【国外标准】 Standard Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems (Withdrawn 2017)

Background:Effective health care delivery requires an efficient information base. A standard description is needed regarding the capabilities of Registration-Admission, Discharge, Transfer (R-ADT) Systems in both automated hospital and ambulatory care information systems. This practice is intended not only to provide a common explanation of the minimum information elements required in such systems, thus augmenting those already published , but also to provide the basis for future patient data interchange formats. This practice has been developed to serve as a uniform minimum description of R-ADT functional components that should be common in all systems and used in both transportable general purpose and custom developed systems. This description requires acceptance of the premise regarding the need for logical integration of concepts in systems development. In the integrated systems concept, the R-ADT function is the foundation module for all patient information and communication among all departments, and it is used in initiating services within the patient care setting. A common R-ADT system in a hospital enables all departments to streamline the initiation and tracking of the services they provide to patients; it also provides an opportunity for accurate tracking of patient movement throughout a hospital stay, for instance, and the linkage of inpatient and outpatient services. It is also the system which provides all inpatient census-related administrative reports. Likewise, an R-ADT component in an Enterprise Architecture captures the initial patient demographic profile for the EHR and is subsequently accessed in posting an individual's clinical data, for inquiry regarding that clinical data and for linkage to financial records. It is an integral part of the EHR function. It may also be linked to other systems which provide patient care information management capabilities.A registration system is capable of providing the initial information capture for all health care facilities; an ADT subsystem can provide common admitting data for all departments in hospitals and other inpatient facilities. Establishing a standard description of a logical R-ADT process model is useful because that standard will become a reference for other documents describing the other functional subsystems used in patient care information systems. It is understood that a minimum set of information elements must be initially captured upon registration and then used for all subsequent ambulatory or inpatient care; the subsequent minimum set of admitting elements is then used to drive or initiate additional services for patients through each subsystem. With a standard minimum R-ADT component definition, standards for constituent subsystems can now be coordinated and developed through reference to this model. This description should be used by vendors and subsystem designers who need to develop their systems in a coordinated and integrated way so that each subsystem will contribute modularly with overall systems planning for the user organization. Such modularity will aid management who are assigned to evaluate each system and subsystem in order to assess the potential of existing technology to provide the needed patient care information management systems capabilities.Use—This practice is written assuming that the health care facility will have several options for gaining the R-ADT capability and may either acquire a system from a commercial vendor or design an integrated in-house system which may be a component of an ambulatory care practice or a hospital information system. Many of the characteristics of existing vendor systems are conventional and can interoperate; the care facility may simply need to identify whether or not the offered features meet its needs. Beyond the general capabilities, the unique systems capabilities can then be identified and structured to meet the special needs of that individual enterprise. A more accurate selection can therefore be made from the features offered by vendors if each health care facility/hospital carefully identifies its own R-ADT functional requirements with the aid of this guide prior to evaluating candidate systems or development approaches and specifying that these requirements be met.4.3 Role of R-ADT Systems in Integrated Delivery Systems—Registration/Reservation-Admission, Discharge. Transfer functions in integrated delivery systems need to provide a uniform enterprise view with data accessible across the IDS. Typical functions in this environment may include registration to an enterprise master patient index, reporting capabilities on R-ADT functions, enterprise scheduling and enterprise capabilities for eligibility and utilization management. Patient data collected should be transferable to medical record abstract applications and contribute to clinical repositories to maintain longitudinal focus to evolve toward electronic health records. IDS networks provide infrastructure and should conform to enterprise technical security requirements that meet legal and accreditation requirements.1.1 This practice identifies the minimum information capabilities needed by an ambulatory care system or a resident facility R-ADT system. This practice is intended to depict the processes of: patient registration, inpatient admission into health care institutions and the use of registration data in establishing and using the demographic segments of the electronic health record. It also identifies a common core of informational elements needed in this R-ADT process and outlines those organizational elements that may use these segments. Furthermore, this guide identifies the minimum general requirements for R-ADT and helps identify many of the additional specific requirements for such systems. The data elements described may not all be needed but, if used, they must be used in the way specified so that each record segment has comparable data. This practice will help answer questions faced by designers of R-ADT capabilities by providing a clear description of the consensus of health care professionals regarding a uniform set of minimum data elements used by R-ADT functions in each component of the larger system. It will also help educate health care professionals in the general principles of patient care information management as well as the details of the constituent specialty areas.1.2 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory requirements prior to use.