Computer-to-Computer

It’s the “Era of Patient Empowerment” — Are we Ready for Patients to Contribute to their Electronic Medical Records?

Guest Editorial by Joy Kuhl, Executive Director, Health Story Project, an HL7 Affiliate

Medical practices are creatively looking for ways to reduce overhead and improve the accuracy of information in patient medical records by empowering patients to electronically complete certain tasks online, such as filling out registration forms, health history forms, and other types of common clinical documents. Often, this is done through a secure web interface controlled by the patient such as a patient portal or a personal health record.

As more and more practices incorporate Electronic Health Record (EHR) system technology into their practice workflow, a new window of opportunity is opened for importing structured, patient-provided information into their own medical records.

Use of standards for electronic clinical document exchange is increasing in adoption — due in part to the inclusion of clinical document standards in national requirements for Meaningful Use of EHR technology. The same standards that are used for exchanging information in clinical documents such as a History & Physical, Discharge Summary, or Continuity of Care Document can now be applied to documents generated by patients.

This is what a project team within the HL7 International data standards organization is pursuing in a recently launched project to create a standard for “Patient Authored Documents” using the HL7 Clinical Document Architecture (CDA®) standard.  In many cases, the project team plans to re-use existing templates within the current Consolidated CDA Template Library with minimal modification. It’s a first step intended to get the industry thinking about using available standards for collecting and sending patient generated information.

The Health Story Project, a nonprofit industry collaborative that has supported the development of HL7 CDA standards for common clinical documents is pleased to support this project. It believes that patient contribution to their own medical records increases the likelihood that complete patient stories will be available electronically.

The HL7 Patient Authored Documents project will be presented to HL7 for ballot January 2013, with plans for publication May 2013.  The project team welcomes input from clinicians, and encourages those interested in serving as an advisor on the project to contact caregivers@HL7.org.

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