Documentation Standards and Data Management in the Health System – HL7, CDISC, DRG
The quantity and complexity of data generated in routine hospital operations, local practices, and clinical studies is growing rapidly. To this we can add the recent volumes of health data generated by quantified self devices such as fitness wristbands and similar. One important area of research is the development of electronic health records (ELGA).
Documentation standards such as HL7 and CDISC are designed to increase interoperability which in turn boosts efficiency and improves data quality. When it comes to routine clinical data, significant coordination is required between the various health and social care sectors. It must be possible to exchange medical and care discharge letters, findings and medication data between hospitals, clinics and care homes. However, to date documentation standards have not found wide acceptance in the non-medical healthcare professions.
Efficiently communicating administrative service and billing data between service providers and health insurance companies and financing hospitals via DRG systems relies on access to a standardised catalogue of diagnoses and procedures. This will allow many fragmented silo solutions to be replaced in the future.
Double data entry also remains a significant problem in the field of clinical research. It is compounded by the constantly increasing number of regulatory requirements and in part inconsistent data requirements. Therefore an important field of research involves building a bridge between routine and research data.