Background Treatment of RA patients in primary care and other non-specialist practices does not commonly follow EULAR and ACR recommendations . Use of interoperable EHR systems, based on globally accepted healthcare data standards, may enable a proper and widespread implementation of recommended diagnosis criteria, disease-specific assessments, monitoring plans and clinical decision support.
Objectives The aim of the study was to design and develop an interoperable standard based EHR module of outpatient consultation note, intended to support a process of monitoring and treatment of RA patients.
Methods 10 RA-specific HL7 CDA  templates (on document, section and entry levels) and the clinical form for document editing were designed and developed. The user acceptance tests were performed by practitioning rheumatologists. The interoperability of the electronic clinical documents generated by the EHR module was tested by schematron validation tool using two different HL7 CDA R2 implementation guides (the Consolidated CDA v. 1.1 and the National Polish Implementation of HL7 CDA v. 0.9.10).
Results The developed EHR module contains RA-specific assessments, including early morning joint stiffness duration, VAS General Health, VAS Pain, DAS28, 66/68 SJC, RA medication and its compliance. The module generates HL7 V3 compliant data objects, that were proved to be conformant to both US and Polish requirements for semantic interoperability in healthcare.
Conclusions The developed HL7 CDA templates for RA-specific document, its sections and entries (assessments) should be submitted to public repositories of HL7 building blocks to be easily accessed and used by EHR system providers in their products.
Singh JA et. al. 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis. Arthritis Care & Research Vol. 64, No. 5, May 2012, pp 625–639.
HL7 CDA R2. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7 (Accessed 27 Jan 2015)
Acknowledgements This work was partially supported by the European Union in the FICHe program.
Disclosure of Interest None declared
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