Archetypes in detail - gov

43 Pages·2011·0.83 MB·English

by  Heather Leslie

Archetypes in detail
Heather Leslie
Ian McNicoll
The electronic health record
EHR
for one person
High-level organisation of the EHR
Folders
eg per episode, per clinical speciality
Set of entries comprising a clinical care
Compositions
session or document eg test result, letter
Clinical headings reflecting the workflow
Sections
and consultation/reasoning process
Clinical “statements” about Observations,
Entries
Evaluations, and Instructions
Compound entries, test batteries
Clusters
eg blood pressure, full blood count
Element entries: leaf nodes with values
Elements
eg reason for encounter, body weight
Date types for instance values eg
Data values
coded terms, measurements with units
© Ocean Informatics 2011
3
Archetypes

A data specification for a single, coherent clinical
concept

Reusable in multiple contexts

maximal data set

for all imaginable use-cases

minimal, universal constraints

maximise interoperability

© Ocean Informatics 2011
4
Archetype Classes
Class Features Contains Design
adherence
Composition Context; Participations Sections Strict
Entries
Section Sections Not
Entries required
Entry Participations Clusters Strict
Elements
• Observation = history model, protocol, state
• Evaluation = evaluation & summary
• Instruction = order (Structures)
• Action = activity and state model (Structures)
Cluster Clusters Strict
Elements
© Ocean Informatics 2011
COMPOSITION
The container class in openEHR
the „clinical document‟

the unit of contribution (and therefore committal

and communication) to the HER
‘You cannot save less than a Composition’

Handles all medico-legal issues
Who, what, where, when

Clinical author, person committing

Responsible healthcare facility

Signature or attestation (all or part)

Other participants


© Ocean Informatics 2011
COMPOSITION II
Can record „context‟ information

Can determine what Sections are permitted in

the document
Once committed, edits or changes 

recommitted as a new version
All data transferred from one EHR to another is

transferred as Compositions.
© Ocean Informatics 2011
Section
A SECTION is an organising class, contained
within a COMPOSITION.
Standardise the organisation of information within a

Composition.
Assist with human navigation

Confer no meaning to the contained entries

Examples of Sections are:

SOAP(E) organisation of the EHR

Physical examination - organised by System

History - organised by presenting complaint, social history, review of

systems etc
© Ocean Informatics 2011
ENTRY
The 'semantic unit' of information.
the „clinical statement‟

Blood pressure 120/80 sitting, large cuff

Blood urea 5.6

Information within an Entry should mean the same

thing no matter where it is used
a fundamental design feature of openEHR architecture.

Examples

Blood pressure - systemic arterial blood pressure

ECG measurement

Medication order

Diagnosis

Lab result

Surgical procedure

© Ocean Informatics 2011
Types of Entries

measurable or
observable
Observations
1
Published Domain Expert
evidence Time/Event series;
Subject
State
base
5 4
Personal
Admin Entry Actions
knowledge
2
base Recording
Evaluation
each
clinically
order or
activity
interpreted
OR initiation of a
findings
Persistent Summary workflow
process
3 Investigator’s
agents
Instructions
© Ocean Informatics 2011
ENTRY: Features
Feature Eval Obs Inst Act
Protocol –
how and basis for b b b b
recording
History –
allows time-series b
and aggregates
State –
records patient data for b
interpretation
Pathway –
work flow steps b
and states
© Ocean Informatics 2009

© Ocean Informatics 2011