HIM FPX 3640 Assessment 3 EHR Standards 

HIM FPX 3640 Assessment 3 EHR Standards 

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Terolyn Pollock

Capella University

HIM-3640

Professor’s Name

20th May, 2025

HIM FPX 3640 Assessment 3 examines EHR standards (FHIR, HL7, DICOM) for interoperability, data security, and clinical decision-making in healthcare systems.

EHR Standards

Utilizing Electronic Health Record (EHR) technology in hospitals can help in delivering effective healthcare for patients by improving workflows and making sure all laws are followed (Reegu and colleagues, 2023). Michigan Heart’s installation of the next generation of EHR systems provides an excellent case study of how industry standards and best practices can transform a current facility into an accessible and interoperable healthcare system (Capella University, 2024). This case study illustrates the significance of EHR guidelines and information and system integration strategies to facilitate the process of clinical decision-making, as well as improve communication between physicians and healthcare providers and guarantee the confidentiality of patient information.

Case Summary

The implementation of NextGen EMR technology at Michigan Heart has significantly enhanced the effectiveness and the quality of care they offer, alongside the manner in which they operate (Capella University, 2024). Previously, before the technology arrived, patient records were managed by departments. Now, they are managed by a team that consists of IT professionals. The IT professionals can see more information regarding patients, including detailed coding of drug administration as well as claim handling. Though there were early challenges that had to be addressed, doctors, along with the staff members, observed enhanced efficacy and efficacy. Standardization of the treatment was created through the use of templates and alerts that, for example, ensure that patients suffering from coronary artery disease get the right drugs.

The medical practitioners could view information remotely, which contributed to the enhancement of the treatment of patients in need. It minimized the likelihood of mistakes, as well as the ease with which the patients could learn quickly. The company spent a lot of money on this project, which was planned on training, management, and planning, which left them with fewer administrative costs for offices (Capella University by 2024). Some of the main problems with EHRs are poor speed and extra work for physicians as they have to employ more clicks in addition to the integration issues of multiple platforms. Additionally, there was an inability to separate life at work and in private.

Standards Governing EHR Systems and Responsible Organizations

Continuous communication and consistent confidential information of patients can be assured in all healthcare settings due to diverse guidelines that regulate the EHR System (Reegu and Co., 2023). Most of them are classified into categories like transportation and information, and the security category, like terminology, transportation, and security. Specifically, Fast Healthcare Interoperability Resources (FHIR) and Digital Imaging and Communications in Medicine (DICOM) are the most widely utilized methods to exchange clinical information as well as images of medicine between various EHR systems (Shivshankar and Co., 2024). Health Level Seven International (HL7) and the Consolidated Clinical Document Architecture (C-CDA) standardize the format and structure of medical records and simplify the documents created for patients to be easier to understand (Talvik and Co. 2024). Utilization of HL7 together with the International Classification of Diseases (ICD-10-CM), CPT (Current Procedural Terminology), SNOMED CT (Systematized Nomenclature of Medical Terms- Clinical terminology) and the LOINC (Logical Observation Identifiers Names, and Codings) enables all individuals to utilize specific terminologies used for describing diagnostic procedure, diagnosis and laboratory investigations (Bhanudas 2025). Moreover, laws such as HIPAA (Health Insurance Portability and Accountability Act) in the United States and GDPR (General Data Protection Regulation) in Europe offer guidelines to maintain patient privacy and information security regarding medical conditions (Tschider and Co., 2024 ).

HIM FPX 3640 Assessment 3 EHR Standards 

The most popular way to share information covered under the Michigan Heart’s Michigan Heart case study is FHIR. It’s operated by HL7 International. FHIR uses today’s online tools that enable the exchange of health information more efficiently and more efficiently for various platforms to work together (Shivshankar and Co., 2024). Through the integration of FHIR into Epic’s electronic healthcare record system, Michigan Heart enhanced the passage of information from patients to their healthcare providers, as well as enabled the patients to access the health record system remotely. With interoperability, it is far more structured to manage procedures and orders to prevent repetition of the identical test and over, besides being easier to comprehend how billing is derived.

The organizations tasked with developing the standards and governing them, also known as Standards Development Organizations (SDOs), can assist in developing EHR capabilities. HL7 International, in this case, is the main SDO responsible for creating an international standardization of transport and information that utilizes FHIR, as well as C-CDA (Shivshankar and Co., 2024). ICD-10-CM, as well as CPT standards, are overseen by the World Health Organization (WHO) alongside the American Medical Association (AMA) (Bhanudas 2025). They both HIPAA alongside GDPR. Both are regulated by the United States, and the GDPR in Europe is regulated by government agencies such as HHS and also the European Union (Tschider et al. 2024). These regulations established within the jurisdiction of SDOs and SDOs enable Michigan Heart to have correct, precise, and secure data in the EHR system.

Types of Data, Data Formats, and Data Reporting Requirements

In HIM FPX 3640 Assessment 3 EHR Standards systems such as the ones that were used in the Michigan Heart case study, various types of clinical as well as administrative data are gathered for patients to assist them with their medical care and to satisfy the conditions of the operation. They contain structured data that consists of patients’ demographics as well as laboratory tests, medical prescriptions, and key indicators. These are entered into pre-designed fields in order to enable those who enable easy search and appraisal (Olson 2023). There are also records, such as a patient discharge note and medical records, that cannot be computer-created and must be read aloud in person. Echocardiograms and CT scans (CT) scans generate multimedia reports. These are kept in databases.

The information that is held in EHR systems is kept and conveyed in a range of forms depending on the nature of the data. Text information, such as notes from laboratory or clinical tests, is normally formatted in the form of C-CDA (Consolidated Clinical Document Architecture) or HL7 information messages that are machine-interpretable forms based on standards. Pictures taken in hospitals are usually stored in DICOM format to ensure that the data is stored and passed in a manner that is suitable (Aiello and Co. 2021). Significant lab results and other markers are usually stored in LOINC format, which provides access to different healthcare systems (Olson, 2023). Certain types of data, like details about accidents that patients suffer or events that cause harm, should be included in the registry so that it can help in monitoring purposes in addition to improving the quality of care. Michigan Heart’s data on patients could be transferred to a registry of cardiovascular health to record the outcome and affect studies of research.

Purpose of Data Modelling and Data Dictionaries

Data modelling is the procedure of designing visual depictions of parts of data and their relationship with the EHR systems (Rostamzadeh and others, 2021). The motivation behind this practice is to ensure that the patient’s record is in order to make sure that every important detail is documented and easily accessible. Data dictionaries contain the acceptable values’ definitions, metadata, and acceptable information for every data element that comprises an EHR System (Hovenga Grain and Hovenga 2022). Data modelling is focused on data design and structure. Data dictionaries may also be the primary source of the accuracy of data understanding in the system. For the Michigan Heart case, Data modelling will give information on the way the data model is associated with the details of the patients, as well as the drugs employed, and the dictionaries of data give information on how every unit of data is encoded and stored.

Standards such as HL7 and SNOMED can be employed to design data models as well as data dictionaries for the purpose of making healthcare systems interoperable (Bhanudas 2025). Standards allow data models, as well as models, for purposes of verifying the accuracy as well as usefulness of the information they offer. The regular structure of information helps ensure no mistakes are made and facilitates easier communication by doctors and easier analysis of the information (Ferreira and colleagues, 2024). Michigan Heart ensured that the information they submitted was uniform, which helped ensure that their reports were accurate and consistent, which assisted with patient care and daily operations (Capella University 2024 ).

Apply Standards for Integration Among Applications

Integrating EHR applications is mostly dependent upon the standards that were developed for the smooth transmission of information and communications among different healthcare systems. Thanks to the HL7 protocol, EHRs can exchange information from clinical studies with software programs such as radiology laboratories or labs, as well as billing appropriate. Application of HL7 in the Michigan Heart case facilitated the exchange of diagnostic codes for patients, i.e., ICD-10-CM, from the doc systems to the payment system. It made for improved quality and standardized methods of payment (Capella University 2024). To ensure that software operates smoothly, is compliant with privacy legislations, and protects data, choose the most accepted standards and be in harmony with prevalent technology. They also permit interoperability across many systems and are adapting to security standards. Integration may enhance the coordination of healthcare and simplify the administration of all aspects of healthcare.

Conclusion

The success of Michigan Heart’s conversion to a contemporary EHR system is a testament to the imperative of following guidelines and utilizing accurate models of data and smooth integration of the software. Using FHIR, ICD-10-CM, and HL7 helped the institution improve the integration of information, reliability, and security, deliver more effective care to patients, and enhance efficiency within the hospital. Additionally, using designs and the utilization of dictionaries in information management, organizations could be assured of the reliability of their information as well as satisfy the clinical and reporting demands. This is clear evidence of the reality that successful EHR implementation in today’s healthcare system is dependent upon a strategy to make staff members interested in how to ensure security and privacy.

References

https://doi.org/10.1186/s13244-021-01081-8

https://www.benthamdirect.com/content/books/9789815305876.chapter-10

https://doi.org/10.3390/healthcare12191967

https://www.sciencedirect.com/science/article/pii/B978012823413600015X

https://doi.org/10.53759/0088/jbsha202303010

https://doi.org/10.3390/su15086337

https://doi.org/10.3390/informatics8010012

https://doi.org/10.1007/978-981-97-3312-5_20

https://doi.org/10.1093/jlb/lsae022

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