02 — Capability · BC-1880
Health Information
Keep a complete, accurate and lawful health record for every patient, release it only to those entitled to it, exchange clinical data with others in standard forms, maintain the vocabularies that make data comparable and supply registries and research. Enterprise records retention and analytics are owned elsewhere.
- HIM
- Health Information Management
- Health Records and Data
- Health Data Stewardship
In scope
- Legal health record definition, completion and correction
- Release of information and patient right of access
- Clinical data exchange and interoperability with other organizations
- Clinical terminology, registries and research data provision
Out of scope
- Records retention, legal hold and document management across the enterprise (see BC-790)
- Enterprise data governance, warehouses and analytics (see BC-750)
- Integration platforms and API delivery in general (see BC-720.40)
- Patient identity and duplicate record resolution at registration (see BC-1810.20)
Realized by · 9
- ServiceNow · Healthcare and Life Sciences Service Managementpartial via BC-1880.50.40
- Epic · MyChartcore via BC-1880.20.10
- Epic · Care Everywhere and Interoperabilitycore via BC-1880.30.10
- Epic · Cosmospartial via BC-1880.50.20
- Oracle Health · Interoperability, Referrals and Public Health Reportingstrong via BC-1880.30.10
- MEDITECH Expanse · Traverse Exchangestrong via BC-1880.30.10
- InterSystems HealthShare · Unified Care Recordcore via BC-1880.30.10
- InterSystems HealthShare · Consent Managementstrong via BC-1880.30.50
- InterSystems HealthShare · FHIR and Standards Servicesstrong via BC-1880.30.20
Used in · 4
- Referral-to-Appointment · 01 Receive Request via BC-1880.30
- Admit-to-Discharge · 06 Discharge & Hand Off via BC-1880.10
- Order-to-Result · 05 Deliver & Act via BC-1880.10
- Enroll-to-Care · 05 Manage Care via BC-1880.30
Build it · 2
- technology Electronic Health Record Systems via BC-1880.10
- technology Health Data Interoperability Engines via BC-1880.30
Decomposes into · 5
- BC-1880.10Legal Health RecordKeep each patient's legal health record complete, accurate, timely and defensible, by defining what it contains, driving incomplete records to completion and correcting entries the proper way. Enterprise retention schedules are records management.
- BC-1880.20Release of InformationGive patients, their representatives and other authorized parties the health information they are entitled to, accurately, securely and within legal deadlines, and record every disclosure. Legal holds and discovery are records management.
- BC-1880.30Clinical Data ExchangeShare patient data with other providers, health plans, patients' apps and public health authorities in standard formats, so care is coordinated and reporting duties are met, while honoring consent. Building the integration platforms themselves is application delivery.
- BC-1880.40Clinical TerminologyKeep the clinical vocabularies, code sets and local dictionaries the organization uses current and mapped to national standards, so data means the same thing in every system and report. Assigning codes to encounters for billing is clinical coding.
- BC-1880.50Clinical Research & RegistriesMake clinical data available to outcome registries and approved research while protecting patients, by abstracting registry cases, running research data requests through oversight, de-identifying data and supporting studies run at the organization's sites.