Medical Records/Information Management
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Status
Merged with Structured Documents.
Background
This group was formed at the plenary meeting in Dallas, Texas in September of 1991. The initial leadership included Peter Spitzer, MD and Elaine Lips, RRA. A small group of 7-10 individuals gathered with the initial objective of developing a general data model of healthcare communications using entity-relationship diagramming techniques. Over the next few meetings this initial effort continued with some question as to the most appropriate group to advance this work. As the QA Work Group expanded its' scope, a general consensus was reached that the modeling effort might be best advances within this Work Group.
This group continued to meet as a SIG (Special Interest Group) until May 1993 at which time it formally petitioned the Technical Steering Committee for a change of status to a technical committee. This was based upon a group proposal to develop consents and durable power of attorney messages. The submitted mission statement was approved.
A new chapter (nine) was produced and approved as part of HL7 version 2.3.
Mission
The goal of the Medical Records/Information Management Work Group is to define messages to support the functional messaging needs of the Information Management or Medical Records Department. The Work Group is comprised of individuals representing vendors of information systems (computer based systems), health information management professionals, and other stakeholders including other allied health professionals and physicians.
Scope:
The primary objective of this Work Group is the construction of domain information models (DIMs) and messages which can be communicated to and from systems which serve the needs of the Health Information Management/Medical Record Department of healthcare organizations. These include functions mandated by law, regulation, licensure and accreditation requirements, as well as organizational procedure. The scope will be limited to cases where information systems specifically support the functional requirements of this domain. Such systems may exist as discrete stand-alone departmental systems or as a set of applications or functions within a larger more functionally expansive system such as an HIS.
Scope Examples:
The following subjects have been or will be specifically reviewed for potential message construction:
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Transcription document management (included in v2.3)
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Medical Records Abstracts
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Advance Directives or living wills
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Durable Power of Attorney for Healthcare Decisions
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Consents, (procedural)
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Medical Record/Chart Tracking
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Release of Information (including authorizations)
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Staff credentialing / staff qualification and appointments documentation
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Chart deficiency tracking
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Utilization Management
In addition, this Work Group will act as a liaison with other organizations such as AHIMA, CPRI, MTIA, AAMT, ASTM, and other HL7 Work Groups concerning medical records and other related issues such as confidentiality, security, and access to medical records both in paper and electronic form. The Work Group will formulate recommendations to the HL7 Technical Steering Committee where appropriate.