A few associates and myself are starting an EMR project (Electronic Medical Records). I have heard talk in the past - and more so lately - about a standard record format - to facilitate the transferring of records when appropriate (HIPAA) from one facility to another. Has anyone seen any information on this?
一些同事和我自己正在启动EMR项目（电子医疗记录）。我听过过去的谈话 - 更近期 - 关于标准记录格式 - 以便于在适当时将记录（HIPAA）从一个设施转移到另一个设施。有没有人见过这方面的任何信息？
9 个解决方案
#1
14
You can look to HL7 for interoperability between systems (http://www.hl7.org/). Patient demographic information and textual notes can be passed. I've been out of the EMR space too long to know if any standards groups have done anything interesting of late. A standard format that maintains semantic meaning is a really, really difficult problem. See SnoMed (http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html) for one long-running ontology effort -- barely the start of a rich interchange format.
您可以通过HL7查看系统之间的互操作性（http://www.hl7.org/）。可以传递患者人口统计信息和文本注释。我已经离开了EMR领域太久了，不知道最近有没有标准组织做过任何有趣的事情。保持语义的标准格式是一个非常非常困难的问题。有关长期运行的本体论工作，请参阅SnoMed（http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html） - 几乎不是丰富的交换格式的开始。
A word of warning from someone who spent several years with an upstart EMR vendor...This is a very hard business to be in. Sales cycles for large health systems literally can take years, and the amount of hand-holding required for smaller medical practices can quickly erode margins. Integration with existing practice management systems is non-standard, even if those vendors claim otherwise. More and more issues abound. I'm not sure that it's a wise space for an unfunded start-up to enter.
来自与新兴EMR供应商共度数年的人的警告......这是一项非常艰难的业务。大型医疗系统的销售周期可能需要数年时间，以及小型医疗所需的手持量实践可以迅速侵蚀利润。与现有的实践管理系统集成是非标准的，即使这些供应商另有要求。越来越多的问题比比皆是。我不确定这是一个没有资金的初创公司进入的明智空间。
#2
8
I think it's an error to consider HL7 to be a standard in the sense you seem to mean. It is heavily customized and can be quite different from one customer to the next. It's one of those standards with too much flexibility.
我认为将HL7视为您似乎意味着的标准是错误的。它是大量定制的，可以从一个客户到另一个客户完全不同。这是具有太多灵活性的标准之一。
I recommend you read the standard (which should take you a while), then try to find a community of developers working with the standard. Ask them for horror stories, and be prepared for what you'll hear.
我建议你阅读标准（这应该花一些时间），然后尝试找到一个使用该标准的开发人员社区。向他们询问恐怖故事，并为你所听到的内容做好准备。
#3
4
A month late, but...
一个月晚了，但......
The standard to shoot for is definitely HL7. It is used in many fields, so is highly customizable but there is a well defined standard for healthcare. Each message (ACK, DSR MCF), segment (PID, PV1, OBR, MSH, etc), sequence and event type (A08, A12, A36) has a specific meaning regardless of your system of choice.
拍摄的标准绝对是HL7。它用于许多领域，因此可高度定制，但有一个明确的医疗保健标准。无论您选择何种系统，每条消息（ACK，DSR MCF），段（PID，PV1，OBR，MSH等），序列和事件类型（A08，A12，A36）都具有特定含义。
We haven't had a problem interfacing MiSYS, Statlan, Oacis, Epic, MUSE, GE Centricity/Lastword and others sending DICOM, ADT, PACS information between the systems we have in use. Most of these systems will be set up with an interface engine to tweak messages where needed, so adding a way to filter HL7 messages as they come through to your system, and as they go out to the downstreams, would be a must.
我们没有遇到与MiSYS，Statlan，Oacis，Epic，MUSE，GE Centricity / Lastword以及其他人在我们使用的系统之间发送DICOM，ADT，PACS信息的问题。这些系统中的大多数都将设置一个接口引擎来根据需要调整消息，因此添加一种方法来过滤HL7消息，因为它们进入您的系统，并且当它们到达下游时，将是必须的。
Even if there would be a new "presidential standard" for interoperability, and I would hazard a guess that it will be HL7 anyway, I would build the system with HL7 messaging as this is currently the industry accepted standard.
即使有一个新的“总统标准”用于互操作性，我也会猜测它将是HL7，我会用HL7消息来构建系统，因为这是目前业界公认的标准。
#4
3
While solving interoperability, you shouldn't care only about the interchange format, the local storage formats should be standardized also, to simplify the transformation to the interchange format and vice versa.
在解决互操作性时，您不应该只关心交换格式，本地存储格式也应该标准化，以简化到交换格式的转换，反之亦然。
openEHR is a great format for storage, it is more expressive than HL7 v2, v3 and CDA, so it can be transformed easily to any of those. The specs are open and here: http://openehr.org/programs/specification/releases/1.0.2
openEHR是一种很好的存储格式，它比HL7 v2，v3和CDA更具表现力，因此它可以轻松转换为任何一种。规范是公开的，在这里：http：//openehr.org/programs/specification/releases/1.0.2
For the interchange format, any of HL7 v2, v3 and CDA are good. Also consider CCR and CCD. http://www.aafp.org/practice-management/health-it/astm.html
对于交换格式，HL7 v2，v3和CDA中的任何一个都是好的。还要考虑CCR和CCD。 http://www.aafp.org/practice-management/health-it/astm.html
#5
2
If you want to go outside HL7 thinking and are looking for an comprehensive EMR or EHR with a specified record format rather than a record extract message interchange format, then have a look at openEHR, http://www.openehr.org/. The ISO 13606 extract standard is (almost) a subset of openEHR. You will also find open source reference libraries and openEHR implementations of different maturity available in Java, .NET, Ruby, Python, Groovy etc.
如果您想在HL7之外思考并且正在寻找具有指定记录格式的综合EMR或EHR而不是记录提取消息交换格式，那么请查看openEHR，http：//www.openehr.org/。 ISO 13606提取标准（几乎）是openEHR的一个子集。您还可以在Java，.NET，Ruby，Python，Groovy等中找到不同成熟度的开源参考库和openEHR实现。
Some organisations are also producing HL7 artifacts like CDA as output from openEHR based EHR/EMR systems.
一些组织也正在生产像CDA这样的HL7工件，作为基于openEHR的EHR / EMR系统的输出。
#6
1
Have a look at the Continuity of Care Record--IIRC, that's what Google Health uses for input. It's not an HL7-family standard (there's a competing HL7-family standard--don't recall what it's called off-top).
看一下护理连续记录 - IIRC，这就是Google Health用于输入的内容。它不是HL7系列标准（有一个竞争的HL7系列标准 - 不记得它被称为off-top）。
#7
1
There likely will not be a standard medical record format until the government dictates the format of one and requires its use by force of law.
在*规定一种格式并要求其依法使用之前，可能不会有标准的医疗记录格式。
That almost assuredly will not happen without socialized national health care. So in reality zero chance.
如果没有社会化的国家医疗保健，这几乎肯定不会发生。所以实际上是零机会。
#8
1
its correct answer but i think some add about meaningful use of emr..... Officials Announce ‘Meaningful Use,’ EHR Certification Criteria Last week, CMS released proposed regulations defining the “meaningful use” of electronic health records, Reuters reports (Wutkowski/Heavey, Reuters, 12/31/09).
正确答案，但我认为有些人对emr的有意义使用有所补充.....官方宣布“有意义的使用”，EHR认证标准上周，CMS发布了规定“有意义地使用”电子健康记录的法规，路透社报道（Wutkowski） / Heavey，路透社，12/31/09）。
In addition, the Office of the National Coordinator for Health IT released an interim final rule describing the required certification standards for EHR technology (Simmons, HealthLeaders Media, 12/31/09).
此外，国家卫生信息技术协调办公室发布了一份临时最终规则，描述了EHR技术所需的认证标准（Simmons，HealthLeaders Media，12/31/09）。
Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs will qualify for incentive payments through Medicaid and Medicare.
根据2009年联邦经济刺激计划，证明有效使用经认证的EHR的医疗保健提供者将有资格通过Medicaid和Medicare获得奖励。
Officials will offer a 60-day public comment period after both regulations are published in the Federal Register on Jan. 13. The interim final rule on EHR certification is scheduled to take effect 30 days after publication (Goedert, Health Data Management, 12/30/09). http://www.myemrstimulus.com/
在两项法规于1月13日在联邦纪事上公布后，官员将提供为期60天的公众意见征询期。关于EHR认证的临时最终规则计划在公布后30天生效（Goedert，Health Data Management，12/30） / 09）。 http://www.myemrstimulus.com/
#9
0
This is a very hard problem because data collection starts with an MD and the only coding they know (ICD and CPT) is all about billing, not anything likely to be of use between providers (esp. in a form where the MD can be held legally liable). And they hate even that much paperwork.
这是一个非常困难的问题，因为数据收集从MD开始，他们所知道的唯一编码（ICD和CPT）都是关于计费的，而不是提供者之间可能使用的任何东西（特别是可以持有MD的形式）法律责任）。他们甚至讨厌那么多文书工作。
Add to that the fact that HIPAA dictates that the patient not the provider owns the data. Not that they could understand it or do anything useful with it if they had it.
除此之外，HIPAA规定患者不是提供者拥有数据。并非如果他们拥有它，他们可以理解它或做任何有用的事情。
Good luck. Whatever happens will result from coercion by the govt and be a long long time coming IMHO.
祝你好运。无论发生什么事都是由*强制造成的，并且需要很长时间才会有恕我直言。
Interestingly the one source of solid medical info turns out to be the VA (because they don't have the adversarial issues of payment and legal liability.) Go figure. That might be a good place to start for a standard with any existing data and some momentum, though. Here's another question with some info.
有趣的是，固体医疗信息的一个来源证明是VA（因为他们没有付款和法律责任的对抗性问题。）去图。不过，这可能是开始制定任何现有数据和一些动力的标准的好地方。这是另一个问题和一些信息。
#1
14
You can look to HL7 for interoperability between systems (http://www.hl7.org/). Patient demographic information and textual notes can be passed. I've been out of the EMR space too long to know if any standards groups have done anything interesting of late. A standard format that maintains semantic meaning is a really, really difficult problem. See SnoMed (http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html) for one long-running ontology effort -- barely the start of a rich interchange format.
您可以通过HL7查看系统之间的互操作性（http://www.hl7.org/）。可以传递患者人口统计信息和文本注释。我已经离开了EMR领域太久了，不知道最近有没有标准组织做过任何有趣的事情。保持语义的标准格式是一个非常非常困难的问题。有关长期运行的本体论工作，请参阅SnoMed（http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html） - 几乎不是丰富的交换格式的开始。
A word of warning from someone who spent several years with an upstart EMR vendor...This is a very hard business to be in. Sales cycles for large health systems literally can take years, and the amount of hand-holding required for smaller medical practices can quickly erode margins. Integration with existing practice management systems is non-standard, even if those vendors claim otherwise. More and more issues abound. I'm not sure that it's a wise space for an unfunded start-up to enter.
来自与新兴EMR供应商共度数年的人的警告......这是一项非常艰难的业务。大型医疗系统的销售周期可能需要数年时间，以及小型医疗所需的手持量实践可以迅速侵蚀利润。与现有的实践管理系统集成是非标准的，即使这些供应商另有要求。越来越多的问题比比皆是。我不确定这是一个没有资金的初创公司进入的明智空间。
#2
8
I think it's an error to consider HL7 to be a standard in the sense you seem to mean. It is heavily customized and can be quite different from one customer to the next. It's one of those standards with too much flexibility.
我认为将HL7视为您似乎意味着的标准是错误的。它是大量定制的，可以从一个客户到另一个客户完全不同。这是具有太多灵活性的标准之一。
I recommend you read the standard (which should take you a while), then try to find a community of developers working with the standard. Ask them for horror stories, and be prepared for what you'll hear.
我建议你阅读标准（这应该花一些时间），然后尝试找到一个使用该标准的开发人员社区。向他们询问恐怖故事，并为你所听到的内容做好准备。
#3
4
A month late, but...
一个月晚了，但......
The standard to shoot for is definitely HL7. It is used in many fields, so is highly customizable but there is a well defined standard for healthcare. Each message (ACK, DSR MCF), segment (PID, PV1, OBR, MSH, etc), sequence and event type (A08, A12, A36) has a specific meaning regardless of your system of choice.
拍摄的标准绝对是HL7。它用于许多领域，因此可高度定制，但有一个明确的医疗保健标准。无论您选择何种系统，每条消息（ACK，DSR MCF），段（PID，PV1，OBR，MSH等），序列和事件类型（A08，A12，A36）都具有特定含义。
We haven't had a problem interfacing MiSYS, Statlan, Oacis, Epic, MUSE, GE Centricity/Lastword and others sending DICOM, ADT, PACS information between the systems we have in use. Most of these systems will be set up with an interface engine to tweak messages where needed, so adding a way to filter HL7 messages as they come through to your system, and as they go out to the downstreams, would be a must.
我们没有遇到与MiSYS，Statlan，Oacis，Epic，MUSE，GE Centricity / Lastword以及其他人在我们使用的系统之间发送DICOM，ADT，PACS信息的问题。这些系统中的大多数都将设置一个接口引擎来根据需要调整消息，因此添加一种方法来过滤HL7消息，因为它们进入您的系统，并且当它们到达下游时，将是必须的。
Even if there would be a new "presidential standard" for interoperability, and I would hazard a guess that it will be HL7 anyway, I would build the system with HL7 messaging as this is currently the industry accepted standard.
即使有一个新的“总统标准”用于互操作性，我也会猜测它将是HL7，我会用HL7消息来构建系统，因为这是目前业界公认的标准。
#4
3
While solving interoperability, you shouldn't care only about the interchange format, the local storage formats should be standardized also, to simplify the transformation to the interchange format and vice versa.
在解决互操作性时，您不应该只关心交换格式，本地存储格式也应该标准化，以简化到交换格式的转换，反之亦然。
openEHR is a great format for storage, it is more expressive than HL7 v2, v3 and CDA, so it can be transformed easily to any of those. The specs are open and here: http://openehr.org/programs/specification/releases/1.0.2
openEHR是一种很好的存储格式，它比HL7 v2，v3和CDA更具表现力，因此它可以轻松转换为任何一种。规范是公开的，在这里：http：//openehr.org/programs/specification/releases/1.0.2
For the interchange format, any of HL7 v2, v3 and CDA are good. Also consider CCR and CCD. http://www.aafp.org/practice-management/health-it/astm.html
对于交换格式，HL7 v2，v3和CDA中的任何一个都是好的。还要考虑CCR和CCD。 http://www.aafp.org/practice-management/health-it/astm.html
#5
2
If you want to go outside HL7 thinking and are looking for an comprehensive EMR or EHR with a specified record format rather than a record extract message interchange format, then have a look at openEHR, http://www.openehr.org/. The ISO 13606 extract standard is (almost) a subset of openEHR. You will also find open source reference libraries and openEHR implementations of different maturity available in Java, .NET, Ruby, Python, Groovy etc.
如果您想在HL7之外思考并且正在寻找具有指定记录格式的综合EMR或EHR而不是记录提取消息交换格式，那么请查看openEHR，http：//www.openehr.org/。 ISO 13606提取标准（几乎）是openEHR的一个子集。您还可以在Java，.NET，Ruby，Python，Groovy等中找到不同成熟度的开源参考库和openEHR实现。
Some organisations are also producing HL7 artifacts like CDA as output from openEHR based EHR/EMR systems.
一些组织也正在生产像CDA这样的HL7工件，作为基于openEHR的EHR / EMR系统的输出。
#6
1
Have a look at the Continuity of Care Record--IIRC, that's what Google Health uses for input. It's not an HL7-family standard (there's a competing HL7-family standard--don't recall what it's called off-top).
看一下护理连续记录 - IIRC，这就是Google Health用于输入的内容。它不是HL7系列标准（有一个竞争的HL7系列标准 - 不记得它被称为off-top）。
#7
1
There likely will not be a standard medical record format until the government dictates the format of one and requires its use by force of law.
在*规定一种格式并要求其依法使用之前，可能不会有标准的医疗记录格式。
That almost assuredly will not happen without socialized national health care. So in reality zero chance.
如果没有社会化的国家医疗保健，这几乎肯定不会发生。所以实际上是零机会。
#8
1
its correct answer but i think some add about meaningful use of emr..... Officials Announce ‘Meaningful Use,’ EHR Certification Criteria Last week, CMS released proposed regulations defining the “meaningful use” of electronic health records, Reuters reports (Wutkowski/Heavey, Reuters, 12/31/09).
正确答案，但我认为有些人对emr的有意义使用有所补充.....官方宣布“有意义的使用”，EHR认证标准上周，CMS发布了规定“有意义地使用”电子健康记录的法规，路透社报道（Wutkowski） / Heavey，路透社，12/31/09）。
In addition, the Office of the National Coordinator for Health IT released an interim final rule describing the required certification standards for EHR technology (Simmons, HealthLeaders Media, 12/31/09).
此外，国家卫生信息技术协调办公室发布了一份临时最终规则，描述了EHR技术所需的认证标准（Simmons，HealthLeaders Media，12/31/09）。
Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs will qualify for incentive payments through Medicaid and Medicare.
根据2009年联邦经济刺激计划，证明有效使用经认证的EHR的医疗保健提供者将有资格通过Medicaid和Medicare获得奖励。
Officials will offer a 60-day public comment period after both regulations are published in the Federal Register on Jan. 13. The interim final rule on EHR certification is scheduled to take effect 30 days after publication (Goedert, Health Data Management, 12/30/09). http://www.myemrstimulus.com/
在两项法规于1月13日在联邦纪事上公布后，官员将提供为期60天的公众意见征询期。关于EHR认证的临时最终规则计划在公布后30天生效（Goedert，Health Data Management，12/30） / 09）。 http://www.myemrstimulus.com/
#9
0
This is a very hard problem because data collection starts with an MD and the only coding they know (ICD and CPT) is all about billing, not anything likely to be of use between providers (esp. in a form where the MD can be held legally liable). And they hate even that much paperwork.
这是一个非常困难的问题，因为数据收集从MD开始，他们所知道的唯一编码（ICD和CPT）都是关于计费的，而不是提供者之间可能使用的任何东西（特别是可以持有MD的形式）法律责任）。他们甚至讨厌那么多文书工作。
Add to that the fact that HIPAA dictates that the patient not the provider owns the data. Not that they could understand it or do anything useful with it if they had it.
除此之外，HIPAA规定患者不是提供者拥有数据。并非如果他们拥有它，他们可以理解它或做任何有用的事情。
Good luck. Whatever happens will result from coercion by the govt and be a long long time coming IMHO.
祝你好运。无论发生什么事都是由*强制造成的，并且需要很长时间才会有恕我直言。
Interestingly the one source of solid medical info turns out to be the VA (because they don't have the adversarial issues of payment and legal liability.) Go figure. That might be a good place to start for a standard with any existing data and some momentum, though. Here's another question with some info.
有趣的是，固体医疗信息的一个来源证明是VA（因为他们没有付款和法律责任的对抗性问题。）去图。不过，这可能是开始制定任何现有数据和一些动力的标准的好地方。这是另一个问题和一些信息。