It’s important to choose vendor software that can help you efficiently and accurately integrate your interRAI assessment data into an electronic health record.
interRAI assessments electronically capture standardized information across different health and social service settings. They share a common language Opens in new window and refer to the same clinical concepts in the same way across assessments. This enables continuity of care as part of an overall integrated health system. The ability for authorized clinicians to connect, share and use health information across the different health care systems, when and where needed, is vital for quality of care for Canadians.
A key component of this integrated system is the electronic health record (EHR). EHRs will help improve Canadians’ access to health services, enhance the quality and safety of care, and help health care systems become more efficient.
Understanding how to integrate interRAI assessment information into an EHR will help support decision-making at the clinical, organizational and system levels.
Integrating your interRAI assessment data with an EHR
What’s the difference between an EHR and an electronic medical record (EMR)?
- The EHR is a longitudinal collection of the electronic health information of a person or population and can serve as an information source for an EMR.
- The EMR is a partial patient record. It is provider- or organization-centric and can serve as an information source for an EHR.
Before you begin integrating your interRAI assessment data into an EHR, you need to answer 6 questions:
- How would systems (EMR, EHR, etc.) share data and assessment information?
- What data sharing standard will be used to move the information among systems? Some examples of data sharing standards include
- Where would the data and assessment information be stored? For example, is the information stored in a centralized repository similar to the Integrated Assessment Record Opens in new window and Clinical Data Repository Opens in new window in Ontario?
- Which components of the EHR are available to use in your jurisdiction?
- Client Registry: For client demographics
- Provider Registry: For provider demographics
- Consent Registry: For consent information
- Drug Information System (DIS): For drugs/medication history
- Panorama/Public Health Surveillance: For immunization history
- Jurisdictional Laboratory Information System (JLIS): For laboratory results
- Shared Health Record (SHR): For observations/health conditions (e.g., allergies, diagnoses, social behaviours, social history, treatments, procedures)
- What data from an EHR can be used to auto-populate an interRAI assessment (e.g., client demographics from the Client Registry)?
- What data from interRAI assessments can be used to populate EHR components (e.g., outcome scales such as Pain Scale, Depression Rating Scale)?
Designing workflow and business processes
These tools can support the design of workflow and help determine business processes.
Having identity management tools/platforms simplifies access to client information and removes the need for separate login credentials for each system. With a single sign-in process, a user logs in once and is able to access a range of applications through multiple channels without having to log in again during that session.
Security and privacy policies
The privacy and security needs of delivering interdisciplinary health care services across and between care settings, organizations and disciplines can be complex. Clearly defined security and privacy policies need to be in place in the areas of
- Accountability for personal health information
- Identifying purposes for the collection, use and disclosure of personal health information
- Accuracy of personal health information
- Safeguards for the protection of personal health information
- Individual access to personal health information
More information can be found in Privacy and Security Requirements and Considerations for Digital Health Solutions Opens in new window.
Clinical and specification requirements
Online tools such as InfoScribe Opens in new window from Canada Health Infoway are available to help you develop your clinical and specification requirements.
Terminology and classification standards
Terminology and classification standards allow information to be captured, retrieved, aggregated, analyzed and shared across health care settings in a consistent, safe and reliable manner.
Examples of classification standards are ICD-10-CA and CCI.
Examples of terminologies include
- Systematized Nomenclature of Medicine Opens in new window — Clinical Terms (SNOMED-CT)
- Logical Observation Identifiers Names and Codes (LOINC)
Access to terminologies used in Canada is available from Canada Health Infoway Opens in new window.