Electronic health records in complementary and alternative medicine

SummaryObjectivesThis paper investigates the potential for a standardised electronic health record (EHR) designed for conventional medicine also to be used by complementary and alternative medicine.MethodThe research was undertaken using anonymised samples of patient records from homoeopathy practices, to investigate if the patient data could be modelled using the forthcoming joint European and International Standard for EHR Communications (ISO/EN 13606). The research deliberately did not consider the effectiveness of complementary and alternative medicine or the clinical evidence for any particular CAM practice or treatment. The focus was purely on the patient data captured routinely by CAM therapists, to determine whether current approaches to the representation and communication of EHRs could incorporate such records.ResultsFive homoeopathic patient records, authored by different practitioners in different practice settings, were re-represented in a structured form in conformance with the ISO/EN 13606 reference Model. A sixth practitioner confirmed that the transposition had been as faithful to the original records as was possible given some limitations in the clarity of the originals.ConclusionThe authors conclude that the ISO/EN 13606 model can be used to represent patient records from homoeopathy, including the evidence and reasoning used to arrive at a formulation and to determine the appropriate remedy. It is therefore feasible that future EHR systems adopting this standard could enable patient records to be shared between complementary and conventional medical practice, in support of integrated healthcare.