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Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...
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Health Information Technology and Healthcare Information System

Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Standards of Care I01:22

Standards of Care I

Federal statutes profoundly impact nursing practice, providing critical guidelines to ensure patient care is equitable, accessible, and of the highest quality. The following laws address distinct aspects of healthcare provision and patient rights:
Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness...
Integrated Healthcare System01:20

Integrated Healthcare System

An integrated healthcare system (IHS) is a set of organizations that provides for or arranges to provide coordinated and continuous service to a defined population. The IHS takes responsibility for that particular population's health status and outcome, both clinically and fiscally. An integrated healthcare system is a well-organized, well-coordinated, and collaborative network. The integrated delivery system is a network that connects different healthcare providers to deliver organized,...

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Related Experiment Video

Updated: May 24, 2026

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
09:00

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

Published on: April 13, 2021

Extending Interoperable Emergency Department Data: Standards-Based Design and Evaluation in AKTIN.

Hauke Heidemeyer1, Emily Wedek1, Raphael W Majeed1,2

  • 1Institute of Medical Informatics, Medical Faculty of RWTH Aachen University, Germany.

Studies in Health Technology and Informatics
|May 23, 2026
PubMed
Summary

This study introduces a "wildcard" mechanism for extending Health Level Seven Clinical Document Architecture (HL7 CDA) datasets, improving flexibility in electronic health record systems. This innovation allows for the structured addition of new clinical data without compromising interoperability.

Keywords:
CDAData WarehousingEmergency ServiceFHIRHealth Level Seven InternationalHospitalMedical InformaticsSemantic Interoperability

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Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
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Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform

Published on: April 12, 2021

Related Experiment Videos

Last Updated: May 24, 2026

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
09:00

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

Published on: April 13, 2021

Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
07:13

Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform

Published on: April 12, 2021

Area of Science:

  • Health Informatics
  • Clinical Data Standards
  • Interoperability

Background:

  • Modifying interoperable healthcare datasets and infrastructures is challenging, hindering the integration of new clinical concepts.
  • Existing systems require flexible, standards-compliant methods to incorporate evolving documentation needs without disrupting established infrastructures.

Purpose of the Study:

  • To enable controlled extensibility of Health Level Seven Clinical Document Architecture (HL7 CDA) and Fast Healthcare Interoperability Resources (FHIR)-based emergency department datasets within the AKTIN infrastructure.
  • To introduce a "wildcard" mechanism for the structured addition of new variables, ensuring flexibility and standards compliance.

Main Methods:

  • Implementation of two open CDA entry templates integrated into the AKTIN data-processing pipeline.
  • Development of corresponding FHIR profiles for semantic alignment across HL7 CDA and FHIR standards.
  • Evaluation using synthetic CDA documents to test processing through validation, transformation, and storage.

Main Results:

  • Demonstrated standards-conformant processing of synthetic CDA documents within the AKTIN data warehouse.
  • Successfully integrated new CDA entry templates and FHIR profiles into the existing data pipeline.
  • Validated the feasibility of the wildcard mechanism for controlled extensibility.

Conclusions:

  • The proposed wildcard mechanism offers a novel approach for controlled extensibility in HL7 CDA infrastructures, complementing FHIR's extension options.
  • This method preserves interoperability and data provenance within defined boundaries, facilitating future governance and evaluation.
  • Establishes a foundation for adapting clinical documentation to emerging requirements while maintaining system integrity.