CIA Principle 1: One Person, One Record
“One Person, One Record: VIHA will create a Virtual, Electronic “Individual Health Record” for each person.”
The “Individual’s Health Record” (InHR) is the collection of all information on a single patient / client within VIHA. The InHR provides informational and management continuity, wherever care is provided within VIHA.
The InHR in VIHA is currently in a hybrid state with records kept in multiple paper files and several electronic systems. Electronic records in the acute care domain are maintained in a single integrated solution. Much of the clinical documentation is currently paper. Electronic Records in other domains are maintained in several other best-of-breed systems or locally developed electronic tools. There are many paper charts. Physically and electronically, the chart resides in multiple locations and are not all connected.
The risk of continuing in this manner is that there will be gaps in care continuity, causing reduction in quality, safety, and effectiveness of care in VIHA. Therefore, VIHA will create a fully electronic InHR (eInHR) for all patients.
The goals of the electronic InHR are to:
- Support the specialized requirements of providing care in broadly diverse environments.
- Ensure that no information is captured and maintained in redundant locations / systems.
- Guarantee that each user knows exactly where to find needed patient information in a timely manner.
- Organize the content of the electronic InHR to support quality improvement, health promotion, Clinical Decision Support, and health planning.
- Clinical Information should be designed to support technical, privacy, security and access principles and laws as applicable.
VIHA will attempt to achieve these goals not through a single electronic system, but through a set of enterprise clinical information systems to create a “virtual eInHR”.
Commentary:
This is the first principle in the VIHA set of Clinical information architecture principles. “Individual’s Health Record” was a term developed to differentiate the contents of a single patient’s record and the regional platform of systems, called the “Electronic Health Record”.
The challenge with achieving this will be the capabilities and compatibilities of the existing clinical information systems within the region.
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