SHR Functional Requirement
Stores patient level clinical data that forms a patient’s electronic health record
a. Stores unstructured clinical data such as PDFs and narrative text
b. Stores structured clinical data such as an encounter with several discrete observations, compatible with a standard exchange format
c. Relating clinical information to other clinical information, e.g., annotating/describing a document with discrete observations
Expose services that have the ability to receive and save patient clinical data in unstructured form, both text or binary (PDF/image), annotated with sufficient metadata to identify patient/provider.
Expose services that have the ability to receive and save patient clinical data in a structured form such as CDA documents or FHIR resources.
Expose services that have the ability to receive and save patient clinical data In a form that contains both structured and unstructured elements.
Exposes services that respond to queries for a patient’s EHR
a. Can return a specific known document or a list of documents for a patient (as it was submitted)
b. Can return a list of discrete observations for a patient that satisfy specific query parameters. This data can subsequently be used for trending or providing the previous encounters that a patient has had.
c. Can return a full set of clinical information stored about a patient
d. Return patient summary - everything the SHR knows about a patient with links to fetch the individual data items
The SHR shall maintain the context in which the data was submitted.
The SHR should keep detailed audit logs of all interactions with clinical data
a. Keep audit logs of any clinical and demographic data that is stored or changed. Logging who has accessed/viewed clinical information does NOT need to be stored, this is something that an interoperability layer could log.
b. Records and versions updates; records can never be deleted, only marked as such; any previous update should not rewrite old data; no information should ever be removed from the system.
The SHR should support the ability to export data for secondary use.
The SHR should provides interfaces/extension points at various stages of the data lifecycle to allow for semantic validation or simple decision support.
The SHR should allow for storage and retrieval of basic privacy/policy constraints (access control-restrict part of record and restrict entire record).
The SHR should be able to store identified and predefined observational data mapped to standard reference terminology.
The SHR should have a mechanism to resolve conflicts if records are submitted simultaneously.