EHR IP Summary

Description

This EHR Interoperability Profile describes the process for a user / system to record a patient Event or Events in the EHRi system. A patient’s Events are created in the EHRi system by health care point of service systems either when the patient is present or after the patient has received a health service such as Allergies, Blood Profiles, Critical Observations, Discharge Summaries, Encounter Records, Referrals etc

EHR IP Put Event will be initiated by trigger event in a PoS application to marshal the patient data to be recorded as different types of events in the EHR. For example, when a PoS creates an Encounter for a patient, this will initiate an interaction to create the Encounter in the EHRi system as an Event with encounter attributes provided as optional parameters to this process. If subsequent patient Events are linked to one Encounter, it is the PoS system’s responsibility to provide the common attribute values to ensure the Events created in the EHR can be viewed / retrieved as belonging to the same Encounter.

EHR IP Put Event will use the communication step EHRCS Put Event to record an Event with all of its associated Events as a single logical record in the EHR Shared Care Record domain repository that can be retrieved using EHR IP Get Event.

In the case where multiple types of Events collected from different data sources to be recorded as a composite interaction with the EHRi system, this service is responsible for marshalling all the data and resources to manage multiple invocations of EHRCS Put Event messages.

EHRIP Put Event links each newly created Event to a Patient as a Patient Role to identify the patient’s role while receiving this service from this provider at this health service location.

The EHRi system will create a unique entry in the EHR Index for each newly created Event using attributes derived from EHRIP Put Event payload information as well as already established user and location identifiers.

Patient events recorded by PoS systems in EHRi Domain Repositories external to the EHR Shared Care Record domain repository such as DI, Drug and Lab will only be indexed in the EHRi Index. This will allow users to search a centralized EHR Index to retrieve patient clinical data from multiple domain sources. See EHRIP Index Event for a description of this service.

If the patient’s consent / data masking directives are included with this Event, they are recorded in the patient’s consent record in the Consent Registry.

Examples

The following is a list of example services that would use the generic “Put Event” type of interoperability profile pattern to record patient clinical data.

EHR Business Requirement reference

This EHR IP is used by the following Clinical Activities:

Actors

This EHR IP includes interactions between the following actors:

Preconditions

• The user is already authenticated and authorized to access the EHRi system and has identified the patient in the POS system to store a clinical Event.
• The service location id and the provider id that requested this process have been established in previous interactions.

Process Steps

User has selected the desired patient and proceeds with the following steps.

Issues

Assumptions / Constraints

Notes

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