What information should be stored in Shared Health Record?

Legacy openhie-shr
1

Hi All,

We had a great discussion on Monday around the OpenSHR work. I seems one of the biggest sticking points was the fact that we don’t, as a group, understand what information should be stored in a Shared health Record. We made some progress on the call, but I would like to generate some discussion around this so that we can converge on this.

This is my understanding of what we mentioned:

We should store:

  • Items related to a patient daily care, such as
    • Care summaries
    • Allergies
    • Medications that the patient is on
    • Observations
    • Referrals
  • Lab results (without full lab sample details)
    Have we missed anything here or does anyone disagree with the list presented here?

Derek, also captured some of the key events of when we would want to capture information in the SHR. These are listed below:

  • capture clinical observations about a subject of care (weight, BP, temperature, etc.)
  • capture diagnoses (e.g. pregnant, HIV+, etc.); this may have the effect of “enrolling” them in a guideline-based care plan
  • drug order
  • drug dispense
  • lab order (including DI)
  • lab result
  • referral (escalation of care)
  • discharge summary (from acute care back to community and/or primary care)
    So, overall, how do people feels about these lists? Is this the sort of data and the events that we would want to support? Are there any items missing from these lists?

Cheers,

Ryan

···

–
Ryan Crichton

Senior Software Developer, Jembi Health Systems | SOUTH AFRICA

Mobile: +27845829934 | Skype: ryan.graham.crichton
E-mail: ryan@jembi.org

2

The list of what will be stored in the SHR seems comprehensive. There are some items we store here in Indiana that I want to make sure are considered as
part of the SHR. These include visit notes and various assessment forms and intake forms such as:

Provider Visit Notes (doctor, nurse, health care provider, and phone call notes)

Prenatal Assessment Forms

-obstetric medical history

-prenatal history

-social history

Nutritional Assessment

Quality of Life Indicators

Action Plans (for Asthma, Diabetes, etc)

Mental Status Assessment

Some of these assessments and questionnaires would be stored as discrete data and some as text reports (non-discrete).

Regards,

Larry

On Behalf Of Ryan

···

Hi All,

We had a great discussion on Monday around the OpenSHR work. I seems one of the biggest sticking points was the fact that we don’t, as a group, understand what information should be stored in a Shared health Record. We made some progress
on the call, but I would like to generate some discussion around this so that we can converge on this.

This is my understanding of what we mentioned:

We should store:

  • Items related to a patient daily care, such as

    • Care summaries
    • Allergies
    • Medications that the patient is on
    • Observations
    • Referrals

  • Lab results (without full lab sample details)

Have we missed anything here or does anyone disagree with the list presented here?

Derek, also captured some of the key events of when we would want to capture information in the SHR. These are listed below:

  • capture clinical observations about a subject of care (weight, BP, temperature, etc.)

  • capture diagnoses (e.g. pregnant, HIV+, etc.); this may have the effect of “enrolling” them in a guideline-based care plan

  • drug order

  • drug dispense

  • lab order (including DI)

  • lab result

  • referral (escalation of care)

  • discharge summary (from acute care back to community and/or primary care)

So, overall, how do people feels about these lists? Is this the sort of data and the events that we would want to support? Are there any items missing from these lists?

Cheers,

Ryan

–

Ryan Crichton

Senior Software Developer, Jembi Health Systems | SOUTH AFRICA

Mobile: +27845829934 | Skype: ryan.graham.crichton
E-mail: ryan@jembi.org

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3

Wow- I am sorry I missed this call. So- just so I am clear- this is the generic “openSHR” not specifically for Rwanda correct?

I have lots of comments here- but not sure if they are supposed to be going in email or in a wiki discussion. So can someone let me know please?

I will be brief this round.

We need to be VERY careful and picky about what “observations” are included in a SHR- they should be few, and should be quantified (my same long standing argument that a CHW observation of “anemia” is not the same as a clinicians, which is still not the same as a diagnosis of anemia based on a low hgb.)

I would suggest we start simple and add complexity as necessary. Lab would be the priority in my opinion.

Inclusion of allergies is good- but in my experience- almost never collected, it is best practice, so we should aspire to include it.

We need to also differentiate items that are more permanent (such as allergies, some diagnoses such as type 1 diabetes etc) and those that are transient- such as malaria diagnosis in May 2012.

Liz

···

On Wed, Mar 13, 2013 at 10:02 AM, Ryan ryan@jembi.org wrote:

Hi All,

We had a great discussion on Monday around the OpenSHR work. I seems one of the biggest sticking points was the fact that we don’t, as a group, understand what information should be stored in a Shared health Record. We made some progress on the call, but I would like to generate some discussion around this so that we can converge on this.

This is my understanding of what we mentioned:

We should store:

  • Items related to a patient daily care, such as
    • Care summaries
    • Allergies
    • Medications that the patient is on
    • Observations
    • Referrals
  • Lab results (without full lab sample details)
    Have we missed anything here or does anyone disagree with the list presented here?

Derek, also captured some of the key events of when we would want to capture information in the SHR. These are listed below:

  • capture clinical observations about a subject of care (weight, BP, temperature, etc.)
  • capture diagnoses (e.g. pregnant, HIV+, etc.); this may have the effect of “enrolling” them in a guideline-based care plan
  • drug order
  • drug dispense
  • lab order (including DI)
  • lab result
  • referral (escalation of care)
  • discharge summary (from acute care back to community and/or primary care)
    So, overall, how do people feels about these lists? Is this the sort of data and the events that we would want to support? Are there any items missing from these lists?

Cheers,

Ryan

Ryan Crichton

Senior Software Developer, Jembi Health Systems | SOUTH AFRICA

–
Mobile: +27845829934 | Skype: ryan.graham.crichton
E-mail: ryan@jembi.org

–

You received this message because you are subscribed to the Google Groups “Shared Health Record (OpenHIE)” group.

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4

Thanks Larry, that is very helpful. I guess the next task for this group to try come up with a list that we think are a priority for low resource settings. We can chat about this on the next call.

Liz, yes we are considering a generic SHR here for the OpenHIE initiative going forward, so a lot of these are likely our vision for the future :slight_smile: The correct place for these conversations is on these email threads. I believe that is the lowest barrier to entry for the whole community.

I agree, the SHR should definitely only store a ‘relevant subset’ of observations. Lab results do seems to be re-occurring as a common theme here is these are likely top priority after collecting some basic observations from the patient visit.

Cheers,

Ryan

···

On Wed, Mar 13, 2013 at 5:28 PM, Liz Peloso liz.peloso@gmail.com wrote:

Wow- I am sorry I missed this call. So- just so I am clear- this is the generic “openSHR” not specifically for Rwanda correct?

I have lots of comments here- but not sure if they are supposed to be going in email or in a wiki discussion. So can someone let me know please?

I will be brief this round.

We need to be VERY careful and picky about what “observations” are included in a SHR- they should be few, and should be quantified (my same long standing argument that a CHW observation of “anemia” is not the same as a clinicians, which is still not the same as a diagnosis of anemia based on a low hgb.)

I would suggest we start simple and add complexity as necessary. Lab would be the priority in my opinion.

Inclusion of allergies is good- but in my experience- almost never collected, it is best practice, so we should aspire to include it.

We need to also differentiate items that are more permanent (such as allergies, some diagnoses such as type 1 diabetes etc) and those that are transient- such as malaria diagnosis in May 2012.

Liz

On Wed, Mar 13, 2013 at 10:02 AM, Ryan ryan@jembi.org wrote:

Hi All,

We had a great discussion on Monday around the OpenSHR work. I seems one of the biggest sticking points was the fact that we don’t, as a group, understand what information should be stored in a Shared health Record. We made some progress on the call, but I would like to generate some discussion around this so that we can converge on this.

This is my understanding of what we mentioned:

We should store:

  • Items related to a patient daily care, such as
    • Care summaries
    • Allergies
    • Medications that the patient is on
    • Observations
    • Referrals
  • Lab results (without full lab sample details)
    Have we missed anything here or does anyone disagree with the list presented here?

Derek, also captured some of the key events of when we would want to capture information in the SHR. These are listed below:

  • capture clinical observations about a subject of care (weight, BP, temperature, etc.)
  • capture diagnoses (e.g. pregnant, HIV+, etc.); this may have the effect of “enrolling” them in a guideline-based care plan
  • drug order
  • drug dispense
  • lab order (including DI)
  • lab result
  • referral (escalation of care)
  • discharge summary (from acute care back to community and/or primary care)
    So, overall, how do people feels about these lists? Is this the sort of data and the events that we would want to support? Are there any items missing from these lists?

Cheers,

Ryan

Ryan Crichton

Senior Software Developer, Jembi Health Systems | SOUTH AFRICA

–
Mobile: +27845829934 | Skype: ryan.graham.crichton
E-mail: ryan@jembi.org

You received this message because you are subscribed to the Google Groups “Shared Health Record (OpenHIE)” group.

To unsubscribe from this group and stop receiving emails from it, send an email to openhie-shr+unsubscribe@googlegroups.com.

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–

–
Ryan Crichton

Senior Software Developer, Jembi Health Systems | SOUTH AFRICA

Mobile: +27845829934 | Skype: ryan.graham.crichton
E-mail: ryan@jembi.org