architecture and data element groups as asupporting model, and according to the requirements of Wuwei EHR and ourproject aim, we established an EHR system.Results:(1) The document architecture are comprised of five levelsincluding the health record document, content module, data element group, dataelement and value domain. The health record document is a data set derivedfrom a specific health event and is used to record resident’s health serviceinformation. The content module is used as building blocks to construct healthrecord document and to provide the context for document data. The dataelement group is made up of a number of data elements whose values areconstrained by value domains. A value domain has zero or more classificationschemes. The architecture can represent all health record documents (including6classes and33sub-classes） from resident’s birth to death.(2) Altogether,75content modules, including12header and63body content modules, wereproposed. The body content modules consisted of24top-level and39second-level content modules. The data element groups included241data elements (60data elements for document header and171data elements fordocument body) and43value domains.(3) Two document instances, includingan infectious disease reporting card and a health record form for rural residents,were created as examples to explain the procedure of creating EHR document.(4) The Wuwei EHR system consisted of six function modules (Login, Import,Create, Browse, Analyze and Export) was built and realized with B/S mode,coded with ASP.NET programming method and C#script language. Databasewas created through IBM DB2. At the end of January2011, the EHR systemwas positioned into use in Wuwei City and there were1,942authorized usersand more than1.6million health records in the system by the end of November2011.Conclusion: The document architecture and data element groups developedbased on the forms of BPHSS and Wuwei health records can be used torepresent resident’s health record information, to convert paper-based forms tostructured and model-based EHR documents and also to guide the building ofEHR system for information sharing. Based on our research and practice, weconcluded that the method using a small number of content modules and dataelement groups to represent numerous and variational paper-based healthrecord documents could be a feasible way. Meanwhile, this study couldcontribute to the construction of structured Chinese EHR documents andprovide some experiences as a reference for building EHR systems.