Delivering care in this new healthcare ecosystem, which is influenced by a digital transformation, a myriad of enabling technologies, apps and mobile devices, pandemics, and an accelerated and heightened consumer expectations and engagement, requires more than ever before, quality health data. A shift in care delivery to remote and tele-based care as well as the deluge of health data by expanding the types and sources of clinical and nonclinical data that is collected and shared, exacerbates the need for interoperability. This chapter describes the design and purpose of health records as the basis of medical and clinical data. It provides an overview of the legal basis of health information management in the USA and the EU emphasizing the patient’s rights, ownership, and legal access to the data. It shows the importance of interoperability including the use of classification systems.
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