UDEF and Electronic Health Records

Ron Schuldt writes:

For those who have not read the President’s Health Information Technology Plan, I recommend that you see the following 

I offer the following based on my assumption that an individual’s electronic health record will include topics such as:

Electronic Health Record Information (identification)

Patient Information (identification, address, phone number, date of birth, gender)

Primary Care Doctor Information (identification, address, phone number)

Insurance Coverage Information (identification, address, phone number)

Medical Conditions (identification and time period)

Medical Treatment Process (identification and time period)

Medical Treatment Substances (identification and time period)

Assuming the above topics and probably others are expected to be an integral part of an individual’s electronic health record, I offer the following UDEF names and IDs for each topic. Note: Proposed UDEF extensions are in italics

For the Electronic Health Record Information (identification) – assumes the US government will assign an identifier to each record

UDEF Name — Health Record Document Government Assigned Identifier    UDEF ID – e.l.2_13.35.8

For the Patient Information (identification, address, phone number, date of birth, gender)

UDEF Name — Patient Person Government Assigned Identifier       UDEF ID — au.5_13.35.8

UDEF Name — Patient Person Family Name                                UDEF ID — au.5_11.10

UDEF Name — Patient Person Given Name                                  UDEF ID — au.5_12.10

UDEF Name – Patient Person Home Address Text                       UDEF ID – au.5_10.12.14

UDEF Name – Patient Person Home Address City Name              UDEF ID – au.5_2.1.10.10

UDEF Name – Patient Person Home Address State Name            UDEF ID – au.5_2.1.36.10

UDEF Name – Patient Person Home Address Postal Zone Code   UDEF ID – au.5_1.1.1.10.4

UDEF Name – Patient Person Home Telephone Identifier              UDEF ID – au.5_5.37.8

UDEF Name – Patient Person Birth Date                                     UDEF ID – au.5_51.6

UDEF Name – Patient Person Gender Code                                 UDEF ID – au.5_3.4

For the Primary Care Doctor Information (identification, address, phone number)

UDEF Name – Primary-Care Doctor Person Family Name                                     UDEF ID — a.aq.5_11.10

UDEF Name — Primary-Care Doctor Person Given Name                                       UDEF ID — a.aq.5_12.10

UDEF Name – Primary-Care Doctor Person Office Address Text                            UDEF ID – a.aq.5_1.12.14

UDEF Name – Primary-Care Doctor Person Office Address City Name                   UDEF ID – a.aq.5_4.1.10.10

UDEF Name – Primary-Care Doctor Person Office Address State Name                 UDEF ID – a.aq.5_4.1.36.10

UDEF Name – Primary-Care Doctor Person Office Address Postal Zone Code        UDEF ID – a.aq.5_3.1.1.10.4

UDEF Name – Primary-Care Doctor Person Office Telephone Identifier                    UDEF ID – a.aq.5_1.37.8

For the Insurance Coverage Information (identification, address, phone number) – assumes commercial provider

UDEF Name – Health Service Commercial Enterprise Name                                              UDEF ID – b.d.b.3_10

UDEF Name — Health Service Commercial Enterprise Office Address Text                          UDEF ID – b.d.b.3_1.12.14

UDEF Name — Health Service Commercial Enterprise Office Address City Name                UDEF ID – b.d.b.3_4.1.10.10

UDEF Name — Health Service Commercial Enterprise Office Address State Name              UDEF ID – b.d.b.3_4.1.36.10

UDEF Name — Health Service Commercial Enterprise Office Address Postal Zone Code      UDEF ID – b.d.b.3_3.1.1.10.4

UDEF Name — Health Service Commercial Enterprise Office Telephone Identifier                 UDEF ID – b.d.b.3_1.37.8

For the Medical Conditions (identification and time period)

UDEF Name – Medical Condition Name                           UDEF ID – a.11_10

UDEF Name – Medical Condition Description Text            UDEF ID – a.11_14.14

UDEF Name – Medical Condition Discovered Date            UDEF ID – a.11_25.6

UDEF Name – Medical Condition Recovery Date              UDEF ID – a.11_52.6

For the Medical Treatment Process (identification and time period)

UDEF Name – Medical-Care Process Name                     UDEF ID aw.8_10

UDEF Name — Medical-Care Process Description Text      UDEF ID aw.8_14.14

UDEF Name — Medical-Care Process Start Date              UDEF ID aw.8_18.6

UDEF Name — Medical-Care Process Release Date          UDEF ID aw.8_8.6

For the Medical Treatment Substances (identification and time period)

UDEF Name – Prescribed Pharmaceutical Substance Name                                 UDEF ID – f.q.15_10

UDEF Name – Prescribed Pharmaceutical Substance Consumption Rate Measure UDEF ID – f.q.15_4.6.13

UDEF Name – Prescribed Pharmaceutical Substance Start Date                           UDEF ID – f.q.15_18.6

I welcome your suggested changes and additions to the list of electronic health record topics and/or the data element concepts that are expressed as UDEF names.

Ron Schuldt

303-977-1414

ron.l.schuldt@lmco.com