Japan Association for Medical Informatics

[2-E-2] Standardized discharge summary.
Current status and its direction in near future.
--- A consideration for its importance as an essential healthcare excerpt ---

*Sunao Watanabe1, Osahiro Takahashi2 (1. Medical Information Development Center (MEDIS-DC), 2. Chiba Foundation for Health Promotion & Disease Prevention)

standardized discharge summary, ICD and ICF, HL7 FHIR, international patient summary, postgraduate clinical education

In 2019, MHLW of Japan determined the “Discharge Summary based on HL7 CDA” as a standardized structure in health-related electronic documents. And in 2022, MHLW also acknowledged the “Standard Specification for Discharge Summary based on HL7 FHIR.” As a structure using open-web technology with easiness of implementation and with good interoperability, HL7 FHIR is suitable for health-data sharing among various healthcare facilities, and also with patients themselves. This “trend” is in line with an expectation of the presence of “excerpta” of a person’s health-related data in a standardized structure, which can be easily obtained at any healthcare institution. In 2021, the International Patient Summary (IPS) is acknowledged as an ISO standard, also in the form of HL7 FHIR. The standardized discharge summary specified in the form of HL7 FHIR can be easily utilized as a convenient tool for forming IPS. This system with is so important that EMR vendors are now expected to implement it anytime soon. Concurrently, healthcare providers must record appropriate contents in each section of the summary structure, so that the necessary information be incorporated sufficiently and concisely. For this fulfillment, postgraduate clinical education about medical recordings is thought to be extremely important. Also, in the era of highly graying population, a summary of each patient’s functional status should be added as an inevitable item. Development of standardized function/disability assessment, based on ICF, along with established diagnoses list based on ICD, must be expedited.