بررسی استانداردهای ساختار، محتوا و واژه‌نامه پرونده الکترونیک سلامت در سازمان‌های منتخب و ارائه الگوی مناسب برای ایران

Introduction: Electronic health record (EHR) is defined as digitally stored healthcare information about an individual's life time with the purpose of supporting continuity of care, education, and research. Major issue that needs to be addressed in order to accomplish with sharing and exchange is the development and use of content and structure standards in the EHR. Based on, this investigation has done on EHR content, structure and vocabulary standards and designs a suitable model for Iran. Methods: This cross section comparative study was conducted in the year 2005-2006. The means for collecting data were check list and questionnaire. Participants include ASTM, HL7, and CEN TC. Data analysis was done by way of qualitative methods and comparative tables. Based on the standards advantages and limitations, a model was recommended. Using Delphi systems, a workable model for content, structure, and vocabulary of EHR was presented. Results: Study shows that there are three main organizations that create standards related to EHR: HL7, CEN TC251, and ASTM E31. HL7 dose not have a compressive standards for content and structure, but in two sections, namely the Clinical Document Architecture (CDA) and the Document Ontology Task force (DOTF) proposal give some ideas regarding EHR and used vocabulary standards such as SNOMED, LOINC, and UMLS. CEN TC 251 defines the structure of an EHR but not it's content. Pre-standard ENV13606-1 suggests structure EHR and ENV13606-2 partially suggests some content of the EHR and dose not any vocabulary standard. ASTM E1384 "Standard Guide for Content and Structure of the Electronic Health Record" partially defines an EHR content and structure and used vocabulary standards such as ICD9, SNOMED, READ. Conclusions: Theses organizations paid a lot attention to the structure, content, and vocabulary standards. Based on theirs weakness and capabilities, a model was recommended and finalized using the Delphi technique.