EHRs are database centric while medical records are document centric. The conventional wisdom is that documents are bad and discrete data is good. Historically, clinicians have resisted efforts to establish structured data standards for dictated reports. This lack of an industry-wide standard for report content and format confounds interoperability efforts. For nearly two decades, information system specialists have attempted to impose new documentation methods that are more suited to database management but do not meet the needs of the practicing physician. Achieving physician buy-in for electronic record systems that do not accommodate narrative documentation methods such as dictation and transcription has proven to be quite difficult for many EHR vendors.
The Health Story Project (formerly the CDA4CDT initiative Clinical Document Architecture for Common Data Types) is an alliance of organizations that have been working together with HL7 for nearly two years to develop and publish data standards for electronic clinical documents. The initiative is based on Clinical Document Architecture (CDA) - a balloted HL7 document markup standard that specifies the structure and semantics of a clinical document for the purpose of exchange. Document templates for the most commonly dictated report types (H&P, Consult, Operative Note, etc) specify required and optional headings. Templates are developed based on prevailing practice and establish consensus on content and format