Electronic Health Care Record Support Action











Electronic Health Care Record Architecture




What should one know about …














December 1998




As computers become more widely used in Healthcare, increasing quantities of clinical data about the care of patients is being held electronically, complementing and gradually replacing paper records. It is vital for the future care of patients that these Electronic Health Care Records (EHCRs) are of good quality, faithfully preserving the data as originally intended, as well as permitting analysis of the data, which can come from many sources. At the same time there are important ethical, legal, security, and educational requirements which need to be met.


The Electronic Health Care Record-Support Action (EHCR-SupA), a project sponsored by the Commission of the European Union and a large number of European Institutions[1] is contributing to a body of Research and Standardisation work that is addressing the need for a generic Architecture to describe Electronic Healthcare Records in such a way that they can safely be communicated and shared. The Project is drawing together ongoing work in this area, synthesising requirements and developing increasingly mature EHCR Architectures. An important link with the European standardisation work of European Committee for Standardisation (CEN)[2] has been established, with EHCR-SupA making specific recommendations to CEN on the scope and content of standards relating to EHCR Architecture.


The link is important because it makes available to CEN the product of considerable research into the most appropriate ways of meeting all the requirements for EHCRs of the future. The process of writing standards involves obtaining consensus from all the nations of Europe. EHCR-SupA is contributing to this consensus through dissemination and feedback. The activities are taking place within a network of "users" of EHCRs throughout Europe. These users comprise many different groups including Healthcare professionals who use EHCR systems, the industrial organisations that develop computer systems for EHCRs, professional, academic and other expert bodies, as well as government and other agencies responsible for establishing policy and for controlling the procurement of EHCR systems.





The Record (EHCR)



  Q: What is it?

A: It is a record of health care in electronic form.


Electronic form implies that it is held on one or more computer systems and is accessed and controlled by one or more computer programs.


Q: What does it contain?

A: It contains “health-related data for a person”.


This is a deliberate limitation that imposes a “boundary” around the EHCR that determines:

·          the type of data contained in the record (health-related).

·          the scope of the data (one person).


The EHCR might contain data about other people, but only where this is relevant to the health (care) of the person.

A typical record might also be expected to contain "administrative" data where this is relevant to the planning and delivery of health care to that person.


Q: What does it do?

A: It provides a medico-legal record of health care planned and given to a person.


The EHCR is deliberately created as a record by one or more persons who have the authority to do so, and who take responsibility for its contents.


Since it is a record, it can assist the future management of health care for a person by providing access to information about previous health care delivered and to stated intentions for future care.


Also since it is a record, it provides information about the quality of care planned and given.


Although the main purpose of the EHCR is clinical, other uses of the EHCR, (e.g. managerial, financial, research etc.), are not precluded.


Q: Who can use it?

A: "Persons who have the appropriate access rights"


Access rights may be different to different parts of the record. The assignment of access rights is the responsibility of the person who authorises the part of the record in question.


Q: Who owns it

A: Ownership in the legal sense differs from country to country. The aspect of ownership which is usually most important relates to who controls the record and decides how it may be used. Increasingly, the patient him/herself plays an important part in determining access to and use of the EHCR.


Q: Where is it?

A: The EHCR to which the EHCRA applies is primarily that which exists within a particular EHCR system and is usually under the control of an Institution.


We know, however, that at any one time, a person may have EHCRs on several computer systems in several places. It is useful to consider these one at a time, and then to consider separately what happens if we try to combine them.


In future, there will be a need to accommodate a “virtual distributed record”. Whilst this may imply some additional Architectural features, any constraints on the federation of records will be dictated by legal and security considerations.



The Architecture

Confusion reigns over the word Architecture. All EHCR systems have a specific architecture. In fact, all software systems have an architecture. When we talk about developing a standard architecture for EHCRs, it is sometimes, erroneously, taken to mean that we are trying to put restrictions on system architectures or trying to say how EHCR systems must be implemented. This is not the case.[3]



Q: What is it?

A: The Architecture is a model of the generic features necessary in any Electronic Health Care Record for it to be communicable and complete, retain integrity across systems, countries and time, and be a useful and effective ethico-legal record of care.


Q: How is it presented?

A: The Architecture is presented as a Conceptual Model of the Information in any Electronic Health Care Record.


Q: What does it do?

A: The EHCR Architecture models the generic features common to all EHCRs. For example, a decision has been taken that one EHCR should contain health care related data for one person. This will be modelled by the EHCR architecture.


Q: What does it NOT do?

A: The Architecture does not prescribe or dictate what specific health-related information must be contained in a record. Nor does it prescribe or dictate how any Electronic Health Care Record system is implemented.


Q: How else can it be used?

A: The EHCRA is not expected to require any particular feature for purposes other than clinical.




Potential Advantages of a Standard EHCR Architecture

The advantages of a standard EHCR Architecture for European Union (and more general for the health care enterprises of the entire world) can be very significant from the economic and political point of view. Above all however the standard Architecture is going to be the single more important factor in improving the quality of the health care delivery. Among the numerous advantages we site here a number of them that will influence positively important sectors and activities:


·        enables system developers to provide users with good quality EHCR systems

·        widens the customer base across medical specialities and professional disciplines

·        The widespread use of standards-based health record systems will allow patient data to be shared between primary and secondary care, across institutions and countries independent of language, realising the long awaited requirement for seamless care

·        will benefit undergraduate and postgraduate training

·         will encourage users (patients and medical workers) to keep good quality EHCRs and be able to share them with others

·        an increase in the quality of the care should be perceived by patients, because of more efficient shared care between health sectors. (e.g. reduction in unnecessary tests and visits because of  the possibility of  General Practitioners’ having Hospital data in their EHCRs and vice versa)

·        will greatly assist with the planning of future health care strategies and the coherence of a region's or nation's health service, by the sharing of health data and information


·        will enable monitoring of clinical care by individuals and by teams of clinicians, subject to ethical constraints. This in turn will facilitate medical audit and will lead to more effective care




The Role of the Clinical Record 

The healthcare record is an important tool supporting quality in clinical care. Just as there will be many different situations in which it is accessed, the record can play many roles in the provision of care to individuals and to populations. The following structure for the roles that the record should fulfil is based on a list originally proposed by Shortliffe & Barnett[4]:


·        Form the basis of a historical account      

·        Record preventative measures      

·        Support communication   

·        Remind clinicians about anticipated health problems and planned actions    

·        Identify deviations from expected trends 

·        Provide a legal account    

·        Enhance efficiency of health professionals          

·        Support continuing professional assessment        

·        Support medical education           

·        Accommodate decision support   

·        Access medical knowledge bases 

·        Assist with audit   

·        Support clinical research  

·        Accommodate future developments


The list includes numerous requirements that are better regarded as 'system' rather than 'architecture' requirements. In many cases, such requirements relate to the actual performance of systems (e.g. speed of reaction) or the administration and operation of the systems. They are listed here for completeness and because, in certain instances, they may have implications for the underlying architecture.




The work of the Project will be concentrated along the following axes:


·        gathering of requirements of health care professionals and support personnel 

·        collection of health care scenarios and confrontation against the Architecture

·        collaboration with other European Projects working on Health Care Telematics Applications

·        collaboration with  other standardisation efforts in Europe and the World


The outcome of the above activities will allow the Project to take the Architecture to further stages of refinement. Feedback and further consideration and research efforts will be the main tools.


The EHCR-SupA Project had duration of 36 months. It started on October 1997 and was completed in October 2000.



[1] Information about the Project and the participants can be found in the Project’s Web Pages at http://www.chime.ucl.ac.uk/SupA

[2] Information about CEN and in particular TC251 (Health Informastics) can be found at http://www.centc251.org/

[3] Of the various forms of denoting the “Architecture” below, form a) is recommended. The others imply that:

b) the Architecture of all instances of Electronic Healthcare Records is the same and that there is such a thing as the EHCR; c) the EHCRA only applies to one particular EHCR; d) there is an infinite set of Architectures.


 a) The Electronic Healthcare Record Architecture

  b)The Architecture of the Electronic Healthcare Record

  c) The Architecture of an Electronic Healthcare record

  d) An Architecture of the Electronic Healthcare record.

[4] Shortliffe E. H and Barnett G. O, Medical Informatics: Computer Applications in Health Care”, Addison Wesley Publishing, Reading, Massachusetts 1990