Standards for the content of the electronic health record

A descriptive, cross-sectional study was performed to measure the awareness, use, and validity of the minimum content recommended in the American Society for Testing and Materials (ASTM) standards for content and structure of electronic health records. A Web-based survey was developed and used as the primary tool to collect this data. Data was collected from a random sample of healthcare facilities from across the country, vendors, and volunteers. Thirteen percent of respondents had an electronic health record (EHR) system fully in place while 10 percent did not have or did not plan to have an EHR system. The majority of respondents (62 percent) used a vendor system for EHR development. The majority of respondents were not aware or slightly aware of the ASTM E1384 standards. Respondents believed that the minimum data elements outlined in the ASTM standards should be included in all EHR systems. Data items such as educational level, patient instructions related to disposition, problem numbers, treatment plan ID, provider agency ID code, and medication date of last refill should not always be included in EHR systems.