Unit IV.pptx. Challenges of capturing rich patient histories in a computable form

Challenges of capturing rich patient histories in a computable form.
Data Standardization
Interoperability
Complexity & Variability
Natural Language Processing
Data Entry Burden
Clinician Workflow
Longitudinal Data Tracking
Privacy, Security & Ethical
Integrating Social Behavioral
Determinants of Health
Incomplete Inconsistent Data
Technological Limitations
Latest global developments
standards to enable lifelong
Adoption of HL7 FHIR Standard
Collaboration Between SNOMED
International and open EHR
Emphasis on Semantic
Implementation of Data Privacy

1. Class: B.Sc. II Semester Topic: Challenges of capturing rich patient histories in a computable form Unit: IV Subject: HEALTH/NURSING INFORMATICS AND TECHNOLOGY Prepared by: Dr. Rahul Sharma

2. Challenges of capturing rich patient histories in a computable form 1. Data Standardization & Interoperability Patient histories are documented in diverse formats (structured and unstructured). Different healthcare systems and providers use varying terminologies and coding standards (e.g., ICD, SNOMED CT (Systematized Nomenclature of Medicine- Clinical Terms), LOINC(Logical Observation Identifiers Names & Codes). Lack of interoperability between electronic health record (EHR) systems leads to fragmented data.

3. Challenges of capturing rich patient histories in a computable form 2. Complexity & Variability of Patient Histories Medical histories include symptoms, past illnesses, family history, medications, allergies, social determinants, and lifestyle factors, making structured capture difficult. Patient-reported information is often subjective and varies in detail.

4. Challenges of capturing rich patient histories in a computable form 3. Natural Language Processing (NLP) Challenges Much of the history is captured as free-text notes, requiring NLP to extract meaningful data. Clinical jargon (vocabulary), abbreviations, and context-specific meanings add complexity.

5. Challenges of capturing rich patient histories in a computable form 4. Data Entry Burden & Clinician Workflow Physicians may find structured data entry time-consuming and prefer free-text notes. Poorly designed interfaces can lead to missing or inaccurate data entry.

6. Challenges of capturing rich patient histories in a computable form 5. Longitudinal Data Tracking & Evolution Patient conditions change over time, requiring ongoing updates and version control. Integrating data from multiple visits and sources without redundancy is difficult.

7. Challenges of capturing rich patient histories in a computable form 6. Privacy, Security & Ethical Concerns Sensitive patient data must comply with regulations (HIPAA, GDPR). Balancing data accessibility with patient confidentiality is a challenge.

8. Challenges of capturing rich patient histories in a computable form 7. Integrating Social & Behavioral Determinants of Health ( SDoH ) Social and environmental factors influencing health are hard to quantify and encode in structured formats. Capturing lifestyle habits (e.g., diet, exercise, substance use) often requires patient self-reporting, which may be inaccurate.

9. Challenges of capturing rich patient histories in a computable form 8. Incomplete or Inconsistent Data Patients may forget or misreport medical history details. Gaps in records due to care received at different institutions.

10. Challenges of capturing rich patient histories in a computable form 9. Technological Limitations Legacy systems may lack advanced AI/NLP capabilities for structured data extraction. High implementation costs for intelligent, interoperable systems.

11. Latest global developments and standards to enable lifelong electronic health records to be integrated from disparate systems. ​ Integrating lifelong electronic health records (EHRs) from disparate systems is a complex endeavor that has seen significant advancements in global standards and collaborative efforts. Key developments include:​

12. Latest global developments and standards to enable lifelong electronic health records to be integrated from disparate systems. 1. Adoption of HL7 FHIR Standard : The Fast Healthcare Interoperability Resources (FHIR) standard, developed by Health Level Seven International (HL7), has become pivotal in facilitating seamless electronic health data exchange. FHIR employs modern web technologies and standardized data formats, enabling interoperability across various healthcare systems and devices.

13. Latest global developments and standards to enable lifelong electronic health records to be integrated from disparate systems. 2. Collaboration Between SNOMED International and open EHR : In March 2025, SNOMED International and open EHR entered a five-year collaboration to enhance health data interoperability. This partnership aims to combine SNOMED CT's comprehensive clinical terminology with open EHR's standardized EHR specifications, promoting consistent and interoperable health data management globally

14. Latest global developments and standards to enable lifelong electronic health records to be integrated from disparate systems. 3. Emphasis on Semantic Interoperability : Achieving semantic interoperability ensures that exchanged data is not only shared but also meaningfully interpreted across systems.

15. Latest global developments and standards to enable lifelong electronic health records to be integrated from disparate systems. 4. Implementation of Data Privacy and Security Standards: Protecting patient data is crucial when integrating electronic health records. Compliance with regulations such as the Health Insurance Portability and Accountability Act (HIPAA) ensures that patient information is kept confidential and secure.

16. Latest global developments and standards to enable lifelong electronic health records to be integrated from disparate systems. 5. National Initiatives and Standards: Countries are developing and adopting national standards to guide EHR integration. For instance, India's Ministry of Health & Family Welfare released the Electronic Health Record Standards for India, outlining protocols for data privacy, security, and interoperability to ensure consistent EHR implementation nationwide.