CIA Principle 4: Core Patient Information will be stored and maintained in Cerner
“Core Patient Information will be stored and maintained in Cerner so that advanced EHR features can be properly supported in VIHA.”
VIHA is deploying advanced EHR functionality to support clinical decision-making, improve quality and patient safety through proactive care planning and clinical decision support. VIHA aims to achieve this in a multi-system environment with limited resources.
In order to provide advanced functionality within VIHA, in a timely and reasonable fashion, a set of interprofessional Core Patient Information (CPI) will need to be defined and reside in VIHA’s primary EHR, Cerner.
Other regionally supported systems will need to be able to interoperate with the Primary EHR to ensure that this data is up to date within Cerner.
What is considered Core Patient Information will evolve over time (see current categories on the left). Additional information, such as Patient Alerts, Social History, and Family History, will be considered. These will be added when there are suitable structures to support them and regionally agreed to use and definitions. Diagnostic data, such as lab and medical imaging are already captured in Cerner.
Without a clear understanding of the CPI, VIHA risks reduced interoperability, hiding key patient information in electronic silos, and not being able to achieve the benefits of electronic health records.
Focusing on the limited scope of the CPI necessary, due to resource demands, complexity, and capability of systems. However, there is a risk that if the CPI is too small, VIHA will be limited in its ability for advanced functionality. Additional standardization of content across systems will also be required.
Commentary:
There are several clinical systems in VIHA and the content that will be stored in each is not yet clear. This principle starts to hammer out a set of fundamental information that will be stored in the primary patient record inside of Cerner. This means that interfaces will need to be created to import data or share data from other systems inside VIHA that contain similar medication. This is deemed the minimum set of content to ensure future clinical decision support.*
The other aspect of this list is that we promoted components that we knew had reasonable models inside the VIHA instance of Cerner. Family History, for example, while useful, was excluded at this time as it would require VIHA to spend time developing that content internally, and there is an expectation that this feature will come from Cerner in the future. This list alone will likely keep VIHA busy for a while. So this list is targeted and will grow as is practical.
*NOTE: laboratory results and medical imaging are already in Cerner and thus were not added to this, but would need to be considered for other organizations where labs were in one or more other systems.
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