The Health Information and Quality Authority (HIQA) today publishes two standards to facilitate the electronic exchange of information between healthcare providers. The purpose of the National Standards for Diagnosis Datasets and Clinical Document Architecture Templates and the National Standards for Adverse Reaction Datasets and Clinical Document Architecture Templates is to improve the delivery of safe, person-centred care by standardising the way health information is shared and stored.

HIQA’s Acting Director of Health Information Dr Kevin O’Carroll said: “Safe and reliable healthcare depends on information that is accurate, timely, relevant and complete. Communication between eHealth systems needs to be standardised to achieve the safe exchange of information. Currently there are no uniform datasets to describe a diagnosis or adverse reaction for use in electronic documents, such as referrals, discharge summaries and in national patient summaries. The two standards and Clinical Document Architecture (CDA) templates published by HIQA today will provide a mechanism for the reliable transfer and recording of clinical documents, paving the way for better, safer services for patients.”

Dr O’Carroll continued: “The main benefit of developing CDA templates is that once they have been defined, they can be used again and again for a variety of patient summaries, for example in both referral and discharge summary documents”.

The adverse reaction and diagnosis standards are part of a suite of data guidelines that HIQA’s Health Information team is currently developing to support the standardisation of national, electronic patient summaries, listed as a key priority in the Department of Health’s 2013 eHealth Strategy.

Interested parties were invited to submit feedback on the draft standards via a five-week public consultation carried out in autumn 2015.

These recommendations have been approved by the HIQA Board and have been sent to the Minister for Health for his consideration.

Ends.

Further Information:

Marty Whelan, Head of Communications and Stakeholder Engagement, HIQA
01 814 7480 / 086 2447 623 mwhelan@hiqa.ie

Notes to the Editor:

• Under the Health Act 2007, HIQA is charged with setting standards for health information, including standards for the communication of health information between health and social care providers.
• Both datasets were developed in conjunction with the eHealth Standards Advisory Group (eSAG) using the international standard known as Health Level 7 Clinical Document Architecture.
• Previous standards developed by HIQA in recent years, and datasets and CDA specifications developed in other jurisdictions, were reviewed in the drafting of these standards.
• A diagnosis is defined by the Australian National eHealth Transition Authority as “any healthcare condition which may impact on the physical, mental or social wellbeing of an individual that may require diagnostic, therapeutic or educational action. A diagnosis is based on scientific evaluation of physical signs, symptoms, history, laboratory test results and procedures”.
• An adverse reaction, meanwhile, is defined as a “harmful or undesirable effect associated with exposure to any substance or agent, including food, plants, animals, venom from animal stings or a medication at therapeutic or sub-therapeutic doses”.