Clinical documents are an electronic representation of clinical information prepared for two main purposes:
- To support interoperability between systems by providing a standard, extensible machine-readable format for representing clinical data
- To provide a human-readable format for clinical data that is consistent with the machine-readable format within the same document
Why use clinical documents?
- They reduce cost in reproducing and transporting paper records.
- They can improve the speed and accuracy of data absorption into other systems.
- They can provide patients with an accurate, readable record of some or all of their medical record.
- May be easier to generate than other forms of e-data.
- At the point of care, they reduce hassle to patient in completing new provider registration materials (that awful clipboard), allow physicians to receive critical health data at transfer of care, and improve the quality of care through complete and timely information.
How do clinical documents compare to other data formats?
For years health IT professionals have been enabling interoperability between systems, both within organizations and between organizations. There are two approaches to preparing and processing information that originates in one system and is destined for another. The first approach is data-centered:
The second approach is document-centered:
Data stored in a document-centered file can be extracted and processed since the underlying electronic data is structured and machine-readable. The purpose of an electronic document, however, is to maintain the integrity of the data represented in it at the moment in time it was produced.
What does this mean to public health?
Clinical documents have become a key strategy in promoting and using electronic information to support patient care. They provide clinicians with a critical tool for quickly and accurately moving data between parties to support a wide variety of clinical needs and information-sharing requirements. Clinical summaries – a form of clinical document – are prominent in the Centers for Medicare and Medicaid Services (CMS) EHR Incentive Programs to encourage eligible professionals and hospitals to implement health information technology, in particular electronic health record (EHR) systems and their “meaningful use” (MU).
- The EHR vendor community has placed increasing emphasis on clinical documents as the most desired format for interoperability between systems. More energy and focus will likely be placed there in the future than in data-centered approaches.
- The public health measures related to meaningful use explicitly require HL7 v2 messages and not clinical documents. This produces a disincentive for public health agencies to add clinical document support to their capabilities.
- Data-centered approaches continue to dominate the public health interoperability landscape, and supporting multiple approaches can place a large burden on public health agencies’ limit technical capabilities.
- Different systems may use different coding and semantic standards, making exchange with retention of clinical meaning more challenging. A lot of work has been done within HL7 v2 messaging standards to ensure semantic interoperability. Similar care needs to be taken within the clinical document community.