Integrated Design and Process Technology, IDPT-2007
Printed in the United States of America, June, 2007
AN OVERVIEW OF INTEROPERABILITY STANDARDS FOR
ELECTRONIC HEALTH RECORDS
A. Begoyan
University of Westminster
School of Informatics
Department of Information Systems
115 New Cavendish Street, London, W1W 6UW
ABSTRACT
This paper gives an overview of the interoperability
standards for Electronic Healthcare Records (EHRs)
which are offered by the world leading standard bodies:
European Committee for Standardisation (CEN),
International Organization for Standardization (ISO),
Health Level Seven (HL7) and Digital Imaging and
Communications in Medicine (DICOM). We have taken
information available in the original standards’ text as the
bases of our research. We outline what each of these
standards offer and we compare the way they address the
interoperability of EHRs.
INTRODUCTION
Healthcare information systems have grown rapidly
in the last decade. They moved from isolated software
systems in hospitals or primary care organizations,
towards solutions which support a continuous medical
process and (i) include multiple healthcare professionals
and institutions, (ii) utilize ubiquitous computing
healthcare environments and (iii) embrace technological
advances, typical of the domain of today’s pervasive
software applications. It is not a surprise that in such an
interactive environment, we need to look at the
information sharing amongst healthcare software systems.
This requires that all relevant patient clinical data is
available and correct, thus supporting healthcare
professionals at any time, any place and improving the
quality and delivery of healthcare. We have witnessed a
proliferation of solutions for effective EHR (Dumay,
2002), (van Ginneken 2002), (Giusse, 2003), (Ueckert,
2003), (Valdes, 2004), (Kuhn, 2001), (Hsyien-Chi, 2007).
We are now in a specific situation characterized by:
(a) Heterogeneities in hardware and software
solutions that support healthcare software applications as
a consequence of their evolution from the early 1960s;
(b) Heterogeneities in the structure, purpose and
deployment of EHR in terms of their suitability for a
variety of healthcare systems that are growing in each
country in the world.
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2007 Society for Design and Process Science
Heterogeneities in healthcare software applications
from (a) above are typical of heterogeneities in any other
problem domain, where a variety of platforms, systems,
databases, software applications, technologies etc exist.
From this point of view, healthcare software systems do
not differ from any other. However, heterogeneity of
EHRs across healthcare systems from (b) above is a
bigger problem. EHRs differ from application to
application and from country to country. This means that
the structure of EHRs and the methods used for
exchanging their content may vary significantly, thus
becoming an obstacle for sharing medical data or medical
records and developing software applications that support
(i)-(iii) above.
The expected answer is in the standardization of
EHRs structure, content and the way of exchanging them,
as described in (Gross, 2005), (Kalra, 2006), (Bossen,
2006). There are initiatives from North America and
European countries to engage their organizations and
bodies responsible for standardization in general, with the
EHR standardization. Thus we have various EHR
standards which differ from country to country and which
cover different issues of EHR standardization. On top of
that, these standards are not very stable. There are a
number of reasons for that. Standards are constantly
evolving and changing, and the content and structure of
EHRs is also changing in parallel due to technology and
science advancement, thus pushing changes within
applications built upon such EHRs outside their initial
domains and purposes (Beale, 2002). Even if we have
achieved a certain level of EHR standardization, the
advancement of medial science would demand further
changes in existing EHR standards. For example, medical
science is currently placing great emphasis on genomics,
which requires the integration of biomedical information
with the EHR. If the current EHR structure has not
already incorporated biomedical information it will have
to be done soon. Therefore, standardization of the EHR
needs to be reviewed on a regular basis to asses the
current situation within the EHR standardization, and take
steps to make EHR standards ‘future proof’ or adaptable
to inevitable changes (Medisell, 2004).
 Healthcare informatics is full of various standards
that help us to structure many aspects of healthcare
software systems: from their architectures, software
applications built from them to semantics stored within
and structures of EHR. In this paper we overview
standards for the interoperability of EHRs which exist
across North America and Europe. We are interested in a
particular aspect of interoperability between diverse
healthcare systems, which should be able to exchange
information about patients and their medical history stored
within EHRs (Bott, 2004). Therefore:
We are interested in software engineering solutions
that can alleviate interoperability problems in healthcare
software applications, which depend on the data structures
of EHRs. Thus any interoperability standard on EHR
could be a starting point when building such applications.
We have learned that in spite of various initiatives for
achieving the interoperability in healthcare software
applications through data sharing, such as e-GIF (Cabinet
Office, 2005) in the UK, current EHRs are simply not
equipped with data items, which are essential if we want
to share them across healthcare institutions (Slevin et al.,
2005) (Akram et al., 2007) .
Five year ago the UK government initiated the
National Program for Information Technology (NPfIT,
2004), which has already approved the development of a
centralized healthcare (patient) database for the UK
National Heath Service. Which standards on EHRs would
they follow, if any?
In order to review the situation within standards,
which deals with the interoperability of EHRs, we started
with the European standardization committee and its
Interoperability working group IV within Technical
Committee 251 (CEN/TC 251). They list the following
standardization bodies responsible for EHR.
ISO is an International Organization for
Standardization which is currently a network of the
national standards institutes of 157 countries. They work
on the basis of one member per country, with a Central
Secretariat in Geneva, Switzerland, that coordinates the
system. ISO produces EHR standards that are limited to
the structure and function of the EHR and the system that
processes EHR.
CEN is a European Committee for Standardisation. It
is involved in developing multi-disciplinary standards
including health care systems and their interoperability.
CEN covers European Union (EU) countries and some
affiliated countries outside the EU.
HL7 stands for Health Level Seven. It is one of the
several American National Standards Institute (ANSI) -
accredited Standards Developing Organizations, which
operates in the healthcare arena. It covers America, some
European and Asian countries and Australia. Its purpose is
to provide standards for data exchange between different
types of healthcare computer applications. HL7’s domain
2
includes clinical and administrative data. Its headquarters
is in Ann Arbor, Michigan.
DICOM – Digital Imaging and Communications in
Medicine is an association of medical industry and
medical professional organizations, working under the
umbrella of the National Electrical Manufacturers
Association (NEMA). They have delivered DICOM,
which is a de facto standard for medical image
communication (DICOM). This standard allows an
independent exchange between medical images and
related information.
The purpose of this paper is to briefly overview the
current situation within standards that regulate the
interoperability of EHRs and to learn the outcomes of
such standardizations. These outcomes then can be
adopted when software applications that deal with
heterogeneities are designed. We would also like to see if
there are any components within such standardizations
which lead towards ‘future-proof’ EHRs.
This paper is structured as follows. In the next section
we define and discuss EHRs, their interoperability and
prerequisites for their semantic interoperability. In the
four sections that follow we discuss four EHR standards:
ISO/TR 20514, ISO/TS 18308, ISO/TR 18307 derived by
ISO; CEN13606 and its five parts from CEN; Version 2x
and Version3x from HL7; and two standards from
DICOM - Web Access to DICOM Persistent Objects and
DICOM Structured Reporting. We briefly touch the
harmonization between standards, and conclude in the last
section.
DEFINITIONS OF EHR AND INTEROPERABILITY
The definition of EHR varies from standard to
standard. According to CEN/TC251 Health Informatics,
EHR is “a healthcare record in a computer readable
format”. According to ISO/TR 20514 the basic-generic
EHR is “healthcare record in a computer processable
format, which encapsulates readability but extends this to
include the notion that information in the EHR must be
amenable to programmatic manipulation and therefore to
automatic processing” (ISO TC 215, ISO/TR 20514,
2005).
‘EHR systems’ are defined uniformly across CEN
and ISO: as “system[s] for recording, retrieving and
manipulating information in electronic health records”.
Interoperability of EHR as defined in ISO (ISO TC
215, ISO/TR 20514, 2005) is “the ability of two or more
applications being able to communicate in an effective
manner without compromising the content of the
transmitted EHR”. They claim that it is important to
develop national and international standards for EHR
interoperability to be able to: (1) share patient health
information between health professionals in a multi-
disciplinary shared-care environment: (2) share patient
health information between organizations within an
enterprise, a regional or national health system, or across
national borders and (3) support interoperability between
software from different vendors.
There are two types of interoperability that are
relevant in this context. The ISO Technical Report (ISO
TC 215, ISO/TR 20514, 2005) defines these as Functional
interoperability and Semantic interoperability. Functional
interoperability deals with the exchange of information
between two or more systems in a format that is readable
by humans. Semantic interoperability deals with the
exchange of information between systems in a format that
is computer processable by the receiving system. We
could not find within the Technical Report explicitly listed
prerequisites for achieving Semantic Interoperability.
Thus we have to refer to the conference paper (Schloeffel
P., 2004) which states that there are four prerequisites that
need to be fulfilled in order to achieve semantic
interoperability: a) a standardized EHR Reference Model.
This deals with the semantics of EHR information
structures; b) a standardized service interface. This deals
with the semantics of interfaces between EHR and other
services: c) a standardized set of domain-specific concept
models. This deals with archetypes and templates for
different domain concepts: d) standardized terminologies.
This defines the language that is used in archetypes. (The
first two prerequisites also apply to functional
interoperability.)
INTERNATIONAL STANDARDS ORGANISATION
ISO’s Technical Committee ISO/TC 215, which deals
with Health Informatics, is an international standards
body, whose aim is to achieve compatibility and
interoperability between independent healthcare systems.
This is a relatively new standards body, which has
produced a set of new standards as well as using other
international standards from HL7, DICOM and CEN as
the basis for their standards. ISO has already published 37
standards relating to different aspects in the field of
medical informatics across 22 countries, including the
UK. The standards produced by ISO/TC 215 are being
observed in 20 countries including Central America,
Europe, Asia and the Middle East.
The following three sub-sections will introduce three
standards – ISO/TR 20514, ISO/TS 18308 and ISO/TR
18307 which are concerned with the EHR interoperability.
ISO/TR 20514 - EHR Definition, Scope and Context.
ISO/TR 20514 is a standard that defines the content
of the EHR, its structure and the context in which the
EHR is used. It also gives definitions of the terminology
used. ISO/TR 20514 defines the EHR structure through
“basic-generic EHR” (ISO TC 215, ISO/TR 20514, 2005).
Thus, it allows the broadest applicability of the given
EHR structure to a wide range of existing and future types
of EHRs and EHR systems. This, in turn, provides
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support for legislative and access control requirements
that would be applicable to all forms of EHR. The basic-
generic EHR definition is supplemented by the detailed
definition which is stated in 1 and 2 below:
1. The ability to share patient health information
between authorized users of the EHR.
2. The ability to supporting continuing, efficient
and quality integrated health care.
According to (ISO/TR 20514, 2005), the sharing of
EHR information can take place at three different levels:
LEVEL1 is between different clinical disciplines or other
users, who could be using the same application but require
different or ad hoc organization of EHRs. LEVEL2 is
between different applications at a single EHR node. (An
EHR node is a physical location where EHRs are stored
and maintained.) LEVEL3 is across different EHR nodes.
When EHRs are capable of being shared at LEVEL3
then the EHRs are called Integrated Care EHRs (ICEHR).
ISO/TS 18308. Requirements for an EHR Reference
Architecture.
This is a new standard that gives requirements for the
architecture of EHR systems and not the specification for
such architectures (ISO TC 215, ISO/TS 18308, 2004). It
specifies the assembling and collating of clinical and
technical requirements for EHR architecture to support
usage, sharing and exchanging of EHRs across different
countries, different health sectors and different models of
healthcare delivery. The main users of this standard will
be developers of EHR architecture standards such as CEN
EN13606 and other reference architectures such as
openEHR (Eichelberg et el, 2005), (openEHR).
ISO TR 18307 – Interoperability and Compatibility in
Messaging and Communication Standards.
This standard describes the main requirements for
achieving interoperability and compatibility in trusted
health information interchange between software
applications and systems in healthcare. The standard
specifies the interoperability needs of the healthcare
community for the subject of care, the healthcare
professional, the healthcare provider organization, its
business units and the incorporated delivery network. It
also provides a criterion for developers and implementers
of standards for messaging and communication in the
healthcare domain. It lays down the foundation for the
health information interchange to be as trustful as possible
(ISO TR 18307).
CEN
CEN’s Technical Committee CEN/TC 251 deals with
the production of Standards in Health Informatics. It has
produced the only comprehensive EHR interoperability
standard in the world called CEN 13606.
CEN13606 The Extract package defines the EHR_EXTRACT
class in an EHR structure, which is the root directory of
CEN 13606 has been previously published as a pre-
the Reference Model, and data structures for EHR content.
standard named ENV 13606 in 1999 (Kalra and Ingram,
The Demographics package provides a data set of
2006). It was not as successfully implemented as
specific entities, which are defined only once and then
expected due to various weaknesses, such as the outdated
used within the EHR_EXTRACT by the means of
architectural concepts of applications that support EHRs,
dedicated class instance identifiers. The whole purpose of
that were recommended by the standard (Eichelberg et el,
this package is to give a sufficient description of each
2005). In 2001, CEN/TC updated ENV13606 and
entity within an EHR system for human interpretation and
adopted the openEHR “archetype methodology” defined
to allow the identification of entities between
by the openEHR Foundation to make it a full European
EHR_Recepient and its own demographic server. We do
Standard EHR (Schloeffel P., 2004), (The OpenEHR
not summarize what Support and Primitives packages
Foundation). The result of this work is in CEN
contain because it was very difficult to follow the text
prEN13606. CEN prEN13606 has been adopted by 48
available in the standard.
countries as at 2007.
CEN EN13606 is a five-part standard as defined in Part two - Archetype Interchange Specification
prEN13606-1:2006 (CEN/TC 251, 2006) and consists of a
The wide-scale sharing of EHR records and their
Reference Model, an Archetype Interchange
meaningful analysis across distributed computing sites
Specification, a Reference Archetypes and Term Lists,
requires that the equivalent clinical information is
Security Features, and Exchange Models.
represented consistently, i.e. when the clinical data
The standard defines an architecture for
structures are communicated via the Reference Model, it
communicating part or all of the EHRs of a single patient,
should have the same semantic meaning. This addresses
making sure that (i) the original clinical meaning intended
the semantic and schematic heterogeneities in the
by the author of the record is preserved and (ii) the
repositories of EHR systems.
confidentiality of the data as intended by the author and
Archetypes introduced in this part have the role of
the patient is not breached. It does not specify the internal
addressing the challenges of semantic interoperability.
structure or database design/schema of the EHR.
EHR systems should be able to cater for any
Part One - The Reference Model. professionals, specialities or services within healthcare
systems, despite the fact that healthcare domains are
The Reference Model defines the generic building
different, complex and prone to frequent changes. Thus
blocks of the EHR by representing the global
the Reference Model represents the generic properties of
characteristics of health record components. It shows how
EHR information, and Archetypes (i.e. meta-data) define
they are aggregated, and how the context information
patterns for the specific characteristics of the clinical data
within the record’s components meets ethical, legal and
that represent the requirements of each particular
provenance requirements. In order to support
profession, speciality or service. Archetype instances
communication between various EHR systems, the
conform to a formal model available at Archetype Model
standard recommends archetypes, i.e. the use of meta-data
prEN13606-2:2005(E)6. Archetypes may also be used
(Frankel, 2006), but they are not mandatory. The
within EHR systems to manage the EHR data, which
archetypes are “definitions of prescribed combination of
belong to a certain data repository. It is assumed that the
the building-block classes defined in the Reference Model
original EHR data, if not already archetyped, may be
for particular clinical domains or organizations”
mapped to a set of archetypes, if needed, when generating
(CEN/TC 251, 2006).
the construct, i.e. EHR_EXTRACT (prEN 13606-2)
This standard may also be used for communication
Archetype Repositories contain many archetypes that
between an EHR system and repositories found in clinical
that have been derived from different sources of EHRs.
applications, or between middleware components
Thus despite the fact that different sources of clinical data
responsible for accessing or providing EHR data.
inputs, and data types detectable in such inputs, have been
Furthermore, the standard may be applied for the
identified, the formats in which these clinical data
communication of individual patient records (i.e. a single
structures are represented remain interoperable across a
identifiable subject) to an EHR system or a centralized
variety of EHR systems. Consequently, the use of
EHR data repository. Anonymization or aggregation of
standardized archetypes ensures an interoperable way of
individual patient records within EHR systems are not the
representing and sharing the specification of archetypes,
focus of this standard.
in support of keeping EHRs consistent and the semantic
The Reference Model consists of four packages –
interoperability of shared EHRs.
Extract, Demographics, Support and Primitive. (CEN/TC
Communicating Archetypes specifies requirements
251, prEN13606-1:2006).
for a comprehensive and interoperable archetype
representation, and defines the Object Distributed

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Processing (ODP) Information Viewpoint representation
for the Archetype Model. It also gives an optional
archetype interchange format called Archetype Definition
Language (ADL). Archetypes expressed in ADL will be
compatible with HL7 Refined Message Information
Models (R-MIMs) and Common Message Element Types
(CMETs) (Garde, 2007). This part (Communicating
Archetypes) of the standard doesn’t require that EHR
models are archetype prEN 13606-2:2005 compliant.
However it does require that these archetypes are capable
of being mapped to the Archetype Model in order to
support EHR communication and interoperability within
an EHR-sharing community.
Part three - Reference Archetypes and Term Lists
This part specifies data objects for describing rules
for distribution or the sharing of EHRs in whole or in part
by establishing general principles for the interaction of
EHRs with other components and mechanisms within an
EHR application. The standard also establishes ways of
creating information with associated security attributes
(ANSI, 2006).
Part four: Security Requirements and Distribution
rules
This part addresses aspects of data safety and security
in the context of exchanging patient related medical
information. It does this by specifying security
requirements and mechanisms for managing access-rights
to components of an EHR of a patient. It also defines
mechanisms for auditing accesses to an EHR. The
implementation and usability of the security functions of
an EHR system is supported through the provision of
easily implementable but course-grained general access
policies, as well as mechanisms for defining fine-grained,
individual access policies (ANSI, 2005).
Part five: Exchange Models
This part describes a set of models that form the basis
of message-based or service-based communication. Parts
four has already passed approval by CEN but the final
draft is yet to be produced and this part has temporarily
been put on hold.
HL7
The term HL7 is used both: i) as a name for the
organization and ii) as a set of messaging standards
(Version 2.x and Version 3.x). The HL7 organization
focuses on the interface requirements that are needed by
the entire health care organization, when communicating
healthcare data within or outside its healthcare systems.
HL7 standards are the most successful messaging
standards in the healthcare industry. It is a protocol that
consists of standardized grammar and vocabulary. HL7
standards work by assuming that an event in the real
5
world of healthcare systems creates the need for data to
flow amongst various systems. This will be initiated by a
trigger, which in the HL7 standard is equal to a Trigger
Event (Eichelberg et al., 2005). When an event occurs in
an HL7 compliant system a message is passed to the
requesting application as EDA (Electronic Data
Interchange) by gathering the relevant data from the
applications (Ericson, 2004).
The HL7 standard supports two message protocols:
Version2 and Version3.
HL7 Version2
The most widely used HL7 Version2 protocol is
limited to the exchange of messages between medical
information systems. It was not developed following any
methodology to ensure that all parts of the standard are
developed consistently. HL7 Version2 does not support
interoperability between healthcare applications very
successfully. The main reason for this is the lack of a
precisely defined underlying information model structure,
plus definitions for many data fields are vague and
overloaded with optional data fields (Eichelberg et el,
2005). However, by not defining a detailed information
model, the HL7 version2 standard allows greater
flexibility, which immediately triggers the problem of
interoperability. Applications participating in
communication using HL7 version2 must therefore have
mutual agreements to achieve interoperability.
HL7 Version3
HL7 Version3 is an improvement from the previous
Version2 by being more focused on specific contexts,
terminology, models and conceptual definitions and
relationships. Its underlying information model, called
the Reference Information Model (RIM), is object-
oriented and the proposal for the Clinical Document
Architecture (CDA) for exchanging clinical documents
across healthcare systems uses Extensible Markup
Language (XML) to encode the documents (HL7 2.5,
2000) (InterfaceWare). Thus the CDA defines the
structure and semantics of medical documents that are to
be exchanged and CDA documents use data types
specified in the HL7 RIM.
The CDA consists of 3 levels (HL7 CDA). Each of
them takes the mark up of the previous level and adds
more mark up to compose a clinical document. However,
this does not change the clinical content of the document
(HL7 CDA Release 1.0, 2000)(HL7 Standards).
Level1 consists of a Coded Header and a Body. The
Coded Header defines the semantics of each entry in the
document. The Body contains clinical data in an
unstructured test format or it can consist of nested data
such as paragraphs, lists and tables. Level2 models
observations and instructions within each heading, thus
making it possible to constrain the structure and content of
the document through templates. This increases
interoperability by using agreed templates between
heterogeneous healthcare systems. Level3 provides
completely structured documents where each element of
the document is adequately coded for machine processing.
The CDA HL7 is not strictly an EHR standard, but
forms its sub-component, that has already been
harmonized with the equivalent structure in CEN13606
and openEHR (HL7 EHR 2004). Thus HL7 and CEN co-
operate and the current areas of harmonization include
data types from (a) HL7 Templates (b) HL7 CDA, (c)
CEN13606 Reference Models, and (d) CEN/openEHR
archetypes (Schloeffel P., 2004).
Digital Imaging and Communications in Medicine
(DICOM)
DICOM is the de facto standard for medical image
communication. It uses binary encoding with hierarchical
lists of data elements identified by numerical tags and a
complex DICOM-specific application level network
protocol (DICOM, 2007). There are two DICOM-based
EHR standards available:
1. Web Access to DICOM Persistent Objects (WADO)
2. DICOM Structured Reporting.
WADO is a cooperative standard between DICOM
(DICOM Supplement 85 2004) and ISO (ISO 17432
2004). This standard was created to enable and maintain
international standards for the communication of
biomedical diagnostic and therapeutic information in
disciplines that use digital images and associated data.
WADO defines a Web based service that can be used to
retrieve persistent objects via HTTP or HTTPS from a
Web server.
The Web client has to specify the DICOM object that
has to be retrieved. This will be done through unique
identifiers available at the instance level of the DICOM
information model. The web client may also request a
specific data type to be sent via the web server. The web
server will convert the existing DICOM object into a
readily presentable format to be sent. The DICOM object
can also be made anonymous before it is sent. This is a
very useful feature for teaching purposes and clinical
studies. WADO doesn’t support query mechanisms.
A WADO server will return a DICOM Structured
Reporting Document to the client in the HTML format if
requested. If not, the format will be dependent on the
current implementation of the server. WADO uses a
simple approach for accessing particular DICOM objects
without requiring the client to be DICOM compatible. It
is very easy to implement applications supporting WADO
as they can be implemented by using readily available
components such as Web browsers, servers and DICOM
viewers (Eichelberg et el, 2005).
DICOM Structured Reporting is a general model for
encoding medical reports in a structured way. This is
done using DICOM’s tag-based format. It allows for
current DICOM infrastructure network services to be used
6
to archive and to communicate, and to digitally sign
structured reports without making significant changes to
the existing systems.
To improve interoperability in practice, DICOM
Structured Reporting specifies a document structure along
with its class definitions and constraints for different
medical applications. It defines templates that need to be
used for this purpose. The collection of the standard
templates, context groups and codes is called the DICOM
Content Mapping Resource.
It is important to note that DICOM does not specify
how a Structured Reporting Document is rendered by an
application, as this is regarded to be out of the scope of
the standard (Eichelberg et el, 2005).
HARMONIZATION BETWEEN STANDARDS
Harmonization between standards and in some cases
their convergence, is very important for the future
interoperability of health information systems within and
between countries. As we have already mentioned in the
previous section, current areas of harmonization include
data types: the HL7CDA and CEN 13606 Reference
Models and CEN/openEHR archetypes with HL7
Templates. The OpenEHR Reference Model uses the
CEN13606 Reference Model, which in turn is used in
HL7CDA. So, it is quite visible that some harmonization
has already taking place. There are also sporadic reports
across EU countries that highlight their individual
attempts to comply with CEN initiatives, thus
recommending harmonization locally (SIST). A detailed
rationale for the harmonization of EHR standards is
available in the white paper about the HL7 EHR System
Functional Model (HL7, 2004).
CONCLUSION
It was very difficult to prepare an overview of EHR
interoperability standards that could have provided better
reading than this paper offers. It was also extremely
challenging to extract information that can be called ‘an
overview of standards’ from such a variety of sources,
where almost none of them are written for wider
healthcare or computing research communities. There are
a few published papers, which have helped us to interpret
the texts found in published standards correctly and which
have been crucial to understanding a variety of issues
covered in these standards. Thus any organizations,
healthcare institutions or software developers willing to
include these standards in order to achieve the
interoperability of EHR systems, will face the same
difficulties as we have had in collecting relevant material
and understanding how to apply it. One of the solutions is
to employ professionals who can interpret the standards so
that they can be understood by software developers and
healthcare professionals.
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Virginia, USA
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7
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