Date

December 2012

Document Type

Capstone

Degree Name

M.B.I.

Department

Dept. of Medical Informatics and Clinical Epidemiology

Institution

Oregon Health & Science University

Abstract

Background: Health Level Seven, an international standards development organization, first developed a Functional Model for Electronic Health Record Systems (EHR-S) in 2004 to provide common language for support functions required for the healthcare setting. Functional profiles, such as the Child Health Functional Profile released in 2008 as a Draft Standard for Trial Use (DSTU), are based upon the EHR-S Functional Model but detail domain specific functions and conformance requirements to support the provision of healthcare in a defined setting. Derived functional profiles, which conform to one or more base functional profiles, inherit and adhere to all the rules of the base profile(s), but add additional requirements and conformance criteria to address more specific functions for care in a given setting or subdomain. This project represents the pre-ballot content for a Draft Standard for Trial Use of the Health Level Seven Child Health Neonatology Functional Profile (Neonatology Functional Profile). Methods: The HL7 Neonatology Functional Profile, derived from the Child Health Functional Profile, was developed following serial input from subject matter experts in neonatology, pediatrics, and informatics. References to other existing policy statements, standards, guidelines, and relevant reference models in development were also established. Results: Novel functional content was developed describing maternal record elements relevant to the infant, capturing vital signs and episodic events, screening and decision support, nutrition, respiratory support, and management of unique circumstance for patient registration and medication administration. Terminology was updated to reflect currently published policy statements by the American Academy of Pediatrics. Relevance to the Agency for Health Research and Quality (AHRQ) Model Children’s Electronic Health Record Format and the Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition (i.e., “Meaningful Use”) was also noted for future harmonization efforts. Conclusion: The HL7 Child Health Neonatology Functional Profile provides a detailed reference for unique and recommended content for the provision of care of neonates and infants in the intensive care setting. This work may be leveraged by as a distinct DSTU for future HL7 balloting, or as a tool for the clarification and harmonization of related electronic health record functions.

Identifier

doi:10.6083/M4HD7SPR

School

School of Medicine

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