Electronic Health Record Standardization

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Definition: EHR standardization refers to the process of applying common structures, terminologies, and communication protocols to electronic health records to ensure consistency and interoperability across healthcare systems.

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:

1. Facilitate sharing of health data across institutions
2. Improve clinical decision-making and patient safety
3. Enable research, audits, and public health initiatives
4. Support AI and analytics by providing high-quality, structured data