J Am Med Inform Assoc - Are Meaningful Use Stage 2 certified EHRs ready for interoperability? Findings from the SMART C-CDA Collaborative.

Tópicos

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{ extract(1171) text(1153) clinic(932) }
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Resumo

CKGROUND AND OBJECTIVE: Upgrades to electronic health record (EHR) systems scheduled to be introduced in the USA in 2014 will advance document interoperability between care providers. Specifically, the second stage of the federal incentive program for EHR adoption, known as Meaningful Use, requires use of the Consolidated Clinical Document Architecture (C-CDA) for document exchange. In an effort to examine and improve C-CDA based exchange, the SMART (Substitutable Medical Applications and Reusable Technology) C-CDA Collaborative brought together a group of certified EHR and other health information technology vendors.MATERIALS AND METHODS: We examined the machine-readable content of collected samples for semantic correctness and consistency. This included parsing with the open-source BlueButton.js tool, testing with a validator used in EHR certification, scoring with an automated open-source tool, and manual inspection. We also conducted group and individual review sessions with participating vendors to understand their interpretation of C-CDA specifications and requirements.RESULTS: We contacted 107 health information technology organizations and collected 91 C-CDA sample documents from 21 distinct technologies. Manual and automated document inspection led to 615 observations of errors and data expression variation across represented technologies. Based upon our analysis and vendor discussions, we identified 11 specific areas that represent relevant barriers to the interoperability of C-CDA documents.CONCLUSIONS: We identified errors and permissible heterogeneity in C-CDA documents that will limit semantic interoperability. Our findings also point to several practical opportunities to improve C-CDA document quality and exchange in the coming years.

Resumo Limpo

ckground object upgrad electron health record ehr system schedul introduc usa will advanc document interoper care provid specif second stage feder incent program ehr adopt known meaning use requir use consolid clinic document architectur ccda document exchang effort examin improv ccda base exchang smart substitut medic applic reusabl technolog ccda collabor brought togeth group certifi ehr health inform technolog vendorsmateri method examin machineread content collect sampl semant correct consist includ pars opensourc bluebuttonj tool test valid use ehr certif score autom opensourc tool manual inspect also conduct group individu review session particip vendor understand interpret ccda specif requirementsresult contact health inform technolog organ collect ccda sampl document distinct technolog manual autom document inspect led observ error data express variat across repres technolog base upon analysi vendor discuss identifi specif area repres relev barrier interoper ccda documentsconclus identifi error permiss heterogen ccda document will limit semant interoper find also point sever practic opportun improv ccda document qualiti exchang come year

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