Towards a comprehensive electronic patient record to support an innovative individual care concept for premature infants using the openEHR approach

被引：35

作者：

Buck, Jasmin ^{[1
]}

Garde, Sebastian ^{[2
]}

Kohl, Christian D. ^{[3
]}

Knaup-Gregori, Petra ^{[3
]}

机构：

[1] Univ Appl Sci Heilbronn, Fac Informat, D-74081 Heilbronn, Germany

[2] Ocean Informat, Dusseldorf, Germany

[3] Heidelberg Univ, Inst Med Biometry & Informat, Heidelberg, Germany

来源：

INTERNATIONAL JOURNAL OF MEDICAL INFORMATICS | 2009年 / 78卷 / 08期

关键词：

Computerized medical record system; openEHR archetypes and templates; Neonatology; MEDICO-LEGAL MODEL; HEALTH RECORDS; SEMANTIC INTEROPERABILITY; SUSTAINABILITY; ARCHITECTURE;

D O I：

10.1016/j.ijmedinf.2009.03.001

中图分类号：

TP [自动化技术、计算机技术];

学科分类号：

0812 ;

摘要：

Purpose: This paper introduces the modelling of a prototype neonatology electronic patient record (EPR) using openEHR archetypes. The EPR is necessary to support the complex communication tasks of the innovative concept of 'Developmental, Family-Centred, Individual Care of Premature Infants and Newborns' established for the Department of Neonatology at Heidelberg University Hospital. Methods: The data to be documented was analysed and modelled using the five step openEHR data modelling approach (odma). Results: The analysis revealed a total of 1818 items, which could be arranged into 70 clinical concepts. The items and concepts were then mapped to 132 openEHR archetypes. Fifty-eight of these archetypes could be reused either directly or via specialisation. from the existing openEHR archetypes. A further 67 archetypes were newly developed. To combine and constrain archetypes for local settings 16 templates were developed. Conclusion: By using the five step openEHR data modelling approach, semantic interoperability, and a reduced need for repeated documentation of the same data can be realised. This is of major importance within the hospital as well as for trans-institutional data exchange. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

引用

页码：521 / 531

页数：11

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