Electronic Health Record Standardization [Neurosurgery Wiki]

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====== Electronic Health Record Standardization ======

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**Definition:**  
EHR [[standardization]] refers to the process of applying common [[structure]]s, terminologies, and [[communication]] [[protocol]]s to [[electronic health record]]s to ensure [[consistency]] and [[interoperability]] across [[healthcare system]]s.

**Key Elements:**  
  * Terminologies: [[SNOMED CT]], [[LOINC]], [[ICD-10]]  
  * Data exchange formats: [[HL7 FHIR]], CDA  
  * Data models: [[OMOP]], [[openEHR]]  
  * Structured documentation: templates for notes, diagnostics, procedures

**Goals:**  
  - Facilitate sharing of health data across institutions  
  - Improve clinical decision-making and patient safety  
  - Enable research, audits, and public health initiatives  
  - Support AI and analytics by providing high-quality, structured data